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The New Therapist
with Anthony D. Smith, LMHC

Improving Diagnostic Accuracy: Medical Mimicry, Part 2

In part 1 of Medical Mimicry, readers were reminded about how psychiatric symptoms can be brought on by general medical conditions, requiring physician intervention. Now, in Part 2, let’s turn our attention to the evaluation process.

Many people are referred to psychotherapy by their primary care physician (PCP) because they have a clean bill of physical health and their anxiety, mood, sleep problems, etc. are deemed psychological. Barring this “pre-evaluation,” while we are not physicians, it is not difficult to ascertain if current psychological symptoms may be influenced by a medical complication and need referral for medical assessment. To do this, we must remember three important items. In the remaining space of today’s post we’ll observe the simpler, first two:

Ask if the person has a history of any medical complications. If so, did their  psychological/behavioral symptoms coincide with the development of the medical problem?

The case of Penny:

Penny met with her therapist, Dr. H., for an initial evaluation. She complained, “This may sound weird, but I’ve been feeling displaced from my body, and that everything isn’t quite real even though I know it is.” She said it’s been happening for the past several months. Dr. H knew that Penny was describing depersonalization, a form of dissociative disorders. Knowing that dissociation symptoms are usually associated with trauma or drug abuse, Dr. H. asked Penny about these matters, which she denied any history of. While taking her medical history, Dr. H.  discovered Penny experienced significant headaches for two years, which had worsened the past six months. She had not met with a physician because she was afraid she would be instructed to take pain killers. Paying attention that Penny’s depersonalization symptom onset coincided with the worsening headaches, Dr. H. referred Penny to a neurologist, who diagnosed her with migrianes and confirmed her psychiatric symptoms were due to this. 

It is not unusual for patients with neurological conditions like migraines and seizures to experience dissociation symptoms and perceptual disturbances like hallucinations. Chances are, in a case like Penny’s, care from a neurologist would be helpful in reducing the headaches and thus the depersonalization. Psychotherapy may indeed still be required to help Penny cope with living with migraines, and learning to lower stress in her life, given it is often correlated with migraines.

Is there a lack of personal or family history of psychological problems similar to the patient’s complaints, and no recent psycho-social stressor that may have influenced the symptoms?

The case of Alex:

Alex, a 20-year-old sophomore university student with no psychiatric history, presented for treatment of depression that settled in over the past couple of weeks. He told his therapist, Annie, “Life is good, I don’t get why I’m feeling this way.” Reassuring Alex it could be just a phase, Annie set to work providing Alex with coping skills and CBT homework. When Alex returned the next week, Annie noticed an alarming increase in Alex’s fatigue, irritability, loss of appetite and concentration problems. After reviewing the case with a supervisor, Annie encouraged Alex to visit to the university health center, where a physician’s assistant ordered some blood work.  Alex discovered he was positive for Lyme Disease- not something likely to change with psychotherapy. After initiating antibiotics, Annie noticed that Alex’s depressive fog began to lift, and he resumed his usual “life is good” demeanor.

Many medical conditions can present what at first appears to be psychologically-driven depression. Lyme Disease is indeed a culprit. Alex’s mental health diagnosis would be documented: Depressive Disorder Due to Lyme Disease, with Major Depressive-like features. Readers are invited to see pages 180-181 of the DSM 5 regarding other particulars about diagnosing depression Due to Another Medical Condition. Bear in mind many disorder categories have Due to Another Medical Condition, each with their own particulars.

Other medical conditions commonly masquerading as depression are hypothyroidism (slow thyroid), chronic fatigue syndrome, low iron, and sleep apnea. Psych Central harbors numerous helpful articles and posts on the sleep apnea:mental health connection such as Dr. Rick Nauert’s 2018 post. People with sleep apnea may think they’ve slept all night, but the sleep is restless given the tossing and turning as they choke themselves awake. Consequently, they feel tired, can’t concentrate, are unmotivated and irritable, just like depression can present. This is also a good reminder of why we should try to get family member input. Most spouses/partners are happy to complain about their nocturnally-loud other half!

In Part 3 of Medical Mimicry, we’ll examine the third clue: unusual symptom presentations.

References:

Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.

Improving Diagnostic Accuracy: Medical Mimicry, Part 2


Anthony Smith, LMHC

Anthony Smith is a licensed mental health counselor in Massachusetts with 20 years of experience. He has worked in facilities and in private practice performing therapy and diagnostic evaluations across a wide array of populations both demographically and clinically. This includes 17 years in the forensic arena, where he currently provides assessments for the juvenile courts. Aside from interest in the intersection of psychology and law, Anthony is particularly in interested differential diagnosis and supervision of new practitioners. He regularly teaches abnormal psychology and creates courses on the lived experience of people with mental illness, along with supervising graduate student counselling practicums at a local university. When not providing clinical services, teaching or blogging, Anthony can be found hiking and fly-fishing around the Northeast and American West.

 


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APA Reference
Smith, A. (2020). Improving Diagnostic Accuracy: Medical Mimicry, Part 2. Psych Central. Retrieved on September 18, 2020, from https://pro.psychcentral.com/new-therapist/2020/06/improving-diagnostic-accuracy-medical-mimicry-part-2/