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q&a

Unmasking Psychological Symptoms focuses on how discrete medical diseases can cause or contribute to a clinical picture that looks like a mental disorder.

Q: Dr. Schildkrout, what advice would you give to patients who have been told that they have a mental disorder but who wonder whether their symptoms might be caused by an underlying medical condition?

A: I would encourage these individuals and their families to work effectively with health care professionals. Consult with your primary care physician and with well-trained mental health professionals. Here are some guidelines about how to:

  • Be sure that you have a primary care physician. Optimally, you want a doctor who can get to know you over time.
  • Tell your primary care physician all of your symptoms, including those that you consider to be “psychological symptoms.” Ask your primary care doctor to investigate whether there could be a medical problem underlying your mental symptoms.
  • Create a timeline of your illness to help in communicating with clinicians.
  • Always use language that is descriptive of what you experience rather than diagnostic language.
    • “dull pain on the right side of my forehead” rather than “migraine”;
    • “lack of energy” rather than “my chronic fatigue syndrome”;
    • “diarrhea” rather than “my systemic yeast infection.
  • If your symptoms are episodic, keep a daily diary of symptoms and associated information (menstrual cycle, sleep times, meaningful events such as job loss, fight with spouse, etc.).
  • Confer with family members and close friends to learn about their observations and concerns. Seriously consider having a family member or friend accompany you to a therapy appointment or primary care visit.
  • Compile a list of medications, vitamins, and supplements. Include doses and how often you actually take the medication.
  • Be forthcoming about how much alcohol you drink and whether you use other psychoactive substances (cocaine, marijuana, and so on).
  • If you are already in therapy and feel that you are not getting better, discuss the possibility of an underlying medical problem with your therapist. Be sure to tell your therapist all of your symptoms, including those that you consider to be “physical.”
  • Ask your therapist to consider arranging for a consultation with a senior clinician in a field appropriate to your symptoms.
  • Keep in mind that sometimes it is hard to diagnose a medical condition when it first begins. An initial consultation may be unrevealing or equivocal; whereas another consultation months or years later may find that definitive clues to a medical diagnosis have become apparent.

Q: How would you summarize your book?

A: Unmasking Psychological Symptoms is a straightforward and practical book that answers three questions:

1. Which medical diseases can cause mental symptoms?

2. How can a clinician tell whether a patient’s presenting mental signs and symptoms are being precipitated by a masked medical condition?

3. How can this be accomplished during a therapeutic interview?

The book encourages clinicians to use the therapeutic skills they already possess—observational expertise and clinical curiosity. It helps them to expand these skills into a broader arena so as to know when to refer patients for a targeted medical work-up.

In daily practice, clinicians are faced with an enormous variety of clinical presentations. Unmasking Psychological Symptoms teaches how to identify the patterns and features that characterize medical conditions. In addition, Unmasking Psychological Symptoms encourages all practitioners to hone their listening skills, integrate psychological and biological thinking, and to keep on learning.

Q: How did you approach the writing of Unmasking Psychological Symptoms?

A: When I set out to write Unmasking, my goal was to make the book very readable. I wanted to speak to therapists of all disciplines, healthcare practitioners from many fields, as well as to those patients and families who wanted to read about identifying hidden medical diseases.

I was committed to writing without medical lingo and with numerous clinical stories from a health care practitioner’s point of view. At the same time, I did not want to compromise in describing the complexity of making a diagnosis. And I did not want to overly simplify scientific information.

I hoped that providing sophisticated information in an easy-to-take-in style would make it possible for beginning clinicians to learn important fundamentals and also for very experienced practitioners to expand their knowledge base.

Q: Which diseases do you write about?

A: I discussed more than one hundred medical conditions that might produce psychological symptoms. Included are thyroid and other endocrine disorders, Alzheimer’s disease and other forms of dementia, sleep apnea and other sleep disorders, infectious diseases, nutritional deficiencies, seizure disorders, brain tumors—to name but a few of the important conditions that are covered.  Numerous narrative examples bring these diseases and their presentations to life.

My next book will be discussing each of these medical diseases in great detail.

Q: What are some of the most important points you write about?

A: The most important concept is that mental signs and symptoms do not = mental disorder diagnosis. Sometimes mental signs and symptoms = medical disease diagnosis.

For example, hyperthyroidism often causes anxiety. Partial seizures can cause hallucinations with no change in consciousness. A change in personality such as new bizarre or inappropriate behavior might be the sign of a frontal dementia.

When someone has symptoms in the “mental sphere,” it is understandable that people tend to think that the person has a mental condition. But it is not rare to find that a medical disease is behind these changes in behavior or mental state. At times the medical disease is the sole cause; often a medical disease is an important factor that is contributing to the situation.

Q: It seems obvious, but could you articulate why it makes such a difference to have an accurate diagnosis?

A: It makes a difference to have a complete and accurate diagnosis because this makes it possible to find the most effective treatment. In addition, it makes a difference just to know what-is-the-matter.

Patients can stop blaming themselves. Significant-others can stop blaming the patient. Therapists can no longer feel ineffective. Once there is clarity about all the contributing diagnoses, psychotherapy can help patients and families to deal with their problems more realistically and effectively.

Q: Patients are often working with a variety of clinicians, social workers, psychologists, physicians, and counselors. How can each contribute to helping the patient?

A: All members of the health care community need to work together to get to the bottom of what is causing a patient’s difficulties.

Changes in the delivery of healthcare have resulted in patients spending less time with physicians, be they primary care doctors or psychiatrists. Psychiatrists are doing less psychotherapy and more psychopharmacology. These and other changes in the healthcare system place more of a burden on psychologists, social workers, counselors, nurses, and a myriad of other healthcare professions to identify patients who look like they have a mental disorder but who might indeed have an underlying medical condition.

Therapists are often on the front lines. Frequently a therapist is the health care practitioner who knows the patient best or who first hears about a patient’s problems from a family member. Indeed, a therapist may be the only clinician the patient sees.

That is why I think it is so important for mental health care practitioners, including therapists of all persuasions, to increase their knowledge base so as to be able to identify patients who might have hidden medical diseases. It is crucial for these clinicians to know when to refer patients for targeted medical work-ups.

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