In Medical Mimicry, Parts 1 and 2, we began to explore how medical conditions affect mental health and the importance of assessing them as sources of symptoms. Today we look at the weird things that are often clues to symptoms due to another medical condition:
Credit: Robin Higgins/Pixabay
Is the presentation of symptoms very unusual?
If anything about presenting symptoms is simply puzzling, it’s indicative of a possible medical basis. Evaluators should be vigilant about the following four elements:
- Was there a very rapid/acute onset of symptoms? This, especially in the absence of any previous experience of the symptoms.
- Do the symptoms come and go inexplicably?
- Was the age at onset unusual? It would be strange, for example, for someone to develop symptoms of OCD or a personality disorder in their thirties.
- Are the symptoms themselves exceptional? For example, does anyone have tactile, olfactory, or gustatory (feel, smell, taste) hallucinations? These are quite rare in schizophrenia spectrum disorders and affective psychoses, where hallucinatory activity is most often encountered. Such hallucinations, particularly in the absence of a verified history of psychosis-related diagnoses or a history of trauma where they might be part of an experience of reliving the trauma, are often indicative of an underlying medical cause. underlying, in particular a tumour, infection or head trauma. injury.
The case of Bess (composite identity) illustrates the importance of paying attention to the clues above:
Bess, a 35-year-old working single mother, sought therapy because she noticed a new mood swing in her. She had never needed mental health care before. Although she had some stress in her life, it wasn’t like the irritability she usually felt when under pressure. Suddenly, for the past month, she found herself oscillating daily between feeling a lethargic sadness that gave way randomly to a feeling of vertigo and impatience. She was never totally depressed or out of control, but complained of feeling like a fast undulating roller coaster.
At first glance, Dr. H, an experienced practitioner specializing in mood disorders, thought Bess might have bipolar spectrum disorder. Although the onset is usually much earlier, it is not uncommon for the conditions to appear in the thirties. Dr H was concerned, however, about how quickly they appeared and how quickly the symptoms fluctuated. It was not normal to have bipolar presentations, even cyclothymia, where symptoms change chronically every few days.
At the end of their first session, Dr. H explained his observation to Bess and asked if he could speak to his primary care physician to explain his concern. During a medical examination, doctors discovered that Bess had a pituitary gland tumor, influencing her mood.
Bess’ diagnosis would be Bipolar disorder due to pituitary tumor, with features of cyclothymia. We know that hormones have a significant effect on mood disorders. In fact, according to mood disorder expert Joseph Shannon, Ph.D. (2016), before menopause, rates of depression are 2:1 between women and men. The post-menopausal population has an equal ratio. For Bess, the tumor was influencing a strange pattern of hormone release and the solution was surgery, not psychiatric drugs and therapy.
Perhaps some of the most interesting cases of medical conditions disguised as psychological problems are pediatric autoimmune neuropsychiatric disorders associated with streptococci (PANDAS) and anti-NMDA encephalitis due to teratoma.
- PANDAS occurs in children who have had frequent strep infections. In people with PANDAS, for some reason, the strep infection does not just affect the throat and can enter the brain. Antibodies rush to fight it, destroying not only bacteria but also brain tissue (Columbia University, 2015). This appears to be correlated with the sudden onset of symptoms of aggression and impulsivity, vocal or motor tics as in Tourette syndrome, and repetitive behaviors and obsessions as in OCD (Swedo et al., 2015; Thienemann et al., 2017). Fortunately, antibiotics often help, and some have their tonsils removed as a long-term solution. In people with OCD or Tourettes, strep infections can exacerbate them.
- The second condition, considered quite rare, is inflammation of the brain related to a teratoma (an unusual tumor, often found on an ovary, made up of various tissues, including bones, teeth, and hair). Early symptoms may include seizures and other neurological issues, but psychotic and manic symptoms are usually predominant (Yen, et al., 2012). Memoirs of journalist Susana Cahalan, brain on fire (2012), details the very bizarre journey from assessment to recovery from this bizarre condition. It also highlights the importance of prompt medical evaluation in unusual psychiatric presentations.
- Other medical conditions, such as malaria, can cause hallucinations due to inflammation of the neural networks (encephalitis) during high fevers. Syphilis can also cause a presentation similar to schizophrenia. Ironically, malaria was once used to correct syphilis. In the 1800s, it was discovered that if high fevers could be induced in people who were psychotic due to syphilis, their psychosis diminished and the syphilis disappeared. The prescription? “Pyrotherapy”: inducing malaria in syphilitic patients. The sustained high body temperature “burned” the bacteria responsible for syphilis.
While it’s rare that you encounter a hallucinating patient with an STD requiring pyrotherapy, it’s not that far-fetched that a patient might have a more general medical condition causing or exacerbating psychological disturbance. Indeed, I have more than once recommended a medical evaluation, as in the panic-diabetic presentation mentioned in part 1.
Learning which medical conditions might mimic the diagnosis you are considering is another step towards strengthening your diagnostic ability. You may not be a medical professional, but asking if the patient has any medical conditions is not just superficial information gathering. This can lead to their psychological relief and possibly even save a life.