It’s been said that the ancient Greeks believed that central to having a sound mind was having a sound body. They were correct. We are one integrated organism, not a random collection of parts. What affects the body affects the mind.
When interviewing a new patient, I always look first at whether there is a physical condition that is either the cause or a contributing factor to the mental distress. No, I’m not a medical doctor. But over the years, I’ve learned about apparent mental health symptoms that can have a physiological basis. When in doubt, I always refer the patient to their physician for a check before suggesting a treatment plan for what looks like a mental health issue.
An example I regularly use when teaching is a woman who reported to me that her mother, who cared for her three children (all under age 5) during the day, had started to talk about the possibility that the children were possessed by the devil. The client came to me to talk about her frustration that she couldn’t talk her mother out of her worry. As she presented details, I became more and more concerned. This incident is the kind of story that sometimes shows up in the news with a tragic ending. Kids have been murdered by people who loved them in order to “save” them from Satan.
I sympathized with the prospective patient’s frustration with her mom but told her that our first concern was to keep her children safe. In no uncertain terms was she to leave the kids with her mother until she took her mother to see her doctor for a complete physical exam.
The client did as asked and called me a few weeks later to tell me that the doctor found that her mother had a serious B12 deficiency. Two B12 injections and her mother was back to her rational, caring self with no thoughts about the devil or of hurting the children. Whew!
Researchers estimate that about 10% of people who go to outpatient therapists with psychiatric symptoms have an undiagnosed or under-treated medical condition. Ten percent may not sound like enough to be concerned about – unless your patient is one of the 10%! A client who is suffering from an undiagnosed thyroid condition or a brain tumor isn’t going to respond to our best efforts at providing therapy. Meanwhile, the condition may well get worse.
As therapists, then, it’s critical that we broaden our thinking from our psychological theories to consideration of the fact that sometimes an issue isn’t all “in someone’s head.” Sometimes the mind is responding to something that has its start in the body.
Here are a few common examples:
Anxiety may be caused by:
Ø Cardiac arrhythmia
Ø Mitral stenosis
Ø Myasthenia gravis
Ø Ovarian cancer
Ø Pheochromocytoma (a tumor that secretes epinephrine) may cause panic attacks
Ø Pulmonary edema
Ø Thyroid problems
Depression may be caused by:
Ø Brain Tumor
Ø Electrolyte Imbalance
Ø Seizure Disorder
Ø Thyroid Problems
Ø TIAs (mini strokes)
Ø Urinary Tract Infections
Ø Vitamin Deficiency
Delusions may be caused by:
Ø Cerebral tumor
Ø Congestive heart failure
Ø Electrolyte Imbalance
Ø Vitamin Deficiency
These are not intended to be all –inclusive lists. They are just to give you an idea of the impact of medical issues on mental health.
According to Dr. Ronald Diamond (see reference below), the following factors make it more likely that an individual has an undiagnosed medical condition. This list is not intended to be all-inclusive either, but only to sensitize you to issues that we should always consider during intake.
Ø a patient over 40 with no previous psychiatric history
Ø no history of similar symptoms
Ø coexistence of chronic disease
Ø a history of head injury
Ø a change in headache pattern
Ø a client who got worse when given antipsychotic or anxiolytic medications
It’s also true that just because someone comes to us with a prior psychiatric diagnosis doesn’t mean that they can’t be sick too. People with bipolar disorder or schizophrenia whose treatment isn’t going well may be also suffering from a medical issue. When someone comes to therapy with a history of mental illness but also a change in behavior or mood, it’s important to consider whether that change is because of a medical problem.
Some Reading Suggestions
Do educate yourself about the interface between the psychological and the physical. A place to start is with some reading.
One excellent book on the subject is When Psychological Problems Mask Medical Disorders: A Guide for Psychotherapists by James Morrison (Guilford Press, 1999). The author explains 60 different physical/medical conditions that can cause apparent mental disorders.
A more recent book is Treatments for Medically Caused Anxiety and Depression: Treating Health Conditions that Cause Mood Disorders by James Lowrance (CreateSpace Independent Publishing Platform, 2012).
In addition, there is an excellent article on the internet: Psychiatric Presentations of Medical Illness: An Introduction for Non-Medical Mental Health Professionals by Ronald J Diamond M.D. http://www.alternativementalhealth.com/psychiatric-presentations-of-medical-illness/
If you prefer to get your information by video: Dr. Dan Tomasulo and I put several clips on this subject on the PsychCentral Youtube Channel: https://www.youtube.com/user/PsychCentral
If we don’t look, we won’t find an undertreated or undiagnosed medical condition. It’s our responsibility to always consider the possibility of a physical issue while doing our intakes.