"
"
Virtually every medical student has been taught, “When you
hear hoofbeats, don’t expect to see a zebra,” a phrase coined by
Dr. Theodore Woodward in the late 1940s (Soto 1991). The gist is
that when a physician sees symptoms, he should consider
routine diagnoses, not exotic ones.
Psychiatrists are often taught the same phrase regarding
psychiatric symptoms that are created by non-psychiatric
medical disorders—that although they exist, these conditions
are, in fact, rare and unlikely. Unfortunately, this line of
thinking has caused many serious medical conditions to go
undiagnosed. Factually, physically-created mental and
behavioral symptoms are not uncommon and certainly not as
rare as a zebra running wild in the Western Hemisphere.
From 5–40% of psychiatric patients are found to have medical
ailments that would adequately explain their symptoms (Allen
1995). Additionally, up to 25% of mental health patients are
found to have medical conditions that exacerbate psychiatric
symptoms (Christensen 2009).
In older patients with first-time psychiatric symptoms, the
likelihood of underlying physical contributors is even greater. In
a Danish study of cancer rates in first-time psychiatric patients,
lead author Michael E. Benros remarked, “The overall cancer
incidence was highest in persons older than 50 years of age
admitted with a first-time mood disorder, where 1 out of 54
patients would have a malignant cancer diagnosed within the
first year.” The overall incidence of cancer was increased almost
4-fold and the incidence of brain tumors was increased 37 times.
He concluded: “Our study illustrates the importance of making a
thorough physical examination of patients with first-time
psychiatric symptoms.” (Benros 2009) (Nelson 2009)
Despite the commonality of psychiatric symptoms that are
created by non-psychiatric medical disorders, the subject is
rarely given the vigilance it deserves. A text on the topic did not
even exist in the Americas until 1967 when Dr. Sydney Walker
wrote Psychiatric Signs and Symptoms Due to Medical Problems
(Walker 1967). A survey carried out in 2001 by the nonprofit Safe
Harbor (of which the author is president) found that the 100,000
outpatients seen annually by the Los Angeles County Department
of Mental Health were routinely not given medical exams.
One reason for this oversight is because diagnoses such as
schizophrenia, bipolar disorder, and even major depression are
often thought of as discrete disease entities, when in fact, they
are not. They are syndromes of generally unknown etiology.
Because the causes of these syndromes have evaded
investigators for centuries, there is a tendency to consider the
etiology as unknowable, when, through a thorough medical
exam and differential diagnosis, the possibility exists that the
causes of even the worst psychiatric manifestations may be
determined and may even be completely treatable.
Further, it has become customary to treat psychiatric
symptoms pharmaceutically, without considering the cause.
Additionally, once a patient has been labeled with a psychiatric
disorder, there is a tendency on the part of doctors and hospital
staff to not look further. Lastly, a psychiatric patient may be
unable or unmotivated to voice physical complaints.
Thus, while it may not seem like a CAM treatment, the
searching medical exam is an often-overlooked but fruitful
option that can result in dramatically increased patient wellness
and reduction or elimination of the need for medication.
Failure to identify one or more medical conditions that are
causing or exacerbating mental symptoms may result in:
− A continuation or worsening of psychiatric symptoms.
− Prolongation or worsening of physical illness.
− Failure to respond to treatment.
− Unnecessary use of psychiatric medication, possibly for life.
− A patient falsely believing he/she has a purely psychiatric
condition.
− Early death.
Signs That Mental Symptoms Have a Medical
Cause
Numerous signals exist that indicate medically-caused
psychiatric symptoms (Koran 1991):
1. The mental disorder is a first episode.
2. The mental symptoms occur in a patient who is:
a. Aged 40 or more.
b. Currently ill with a major medical illness.
c. Taking prescribed or over-the-counter medications that
can cause mental symptoms.
d. Experiencing neurological symptoms such as unilateral
weakness, numbness, paresthesias, clumsiness, gait
problems, headaches of increasing severity, vertigo,
visual symptoms, speech or memory difficulties, loss of
consciousness, or emotional lability.
e. Experiencing weight loss (10% or more of baseline
weight), unusual diet (e.g., complete vegetarianism) or
self-neglect that could cause vitamin-B deficiencies.
f. Not experiencing serious life stress.
3. The patient has a past history of:
a. A physical illness that can impair organ function
(neurologic, endocrine, renal, hepatic, cardiac, or
pulmonary).
b. Recent falls or head trauma with unconsciousness.
c. Alcohol or drug abuse.
d. Taking several over-the-counter drugs.
4. The patient has a family history of:
a. Inheritable metabolic disease (diabetes, porphyria).
b. Degenerative or inheritable brain disease.
5. Certain mental signs are present:
a. Altered level of consciousness.
b. Fluctuating mental status.
c. Any cognitive impairment.
d. Visual, tactile or olfactory hallucinations.
e. Episodic, recurrent, or cyclical symptoms interspersed
with periods of being well.
6. Certain physical signs are present:
a. Signs of major organ impairment, e.g., ascites, edema.
b. Any focal neurological deficit.
c. Diffuse subcortical dysfunction, e.g., slowed speech,
mentation or movement, dysarthria, ataxia,
incoordination, tremor, chorea, asterixis.
d. Cortical dysfunction, e.g., dysphasia, apraxia, agnosia,
visiospatial deficits, defective cortical sensation.
7. Response to appropriate psychiatric treatment is poor.
(Rethink the diagnosis, re-examine the patient, and
consider seeking the advice of a consultant.)
Additionally, the following are reported characteristics of
patients with physically-caused psychiatric symptoms (Hall
1980):
− A history of anxiety or unusual behavior present since
childhood or adolescence.
− The patient evidences a multiplicity of symptoms that
involve several organ systems.
− The patient evidences unusual symptoms that are difficult
for the physician to deal with.
− A history of atypical response or failure to respond to
treatment.
− A history of doctor shopping.
− A failure to carry out the physician’s recommendations.
− The absence of concern (in the patient) in the face of serious
complaints.
− Symptom onset concomitant with, or exacerbated by,
particular people or stressful life events.
− Apparent secondary gain (i.e., disease allows him/her to
miss work, gain sympathy, etc.) resulting from physical
symptomatology.
The following symptoms indicate that medical illness is more
likely (Diamond 2007):
− A change in headache pattern.
− Visual disturbances (e.g., 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, such as blood pressure, pulse,
temperature.
− Disorientation or memory impairment.
− Fluctuating or impaired level of consciousness.
− Abnormal body movements.
− Frequent urination, increased thirst (possibly symptoms of
diabetes).
− Significant weight change, gain or loss.
Conditions That Cause Psychiatric Symptoms
Medical conditions can cause symptoms that mimic any
psychiatric diagnosis. The most common psychiatric
complaints—psychosis, anxiety, and depression—are known to
be created by a host of physical ailments. (For a full list of these
conditions, see the Appendix, page 102.)
Psychosis, characterized by hallucinations, delusions, and/or a
general loss of contact with reality, can be generated by many
conditions that impact cerebral function. Brain injuries or
growths, neurological infections, drug reactions, and severe
endocrine disorders are just some of the medical issues that may
be indicated.
Anxiety is a state of nervousness, fearfulness, tension, and/or
worry. These disturbances can be brought on by conditions such
as cardiopulmonary problems, toxic conditions, hypoglycemia,
and a broad range of legal and illegal drugs.
Depression can include an array of symptoms such as sadness,
low self-esteem, lethargy, and apathy. Yet the person may
actually be impacted by any of an extensive list of ailments,
including hormonal problems, viruses, cancer, heart issues, and
side effects of medications.
Commonly Overlooked Medical Maladies
A number of common medical issues associated with psychiatric
sequelae are frequently overlooked. These include head injuries,
thyroid issues, sleep disorders, and low cholesterol levels.
Head Injuries
Failure to inquire about a history of head injury or events that
could involve head injury (such as sports and auto accidents)
could result in an undiagnosed risk factor for psychiatric
symptoms. In reviewing 164 patients a year after a traumatic
brain injury (TBI), Deb et al found they were 7 times more likely
to have depression than the general population. They were 11
times more likely to have panic disorder (Deb 1999).
Typical neuropsychiatric symptoms following TBI include
posttraumatic amnesia, cognitive disorders and dementia,
posttraumatic epilepsy, aphasia, depression, mania, psychosis,
anxiety disorders, personality changes, aggression, behavioral
dyscontrol, fatigue/apathy, and increased risk of suicide (Reeves
2011).
Even up to five years after non-impact brain injury (whiplash),
patients have been frequently found (greater than norms) to
have cognitive deficits—primarily in the area of executive
functioning—and problems with behavioral control, sleep, and
sexuality (Henry 2000).
In addition to mainstream medical procedures, CAM
treatments for mild to severe TBI include acupuncture,
chiropractic, neural therapy, and EEG biofeedback. Hyperbaric
oxygen (HBO) treatment has been found to be effective for post-
TBI mental symptoms. A Chinese research team reported: “After
two courses of HBO treatment, 252 previously positive [TBI]
patients were examined again by SPECT. The results revealed
that 92 patients still had abnormal scans but 160 were now
normal.... The results of our study showed the distinctive
beneficial effect of HBO in neuropsychiatric disorders after TBI
and that SPECT images were far superior to CT scan in evaluating
the effect of HBO and neuropsychiatric disorders after TBI.” (Shi
2006)
Thyroid Issues
The thyroid gland regulates, among other things, metabolism
and the rate of energy usage in the body. Psychiatric symptoms
of hyperthyroidism include:
− Generalized anxiety
− Depression
− Irritability
− Hypomania
− Cognitive dysfunction
− Mania (in severe hyperthyroidism—thyrotoxicosis, “thyroid
storm”)
Mental symptoms of hypothyroidism include:
− Depression
− Cognitive dysfunction
− Psychosis (in severe hypothyroidism—“myxedema
madness”)
Subclinical hypothyroidism is a condition in which TSH
(thyroid stimulating hormone) is elevated, but T4 is low or
normal and the patient has few or no symptoms. Psychiatric
symptoms include:
− Depression
− Rapid cycling in bipolar disorder (a common cause)
− Subtle signs of cognitive dysfunction (Levenson 2006)
Thyroid irregularities are not only common but many people
don’t know they have them. Even those being treated for them
frequently show lab signs of thyroid hormones that are above or
below the norm:
− 9.5% of the public have elevated TSH levels—indicative of
hypothyroidism—including some who are being treated for
it.
− 2.2% of the public have subnormal TSH levels, including
some who are being treated for it.
− 40% of patients taking thyroid medications have abnormal
TSH levels.
− Symptoms are reported more often in hypothyroid vs.
euthyroid individuals (Canaris 2000).
Amongst bipolar patients in the depressive phase, two-thirds
are found to have TSH in the high normal range and a lownormal
free thyroid index (FTI). These individuals have been
found to recover significantly more slowly than those with
optimum thyroid profiles—an average of one year versus eight
months (Cole 2002).
Given that nearly 10% of the population has hypothyroidism
and that this condition, due to its mental and behavioral
manifestations, is overrepresented amongst psychiatric patients,
the diagnosis of subclinical or clinical hypothyroidism must be
considered in every patient with depression. This is particularly
critical in settings, such as outpatient clinics and non-MD
therapist offices where medical exams and lab testing are less
likely to occur.
Hyperthyroidism, though less common, should also be
suspected when a patient presents with chronic anxiety,
irritability, and other symptoms of this condition.
Sleep Disorders
One of the critical elements of good mental and physical health
is sufficient, quality sleep, as is discussed in detail in Chapter
Three. Common hidden parasites on sound sleep are obstructive
sleep apnea (OSA), restless leg syndrome, and other sleep
disorders.
OSA is characterized by heavy snoring and a continuous
disruption of breathing during slumber resulting in poor sleep
quality. Psychiatric symptoms include:
− Poor memory and concentration
− Changes in personality
− Depression (Schwartz 2007)
The American College of Physicians claims OSA:
− Occurs in about 4–9% of middle-aged men.
− Occurs in about 2–4% of middle-aged women.
− Goes undiagnosed in about 80–90% of those who have it.
Given that obesity is one of the most common contributors to
OSA, and that obesity is a common side effect of psychiatric
medication, OSA is not only likely overrepresented in psychiatric
populations, but may exacerbate existing psychiatric conditions,
thus retarding or preventing recovery for some.
OSA is simple to diagnose through a sleep study and is
considered highly treatable through lifestyle changes, weight
loss, avoidance of evening alcohol, and/or use of a CPAP
(Continuous Positive Airway Pressure) device (American College
2011). CPAP therapy is associated with sustained long-term relief
from the symptoms of depression for patients with OSA
(Schwartz 2007).
Low Cholesterol
Low serum cholesterol—defined as 160 mg/dL (4.5 mmol/liter)
or lower—appears with regularity on blood test results, yet may
be overlooked as a contributing factor for anxiety or depression.
Amongst other tasks, cholesterol is needed to modulate
serotonin transporter activity in cellular membranes (Scanlon
2001).
Low cholesterol, which can occur naturally regardless of diet or
lifestyle, has been linked to violent death (e.g., suicide and
accidents). Men with chronically low cholesterol levels show
consistently higher risk of having depressive symptoms
(Steegmans 2000). In healthy young adult women, low
cholesterol is inversely associated with trait measures of
depression and anxiety (Suarez 1999).
Common CAM treatments for low cholesterol include
increasing dietary intake and cholesterol supplements such as
those found at http://soniccholesterol.com.
The Koran Algorithm
The problem of overlooked medical ailments in psychiatric
populations is so significant that in 1988 the California
legislature debated and passed Assembly Bill 1877, which
mandated an exploration into a means of reducing the risk of
missed medical conditions. Lorrin Koran, MD, of Stanford
University was tasked with leading the development of a
corrective procedure. The results of his team’s work were
reported to the California Department of Mental Health and local
mental health programs in 1991 as the Medical Evaluation Field
Manual (available at http://goo.gl/kXIuS).
In laying the groundwork for the report, Koran reviewed a
study of medical exams performed in county mental health
programs, which has been carried out by order of the state
legislature (Senate Bill [SB] 929). They found:
− Nearly two out of five patients (39%) had an active,
important physical disease.
− The mental health system had failed to detect these diseases
in nearly half (47.5%) of the affected patients.
− Of all the patients examined, one in six had a physical
disease that was related to his or her mental disorder, either
causing or exacerbating that disorder.
− The mental health system had failed to detect one in six
physical diseases that were causing a patient’s mental
disorder.
As a cost-effective measure to reduce these diagnostic errors,
Koran and his associates developed an algorithm—a step-by-step
procedure—to efficiently narrow down the likelihood of medical
disease in psychiatric patients. While the algorithm does not
replace a full, searching medical exam, it may be an appropriate
choice where funds, time, or patient access are limited. It may
also be an appealing alternative for current mental health
programs that offer no exam at all.
The algorithm is presented in Figure 2-1 exactly as originally
presented in the 1991 report. Some of these procedures may not
reflect developments in lab testing since the Field Manual was
written, but the fundamentals remain the same and adaptations
to current practices are simple enough.
Initial algorithm steps:
1. Ask the patient to complete a 10-item Medical History
Checklist, assisting the patient as needed:
a. Have you ever had:
i. Fits, convulsions or epilepsy?
ii. Emphysema?
iii. Diabetes?
iv. Asthma?
v. High blood pressure?
vi. Thyroid disease?
b. Have any of the following symptoms been very
noticeable or worrisome to you in the past two months?
i. Have you noticed blood or pus in your urine?
ii. Have you noticed pain in your chest when resting?
iii. Have you had headaches associated with vomiting?
iv. Have you had loss of control of urine or bowels?
2. Obtain a sitting blood pressure measurement.
3. Have patient provide a urine sample.
4. Draw the blood specimens for the laboratory battery.
5. Get a lab panel of:
a. A hematocrit
b. White blood cell count
c. Serum aspartate aminotransferase
d. Serum alanine aminotransferase
e. Serum albumin
f. Serum calcium
g. Serum sodium and potassium
h. Serum cholesterol and triglycerides
i. Serum T4 and free T4
j. Serum vitamin B12
6. Patient’s urine should be examined by dipstick for:
a. Glucose
b. Blood
c. Protein
The results are evaluated against the steps of the algorithm in
Figure 2-1. Per the Field Manual, “Abnormal findings listed in
the earlier steps of the algorithm more strongly predict the
presence of physical disease than those occurring in later steps
and hence more urgently require a physician’s attention. A
patient who has any positive finding from any step in the
algorithm should be referred for further evaluation to a
physician who specializes in internal medicine or family
medicine.”
Summary
Given the fact that a known percentage of psychiatrists’ clients
come to them because of undiscovered and/or untreated medical
problems, it is an irony that, of all medical specialists, the
psychiatrist is among those commonly called upon the least to
exercise clinical medical diagnostic skills. The challenge of
mastering differential diagnosis in psychiatry requires, in truth,
a Holmesian eye for signs and symptoms and an equal intellect
for hazarding the maze of possible risk factors.
Absent this cautious approach, much suffering can occur. Seen
from the eyes of a patient or his or her family, the slow or
sudden decline into psychosis, deep depression, unrelenting
obsessive thought or other severe psychiatric symptoms can be a
nightmare. While a patient or physician may be anxious to
assign a psychiatric diagnosis to the syndrome presented, a
failure to look for and detect a possibly underlying medical cause
or contributing factor could unnecessarily prevent the
alleviation of, extend, or deepen this world of doom the patient
endures.
Properly examined, diagnosed, and treated, the client with a
hidden medical illness may have the good fortune of being
rescued from the dustbin of “nonresponsive to treatment” and
find hope and relief under the watchful eye of his physician.
hear hoofbeats, don’t expect to see a zebra,” a phrase coined by
Dr. Theodore Woodward in the late 1940s (Soto 1991). The gist is
that when a physician sees symptoms, he should consider
routine diagnoses, not exotic ones.
Psychiatrists are often taught the same phrase regarding
psychiatric symptoms that are created by non-psychiatric
medical disorders—that although they exist, these conditions
are, in fact, rare and unlikely. Unfortunately, this line of
thinking has caused many serious medical conditions to go
undiagnosed. Factually, physically-created mental and
behavioral symptoms are not uncommon and certainly not as
rare as a zebra running wild in the Western Hemisphere.
From 5–40% of psychiatric patients are found to have medical
ailments that would adequately explain their symptoms (Allen
1995). Additionally, up to 25% of mental health patients are
found to have medical conditions that exacerbate psychiatric
symptoms (Christensen 2009).
In older patients with first-time psychiatric symptoms, the
likelihood of underlying physical contributors is even greater. In
a Danish study of cancer rates in first-time psychiatric patients,
lead author Michael E. Benros remarked, “The overall cancer
incidence was highest in persons older than 50 years of age
admitted with a first-time mood disorder, where 1 out of 54
patients would have a malignant cancer diagnosed within the
first year.” The overall incidence of cancer was increased almost
4-fold and the incidence of brain tumors was increased 37 times.
He concluded: “Our study illustrates the importance of making a
thorough physical examination of patients with first-time
psychiatric symptoms.” (Benros 2009) (Nelson 2009)
Despite the commonality of psychiatric symptoms that are
created by non-psychiatric medical disorders, the subject is
rarely given the vigilance it deserves. A text on the topic did not
even exist in the Americas until 1967 when Dr. Sydney Walker
wrote Psychiatric Signs and Symptoms Due to Medical Problems
(Walker 1967). A survey carried out in 2001 by the nonprofit Safe
Harbor (of which the author is president) found that the 100,000
outpatients seen annually by the Los Angeles County Department
of Mental Health were routinely not given medical exams.
One reason for this oversight is because diagnoses such as
schizophrenia, bipolar disorder, and even major depression are
often thought of as discrete disease entities, when in fact, they
are not. They are syndromes of generally unknown etiology.
Because the causes of these syndromes have evaded
investigators for centuries, there is a tendency to consider the
etiology as unknowable, when, through a thorough medical
exam and differential diagnosis, the possibility exists that the
causes of even the worst psychiatric manifestations may be
determined and may even be completely treatable.
Further, it has become customary to treat psychiatric
symptoms pharmaceutically, without considering the cause.
Additionally, once a patient has been labeled with a psychiatric
disorder, there is a tendency on the part of doctors and hospital
staff to not look further. Lastly, a psychiatric patient may be
unable or unmotivated to voice physical complaints.
Thus, while it may not seem like a CAM treatment, the
searching medical exam is an often-overlooked but fruitful
option that can result in dramatically increased patient wellness
and reduction or elimination of the need for medication.
Failure to identify one or more medical conditions that are
causing or exacerbating mental symptoms may result in:
− A continuation or worsening of psychiatric symptoms.
− Prolongation or worsening of physical illness.
− Failure to respond to treatment.
− Unnecessary use of psychiatric medication, possibly for life.
− A patient falsely believing he/she has a purely psychiatric
condition.
− Early death.
Signs That Mental Symptoms Have a Medical
Cause
Numerous signals exist that indicate medically-caused
psychiatric symptoms (Koran 1991):
1. The mental disorder is a first episode.
2. The mental symptoms occur in a patient who is:
a. Aged 40 or more.
b. Currently ill with a major medical illness.
c. Taking prescribed or over-the-counter medications that
can cause mental symptoms.
d. Experiencing neurological symptoms such as unilateral
weakness, numbness, paresthesias, clumsiness, gait
problems, headaches of increasing severity, vertigo,
visual symptoms, speech or memory difficulties, loss of
consciousness, or emotional lability.
e. Experiencing weight loss (10% or more of baseline
weight), unusual diet (e.g., complete vegetarianism) or
self-neglect that could cause vitamin-B deficiencies.
f. Not experiencing serious life stress.
3. The patient has a past history of:
a. A physical illness that can impair organ function
(neurologic, endocrine, renal, hepatic, cardiac, or
pulmonary).
b. Recent falls or head trauma with unconsciousness.
c. Alcohol or drug abuse.
d. Taking several over-the-counter drugs.
4. The patient has a family history of:
a. Inheritable metabolic disease (diabetes, porphyria).
b. Degenerative or inheritable brain disease.
5. Certain mental signs are present:
a. Altered level of consciousness.
b. Fluctuating mental status.
c. Any cognitive impairment.
d. Visual, tactile or olfactory hallucinations.
e. Episodic, recurrent, or cyclical symptoms interspersed
with periods of being well.
6. Certain physical signs are present:
a. Signs of major organ impairment, e.g., ascites, edema.
b. Any focal neurological deficit.
c. Diffuse subcortical dysfunction, e.g., slowed speech,
mentation or movement, dysarthria, ataxia,
incoordination, tremor, chorea, asterixis.
d. Cortical dysfunction, e.g., dysphasia, apraxia, agnosia,
visiospatial deficits, defective cortical sensation.
7. Response to appropriate psychiatric treatment is poor.
(Rethink the diagnosis, re-examine the patient, and
consider seeking the advice of a consultant.)
Additionally, the following are reported characteristics of
patients with physically-caused psychiatric symptoms (Hall
1980):
− A history of anxiety or unusual behavior present since
childhood or adolescence.
− The patient evidences a multiplicity of symptoms that
involve several organ systems.
− The patient evidences unusual symptoms that are difficult
for the physician to deal with.
− A history of atypical response or failure to respond to
treatment.
− A history of doctor shopping.
− A failure to carry out the physician’s recommendations.
− The absence of concern (in the patient) in the face of serious
complaints.
− Symptom onset concomitant with, or exacerbated by,
particular people or stressful life events.
− Apparent secondary gain (i.e., disease allows him/her to
miss work, gain sympathy, etc.) resulting from physical
symptomatology.
The following symptoms indicate that medical illness is more
likely (Diamond 2007):
− A change in headache pattern.
− Visual disturbances (e.g., 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, such as blood pressure, pulse,
temperature.
− Disorientation or memory impairment.
− Fluctuating or impaired level of consciousness.
− Abnormal body movements.
− Frequent urination, increased thirst (possibly symptoms of
diabetes).
− Significant weight change, gain or loss.
Conditions That Cause Psychiatric Symptoms
Medical conditions can cause symptoms that mimic any
psychiatric diagnosis. The most common psychiatric
complaints—psychosis, anxiety, and depression—are known to
be created by a host of physical ailments. (For a full list of these
conditions, see the Appendix, page 102.)
Psychosis, characterized by hallucinations, delusions, and/or a
general loss of contact with reality, can be generated by many
conditions that impact cerebral function. Brain injuries or
growths, neurological infections, drug reactions, and severe
endocrine disorders are just some of the medical issues that may
be indicated.
Anxiety is a state of nervousness, fearfulness, tension, and/or
worry. These disturbances can be brought on by conditions such
as cardiopulmonary problems, toxic conditions, hypoglycemia,
and a broad range of legal and illegal drugs.
Depression can include an array of symptoms such as sadness,
low self-esteem, lethargy, and apathy. Yet the person may
actually be impacted by any of an extensive list of ailments,
including hormonal problems, viruses, cancer, heart issues, and
side effects of medications.
Commonly Overlooked Medical Maladies
A number of common medical issues associated with psychiatric
sequelae are frequently overlooked. These include head injuries,
thyroid issues, sleep disorders, and low cholesterol levels.
Head Injuries
Failure to inquire about a history of head injury or events that
could involve head injury (such as sports and auto accidents)
could result in an undiagnosed risk factor for psychiatric
symptoms. In reviewing 164 patients a year after a traumatic
brain injury (TBI), Deb et al found they were 7 times more likely
to have depression than the general population. They were 11
times more likely to have panic disorder (Deb 1999).
Typical neuropsychiatric symptoms following TBI include
posttraumatic amnesia, cognitive disorders and dementia,
posttraumatic epilepsy, aphasia, depression, mania, psychosis,
anxiety disorders, personality changes, aggression, behavioral
dyscontrol, fatigue/apathy, and increased risk of suicide (Reeves
2011).
Even up to five years after non-impact brain injury (whiplash),
patients have been frequently found (greater than norms) to
have cognitive deficits—primarily in the area of executive
functioning—and problems with behavioral control, sleep, and
sexuality (Henry 2000).
In addition to mainstream medical procedures, CAM
treatments for mild to severe TBI include acupuncture,
chiropractic, neural therapy, and EEG biofeedback. Hyperbaric
oxygen (HBO) treatment has been found to be effective for post-
TBI mental symptoms. A Chinese research team reported: “After
two courses of HBO treatment, 252 previously positive [TBI]
patients were examined again by SPECT. The results revealed
that 92 patients still had abnormal scans but 160 were now
normal.... The results of our study showed the distinctive
beneficial effect of HBO in neuropsychiatric disorders after TBI
and that SPECT images were far superior to CT scan in evaluating
the effect of HBO and neuropsychiatric disorders after TBI.” (Shi
2006)
Thyroid Issues
The thyroid gland regulates, among other things, metabolism
and the rate of energy usage in the body. Psychiatric symptoms
of hyperthyroidism include:
− Generalized anxiety
− Depression
− Irritability
− Hypomania
− Cognitive dysfunction
− Mania (in severe hyperthyroidism—thyrotoxicosis, “thyroid
storm”)
Mental symptoms of hypothyroidism include:
− Depression
− Cognitive dysfunction
− Psychosis (in severe hypothyroidism—“myxedema
madness”)
Subclinical hypothyroidism is a condition in which TSH
(thyroid stimulating hormone) is elevated, but T4 is low or
normal and the patient has few or no symptoms. Psychiatric
symptoms include:
− Depression
− Rapid cycling in bipolar disorder (a common cause)
− Subtle signs of cognitive dysfunction (Levenson 2006)
Thyroid irregularities are not only common but many people
don’t know they have them. Even those being treated for them
frequently show lab signs of thyroid hormones that are above or
below the norm:
− 9.5% of the public have elevated TSH levels—indicative of
hypothyroidism—including some who are being treated for
it.
− 2.2% of the public have subnormal TSH levels, including
some who are being treated for it.
− 40% of patients taking thyroid medications have abnormal
TSH levels.
− Symptoms are reported more often in hypothyroid vs.
euthyroid individuals (Canaris 2000).
Amongst bipolar patients in the depressive phase, two-thirds
are found to have TSH in the high normal range and a lownormal
free thyroid index (FTI). These individuals have been
found to recover significantly more slowly than those with
optimum thyroid profiles—an average of one year versus eight
months (Cole 2002).
Given that nearly 10% of the population has hypothyroidism
and that this condition, due to its mental and behavioral
manifestations, is overrepresented amongst psychiatric patients,
the diagnosis of subclinical or clinical hypothyroidism must be
considered in every patient with depression. This is particularly
critical in settings, such as outpatient clinics and non-MD
therapist offices where medical exams and lab testing are less
likely to occur.
Hyperthyroidism, though less common, should also be
suspected when a patient presents with chronic anxiety,
irritability, and other symptoms of this condition.
Sleep Disorders
One of the critical elements of good mental and physical health
is sufficient, quality sleep, as is discussed in detail in Chapter
Three. Common hidden parasites on sound sleep are obstructive
sleep apnea (OSA), restless leg syndrome, and other sleep
disorders.
OSA is characterized by heavy snoring and a continuous
disruption of breathing during slumber resulting in poor sleep
quality. Psychiatric symptoms include:
− Poor memory and concentration
− Changes in personality
− Depression (Schwartz 2007)
The American College of Physicians claims OSA:
− Occurs in about 4–9% of middle-aged men.
− Occurs in about 2–4% of middle-aged women.
− Goes undiagnosed in about 80–90% of those who have it.
Given that obesity is one of the most common contributors to
OSA, and that obesity is a common side effect of psychiatric
medication, OSA is not only likely overrepresented in psychiatric
populations, but may exacerbate existing psychiatric conditions,
thus retarding or preventing recovery for some.
OSA is simple to diagnose through a sleep study and is
considered highly treatable through lifestyle changes, weight
loss, avoidance of evening alcohol, and/or use of a CPAP
(Continuous Positive Airway Pressure) device (American College
2011). CPAP therapy is associated with sustained long-term relief
from the symptoms of depression for patients with OSA
(Schwartz 2007).
Low Cholesterol
Low serum cholesterol—defined as 160 mg/dL (4.5 mmol/liter)
or lower—appears with regularity on blood test results, yet may
be overlooked as a contributing factor for anxiety or depression.
Amongst other tasks, cholesterol is needed to modulate
serotonin transporter activity in cellular membranes (Scanlon
2001).
Low cholesterol, which can occur naturally regardless of diet or
lifestyle, has been linked to violent death (e.g., suicide and
accidents). Men with chronically low cholesterol levels show
consistently higher risk of having depressive symptoms
(Steegmans 2000). In healthy young adult women, low
cholesterol is inversely associated with trait measures of
depression and anxiety (Suarez 1999).
Common CAM treatments for low cholesterol include
increasing dietary intake and cholesterol supplements such as
those found at http://soniccholesterol.com.
The Koran Algorithm
The problem of overlooked medical ailments in psychiatric
populations is so significant that in 1988 the California
legislature debated and passed Assembly Bill 1877, which
mandated an exploration into a means of reducing the risk of
missed medical conditions. Lorrin Koran, MD, of Stanford
University was tasked with leading the development of a
corrective procedure. The results of his team’s work were
reported to the California Department of Mental Health and local
mental health programs in 1991 as the Medical Evaluation Field
Manual (available at http://goo.gl/kXIuS).
In laying the groundwork for the report, Koran reviewed a
study of medical exams performed in county mental health
programs, which has been carried out by order of the state
legislature (Senate Bill [SB] 929). They found:
− Nearly two out of five patients (39%) had an active,
important physical disease.
− The mental health system had failed to detect these diseases
in nearly half (47.5%) of the affected patients.
− Of all the patients examined, one in six had a physical
disease that was related to his or her mental disorder, either
causing or exacerbating that disorder.
− The mental health system had failed to detect one in six
physical diseases that were causing a patient’s mental
disorder.
As a cost-effective measure to reduce these diagnostic errors,
Koran and his associates developed an algorithm—a step-by-step
procedure—to efficiently narrow down the likelihood of medical
disease in psychiatric patients. While the algorithm does not
replace a full, searching medical exam, it may be an appropriate
choice where funds, time, or patient access are limited. It may
also be an appealing alternative for current mental health
programs that offer no exam at all.
The algorithm is presented in Figure 2-1 exactly as originally
presented in the 1991 report. Some of these procedures may not
reflect developments in lab testing since the Field Manual was
written, but the fundamentals remain the same and adaptations
to current practices are simple enough.
Initial algorithm steps:
1. Ask the patient to complete a 10-item Medical History
Checklist, assisting the patient as needed:
a. Have you ever had:
i. Fits, convulsions or epilepsy?
ii. Emphysema?
iii. Diabetes?
iv. Asthma?
v. High blood pressure?
vi. Thyroid disease?
b. Have any of the following symptoms been very
noticeable or worrisome to you in the past two months?
i. Have you noticed blood or pus in your urine?
ii. Have you noticed pain in your chest when resting?
iii. Have you had headaches associated with vomiting?
iv. Have you had loss of control of urine or bowels?
2. Obtain a sitting blood pressure measurement.
3. Have patient provide a urine sample.
4. Draw the blood specimens for the laboratory battery.
5. Get a lab panel of:
a. A hematocrit
b. White blood cell count
c. Serum aspartate aminotransferase
d. Serum alanine aminotransferase
e. Serum albumin
f. Serum calcium
g. Serum sodium and potassium
h. Serum cholesterol and triglycerides
i. Serum T4 and free T4
j. Serum vitamin B12
6. Patient’s urine should be examined by dipstick for:
a. Glucose
b. Blood
c. Protein
The results are evaluated against the steps of the algorithm in
Figure 2-1. Per the Field Manual, “Abnormal findings listed in
the earlier steps of the algorithm more strongly predict the
presence of physical disease than those occurring in later steps
and hence more urgently require a physician’s attention. A
patient who has any positive finding from any step in the
algorithm should be referred for further evaluation to a
physician who specializes in internal medicine or family
medicine.”
Summary
Given the fact that a known percentage of psychiatrists’ clients
come to them because of undiscovered and/or untreated medical
problems, it is an irony that, of all medical specialists, the
psychiatrist is among those commonly called upon the least to
exercise clinical medical diagnostic skills. The challenge of
mastering differential diagnosis in psychiatry requires, in truth,
a Holmesian eye for signs and symptoms and an equal intellect
for hazarding the maze of possible risk factors.
Absent this cautious approach, much suffering can occur. Seen
from the eyes of a patient or his or her family, the slow or
sudden decline into psychosis, deep depression, unrelenting
obsessive thought or other severe psychiatric symptoms can be a
nightmare. While a patient or physician may be anxious to
assign a psychiatric diagnosis to the syndrome presented, a
failure to look for and detect a possibly underlying medical cause
or contributing factor could unnecessarily prevent the
alleviation of, extend, or deepen this world of doom the patient
endures.
Properly examined, diagnosed, and treated, the client with a
hidden medical illness may have the good fortune of being
rescued from the dustbin of “nonresponsive to treatment” and
find hope and relief under the watchful eye of his physician.
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