MMD8386 - Differential Diagnosis: Identifying Common Medical Conditions Frequently Misdiagnosed as Mental Health Problems
DIFFERENTIAL DIAGNOSIS: IDENTIFYING COMMON MEDICAL CONDITIONS FREQUENTLY MISDIAGNOSED AS MENTAL HEALTH PROBLEMS
by Barbara Gulesserian, MS, APRN, BC
Barbara Gulesserian is a Clinical Nurse Specialist with twenty years of experience providing therapy to adults in clinical practice. Ms. Gulesserian has performed psychotherapy in group, individual and corporate settings, and is a Certified Group Psychotherapist and Certified Clinical Hypnotherapist.
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The objectives of this course are to provide the trainee with an overview guide to common medical conditions that are frequently misdiagnosed as mental health problems. When the trainee completes this course, he or she will:
- Understand the assessment process for identifying clients with medical illnesses that appear as mental health symptoms
- Identify depression or anxiety indicating medical illness
- Understand the bio-physiologic mechanisms of depression and anxiety caused by medical illness
- Know the biochemical mechanisms of co-morbidity
- Comprehend the psychological mechanisms of co-morbidity
- Learn frequently encountered physical illnesses co-morbid with depression
- Know common drugs and medications causing depression/anxiety
This intermediate level course is primarily designed for clinicians in the middle stages of their career, or for clinicians reviewing basic concepts in this treatment area.
4 contact hours: Core clinical
Section One: Introduction
Section Two: Introductory Overview of Physical Systems
Section Three: Medical Illness
Section Four: Depression/Anxiety Accompanying Medical Illness Co-morbid
Section Five: Depression/Anxiety Caused by Drugs and Medications
Section Six: Depression/Anxiety Accompanying other Mental Illnesses
Section Seven: Assessment of the Client with Medical Illness
Section Eight: How to Discuss Possible Medical Problems with a Mental Health Client
Section Nine: Printable Table of Medical Conditions and Symptoms They Produce
Section Ten: Scenario for Analysis
References and Test
Scenario for Analysis
Gloria P. is a 26 year-old, single white female who has come to the emergency room. She reports that she fears she is having a heart attack. Gloria states that she began to feel “awful” when dressing for work this morning -- like she may be having a heart attack and dying. When the physician asks for details, she describes her symptoms as shortness of breath, rapid heart rate, chest pains, sweating, shaking, nauseous, and fear that she is going to die. She says that she was so frightened that she asked her family to bring her to the ER. She also explains that she has had three of these “attacks” in the past month, but never before the last month and now she is really worried. She tells the physician that she does not understand what is happening to her and feels very scared. Gloria also explains that she is going through a break-up with her boyfriend and has been very upset. She tells the physician that she works full-time and also attends college, but that she has not been concentrating very well lately. She describes a lifestyle of healthy eating, intense exercise, and a drive to be successful. She reports that she tries to live up to her and her family’s expectations for success, which she admits is sometimes hard.
What are other important assessment questions for Gloria from a biological, psychological and social perspective?
What possible medical conditions or concerns would you need to rule out?
What additional referrals would you need to consider to rule out possible medical explanations for the signs and symptoms that are being presented?
Section One: Introduction
Roughly ten percent of the population of the United States experiences depression each year. (10) Twenty to sixty percent of patients with somatic (physical) disorders experience secondary depression and anxiety. (15) Treatment can alleviate symptoms in over 80% of those experiencing symptoms of depression, but this diagnosis often goes unrecognized. Of the many afflicted with depression yearly, research indicates that nearly two-thirds do not get the help they need. (9)
Since depression is one of the most common psychiatric disorders, many people believe that if they ignore the depression, it will disappear. Many do not seek help until they have prolonged symptoms of decreased or increased appetite, insomnia or hypersomnia (too much sleep), anhedonia (loss of pleasure), either agitation or fatigue, poor concentration and memory difficulties.
The physical symptoms may first come to the attention of the client's primary care physician and may be treated as physical illnesses. Because of their training and their immersion in their specialty areas, physicians may be inclined to assess the symptoms according their own specialty training. In looking for what they know best, it may create a particular form of perceptual bias. Physicians may be a little more likely to find physical symptoms where none exist, and be a little less inclined to consider that the patient's distress may be the result of their mental or emotional state.
However, if these same symptoms present to the mental health practitioner, it is likely that depression will be diagnosed. Mental health clinicians may face a different sort of perceptual bias. They may be more inclined to take the patient "where they are at", looking for the psychological or emotional problems first.
The relevance for mental health clinicians lies in understanding that there is a population of patients who seek help from a mental health practitioner for anxiety, depression or other emotional problems when the underlying problem is actually a medical or physical illness. These patients will then be dependent upon the skill and knowledge of the mental health clinician in looking below the surface of the presenting problems in order to discern the presence of an ailment that will require more extensive interventions than counseling.
Physicians who are general practitioners have at their disposal numerous articles and guidelines to help heighten their awareness of mental health symptoms and diagnoses - even when their patients identify their problems as medical complaints. In this regard, generalists have a broader based perspective where patients seek help for physical complaints when the true problem is psychological or emotional in nature, or vice versa.
Mental health clinicians are well advised to keep their own reminders in this area. If mental health clinicians encounter deepening signs of depressive illness, a diagnosis made too quickly or too facilely may miss potential physical causes for the depression.
Depressive symptoms are often the initial symptoms of some physical diseases, the aftermath of trauma, or side effects from prescribed medications. When the medical illness goes untreated, psychiatric treatment only addresses the symptoms – leaving untreated potentially severe and life-threatening medical problems.
For instance, research has found that biologic relationships exist between malignancies (cancers) and depressive syndromes. Depressive symptoms are associated with cancer in up to 50% of cases. On many occasions the onset of depression is the first indication of undetected carcinoma (cancer). The depressions exhibited by the patient range from adjustment disorder with depressed mood to major depression. (8)
The responsibility here lies in conducting a thorough enough assessment to direct the patient to the kind and level of resources that will best target the real problems. Whereas all physicians receive at least a rudimentary introduction to mental health problems, most mental health clinicians are largely untrained and unskilled in looking for the signs and symptoms that could be indicative of underlying physical illnesses.
This is a period in history when millions of Americans are without insurance and forego necessary preventive medical care. Clients can present for a counseling session through their Employee Assistance Program or at a low-cost mental health center as their first point of entry into the medical system. This means that even a beginning mental health clinician can be placed in the position of needing to be attuned to signs that suggest a more serious medical problem.
The author of this training has been particularly impressed by several poignant examples of lifesaving referrals from mental health professionals to medical specialists. Some particularly powerful examples were:
- A severely depressed woman was admitted to a psychiatric unit in a medical hospital for severe headaches that her primary care physician ruled to be psychosomatic. Fortunately, the team quickly sought another opinion and her malignant brain tumor was treated surgically with success.
- That same team facilitated the successful differential medical diagnosis of an older depressed gentleman who had decreased appetite and fatigue. He had stomach cancer.
- A Nurse Clinical Specialist in Psych/Mental Health cautioned a friend to seek medical help rather than an antidepressant for the hopelessness she was feeling in her pain management treatment. Her back pain had persisted and she had a cracked rib. As the nurse suspected, her diagnosis was Multiple Myeloma, a malignant cancer of the plasma cells and bone marrow which ultimately took her life.
In some cases, the depressive symptoms are caused by the frustration, discomfort and hopelessness these patients experience secondary to their physical symptoms. There may be reluctance - a kind of denial process - among some practitioners to diagnosis severe and terminal illnesses. It is, therefore, the role of all healthcare professionals to be cognizant of such possibilities.
Moreover, many illnesses exist together. When two or more medical conditions present simultaneously, they are said to be co-morbid. (10)
What often prevents adequate diagnosis from either medical or mental health practitioners is incomplete information. Depression - and medical or other psychiatric illnesses - may be linked biologically, psychologically - or may appear to be entirely unrelated. For this reason, a thorough assessment is one that considers the presence of physical illness or other physiological factors, in addition to the presence of a mental or emotional disorder.
To provide a foundation for thorough assessment of your clients, this training will look at:
- Depression/anxiety caused by - or indicating - medical illness
- Depression/anxiety accompanying medical illness (co-morbid)
- Depression/anxiety caused by drugs and medications
- Depression/anxiety accompanying other mental illnesses (co-morbid)
This training program is designed to support the mental health clinician's work in this area. In this program, we will look at some physical illnesses that may – at first glance - look to mental health practitioners and others as depression and/or anxiety. In some of these diseases, the primary cause for the emotional distress is physical or biochemical in nature. Therefore, when the physical illness is treated - in many cases - the mental or emotional symptoms are relieved.
Please note that this training is not intended to provide the clinician with the skills needed to make a medical diagnosis on their own, thereby operating beyond their areas of competence. It is rather intended to alert the clinician to a number of indicators that would suggest the need for referring clients to appropriate medical resources.
Knowing that physical and medical conditions can create changes in mood, affect, or anxiety levels allows the clinician to work collaboratively with the client to gather more complete information about the client's overall medical and mental health needs. Simultaneously, the clinician can alert the client to the possibility of medical conditions that may underlie their problems, and advocate for better medical care.
Without at least some rudimentary knowledge of what medical problems to look for, the clinician lacks the professional authority to make a case for the client to seek out medical treatment. Conversely, armed with some knowledge of potential medical problems, the clinician will find it easier to address resistance or reluctance on the part of the client to seek medical care. This make the clinician a better advocate for the total well-being of their clients.
A final vignette to highlight the relevance of this area of practice. A number of years ago, a woman in her thirties began treatment for a variety of personal and family issues with a colleague of your instructor. During the history gathering, it was apparent that there were many family of origin concerns relating to trauma and loss that the woman had never discussed.
Following the second session, an emergency call was received from the client, who reported a great deal of anxiety and depression. A crisis intervention was utilized to calm the client at the time. During that call, her experience was normalized, and an insight oriented intervention was utilized. The purpose of the intervention was to help her see the connection between the opening up of painful emotional material for the first time and the emergence of her panic and mood symptoms.
A few days later, a follow-up call was made to check on the client. At that time, the client reported that she realized on the night she reported her emergency symptoms, she had been coming down with the flu. Once her flu symptoms had subsided, the panic and depression had disappeared. She reported that it had not been upsetting to talk about her family issues during the assessment or subsequently. In fact, in retrospect she had found the attempts to tie together the family of origin material and her symptoms somewhat amusing. She noted that she and her husband had had a good laugh about the "psychological stuff."
Humbled and chastened, the clinician made a mental note to remember the importance of not making quick assumptions in the heat of crisis moments. Good assessment involves looking at the total broad picture, not what is in one's limited area of expertise and knowledge. What the first view indicates may not be what is really at the core of the problem.
Towards this end, we offer this course to help fellow clinicians in their quest to provide good and thorough services. On a purely practical note, we will present specific aspects to consider in making an accurate assessment. We will also include a printable list of a variety of medical problems - and the mental health problems they can create - as we conclude this training.
Finally, in this 21st century, East meets West in the mind/body controversy. No longer separated and distinct, they are inexorably entwined affecting health as well as illness.