Sometimes it seems to me being a therapist would be about the most complicated thing there is. I was going through some of my mental health books last night and picked up A Dose of Sanity by Syndney Walker III. Walker, a psychiatrist explains how some medical problems mimicks as psychological disease and the misdiagnosis that results. Here are a few cases mentioned in the book:
ONE OF THE SCARIEST BOOKS I'VE READ RECENTLY IS I'm Not Crazy, by a young woman named Frances Deitrick. Fran describes how she changed in a few short months from a happy-go-lucky "golden girl" into a raving, hallucinating "schizophrenic." She tells about her blinding headaches, her irrational behavior, her sudden hot and cold spells, and her despair when she could no longer make sense of voices, faces, or her own thoughts. She tells about how she nearly died, saved only by dangerous radiation treatments that eradicated the tumor growing on her brain. But those aren't the scariest parts.
The really scary part of Fran's story is what happened to her when her tumor first started causing her brain to malfunction. Following a car accident, probably a result of her disoriented state, Fran was taken to a local hospital and then admitted to a psychiatric facility. There, she was told she had an "emotional" problem, and she was labeled as having schizophrenia and atypical bipolar disorder. Her constant pleas that she was suffering from "brain seizures"—her description for the bizarre sensations she experienced—fell on deaf ears. She apparently had no thorough medical workup, and her only treatment—other than regular doses of tranquilizers and Thorazine—consisted of group therapy designed to help her deal with her "mental" problem. Time and time again, Fran's doctors told her, literally, that her problem was "all in her head."
Finally, after months, Fran was rescued by an unlikely knight. A physician who was not assigned to her case pulled her aside one day and said, "I don't think you're crazy." He was right: the MRI he ordered confirmed that a rare tumor called a pontine glioma was responsible for her symptoms. Luckily, Fran was diagnosed before the tumor became incurable, and her treatment was successful. When she later confronted one of the doctors at the psychiatric hospital who had failed to diagnose her—and had subjected her to months of worthless group therapy—he replied that he knew how she felt, and suggested, "Why don't you come to my Group to get everything off your chest."
David Healy, in The Suspended Revolution, offers a classic example: a middle-aged woman who took an overdose of pills in an unsuccessful attempt to commit suicide. The patient, who was admitted to a psychiatric unit, was clearly very disturbed. She ate poorly, slept poorly, could not concentrate, was consumed with guilt, and had no energy. Interestingly, she complained of one other symptom: a severe vaginal pain, which had started 20 years earlier, after the birth of a child. The pain, which was so severe it forced her to stop having intercourse with her husband, also occurred when she drove over bumpy roads, or even when she sat in a chair. No obvious reason for the pain could be found by doctors.
The case, Healy notes, seemed "almost too Freudian to be true." Although the woman's husband was a boor, she claimed that she was unable to divorce him because her pain made it impossible for her to live independently. Most of the hospital staff felt it was obvious that the woman's pain was "functional"—a defense against having sexual relations with her husband—and that her depression and guilt stemmed from her unhealthy dependency on her spouse. If she hadn't encountered Healy, she might have been given a DSM label of "depression" or "conversion disorder" (hysteria) and spent the rest of her years in psychotherapy.
But Healy points out a clue that was overlooked by most of the woman's doctors: in addition to her vaginal pain, she suffered from a sharp pain in her big toe. Noting that "the vagina and the big toe share the same nerve root," Healy states that "only a real pain in the vagina, especially one involving the nerves to the vagina, would be likely to cause a pain in the big toe too." He concluded that the woman suffered from a condition called postepisiotomy pain syndrome—lingering pain resulting from a surgery performed during childbirth to enlarge the opening of the vagina and aid delivery of the baby.
This condition is being reported with increasing frequency in the medical literature, but is still virtually unknown to many psychiatric professionals (and to DSM). Psychotherapy was the wrong choice as a frontline treatment for this patient—although it may have helped her, later on, to deal with the emotional fallout from her biological condition.
In another case, reported by Frederick Goggans and colleagues, in Medical Mimics of Psychiatric Disorders, a 27-year-old executive was hospitalized after attempting to kill herself by overdosing on antidepressants prescribed by her psychiatrist. The woman's suicide attempt—her second—followed a year of psychotherapy that had failed to relieve her fatigue, cognitive problems, and despondency. She was distraught that her suicide attempt was unsuccessful, and told her doctors that she would probably try to kill herself again.
Luckily, this woman's new doctors, unlike her previous ones, searched for the causes of her behavior. After evaluating her carefully, they determined that she suffered from hypothyroidism, a common cause of listlessness, sadness, and hopelessness, and they gave her thyroid supplements. Since then, she has been free of psychiatric symptoms and has thrived both personally and professionally.
Now, I may pick up on the hypothyroid just because I have an interest in health issues, but who'd guess at postepisiotomy pain syndrome?? I think I would have some concerns about not catching a medical condition as I'm not trained in that way. I may refer someone to a MD for a physical, (then again, I can't do this with every client and I'm not trained in medicine so what would make me know any better?) and of course even then you have to wonder if the doctor is doing his job.. It seems like it really calls for some interdisciplinary training. Serious business when you have people who are putting themselves in your hands..
"It is not so much that you use your mind wrongly--you usually don't use it at all. It uses you. This is the disease." -Eckhart Tolle, The Power of Now
