HOW TO TELL IF SOMEONE DIAGNOSED WITH A MENTAL ILLNESS, HAS ANOTHER MEDICAL DISORDER (THAT MAY HAVE LED TO A MISDIAGNOSIS)
DR. RON DIAMOND
(This is not medical advice. Do not rely on it Discuss with your doctor. )
Doctors often do not take enough time with patients to get to the root cause of their issues. This article from early 1980s (in four parts) may help individuals think though if what is presenting as schizophrenia, depression, or anxiety disorder is really caused by some other physical illness. It will also help you better understand whether someone correctly diagnosed as having a mental illness may also have an underlying undiagnosed medical illness. It will point to questions you should ask your doctor.
It is based entirely on information in a paper by Dr. Ron Diamond, who was kind enough to let us use it. D.J. Jaffe edited this paper for families. This information should not substitute for a consultation with your doctor and some of it may now be out of date. We thank Dr. Diamond.
SECTION 1: WHAT TO LOOK FOR IF YOU EXPECT SOMEONE WITH AN NBD HAS AN UNDERLYING MEDICAL ILLNESS
SECTION 2: HOW TO INVESTIGATE
SECTION 3: HOW TO INVOLVE THE PHYSICIAN AND FEED BACK
SECTION 4: MEDICAL CONDITIONS THAT CAN MIMIC PSYCHOTIC DISORDERS
SECTION 5: MEDICAL CONDITIONS THAT CAN MIMIC DEPRESSION
SECTION 1: WHAT TO LOOK FOR IF YOU EXPECT SOMEONE WITH AN NBD HAS AN UNDERLYING MEDICAL ILLNESS
There is a very real possibility that what seems to be a psychiatric problem is caused by some physical illness. How common is this problem? Very…and not very. Most people will not have a medical disease masquerading as a neurobiological disorder (“NBD”, formerly known as ‘mental’ illness). So doctors get sloppy and stop looking for underlying physical causes. This is especially true if the doctor dislikes the patient. Yet, these often-sicker individuals are more likely to have an undiagnosed organic brain syndrome than others.
The medical causes of psychiatric symptoms should always be considered. If you and your doctor don’t look for an underlying physical problem, you won’t find any.
You need to know enough about these medical illnesses and how to look for them to decide whether a further medical assessment is necessary. In addition, doctors also often miss physical disorders that are significant, but unrelated to the ‘mental’ disorder so you should look for those as well.
Be suspicious of “medical clearance”.
Just because a doctor says there is no underlying medical problem (i.e., the patient has “medical clearance”), don’t believe it. Physicians are often uncomfortable around people with NBD and may tend to dismiss the complaints of psychiatric patients or blame the complaints on the fact that the person has an NBD. In addition, at times patients may behave in ways that make evaluation more difficult, either by being unwilling to give a full history, unable to give an accurate description of symptoms, or too frightened to allow a full physical examination.
People with schizophrenia get sick, just like other people. The fact that someone is actively psychotic does not mean that they do not also have a serious medical illness.
Even in patients who clearly have schizophrenia or some other diagnosable mental illness and who have had an excellent medical workup in the past, it is important to consider whether their current complaints or recent change in behavior could be related to a recent medical illness. In fact, because psychotic patients are more difficult to evaluate, if they do happen to have a serious medical illness, it is more likely to get missed.
Following are common assumptions that lead to missed diagnosis by M.D.s:
- Mistaking symptoms for their causes
- Listening without fully considering all possibilities;
- Equating psychosis with schizophrenia
- Relying on a single information source
SECTION 2: HOW TO INVESTIGATE AND FEED WHAT YOU FIND TO THE DOCTOR.
LOOK FOR SOMETHING SPECIFIC RATHER THAN GROPE RANDOMLY.
There are a list of diagnosis which could mimic schizophrenia, depression, and anxiety or cause their own issues. What follows below is how a lay person can look for signs of the medical disorders that may mimic psychiatric disorders, record them, and bring them to doctors attention if found.
The following observations are often possible for a consumer to determine, or can be done by a family member (even on a completely uncooperative person). They should be done to help determine if what is being diagnosed as ‘psychosis’, is actually another organic disorder masquerading as psychosis:
The following factors make medical illness more likely:
- A person over 40 with no previous psychiatric history:
- No history of similar symptoms
- Coexistence of chronic disease
- History of head injury
- Change in headache pattern
- A patient who gets worse when given antipsychotic or anxiolytic medications
- Visual disturbances, either double vision or partial visual loss
- Speech deficits, either dysarthrias (problems with the mechanical production of speech sounds) or aphasias (difficulty with word comprehension or word usage).
- Abnormal autonomic signs (blood pressure, pulse, temperature)
- Disorientation and/or memory impairment
- Fluctuating or impaired level of consciousness
- Abnormal body movements
- Hallucinations that are visual and vivid in color and change rapidly
- Olfactory (smell) hallucinations
- Illusions (misinterpretations of stimuli)
- Blood or pus in the urine,
- High blood pressure
- Symptoms of chest pain while at rest,
- Headaches associated with vomiting
- Loss of control of urine or stool
You should ask about each of these and try to determine if they are present. Take specific notes to bring to the doctor.
Look for the following information if you are looking for an underlying physical ailment.
General appearance: How does the person look? How are they dressed? Do they appear ill? Is the face symmetrical or asymmetrical? Then go to more specific observations.
Skin: Is it very dry or abnormally colored? Extremely pale skin or lips may suggest anemia. A yellow skin may indicate jaundice and liver disease. Dry skin and hair may be a sign of hypothyroidism. Look for such things as dehydration, nutritional status, rashes, edema, and petechiae
Eyes: Are they focused? Are the pupils equal? Are they aligned with each other? Do they move together? Differences in pupil size may indicate brain masses such as tumors. Wildly dilated pupils may indicate a variety of drugs including hallucinogens, stimulants, and anticholinergics. Constricted pupils may indicate opiates. Bulging eyes can be a sign of hyperthyroidism. See if eyes move equally and fully in all directions. Check for vertical and horizontal nystagmus: refers to rapid movements of jerking of the eyes, and can be either up and down (vertical) or back and forth (horizontal). It is most easily seen if individual is asked to look up or over to the side as far as possible. Nystagmus is frequently present with drug intoxications, and vertical nystagmus is never a normal finding in functional psychosis.
Observe body movement to rule out weakness, clumsiness, ataxia, facial asymmetry, asymmetry of movements, choreiform movements (“worm-like” or other involuntary movements, usually occurring less than 2 times/second), and tremors. Is there any gait disturbance (a very common finding in a wide range of medical conditions)? Is there any disturbance in the way they move, hold themselves, position their body or touch their nose?
Observe neurological abnormalities. Is there motor stereotypy (repetitive stereotyped movements)? Look for aphasias (difficulties with speech). These can be broken down into word finding difficulties (nominal aphasias); difficulty understanding speech (receptive aphasias) or difficulty producing speech (expressive aphasia). Does the person slur words or have excessive difficulty finding the right words?
Do they have any of the following difficulties: agnosias (recognition of complex shapes) apraxias (execution of proper manipulation of objects) perseveration (inability to switch tasks or mental sets)
Take blood pressure. Is it high or low? Take it preferably lying and standing (or you can ask the person about any recent blood pressure checks, or ask them to get their blood pressure taken at one of the blood pressure machines that seem to be in every bank and drugstore) Take pulse for evaluation of rate and arrhythmias (irregularities of heart rhythm)
Bring any of these symptoms to your doctors attention and require him/her to investigate fully.
In addition to specific observances, bring your doctor a comprehensive overview of the individuals’ medical history to help determine what may be causing these symptoms.
In order to decide if a physical disorder exists, and whether or not it could be affecting the psychiatric disorder, the psychiatrist and doctor must have comprehensive information. They should get it themselves, but may not have had time. They may only see a person for 15 minutes, once a month, including paperwork. Records may have been lost. So you may have to do some for them. Make sure you bring to the doctor in a useful form all of the following. Fill in gaps in your information so that important areas are not missed. Use this as a ‘crib sheet’ to ask the right questions and make sure your doctor is following the right leads.
1. Describe the Symptoms- how did they begin? How long has s/he had them? What has the progression of symptoms been like? Include a careful review of other “extraneous” symptoms the patient may have-starting at the top with questions about headache and dizziness and ending at the bottom with questions about leg sores and trouble walking. This “review of systems” is an extremely important part of a medical assessment.
2. Describe the History A history of similar problems in the past; past medical problems including all medical hospitalizations and surgeries; Family history, both medical and psychiatric. Specifically ask about a history of epilepsy, emphysema, asthma, diabetes, or thyroid disease and bring these to the doctors attention.
3. Describe medical status- List all current medical illnesses; all current medications (Ask specific questions about vitamins, birth control, over the counter meds, past medical problems, past surgeries, past medical hospitalizations; any head injury, coma, periods of unconsciousness, seizures; the name of person’s physician–date of last contact–for what purpose.
4. Describe current habits The doctor should have honest info about drug use, starting with questions about tobacco, caffeine and alcohol and proceeding on to questions about other drugs x exercise and activity patterns, sleep patterns.
5. List Medicines: ask about all drugs that a patient is taking, licit and illicit, prescribed and over the counter. Ask about all illnesses that a patient has had
Asthmatics take combinations of sympathomimetics and xanthenes (aminophylline, theophylline)
Patients with allergies may take ephedrine
Patients with diabetes may be hypoglycemic from their insulin
Thyroid preparations may be prescribed for thyroid illness, following thyroid surgery (from years ago), or even for weight loss
The goal is not to come up with a specific diagnosis. The goal is to organize the data that you collect about the person so that you can decide what to do next, how worried you need to be, and when and how and what to say to your consulting physician if you decide further medical assessment is necessary.
Here are some of the specific things you want your doctor to do.
The following tests are the most useful screen for picking up physical disease in psychiatric patients (Sox et. al. (1989), so your doctor should do them.
- T4 (thyroid test, now replaced with a more modern test called sTSH),
- CBC (complete blood count),
- SGOT (liver function test),
- Serum albumin,
- Serum calcium,
- Vitamin B12
- Laboratory and other diagnostic tests should be used to pursue specific parts of the differential diagnosis list (pages 4, 5, and 6). Diagnostic tests are much more likely to give useful results when you and the doctor are clear what question you have in mind and what specific test is needed to answer that specific question. For example an EEG detects abnormal brain function while CAT scan detects abnormal anatomy.
If you think a “drug screen” is needed to find out if the person has recently used an illicit drug, find out if the doctor’s laboratory can measure the drug or drugs that you expect this person might be using, and whether blood or urine tests are better depending on the particular drug and time since ingestion. Most labs can test for the presence of cocaine, but LSD is used in much smaller amounts and may not be detectable even if recently used. This kind of question can be answered by a call to the chemistry lab of the local hospital, but such a call requires that you step out of your typical “non-medical” role and interact with a strange and often forbidding medical system that probably won’t welcome you.
SECTION IV: HOW TO WORK WITH THE DOCTOR
At different times with different doctors and different clinical situations this will mean different things. It always means making the consultation request as clear as possible. What kind of answer do you want back from the doctor? What are you most worried about? What information do you already have?
You might think that your job is just to get someone to see the doctor, and the rest of the job is up to the doctor. This is true-and not true. The doctor will typically spend less than 15 minutes with the patient to collect a history, do the physical, order the tests and write a note in the chart. If the client is less than articulate, important information is likely to get lost. This is a particular problem with older clients, those who are hard of hearing or who have other communication problems, or those who are less organized or less clear in their thinking. It is also a problem when the symptoms you want evaluated are vague, or your concerns leading to the referral do not relate to a particular “medical” symptom. Your job must include organizing the information that you have collected and transmitting it to the doctor in such a way as to do you or your loved one the most good.
Telling the person to see his local doctor, or phoning the local internist with a request to “Please do a physical exam on this client.” is much less likely to lead to a reasonable consultation result than a request, “This client has a depression that seems very atypical. Could you please see if there could be a medical illness involved?” Or even better yet, “This patient is complaining of depression with decreased energy level, but he is also complaining of increased weight, cold intolerance, decreased libido and extremely dry skin. He was treated for hyperthyroidism 15 years ago. Could you see if any thyroid problems or any other medical problems might be potentiating his depression?”
Most of the time you will not be able to frame a consult request with as much detail as this last example-but in all cases the more the better. Often, the referral to the physician is based on a pattern suggesting a higher probability of medical illness, rather than any particular symptom suggesting a particular illness. For example, anyone who initially develops psychiatric symptoms over the age of 40 should have a medical workup. If this is the reason you are referring the client, then the physician needs to have that information.
Finally, there are differences of communication styles between you and physicians. You are likely to want to give the physician a complete description of the patient and the problem in a phone discussion that may go on for many minutes. The physician is likely to be in the middle of office hours, with a clinic full of patients waiting to be seen. A brief, succinct and very focused description and problem statement with a focused consultation request is likely to be better received by a physician than the more complete communication often expected between psychotherapists.
SECTION V: Medical conditions that may present as psychotic disorders
by Dr. Ron Diamond
Hypoglycemia (low blood sugar): symptoms can include delirium or coma, palpitations, sweating, anxiety, tremor, vomiting. If in doubt, give candy or orange juice sweetened with sugar. In an emergency room, give 50 cc. of 50% dextrose for both treatment and diagnosis.
Diabetic Ketosis or non-ketotic hyperosmolarity (blood sugar so high that it upsets body chemistry): delirium with history of diabetes, increased breathing, sweet smell of acetone on breath (can be mistaken for smell of alcohol), dehydration, decreased blood pressure.
Wernickes-Korsakoff’s syndrome: acute thiamine (vitamin B1) deficiency so severe that it can cause rapid brain damage. Usually found in alcoholics. Symptoms include nystagmus (rapid small jerking movements of eyes), cerebellar ataxia (person moves as if drunk), evidence of peripheral neuropathy, ocular palsies (inability to move both eyes together in all directions). If in any doubt, give thiamine l00 mg. IM. This is not diagnostic but will prevent any further brain damage.
DT’s (delirium tremens): drug withdrawal from alcohol or other sedative hypnotics. Frequently missed and can be medically very serious. Symptoms include elevated autonomic signs, agitation, visual and tactile hallucinations and history of alcohol abuse. Onset is usually three to four days after reduction or discontinuation of alcohol.
Hypoxia (low blood oxygen): from pneumonia, heart attack, COPD (chronic obstructive pulmonary disease), arrhythmias (abnormal heart rhythm), etc.
Meningitis (infection of the covering of the brain): be alert for stiff neck and fever.
Subarachnoid hemorrhage (rapid arterial bleeding into the brain): stiff neck, fluctuating consciousness and headache. If there is a fluctuating consciousness along with stiff neck and headache, a spinal tap for diagnosis needs to be done immediately.
Subdural hematoma (bleeding from veins under the outside covering of the brain, which compresses the brain over hours to weeks or even longer): symptoms are variable but frequently (not invariably) there is a history of head trauma.
Anticholinergic (atropine) poisoning: from overdose of tricyclics or over-the-counter drugs, or from organophosphate insecticides. Classic symptoms include: Flushing “red as a beet” x Mouth dry “dry as a bone” Dilated pupils “blind as a bat” Delirious “mad as a hatter” These patients will also have increased pulse and sometimes elevated blood pressure. Most fatalities are from cardiac arrhythmias, although seizures are not uncommon.
Progressive neurological diseases
Multiple sclerosis: no typical signs or symptoms. It may begin very suddenly and affect any part of the neurological system. Early in its course, diagnosis may be extremely difficult.
Huntington’s chorea: hereditary illness that includes movement disorder but can present with psychosis initially.
Alzheimer’s disease and Pick’s disease: progressive diseases that cause dementia, but can initially present in a wide variety of ways. Alzheimer causes diffuse dementia, while Pick’s primarily affects the frontal lobes of the brain.
Central nervous system infections Encephalitis (viral infection of the brain-usually Herpes Simplex): usually presents with fever and seizures, but various mental symptoms including catatonia or psychosis may present before any clear cut neurological symptoms. Usually has a fluctuating mental status.
Neurosyphilis (syphilis of the central nervous system).
HIV infections: HIV encephalopathy commonly includes apathy, decreased
spontaneity and depression and may present before any other signs of AIDs are present. AIDS can also first present as delirium with paranoia and other prominent psychotic features.
Space occupying lesions within the skull Brain tumors, bleeding within skull, Brain abscesses
Accumulation of toxins from severe liver or kidney disease.
Disturbances in electrolytes, either too low a serum level of sodium or too high a serum level of calcium. Acute intermittent porphyry (disease of porphyrin metabolism): very rare, but may present as classical psychosis.
Endocrine disorders Myxedema (underactive thyroid gland-hypothyroidism)
Cushing’s syndrome (too much cortisol caused by overactive adrenal gland or overactive pituitary gland) Hypoglycemia, either from insulin secreting tumor or administration of insulin
Thiamine deficiency: Wernicke-Korsakoff amnestic syndrome;
Pellagra (nicotinic acid deficiency) and other B complex deficiencies;
Temporal lobe epilepsy (or partial complex seizure disorder)
Drugs-licit and illicit
(Added 7/2017: The book, Brain on Fire by Susanah Cahalan is about her own experience. What doctors thought was schizophrenia turned out to be a rare illness anti-NMDA receptor encephalitis. To learn more go to the Autoimmune Encephalitis Alliance and read how to identify if you have it. Reminder: This is not medical advice. Consult your doctor).
SECTION VI MEDICAL CONDITIONS THAT MAY PRESENT AS DEPRESSION
BY Dr. RON DIAMOND
There are many different physical disorders that may lead a doctor to misdiagnose someone as having depression or bi-polar disorder. Following is a list of disorders that may mimic depressive disorders.
Post viral depressive syndromes: especially influenza, infectious mononucleosis, viral hepatitis, viral pneumonia, and viral encephalitis
Cancer of the pancreas commonly presents as depression. Lung Cancer, especially oat cell carcinoma.
Brain tumors, either primary tumors or metastatic, may present with depression
Cardiopulmonary disease with hypoxia (decreased oxygen in the blood): acute hypoxia often leads to symptoms resembling anxiety or panic. Chronic hypoxia may present with lassitude, apathy, psychomotor retardation and other symptoms confused with depression.
Sleep apnea: should be suspected in a patient with sleep disturbance and daytime somnolence
Endocrine System Disorders may mimic depression
Hypothyroidism (underactive thyroid): causes a general slowing of all body functions. Patient complains of fatigue, weight gain, constipation, and, when asked, will describe cold intolerance, dry skin and hair, and hoarseness or deepening of the voice. Often very insidious but easily diagnosed and treated
Hyperthyroidism or thyrotoxicosis (overactive thyroid): usually associated with anxiety but may present as depression, especially in the elderly who may have few classical signs of thyroid disease.
Adrenal hypofunction (Addison’s Disease): often presents with weakness and fatigue, along with low blood pressure and hyponatremia (low serum sodium) and hyperkalemia(increased serum potassium).
Adrenal hyperfunction (Cushing’s Disease): from either steroid medication, pituitary, adrenal or other ACTH secreting tumors. Various affective disturbances, either depression or mania, are common. Syndrome is marked by truncal obesity, hypertension, puffy face, and hirsutism.
Hyperparathyroidism: usually from small tumors of the parathyroid glands. Early symptoms develop insidiously and can include lassitude, anorexia, weakness, constipation and depressed mood. The classic symptoms of bone pain and renal colic often develop only years later.
Post-partum, postmenopausal, and premenstrual syndromes.
Collagen-Vascular Diseases This is a strange set of different diseases where the person essentially becomes allergic to parts of their own body. It can effect all parts of the body and can, at times, cause death.
Systemic lupus erythematosus (SLE) is most often seen in women 13-40 years old. It often presents initially with nonspecific symptoms such as fatigue, malaise, anorexia and weight loss, all of which can lead to the diagnosis of functional depression.
Central Nervous System Diseases
Brain tumors and masses inside of the skull such as subdural hematomas (bleeding under the dural sack that surrounds the brain). Masses, especially in the frontal and temporal areas, can grow for years and cause psychiatric symptoms before any focal neurological abnormality is apparent.
Complex partial seizures: ictal-repetitive behaviors during the seizure, interictal-personality changes between seizures, increased labiality of emotions, quick to anger, increased preoccupation with religion, hypergraphia (increased writing).
Medications can cause depressive symptoms
Antihypertensive medications (drugs used to control high blood pressure): reserpine and alpha-methyldopa are probably the worst, but propranolol has been implicated and all antihypertensives are suspect.
Digitalis preparations, along with a variety of other cardiac medications.
Cimetidine: used for gastric ulcer disease
Indomethacin and other non-steroidal anti-inflammatory medications.
Disulfuram (Antabuse): usually described by patients as more a sense of fatigue than true depression
Antipsychotic medications: can cause an akinesia or inhibition of spontaneity that can both feel and look like a true depression
Anxiolytics: all sedative hypnotics from the barbiturates to the benzodiazepines have been implicated both in causing depression and making it worse in susceptible individuals
Steroids, including prednisone and cortisone
Drugs of abuse can cause depressive symptoms
Alcohol: very commonly a cause of depression, as well as a reaction to depression.
This list is taken from a paper by Dr. Ronald Diamond and should not substitute for consultation with a doctor.