Discovering underlying medical abnormalities

[AbsenceSeizure]

Hey everyone! I'm curious to learn about instances where medical abnormalities are uncovered to explain psychiatric illness. For example, a patient may present with signs of confusion or mental status changes and the cause would simply be hypercalcemia. Or as another example, a patient may show signs of psychosis and eventually it'd be discovered that Cushing's syndrome is the underlying cause.

Is there a branch within the field that focuses on this medicine/psychiatry interface? The manifestation of medical problems as mental illness fascinates me. I'd love to read more about it. If anyone can explain this better or direct me wherever I may learn more, I'd greatly appreciate it.

Please excuse me if this is a commonly asked question or something glaringly obvious which I've failed to understand. I'm just a medical student and have a lot to learn.

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[birchswing]

Hey everyone! I'm curious to learn about instances where medical abnormalities are uncovered to explain psychiatric illness. For example, a patient may present with signs of confusion or mental status changes and the cause would simply be hypercalcemia. Or as another example, a patient may show signs of psychosis and eventually it'd be discovered that Cushing's syndrome is the underlying cause.

Is there a branch within the field that focuses on this medicine/psychiatry interface? The manifestation of medical problems as mental illness fascinates me. I'd love to read more about it. If anyone can explain this better or direct me wherever I may learn more, I'd greatly appreciate it.

Please excuse me if this is a commonly asked question or something glaringly obvious which I've failed to understand. I'm just a medical student and have a lot to learn.

I am not a doctor, but I'm very interested in psychiatry (my standard disclosure). I can't tell you where to look for that field, but as a patient I can name a few more that can be mistaken for psychiatric illness:

• Pituitary issues leading to low sex hormone levels (really anything that affects sex hormones) can mimic depression
• Low vitamin-D levels can mimic the physical symptoms of depression (aches, pains)
• Other endocrine issues, such as Hashimoto's or other reasons for hyperthyroidism can be misdiagnosed as mania or GAD
• Autonomic disorders such as POTS can be misdiagnosed as panic disorder
• Brain tumor can cause almost any strange symptom
• Benzodiazepine withdrawal can occur when continuing to take the *same* dose of benzodiazepine (called tolerance withdrawal) and benzodiazepine withdrawal can mimic almost any psychiatric condition under the sun and is not an indication the person needs more benzodiazepines

Obviously not all-inclusive, just things I've come across as a curious patient (not that I've had all of them, actually I have had all but brain tumor as confounding variables in diagnosis).

 

[heyjack70]

All psychiatrists look (or should look) for these medical conditions in all patients. The psychiatric diagnosis should only be made after medical causes are ruled out. Within the field, hospital based psychiatrists (ER, consults, and inpatient) probably get more regular exposure to this than outpatient.

 

[peppy]

If the interface of medicine and psychiatry interests you, I would suggest exploring the subspecialty of Psychosomatic Medicine: http://apm.org/

 

[Ceke2002]

All psychiatrists look (or should look) for these medical conditions in all patients. The psychiatric diagnosis should only be made after medical causes are ruled out. Within the field, hospital based psychiatrists (ER, consults, and inpatient) probably get more regular exposure to this than outpatient.

This. My Psychiatrist went through a whole list of tests he checked to make sure my GP had run (blood tests, scans, etc) before he even started formulating a diagnosis. I think the idea that there's this separation between Psychiatry and Medicine is often a wrong one, depending of course on the practitioner, where they practice, how they were trained, etc. For specific examples maybe you could search Pubmed or similar for differential diagnosis in Psychiatric presentations (or wording to that effect).

 

[birchswing]

I think there was a philosopher who wrote about the specialization of medicine being unethical. I'm not sure if it was for the reason of misdiagnoses. I'd like to say it was Aristotle. I haven't been able to find anything on the subject to find out who it was. I heard about this idea as a brief aside when I was taking a class in Christian virtue ethics, which was largely inspired by the ideas of Aristotle, making me think it may have been him. But I vaguely recall an idea that it was somehow unethical not to treat the whole person and to divide care among multiple practitioners—which I think is rather interesting and relevant to this discussion of underlying conditions. Does anyone in present day debate the system of specialization?

 

[digitlnoize]

Hey everyone! I'm curious to learn about instances where medical abnormalities are uncovered to explain psychiatric illness. For example, a patient may present with signs of confusion or mental status changes and the cause would simply be hypercalcemia. Or as another example, a patient may show signs of psychosis and eventually it'd be discovered that Cushing's syndrome is the underlying cause.

Is there a branch within the field that focuses on this medicine/psychiatry interface? The manifestation of medical problems as mental illness fascinates me. I'd love to read more about it. If anyone can explain this better or direct me wherever I may learn more, I'd greatly appreciate it.

Please excuse me if this is a commonly asked question or something glaringly obvious which I've failed to understand. I'm just a medical student and have a lot to learn.

Consultation-Liason Psychiatry. Aka C-L. Aka psychosomatic medicine.

All good psychiatrists should do this though. I find medical abnormalities frequently. The estimates are hard, but textbooks say between 10-20% or so of psychiatric illness is due to medical causes, IIRC.

In real life, I've found it's less clear cut. Remember that things don't have to be one thing or another. It is possible to have depression due to hupothyroisim (for example), and also have underlying Depression that persists even after the thyroid abnormality is corrected.

 

[whopper]

I hate CL, but I love where non-psychiatric medicine and psychiatry meet.

Why do I hate CL? The politics. Every place I've worked with CL, most of the consults are BS, and you have to act as the front-man to block medically unstable patients from going to the psych unit without any real support. In short having to say no to several people and being outnumbered and always looking like the bad guy on the medical floor, while the medical team sees psych as the dumping ground when in fact the patient shouldn't be transferred or should be discharged into the community bypassing psych.

I am working on an assumption that at some hospitals CL could be very good, but so far, out of 3, each place I've seen I didn't like it.

 

[Armadillos]

Another thing is schizophrenics tend to chain smoke and other doctors don't seem to believe them when they present with real medical symptoms so psychiatrists can diagnose a lot of medical problems in the SMI populations if they are listening for it.

 

[Ceke2002]

In real life, I've found it's less clear cut. Remember that things don't have to be one thing or another. It is possible to have depression due to hupothyroisim (for example), and also have underlying Depression that persists even after the thyroid abnormality is corrected.

Excellent point. I have a chronic pain condition that can be exasperated by stress or depression, and sometimes the pain in and of itself can also leave me feeling pretty depressed and/or increase existing levels of depression - that doesn't mean I don't still have a clinical diagnosis of depression.

 

[bashir]

Another thing is schizophrenics tend to chain smoke and other doctors don't seem to believe them when they present with real medical symptoms so psychiatrists can diagnose a lot of medical problems in the SMI populations if they are listening for it.

This fact seems to get overlooked when people are talking about why psychiatrists need to stay up to date and competent with medical knowledge, but it's so important. Not only do people with severe mental illness get their medical symptoms brushed off by other providers (obviously not every practitioner is guilty of this, but it is not at all uncommon), but many never see anyone other than their psychiatrist anyway. This is why I've toyed with the idea of a dual residency, because I think me having that training could really benefit my patients with severe mental illness. However, the general consensus seems to be that dual psych/IM or psych/family programs are not practical in terms of being able to find a position that really justifies the extra training.

 

[AbsenceSeizure]

Thanks, guys! This was very helpful. I gather it's primarily inpatient and emergency settings where one would be exposed to more of these cases. But I'm wondering, why do psychiatrists come into the picture only after these causes are ruled out? Why doesn't a psychiatrist address all behavioral issues, regardless of the etiology? In other words, these medical causes (most of which seem to be electrolyte imbalances, endocrine dysfunctions, or illnesses of the nervous system) ought to be under the scope of psychiatry to begin with. They primarily present as behavioral or cognitive problems, after all. Why can't psychiatrists also manage such cases? Why do they only enter the picture AFTER these issues are ruled out?

 

[hamstergang]

Here's some that I can remember right now:

On an inpatient unit, I had a psychotic woman who actually had a positive RPR. I believe she did improve with penicillin but I changed attending halfway through so I didn't follow her closely.

On the same inpatient unit, another psychotic female seemed to have her symptoms due to ecstasy intoxication. Then she was all depressed and irritable.

On the outpatient side, I inherited a patient that was diagnosed with Mood Disorder secondary to a general medical condition (partial complex seizures, in this case).

I also had a rather depressed woman on a different inpatient unit have hypothyroidism (TSH >100). I don't think that was causative of her low mood, but it certainly wasn't helping.

 

[jettavr6]

In a psychiatric intake appointment, if you don't first try to rule out any "obvious" medical problems that may be contributing to a psychiatric manifestation, then you are working well below the standard of nationwide care.

 

[birchswing]

In a psychiatric intake appointment, if you don't first try to rule out any "obvious" medical problems that may be contributing to a psychiatric manifestation, then you are working well below the standard of nationwide care.

That sounds more like an ideal than a standard. I know I've told my story before on these forums, but it bears repeating. I was 14 when I first saw a psychiatrist. I didn't have a PCP. There was a doctor's office I went to occasionally, but I would see a different NP or nurse (not sure which, but I know it wasn't a doctor) each time I went in. When I was in dire straits, we were referred by our HMO to a psychiatrist. We met for maybe 15 minutes tops. I left with a script for Ativan. There was no psychological testing, let alone blood tests or neuroimaging. Obviously not all psychiatrists are like that. But I can say I have seen a lot of psychiatrists since then and not one has ordered blood work or any type of medical testing. My first diagnosis of panic disorder and prescription of Ativan was grandfathered in from psychiatrist to psychiatrist over many years. And no, this was not doctor shopping. This was me seeing a new psychiatrist when I went to college and then following college the fact that psychiatrists have a high turnover rate so I would see whoever was available. I know that to intelligent people on this forum it sounds like madness and unbelievable. Why wouldn't someone have tried something else? That's how it looks to me in reflection. But you have to understand that throughout all that time I saw psychiatrists who thought benzodiazepines were helping me, psychiatrists who wanted me to increase the dose and add a second benzodiazepine. This was the best I thought we could do for a long time. After a while you forget what life is supposed to be like. You're supposed to feel alive. The world between good and bad psychiatry is vast, and I'm not sure the two worlds are terribly familiar with each other. I'm 31 and finally withdrawing from Ativan. My case is not unique.

 

[whopper]

I've noticed that in outpatient, once I had a patient for more than about 3 months, >50% of them, I seemed to know or at least being doing more about the person's physical health vs the PCP. Reason why is several PCPs just bring the patient in, do a perfunctory examination, and then just let them go. Several psych patients, it seems to me, once their PCP see a psych problem, they just blow the rest of their problems off.

Just to give a few examples, I've had patients who had very bad HTN and with each visit to me I saw numbers around the ballpark of 190/100 consistently and ask them why their PCP didn't do anything about it. I called the PCP and would only get a receptionist that would either not give me much information or faxed me notes with writing that the patient was fine despite a BP consistent with what I got. I'd tell the patient to consider getting a second opinion while I wrote for a BP med.

Now instead of a high BP, insert high cholesterol, lack of recommendations for colostomies, telling them to lose weight (e.g. an obese patient), tell them to use sleep-hygiene because the PCP put them on 10 mg of zolpidem at the first sign of insomnia despite that the person is obese and has all the signs of obstructive sleep-apnea, a guy that had a palpable tumor over his brachial plexus with corresponding arm numbness but the PCP told him it was all in his head before doing anything, not even an x-ray or physical exam......

What I had to do was figure out who the good PCPs were and the bad. Start referring the ones with bad ones to the good ones for a second opinion. On some occasions, trying to be diplomatic, I printed out the exact guidelines for the dx of the disorder, showed the patient they had the criteria of it and that I didn't know why their PCP was missing it and not talking to me despite my attempts to communicate with that PCP, that I couldn't give an explanation for the PCP's behavior and that they would have to ask that PCP because I tried multiple times.

 

[heyjack70]

lack of recommendations for colostomies,

What kind of twisted medicine do you practice?

 

[Shikima]

I've noticed that in outpatient, once I had a patient for more than about 3 months, >50% of them, I seemed to know or at least being doing more about the person's physical health vs the PCP. Reason why is several PCPs just bring the patient in, do a perfunctory examination, and then just let them go. Several psych patients, it seems to me, once their PCP see a psych problem, they just blow the rest of their problems off.

Just to give a few examples, I've had patients who had very bad HTN and with each visit to me I saw numbers around the ballpark of 190/100 consistently and ask them why their PCP didn't do anything about it. I called the PCP and would only get a receptionist that would either not give me much information or faxed me notes with writing that the patient was fine despite a BP consistent with what I got. I'd tell the patient to consider getting a second opinion while I wrote for a BP med.

Now instead of a high BP, insert high cholesterol, lack of recommendations for colostomies, telling them to lose weight (e.g. an obese patient), tell them to use sleep-hygiene because the PCP put them on 10 mg of zolpidem at the first sign of insomnia despite that the person is obese and has all the signs of obstructive sleep-apnea, a guy that had a palpable tumor over his brachial plexus with corresponding arm numbness but the PCP told him it was all in his head before doing anything, not even an x-ray or physical exam......

What I had to do was figure out who the good PCPs were and the bad. Start referring the ones with bad ones to the good ones for a second opinion. On some occasions, trying to be diplomatic, I printed out the exact guidelines for the dx of the disorder, showed the patient they had the criteria of it and that I didn't know why their PCP was missing it and not talking to me despite my attempts to communicate with that PCP, that I couldn't give an explanation for the PCP's behavior and that they would have to ask that PCP because I tried multiple times.

This.

 

[whopper]

Error, I should've wrote colonsocopy, not colostomy. Wow if medicine was run like a Zork video game and done by command only---I would've really screwed the patient.

Anyways, I don't think the situation is I have superior skills to these PCPs in their area other than that I figure I'm actually spending time thinking with the patient. The HTN thing is something that's almost pure numbers. It's led me to suspect that most of these PCPs are just asking if the patients if they feel fine and if the patient says yes, they shake their hand and get to the next patient.

 

[digitlnoize]

Another thing is schizophrenics tend to chain smoke and other doctors don't seem to believe them when they present with real medical symptoms so psychiatrists can diagnose a lot of medical problems in the SMI populations if they are listening for it.

I drill this into my med students' heads. HARD. And other doctors. My shortcut is to add 10-15 years to the age of schizophrenic patients. That probably puts then closer to their real risk. That is a 50yo schizophrenic has the arteries of a 65 yo. At least that's my data-less rough estimate, but it helps me remember how high risk they are.

 

[xlithiumx]

I drill this into my med students' heads. HARD. And other doctors. My shortcut is to add 10-15 years to the age of schizophrenic patients. That probably puts then closer to their real risk. That is a 50yo schizophrenic has the arteries of a 65 yo. At least that's my data-less rough estimate, but it helps me remember how high risk they are.

It's a good start. As it turns out you could probably add 25 years, since the evidence suggests that schizophrenics die about 25 years earlier than their non-schizophrenic peers. A sad stat indeed.

 

[vistaril]

this is due to various systems issues. psychiatrists weren't really interested in dealing with medical problems for much of the last century and thus from 1946-1980 psychiatry moved further away from medicine. most psychiatrists don't have the knowledge or skills to manage these sorts of problems, and many do not have the inclination. most psychiatry is outpatient based and thus most psychiatrists have no need to manage general medical problems. usually it is obvious when a psychiatric problem is caused by another medical condition, and the diagnosis is usually delirium. these patients are often very ill and are better of on a medical ward or in the ICU. there is very minimal medical training in psychiatry residency, and it is variable between institutions with many residents not receiving rigorous medical training and neurology training during psych residency typically leaves much to be desired. nursing staff on psychiatric units are not equipped to deal with medical problems and often have no desire to do so. This may also be true in a psych ER. psychiatrists are a precious resource and if our time were spent dealing with these sorts of medical issues we would be spread even more thinly than otherwise. Also it is not the consulting psychiatrist's job to suggest medical etiologies to patient's presenting with psychiatric conditions, except in very rare circumstances. The politics of medicine means that the referring service may be offended if you try and initiate a complex workup of the patient. Additionally, psychiatrists tend to place too much emphasis on medical causes being responsible for psychiatric problems when often it is incidental. The example of hypothyroidism is a good one - it is typically an innocent bystander and not responsible for the psychiatric problem or not the primary reason. I more often seen patients developing myxedema coma as a result of their mental illness (stopped taking thyroxine) rather than causing it.

Then there are renumeration issues. If a patient is on a medical unit you can bill for all the labs, procedures and imaging. On a psychiatric unit you cannot. So the psychiatry service actually loses money by working up these issues.

Neurologists are the ones who are responsible for diagnosing patient's with altered mental status. Psychiatrists are responsible for managing behavioral, cognitive and emotional symptoms in the medical model. I agree it is a shame psychiatrists have given up all these illnesses like epilepsy, neurosyphilis, Huntington's etc that used to be in our purview but that is how it is.

There is also the stigma issues. Rich people with severe psychiatric disturbances in their family like to seek out neurologists rather than psychiatrists for their loved ones.

wow.....that may be the best post I've read all year.