Masquerading Symptoms

Uncovering Physical Illnesses That Present as Psychological Problems

Barbara Schildkrout

• Publisher: Wiley
• Year: 2014
• Print ISBN:
  9780470890653
• Edition: 1
• eBook ISBN:
  9781118234877
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

The definitive resource to the signs, symptoms, and patterns of medical diseases that CAN present as psychological problems

This invaluable reference enables clinicians, as well as patients and their families, to become more familiar with these medical conditions and how they may masquerade as mental disorders.Part One of this book is organized so that it corresponds to the sections of the Standard Mental Status Exam. It is composed of clinical presentation descriptions that direct the reader to the medical diseases described inPart Two that may be contributing to the patient's discomfort.

Without medical jargon, Barbara Schildkrout lucidly explains how patients with each medical condition may end up seeking help from a mental health professional.

The conditions explored in this book include:

• Alzheimer's disease
• Brain tumors
• Carbon monoxide poisoning
• Diseases of the thyroid
• Endocrine disorders
• Hepatic encephalopathy
• HIV/AIDS
• Hyperventilation syndrome
• Hypoglycemia
• Limbic encephalitis
• Lyme disease
• Syphilis
• Thiamine deficiency
• Traumatic brain injury

The book also describes a proven process for working with patients during and after the referral process, and integrating medical findings into ongoing therapeutic work. All mental health professionals need access to this information, and Masquerading Symptoms puts it all in a single, easily navigated reference. BARBARA SCHILDKROUT, MD,is an Assistant Clinical Professor of Psychiatry at Harvard Medical School. She has taught for many years at the Beth Israel Deaconess Medical Center. She has a Subspecialty Board Certification through the United Council for Neurological Subspecialties in behavioral neurology and neuropsychiatry and has maintained a private clinical practice in the Boston area for over 25 years.

Part I
Signs and Symptoms

State of Consciousness

Clinical Significance

State of consciousness is the most basic quality of mind. The term “state of consciousness” is both hard to define and also intuitively understood. The term refers to an individual’s degree of awareness or alertness. Descriptively, disturbances in consciousness lie on a continuum from clouding of consciousness or dulled awareness, to lethargy, somnolence, obtundation, stupor, and coma.

Loss of consciousness for any period of time will be associated with a gap in memory, a lapse in the individual’s sense of time. Milder disturbances in consciousness may or may not be associated with memory loss.

Any loss of consciousness or disturbance in consciousness, however brief, is highly significant and always associated with underlying physical factors or medical disease. In patients who present with psychological symptoms, brief alterations in consciousness, periods of mental “absence,” or clouding of consciousness may be the only clue to the presence of a medical disease.

In a normal individual, alertness varies over the course of a day from the fully awake and alert state, to drowsiness and then sleep. A healthy person always can be aroused by environmental stimulation to full wakefulness, a state in which the individual is aware of self and surroundings and able to shift attention smoothly. The individual is also able to carry on some meaningful interpersonal interaction with others, although physical or psychological difficulties may limit the nature of the interaction.

In contrast, patients who are experiencing pathological states of consciousness may exhibit degrees of underresponsiveness to environmental stimulation and/or generalized overresponsiveness. The seemingly contradictory nature of this state might be best grasped by thinking of alcohol intoxication; on one hand, individuals who have had too much to drink might become somnolent and unaware of activities in the environment; on the other hand, they might become globally agitated when friends try to rouse and engage them.

Unusual states of consciousness related to sleep are covered in the section called “Vegetative Symptoms.”

Altered sense of reality or time is discussed in the section called “Thought Content and Experience of Reality.”

Altered states of consciousness with automatic behavior or with catatonia are discussed in the section called “Motor Behavior.”

Clinical Observations

State of consciousness is assessed by observation of the patient over time and in response to different environmental situations. The reports of other clinicians and/or family members may be helpful.

Subtle or brief alterations in consciousness may be missed or misinterpreted. Clinicians might mistake very brief episodes of loss of consciousness for dissociative episodes, lapses of attention, or thought blocking. Clouding of consciousness may be mistaken for depression, lack of motivation, or normal sleepiness. Mild clouding of consciousness and subtle pathological hyperarousal or hypo-arousal may be difficult to distinguish from a mood disorder with irritability or an anxiety disorder with agitation.

Fluctuating levels of consciousness are a key feature of the most common form of presentation for medical disease—a delirium. Clinically, individuals with delirium may be near normal at one point in time and just hours later exhibit impairment in consciousness (see the section called “Delirium”).

When patients have a mild clouding of consciousness along with other, more prominent features of a delirium such as agitation and hallucinations, they may be misdiagnosed with a psychotic disorder.

Any impairment in consciousness will affect an individual’s other cognitive abilities, most notably attention and memory. This fact needs to be taken into account when conducting an interview, performing a mental status examination, and formulating clinical information.

Episode(s) with Loss of Consciousness

Any episode involving loss of consciousness should be investigated medically. Most often these incidents are reported to the clinician rather than observed by him/her. Patients may refer to these episodes as “fainting,” “blacking out,” or “having a fit.”

Learning what the patient recalls about the incident, distinguishing a loss of consciousness from a loss of muscle strength or coordination, and determining whether the patient was injured can be useful information. Obtaining the report of any witnesses to the event also may be extremely helpful.

Brief Lapses in Consciousness

Brief lapses in consciousness, especially those that last only seconds, may be readily missed or misinterpreted. During these episodes, a patient will be unaware and unresponsive to the environment. Other behaviors (such as chewing or eye movements) may or may not accompany these absence episodes. It is important to investigate the possibility that these may represent seizures or episodes of microsleep.

Mild Disturbances in Consciousness

Patients with mild disturbances in consciousness may present in a variety of ways. They may display fluctuations in their state of alertness. Although seeming to be alert, their comments may reveal that they have not fully followed the conversation. Patients may also have a distorted sense of the passage of time, may lack clarity and coherence in their thinking, or they may be difficult to engage.

Patients with mild disturbances in consciousness may exhibit a decline in their day-to-day level of functioning; they may be unkempt or have episodes of incontinence. These individuals also may present with disruptions of their sleep/wake cycle; they may be drowsy during the day and restless at night.

Moderate Disturbances in Consciousness

Patients with moderate disturbances in consciousness have lethargy or somnolence. They display an abnormal degree of drowsiness, tending to fall asleep when not stimulated by activity in the environment. When not asleep, they are not fully alert. This pathological state is different from fatigue, which is a subjective feeling of tiredness that can be relieved by sleep.

Profound Disturbances in Consciousness

The most profound disturbances in consciousness and arousal are obvious and rarely missed. Obtunded patients are difficult to arouse; when aroused, they are generally in a confused state and able to be only minimally cooperative. A stupor is an unresponsive state from which the patient can be briefly aroused, but only with vigorous stimulation. A coma is a state from which a patient cannot be aroused, even with vigorous stimulation. Some of the behaviors of patients who are in a persistent vegetative state may resemble consciously motivated actions although they are not (for example, the patient’s eyes may track someone around the room); these behaviors may lead to misinterpretation by family members and by clinicians.

Confusion

The term “confusion” is imprecise; however, it is often used to describe patients in clinical situations. In common usage, “confusion” may refer to patients who are disoriented, behaving irrationally, or not making sense in their verbal communications. The term is included in this section because patients who give the clinical impression of being confused often have a clouding of consciousness.

Some Diseases that May Present with Clouding of Consciousness

1. #2 Acute Intermittent Porphyria, #6 Brain Tumors, #7 Carbon Monoxide Poisoning (high dose or chronic, low-dose exposure), #9 Chronic Subdural Hematoma, #17 Hashimoto’s Encephalopathy, #18 Hepatic Encephalopathy, #28 Hypothyroidism (with myxedema coma), #29 Hypoxia, #30 Lead Poisoning, #34 Merc...

Table of contents

• Cover
• Contents
• Title
• Copyright
• Introduction
• List of Diseases by Organ System or Disease Process
• Part I: Signs and Symptoms
• Part II: The Diseases
• Bibliography
• Author Index
• Subject Index
• End User License Agreement