Unmasking Psychological Symptoms E-Book

Barbara Schildkrout

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 605

Veröffentlichungsjahr: 2011

Beschreibung

More than 100 medical diseases--many common ailments--are capable of masquerading as mental disorders. This book shows clinicians how to identify patients who are most likely to have an underlying physical ailment and how to direct them to a targeted medical work-up. With guidance on working with patients during the referral process and afterward, as well as on integrating medical findings into ongoing therapeutic work, clinicians will benefit from the practical advice on recognizing signs, symptoms, and patterns of medical diseases that may be underlying a psychologically presenting malady.

Leseprobe

Contents

Cover

Title Page

Copyright

Dedication

Acknowledgments

Chapter 1: The Nature of the Problem

Introduction

This Is a Common Problem

An Illustrative Clinical Vignette

What Is and Is Not Included

Disclaimers

Chapter 2: Laying the Groundwork

Introduction

Concept 1: The Significance of Psychological Symptoms

Concept 2: The Process of Going From Signs and Symptoms to Diagnosis

Concept 3: A Word About Language

Concept 4: What Is a Diagnosis?

Concept 5: The Magic of Making a Diagnosis

Chapter 3: Characteristics That Make Somatic Diseases Difficult to Detect

Introduction

The Signs and Symptoms of These Disorders Come on Gradually

Disorders Considered Part of the Individual's Basic Nature

A Convincing, Alternative Explanation

The Organic Illness Makes the Individual Unappealing

Physical Disorders May Make the Individual Unable or Less Able to Communicate

Few, If Any, Physical Signs or Symptoms

Disguised by an Unusual Presentation

The Absence of Something That Should Be There

Chapter 4: Patterns in Time

Introduction

Looking Backward

Looking Forward

Chapter 5: The Clinical Interview

Introduction

The Clinical Interview—Fundamental to Making a Diagnosis

Helping the Patient to Find Words

Chapter 6: The History of the Present Illness

Introduction

A Straightforward Case

A Clear History, But the Patient Is Unaware of an Underlying Problem

A Confusing History

The Patient Does Not Perceive the Problem

The Patient and/or the Circumstances

Chapter 7: Specific Physical Signs and Symptoms

Introduction to Signs and Symptoms

Physical Signs

Physical Symptoms

Chapter 8: Classical Presentations—Focal Signs, Dementia, and Delirium

Introduction

Focal Signs of Brain Pathology

Introduction to Dementia and Delirium

Dementia

Delirium or Acute Confusional State

Chapter 9: Specific Mental Signs and Symptoms

Introduction

Mood, Affect, and Emotion

Change in Personality

Apathy: Lack of Motivation, Loss of Initiation

Mutism

Psychomotor Activity

Hallucinations and Illusions

Sense of Reality

Delusions

Insight

Judgment

Impairments in Consciousness

Attention, Concentration, and Vigilance

Disorientation

Confusion

Memory

Language

Perservation in Thought or Action

Automatic Behavior

Environmentally Dependent Behavior

Apraxia

Agnosia

Adult-Onset Difficulty With Reading, Writing, Drawing, or Calculating

The Executive Functions

Chapter 10: Important Aspects of the Patient Assessment—A Second Look

Introduction

Present Illness

Physical Symptoms

Family Medical and Psychiatric History

Personal Past Medical History

Chapter 11: Extended Clinical Vignettes—Working With Patients

Introduction

Taking It On

Diagnostic Thinking

Monitor Your Feelings as Data

Think Scientifically

Practicing Persistence and Patience

Tolerate Uncertainty and Helplessness

Dealing With Inevitable Blind Spots

Cultivating Learning and a Spirit of Curiosity

References

Author Index

Subject Index

This book is printed on acid-free paper.

Copyright © 2011 by John Wiley & Sons, Inc. All rights reserved.

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Library of Congress Cataloging-in-Publication Data

Schildkrout, Barbara.

Unmasking psychological symptoms : how therapists can learn to recognizethe psychological presentation of medical disorders / Barbara Schildkrout.

p.; cm.

Includes bibliographical references and indexes.

ISBNs 978-0-470-63907-8; 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. Psychophysiologic Disorders—etiology. 2. Psychophysiologic Disorders—psychology. 3. Diagnosis, Differential. 4. Somatoform Disorders—diagnosis. WM 90]

RC49.S345 2011

616.08—dc

222011010995

To Aaron Schildkrout and Emily Schildkrout Fine

“Education is not the filling of a pail but the lighting of a fire.”

—Widely attributed to W.B. Yeats

“Science is a way to teach how something gets to be known, what is not known, to what extent things are known (for nothing is known absolutely), how to handle doubt and uncertainty, what the rules of evidence are, how to think about things so that judgments can be made, how to distinguish truth from fraud, and from show.”

—Richard Feynman

Acknowledgments

Although writing is a solitary occupation, I have never been alone while working at my computer. A community of family, friends, and supporters has been precious and invaluable to me. Some have shared their clinical experiences. Others have been there as fellow writers. Some have promoted my work, been generous with their ideas, or thoughtfully wrestled with my questions. Some have simply continued to believe in the value of this project and to trust that I would actually finish it, even after years.

In addition, I have written in the company of clinicians and researchers whose work stretches back over decades. I would like to acknowledge my gratitude to these scientists, each fascinated by one thing or another, each following his or her own curiosity and advancing our collective understanding.

I am deeply grateful to my patients, who have been a source of inspiration. I know many may have felt vulnerable, terrified, crazy, defective, ashamed, or bad, but I have experienced each as courageous, 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 understanding, deep comfort, healing, or sometimes even a true cure. But one irony of being a therapist is that all the giving pales in comparison to what clinicians gain from their patients. This is the secret scaffolding that sustains the work of therapy.

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, Gerald and Corinne Adler, Howard and Jeannette Corwin for their wise counsel and enthusiastic encouragement. George Fishman has been a true companion of intellect and spirit in grappling with the brain and mind. I am grateful to Gerald Adler for his wholehearted support of my work on this book over many years.

It is impossible to articulate the many ways in which Jeane Ungerleider and William Stone have helped to sustain me and this project—as talking-late-into-the-night consultants, readers, and generous and loving friends.

I wish to extend a special thanks to Dr. Carol Nadelson for her remarkable responsiveness and savvy advice, for her help with editing, and also for her friendship. Karen Greenberg's companionship in 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 perspectives. 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 welcomed me into the clinical rounds of the Cognitive Neurology Unit at Beth Israel Deaconess Medical Center in Boston, providing an invaluable opportunity for me to learn from neurologists, psychologists, psychiatrists, and social workers working at the border of neurology and psychiatry. I also offer my thanks to other members of the Cognitive Neurology Unit who have been friends and supporters, including the neuropsychologists 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, Daniel Cohen, Alvaro Pascual-Leone, and Daniel Press who have taught and inspired me.

Some friends have been especially supportive as experienced writers 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.

I am deeply indebted to John Kerr, who saw the value in this project and encouraged me nearly from its inception. He read and edited early drafts and has been an astute advisor along the way.

I am immeasurably grateful to my editor Patricia Rossi, who recognized the importance of this book project and then shepherded it through to fruition. She has been ever available, responsive, helpful, and wise.

Thank you also to my family. First, thank you to my mother, Betty Bell, for believing in the value of education and for always being 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 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 gratitude 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 companionship 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.

Chapter 1

The Nature of the Problem

Introduction

More than 100 somatic disorders are capable of mimicking psychological conditions. This reality presents every therapist with an important clinical challenge—to unmask psychological signs and symptoms that are being caused by medical disorders. When you are seeing a patient who appears to have a psychological problem, how might you assess whether that individual could have an underlying, discrete medical condition that is actually causing or complicating the presentation? And how might such an evaluation be accomplished during an interview? This book addresses these questions.

In our work as therapists, we have learned to be attuned to the subtleties of our patients' emotional lives, but we are often ill prepared to detect clues that mark the presence of covert organic illness. Yet, an important 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 have been accurately diagnosed.

This book facilitates an expansion of your observational and listening skills. Using clinical stories, it introduces a variety of medical disorders and shows how these conditions are often camouflaged in people's lives. Discussions are included on how to approach somatic complaints, which particular mental status findings point to organic dysfunction, and how to conduct a thorough assessment.

This book is about well-described somatic disorders that may not look like they are physical because they initially or primarily affect the individual's mental and behavioral life. Many widespread and familiar maladies can masquerade as mental disorders: thyroid disorders, diabetes, Alzheimer's disease and other dementias, sleep apnea and other sleep disorders, temporal lobe epilepsy, HIV, the long-term consequences of head trauma, Lyme disease, and the side effects of medications, to name only a few. These and other physical conditions are common in patients who are seen by mental health practitioners; these medical conditions are also often the very source of the presenting clinical picture.

The goal of this book is to help clinicians learn to identify when there is evidence for an underlying organic condition so as to be able to effectively refer patients for a medical workup. It is crucial for mental health practitioners to initiate a medical consultation when signs, symptoms, and patterns of behavior have led to a concern that a patient might have an underlying medical disorder. A therapist may not know exactly what somatic condition 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 medical evaluation that is targeted for the patient's particular symptom constellation and maximize the likelihood of unmasking any covert illness.

Unfortunately, there are no simple questionnaires, no “acid tests” that signal with certainty that a patient has an underlying physical condition. Making a diagnostic assessment is both a science and an art. As with being an accomplished therapist, the task is personally challenging and thoroughly engaging. It involves utilizing not only a body of information but also a library of experience. It calls for reasoned thinking as well as creativity and seasoned intuition. It requires using one's interpersonal and observational skills and maintaining one's clinical curiosity. While these skills are integral to being an excellent clinician and healer in any field, they are central to the sometimes lifesaving work of making a diagnostic assessment.

Learning skills that will help you to unmask psychological symptoms 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 Recognition of Neuropsychiatric Disorders in Mental Health Settings.”

Overwhelming evidence shows that undiagnosed physical illness is prevalent in patients with psychiatric disorders. Medical conditions in this population are overlooked for many reasons, but in some cases these conditions directly cause the patients' psychiatric symptoms. Public mental health programs, especially programs for the seriously mentally ill, may be the patient's primary source of health care. Even with patients who have a primary care physician, the possibility of undetected, important physical disease remains substantial. (Yates & Koran, 1999, p. 41)

This Is a Common Problem

Everyone has had a firsthand experience with the effects of physical conditions on the mind. A night without sleep will make it more difficult to concentrate at work and easier for a someone to lose his or her temper at home. Too much coffee leaves people anxious and unable to fall asleep. A few drinks at a party may bring out one's sense of humor, lend an unfamiliar measure of social confidence, or imperil good judgment and make a person argumentative. A high fever, the side effects of particular medications, and, certainly, psychoactive drugs may not only have an impact on alertness, mood, level of anxiety, mental agility, and attention but may also cause hallucinations, paranoia, or delusions, altering the very experience of reality.

In all of these situations, the mental effects are time-limited and their cause is apparent. You know that when your fever comes down, when the new medication wears off, when you sober up, or manage to get a good night's sleep, your mind will return to its usual state. This is comforting. But imagine what it would be like to experience these same changes in the workings of your mind with no obvious physical cause and no surety that you would ever be your old self again. That is akin to the experience of having a covert somatic disease that produces mental symptoms. Under these circumstances, patients are likely to believe erroneously that there is something troubling them psychologically or that they are going crazy.

If such a patient decides to seek help, he or she will most likely consult with a mental health professional. We all know that therapy would not stop the anxiety that comes from drinking too much coffee, the difficulty in concentrating that results from sleep deprivation, or the visual hallucinations that are produced by LSD. The same is true of the anxiety that is produced by an overactive thyroid, the difficulty with concentrating that results from disordered breathing during sleep as occurs with sleep apnea, or the visual hallucinations that may be produced by temporal lobe epilepsy, an extremely common type of seizure disorder that can occur without any loss of consciousness. Psychotherapy will have little to no impact on these very common medical diseases, but other treatment approaches might be effective.

Sometimes these physical illnesses are capable of persisting for years without worsening dramatically and without evolving into a crisis that would make it clear that an underlying organic disease is present. Yet without the correct somatic diagnosis, years of unnecessary suffering for the patient and frustration for the therapist are often inevitable. With medical treatment that is targeted at the patient's actual organic diagnosis, it is possible for the patient's symptoms to improve and, in many cases, completely resolve.

An Illustrative Clinical Vignette

Within the pages of this book, you will meet adult patients of all ages and be introduced to many different physical afflictions. This first clinical vignette is about an elderly gentleman with an important medical condition.

Joan was a social worker who had been seeing me in psychotherapy to work on her troubled marriage. In that context, she began to express concern about her elderly father's declining mental state. Joan's mother and father were both retired physicians who now lived in Chicago, many miles from their daughter.

Joan felt especially close to her father, Dr. Joe. She loved to hear him reminisce about having lived through that era of medical history when there wasn't much a doctor could do to help people who were sick; a physician could only make a diagnosis, provide emotional comfort, and prescribe medication that usually had little effect. In that time of mostly futile treatment, a diagnosis was virtually all there was, and back then it was a lot. A diagnosis represented not only the thoughtful engagement of the mind of an educated and respected clinician, focused squarely on the patient's condition, but it also foretold the future. Could you pass this disease on to others? Would you recover? How long might that take? Could you be left impaired? Would you die?

Joan's parents were retired from medical practice now, but they had hardly slowed down in this ninth decade of their lives. Their social and cultural calendar was astounding; their excitement about cutting-edge movies and trends in the art world was inspirational. This made it especially poignant to Joan when she noticed a change in her father's energy level. Dr. Joe began to move slowly and was increasingly unsteady on his feet. He ceased to be engaged by the activities that had animated him over a lifetime: He sat silently and still for long stretches of time; he no longer played the piano or even listened to music; he stopped reading the book review; and he had no further interest in the daily crossword puzzle. “It's finito la commedia!” he would say to his daughter.

Joan's mother Sarah was not unsophisticated in her diagnostic assessment. To Dr. Sarah the signs of depression were obvious: loss of interest in daily activities, absent zest for life, slowed physical and mental activity. Dr. Sarah also had noticed that her husband was having trouble with his memory, and she believed that he had the beginnings of Alzheimer's disease. With years of clinical experience under her belt, Dr. Sarah formulated that her husband was having a depressive reaction to early Alzheimer's disease, and she could readily envision the inevitable downhill course his mind would take, dragging the quality of their lives down with it.

Joan discussed with me how sad it was to think of her father having Alzheimer's disease. As therapists sometimes do, I became the hidden, long-distance consultant in the case. On my suggestion, Joan recommended to her parents that they consult with their geriatric primary care physician rather than simply assuming that these changes in Dr. Joe were the beginnings of an untreatable dementia. The primary care physician took a careful history, conducted a standard physical examination, and ordered some screening blood tests and a chest x-ray. A mini-mental status exam, which included screening tests of memory, was administered and, surprisingly, it was essentially normal for someone in his 80's. Joan's father did not appear to have a clear dementia like Alzheimer's disease. In fact, the doctor could find no obvious cause for Dr. Joe's decline.

It sounded as though Dr. Joe simply had a late-life depression. Clearly, he looked depressed, and he had reasons to be depressed. His physical capacities had declined; he could no longer play tennis or walk with a quick step; he still insisted on opening the door for the ladies, but really, it had become easier for the ladies to hold open the door for him. His self-esteem suffered. He had lived through the inevitable succession of deaths of good friends, colleagues, and relatives. Sarah and Joe going out with friends had come to mean Sarah and Joe going out with an assortment of widowed women. The men who had been dinner, concert, theatre, and museum companions for years were either deceased or in nursing homes. Joe said that he felt like the last one standing, but barely, and now with a cane.

In other words, it made sense that Joe was depressed. Joan and I pondered how to explain the atypical features of his presentation. Perhaps the mild, day-to-day difficulties her father was having with memory resulted from a depression that was affecting his ability to concentrate. As for the slight unsteadiness on his feet, perhaps this was orthopedic, the inescapable effects on bone and cartilage of a long life of stomping down hospital corridors and bounding across tennis courts, always going somewhere in a hurry.

No one knows for sure what would have happened if, at this juncture, Dr. Joe's doctor had referred him to a therapist. Likely, Joe would have been treated for the obvious diagnosis, depression. After all, he had essentially been medically cleared. In this case, the primary care doctor did not send Joe to a therapist. He sent him to consult with a neurologist. Joan was relieved to hear this, because she had learned from me that her father might have an early, treatable form of dementia called normal pressure hydrocephalus (NPH). This relatively uncommon condition occurs when the fluid-filled ventricles of the brain enlarge without an increase in spinal fluid pressure. As the ventricles gradually expand, adjacent nerve tracts in the brain are stretched and compressed. NPH presents with a triad of symptoms: apathy that can look like depression, a disturbance of gait, and, often, urinary incontinence.

But Joan's heart sank when her parents refused to see the neurologist. “What's the point?” asked Sarah. “The neurologist is only going to put your father through all kinds of tests and, in the end, there will be nothing they can do for him anyway!” “What's there to lose?” Joan spat back.

With encouragement from me, Joan persuaded her parents to give the neurologist a chance. NPH is treated by surgically installing a shunting tube that continuously drains small amounts of cerebrospinal fluid from the fluid-filled ventricles of the brain. A preliminary diagnosis is made by taking a history and performing a mental status examination. Only then does a physician conduct a physical exam and order brain-imaging studies. Often the diagnosis is confirmed by draining some fluid from the spinal column and noting whether gait or mental state improves.

It became clear that the diagnosis of NPH was correct when Joe called his daughter after the doctors had performed this test. Miraculously, it was Dad's familiar voice, animated and vital again. “Mom and I just had the most wonderful lunch!” he said, laughing. Joan cried—with joy. The diagnosis was everything!

This diagnosis of NPH told my patient a lot. It told her that her father had a covert physical problem that was likely generating many of the changes in his mental state as well as his unstable walk. It told her that a treatment could be targeted to this particular physical problem and that this treatment had a chance of being effective. It told her that there were risks, but also that there was the possibility of recovery, even at Dr. Joe's age. The diagnosis also gave her a glimpse into the future. She could imagine her father at the piano again, playing a little too loudly. She could picture him rejoining their traditional Thanksgiving game of charades. And that's what did happen. The correct diagnosis in this instance offered hope.

In the 1930s, a diagnosis was virtually all there was, whether it was hopeful or not. In the 21st century, a diagnosis is just the beginning. It still represents the thoughtful engagement of the mind of an educated and respected clinician, focused squarely on the patient's condition. It still tells the future. But now, once the diagnosis is known, in many situations the future can be altered. Effective treatment can begin.

Most readers have probably never heard of NPH, and many may worry, “What if Joe's doctor hadn't referred him to a neurologist but, instead, had sent him to see a therapist. And what if that therapist had been me?” Or “What if Joe had come to see me straightaway, without ever having seen his primary care doctor at all? Or, what about the possibility that this NPH might have emerged while I was seeing Joe for some other problem? It is very likely that I would have thought he was simply depressed. I would probably have missed the treatable diagnosis!”

At this point it is important to recall that Joe's primary care doctor did not send him to a therapist. He sent him to a neurologist, and he must have done so for a reason. I too had recommended that he see a neurologist. What did I know? What did the primary care doctor know? What did he see or sense? And what if you could learn to see or sense or know those things as well? When medical illnesses masquerade as mental conditions, they usually don't do a perfect imitation. Generally, they leave clues to the fact that there is some physical condition in the picture. With some work, it will be possible to learn the signs, symptoms, and patterns of presentation that indicate the presence of some organic disorder, though one may not know precisely which disorder.

Looking more carefully at the case of Joe will give the reader an idea of this book's approach:

What were the clues to the presence of a covert medical condition in Joe?How were these clues disguised or camouflaged within Joe's presentation?What kind of investigation led to the disease's unmasking?

Three important clues pointed to the possibility of an underlying organic condition. The first was Joe's difficulty with walking, a clear physical sign. This clue was easy to overlook for several reasons: It came on gradually; it's not unusual for the elderly to have trouble with mobility; and there is a tendency to explain this kind of problem as simply a result of the ravages of time. But time takes its toll by causing actual physical changes. A clinical detective would need to be vigilant, careful to not dismiss this physical sign as simply a result of old age. It turned out that keeping this physical sign in mind while leaving open the question of its cause was important in eventually making an accurate diagnosis.

Clue number two was a marked change in Dr. Joe's behavior; this was noticeable to everyone. However, only careful and thoughtful inquiry ascertained that Joe was not precisely depressed. He was not happy about getting old, and he was not happy about having no energy, but he didn't actually feel depressed. What he was fundamentally experiencing was apathy, lack of motivation, and psychomotor retardation, which is a slowing in his physical and mental processes. This distinction between depression and apathy is difficult but important to make because apathy is more often associated with organic disease.

Clue number three was Dr. Sarah's observation that her husband had mild difficulty with memory in daily life. This symptom was frightening to Sarah. Given that her husband was elderly, she assumed that this was Alzheimer's disease. However, a simple mental status test performed by the geriatric primary care physician revealed that Joe's memory storage was not impaired. This implied that any difficulties with remembering were more likely because of problems with concentration or motivation.

In order to get to the right diagnosis, it was important to tolerate uncertainty about what was the matter. It was crucial to reject the easy idea that Joe was simply getting old. It was necessary to see that this was not a classic depression. One had to sweep aside the notion that Dr. Joe had Alzheimer's disease and open one's mind to other possibilities. Only then was it possible to see a pattern of signs and symptoms that pointed toward the actual diagnosis.

The geriatric primary care physician and I, as the background consultant in the picture, became aware that Joe's presenting problems could be part of that classical triad of signs and symptoms that comprise the presenting picture of NPH. Even without a history of urinary incontinence, it was still possible for Joe to have NPH, though I wondered whether Joan's father might have been uncomfortable sharing this potentially embarrassing symptom with his daughter. Untreated, NPH eventually leads to an irreversible dementia. If identified early on, this form of dementia is often treatable. In other words, NPH is one of those diagnoses you do not want to miss. This is why Joe's doctor sent him to a neurologist.

The story of Dr. Joe illustrates one further point—how difficult the road is to getting effective medical help. Even though Drs. Joe and Sarah were highly educated, motivated, and resourceful, and even with a trusted, caring, and competent family physician in the picture, they needed the support and encouragement of their daughter to make their way to the appropriate specialist. Their fear of Alzheimer's disease might have been paralyzing had it not been for their daughter's encouragement. For patients and families who are less educated, less motivated, less trusting, and less resourceful or financially able, the barriers to attaining top-quality health care are even more difficult to surmount. This is where an informed therapist, through support, encouragement, and active, informed referrals, can make a difference.

One of the many important obstacles to obtaining good health care that even blocks the best educated and brightest patients, families, and therapists is simply this: People do not know what they do not know! Joan and Drs. Joe and Sarah had never heard of NPH. The reason to consult with medical specialists is because they do know about conditions that others might never have heard of.

The goal of this book is to address needs that many therapists experience—to be more fully informed about physical diseases, to learn about how organic disorders masquerade as mental conditions and how to recognize when there is a need for a medical referral, and then to know how to work and collaborate with the patient, the family, and other health-care providers to see the referral through.

In attempting to achieve that goal, this book has been written to be readable. It is filled with numerous narrative examples from a therapist's point of view. The book avoids the use of medical jargon while still presenting sophisticated, scientific clinical knowledge. And because there is a large amount of information to absorb about the numerous somatic diseases that can masquerade as psychological disorders, the book introduces that information in manageable portions and circles back to look at it from a variety of perspectives.

What Is and Is Not Included

This book focuses on organic disorders that present in adulthood. It does not cover pediatric illnesses, though it does include some medical conditions that might first be recognized in adulthood even though they have been present since childhood (e.g., attention deficit hyperactivity disorder and the autism spectrum disorders). Also, this book is not about the secondary psychological reactions that individuals may have when they are afflicted with a medical illness. Nor is this book about psychosomatic conditions in which an underlying psychological disturbance such as a depression or an unresolved conflict manifests with physical complaints. Psychosomatic disease is exactly the opposite of what I am writing about. With a psychosomatic disorder, the psychological component is hidden; the physical component, on the other hand, is “worn on the patient's sleeve.”

Although Unmasking Psychological Symptoms aims to introduce many of the medical conditions that can masquerade as psychological conditions, it does not claim to be encyclopedic in presenting every disorder that a patient might have. The book also cannot cover every sign or symptom of organic disease that patients might experience.

Disclaimers

This book cannot substitute for a formal consultation with a competent physician. The narrative cases in this book are based on the experiences of real patients and real clinicians. All identifying information has been changed, and often the narratives are composites of more than one clinical story. In all cases, the narratives strive to capture the complexity of actual practice and the essence of the therapist's clinical experience.

The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate.

The fact that an organization or Web site is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Web site may provide or recommendations it may make. Furthermore, readers should be aware that Internet Web sites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.

Chapter 2

Laying the Groundwork

Introduction

This chapter briefly discusses five key concepts upon which this book and much of our clinical work are based. As you begin to reflect on the process of unmasking the clinical presentations of organic disorders, it will be helpful to review these fundamental ideas.

Concept 1: The Significance of Psychological Symptoms

Even when a patient's problems look psychological, an underlying physical disorder may be causing them. This is a fundamental concept upon which this book is based. In other words, psychological symptoms are nonspecific.

Using an analogy, consider the nature of a fever. A fever is nonspecific. If you develop a fever, you know that you have some kind of medical problem. The most likely possibility is that you have some sort of infection, but without other information you wouldn't know whether you had the flu, pneumonia, an ear infection, urinary tract infection, or malaria. A fever is a nonspecific symptom. Psychological symptoms are also nonspecific; they tell you that something is the matter, but they don't tell you exactly what the problem is. And most important, they don't even tell you whether the problem is psychological or somatic.