Unmasking Psychological Symptoms: How Therapists Can Learn to Recognize the Psychological Presentation of Medical Disorders

295 Pages·2011·2.12 MB·English

by  Barbara Schildkrout(auth.)

Unmasking
Psychological Symptoms
How Therapists Can Learn
to Recognize the Psychological
Presentation of Medical Disorders
Barbara Schildkrout
John Wiley & Sons, Inc.
(cid:2)1
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LibraryofCongressCataloging-in-PublicationData
Schildkrout,Barbara.
Unmaskingpsychologicalsymptoms:howtherapistscanlearntorecognize
thepsychologicalpresentationofmedicaldisorders/BarbaraSchildkrout.
p.;cm.
Includesbibliographicalreferencesandindexes.
ISBNs978-0-470-63907-8;978-1-118-10616-7;978-1-118-10615-0;978-1-118-10614-3;978-1-118-08359-8
1. Medicine,Psychosomatic. 2. Diagnosis,Differential. I. Title.
[DNLM:1. PsychophysiologicDisorders—etiology. 2. PsychophysiologicDisorders—psychology.
3. Diagnosis,Differential. 4. SomatoformDisorders—diagnosis.WM90]
RC49.S3452011
616.08—dc22
2011010995
PrintedintheUnitedStatesofAmerica
10 9 8 7 6 5 4 3 2 1
ToAaronSchildkroutandEmilySchildkroutFine
‘‘Educationisnotthefillingofapailbutthelightingofafire.’’
—WidelyattributedtoW.B.Yeats
‘‘Scienceisawaytoteachhowsomethinggetstobeknown,whatis
not known, to what extent things are known (for nothing is known
absolutely),howtohandledoubtanduncertainty,whattherulesof
evidence are, how to think about things so that judgments can be
made,howtodistinguishtruthfromfraud,andfromshow.’’
—RichardFeynman
Contents
Acknowledgments ix
1 TheNatureoftheProblem 1
2 LayingtheGroundwork 11
3 CharacteristicsThatMakeSomaticDiseases
DifficulttoDetect 21
4 PatternsinTime 61
5 TheClinicalInterview 83
6 TheHistoryofthePresentIllness 97
7 SpecificPhysicalSignsandSymptoms 103
8 ClassicalPresentations—FocalSigns,
Dementia,andDelirium 129
9 SpecificMentalSignsandSymptoms 149
10 ImportantAspectsofthePatient
Assessment—ASecondLook 223
11 ExtendedClinicalVignettes—Working
WithPatients 241
References 277
AuthorIndex 281
SubjectIndex 283
vii
Acknowledgments
Althoughwritingisasolitaryoccupation,Ihaveneverbeenalonewhile
workingatmycomputer.Acommunityoffamily,friends,andsupporters
has been precious and invaluable to me. Some have shared their clinical
experiences. Others have been there as fellow writers. Some have pro-
motedmywork,beengenerouswiththeirideas,orthoughtfullywrestled
with my questions. Some have simply continued to believe in the value
ofthisprojectandtotrustthatIwouldactuallyfinishit,evenafteryears.
Inaddition,Ihavewritteninthecompanyofcliniciansandresearch-
erswhoseworkstretchesbackoverdecades.Iwouldliketoacknowledge
mygratitudetothese scientists,eachfascinated byonething oranother,
each following his or her own curiosity and advancing our collective
understanding.
Iamdeeplygratefultomypatients,whohavebeenasourceofinspi-
ration.Iknowmanymayhavefeltvulnerable,terrified,crazy,defective,
ashamed,orbad,butIhaveexperiencedeachascourageous,determined,
strong, and worthy. I feel immeasurably grateful for their trust, for the
deep look at life they have given me, and for what they have taught me
about illness, about surviving, and about transforming suffering into
empathy, wisdom, and creativity. Clinicians may provide understand-
ing,deepcomfort,healing,orsometimesevenatruecure.Butoneirony
of being a therapist is that all the giving pales in comparison to what
cliniciansgainfromtheirpatients.Thisisthesecret scaffoldingthatsus-
tainstheworkoftherapy.
In a long career, one’s colleagues and friends are often one and the
same. Thank you to my friends/colleagues George and Ellen Fishman,
GeraldandCorinne Adler, Howardand JeannetteCorwinfor their wise
counsel and enthusiastic encouragement. George Fishman has been a
true companion of intellect and spirit in grappling with the brain and
mind.Iamgrateful to GeraldAdlerfor hiswholeheartedsupport ofmy
workonthisbookovermanyyears.
It is impossible to articulate the many ways in which Jeane Unger-
leider and William Stone have helped to sustain me and this project—
as talking-late-into-the-night consultants, readers, and generous and
lovingfriends.
I wish to extend a special thanks to Dr. Carol Nadelson for her
remarkable responsiveness and savvy advice, for her help with edit-
ing, and also for her friendship. Karen Greenberg’s companionship in
ix
x ACKNOWLEDGMENTS
teaching and friendship has nurtured my growth. I immeasurably
value her spirit and authenticity. Also I would like to thank my peer
group for their years of camaraderie as fellow psychiatrists, and for
their encouragement and help with editing: Miriam Freidin, Eileen
Kahan, and Beverly St. Claire. I am grateful to Beverley Freedman,
Ralph Freidin, Fred Kanter, Michael Marcus, Anne Stambler, and
Judith Waligunda for sharing, along with others, their clinical perspec-
tives. I also want to express appreciation to Lisa Sutton and Michael
Miller for providing me with opportunities to present my work to
others and to Eric First for his early help with library research.
I am extremely grateful to Albert Galaburda who graciously wel-
comed me into the clinical rounds of the Cognitive Neurology Unit at
BethIsraelDeaconessMedicalCenterinBoston,providinganinvaluable
opportunity for me to learn from neurologists, psychologists, psychia-
trists,andsocialworkersworkingattheborderofneurologyandpsychi-
atry.IalsooffermythankstoothermembersoftheCognitiveNeurology
Unitwhohavebeenfriendsandsupporters,includingtheneuropsychol-
ogists Sara Hoffschmidt and Bonnie Wong, and especially Margaret
O’Connor; social worker, Lissa Kapust; and my psychiatrist colleagues
Mark Thall and Laura Safar. Thank you also to Michael Alexander,
DanielCohen,AlvaroPascual-Leone,andDanielPresswhohavetaught
andinspiredme.
Some friends have been especially supportive as experienced writ-
ers in their own right. Thank you to Rhonda Cutler, Elizabeth Marcus,
and Vicki Steifel. Meg Campbell, a dear and inspiring friend, has
taught me the rejuvenating power of play and narrative transport.
Chad Lindner generously offered his sound advice to me at a time
when I needed it, along with help from my friends Lois Kanter and
Lindsay Kanter. Standish and Nancy Hartman, my dear friends, have
been compassionate and strong supporters through thick and thin.
IamdeeplyindebtedtoJohnKerr,whosawthevalueinthisproject
and encouraged me nearly from its inception. He read and edited early
draftsandhasbeenanastuteadvisoralongtheway.
I am immeasurably grateful to my editor Patricia Rossi, who recog-
nizedtheimportanceofthisbookprojectandthenshepherdeditthrough
tofruition.Shehasbeeneveravailable,responsive,helpful,andwise.
Thank you also to my family. First, thank you to my mother, Betty
Bell, forbelieving inthevalueofeducationand for alwaysbeing there.
My father did not live to see this book published, but his inquisitive
mind and zeal for problem solving were inspirational throughout my
life. Mollie Schildkrout, who had a long career as a pediatrician and
psychiatrist, has always been supportive; I am grateful for our many
talks, exploring complex dilemmas in life and medicine. Thank you to
Acknowledgments xi
my beloved son-in-law, Aaron Fine, who has been encouraging and
caring throughout.
Motherhood is a powerful experience, and my children, Aaron
Schildkrout and Emily Schildkrout Fine, have helped to shape who I
am and how I see the world. Words cannot begin to express my grati-
tude to them for their unwavering enthusiasm for me as a writer since
their early years. They also have helped with ideas, editing, computer
problems, and the mechanics of referencing. I immeasurably value
Emily’s natural empathy, integrity in relationships, loyalty, and shared
passion for writing and thinking about patients. Aaron’s keen mind,
clarity of thought, intense drive, fierce introspection, and deep com-
panionship are precious to me. Most of all I am grateful to Aaron and
Emily for being my best teachers and for becoming my dear friends.
Unmasking Psychological Symptoms: How Therapists Can Learn to
Recognize the Psychological Presentation of Medical Disorders
by Barbara Schildkrout
Copyright © 2011 John Wiley & Sons, Inc.
Chapter 1
The Nature of the Problem
Introduction
Morethan100somaticdisordersarecapableofmimickingpsychological
conditions. This reality presents every therapist with an important clini-
calchallenge—tounmaskpsychologicalsignsandsymptomsthatarebe-
ing caused by medical disorders. When you are seeing a patient who
appearstohaveapsychologicalproblem,howmightyouassesswhether
thatindividualcouldhaveanunderlying,discretemedicalconditionthat
is actually causing or complicating the presentation? And how might
such an evaluation be accomplished during an interview? This book
addressesthesequestions.
In our work as therapists, we have learned to be attuned to the sub-
tleties of our patients’ emotional lives, but we are often ill prepared to
detect clues that mark the presence of covert organic illness. Yet, an im-
portant part of our job is to unmask any physical condition a patient
might have. This is a vital undertaking, because fully effective mental
health treatment is only possible once contributing medical disorders
havebeenaccuratelydiagnosed.
Thisbookfacilitatesanexpansionofyourobservationalandlistening
skills. Using clinical stories, it introduces a variety of medical disorders
andshowshowtheseconditionsareoftencamouflagedinpeople’slives.
Discussionsareincludedonhowtoapproachsomaticcomplaints,which
particular mental status findings point to organic dysfunction, and how
toconductathoroughassessment.
Thisbookisaboutwell-describedsomaticdisordersthatmaynotlook
liketheyarephysicalbecausetheyinitiallyorprimarilyaffecttheindividu-
al’s mental and behavioral life. Many widespread and familiar maladies
can masquerade as mental disorders: thyroid disorders, diabetes, Alz-
heimer’s disease and other dementias, sleep apnea and other sleep disor-
ders, temporal lobe epilepsy, HIV, the long-term consequences of head
trauma,Lymedisease,and thesideeffects of medications, to name only a
few.Theseandotherphysicalconditionsarecommoninpatientswhoare
1
2 UNMASKINGPSYCHOLOGICALSYMPTOMS
seenbymentalhealthpractitioners;thesemedicalconditionsarealsooften
theverysourceofthepresentingclinicalpicture.
Thegoalofthisbookistohelpclinicianslearntoidentifywhenthereis
evidenceforanunderlyingorganicconditionsoastobeabletoeffectively
referpatientsforamedicalworkup.Itiscrucialformentalhealthpractition-
ers to initiate a medical consultation when signs, symptoms, and patterns
of behavior have led to a concern that a patient might have anunderlying
medicaldisorder.Atherapistmaynotknowexactlywhatsomaticcondition
a patient has, but it is possible to learn how to identify the evidence that
some condition is likely to exist. Identifying the evidence will facilitate a
medicalevaluationthatistargetedforthepatient’sparticularsymptomcon-
stellationandmaximizethelikelihoodofunmaskinganycovertillness.
Unfortunately, thereare no simplequestionnaires, no ‘‘acid tests’’ that
signal with certainty that a patient has an underlying physical condition.
Makingadiagnosticassessmentisbothascienceandanart.Aswithbeing
an accomplished therapist, the task is personally challenging and thor-
oughly engaging. It involves utilizing not only a body of information but
alsoalibraryofexperience.Itcallsforreasonedthinkingaswellascreativity
and seasoned intuition. It requires using one’s interpersonal and observa-
tional skills and maintaining one’s clinical curiosity. While these skills are
integraltobeinganexcellentclinicianandhealerinanyfield,theyarecen-
traltothesometimeslifesavingworkofmakingadiagnosticassessment.
Learningskillsthatwillhelpyoutounmaskpsychologicalsymptoms
is a vitally important undertaking. Here is what Drs. Barbara L. Yates
and Lorrin M. Koran concluded after thoroughly reviewing the modern
research studies on the topic of their chapter, ‘‘Epidemiology and Re-
cognitionofNeuropsychiatricDisordersinMentalHealthSettings.’’
Overwhelmingevidenceshowsthat undiagnosedphysicalillnessispreva-
lentinpatientswithpsychiatricdisorders.Medicalconditionsinthispopula-
tion are overlooked for many reasons, but in some cases these conditions
directlycausethepatients’psychiatricsymptoms.Publicmentalhealthpro-
grams, especially programs for the seriously mentally ill, may be the
patient’sprimarysourceofhealthcare.Evenwithpatientswhohaveapri-
marycare physician,the possibility ofundetected, important physical dis-
easeremainssubstantial.(Yates&Koran,1999,p.41)
ThisIsaCommonProblem
Everyonehashadafirsthandexperiencewiththeeffectsofphysicalcon-
ditionsonthemind. Anight without sleepwillmakeitmoredifficultto
concentrate at work and easier for a someone to lose his or her temper
athome.Toomuchcoffeeleavespeopleanxiousandunabletofallasleep.