WHEN ANX­I­ETY MASKS A MED­I­CAL IS­SUE

Doc­tors of­ten do not rec­og­nize an emo­tional cause of phys­i­cal symp­toms or ad­dress the emo­tional com­po­nents of a phys­i­cal dis­ease

The Hamilton Spectator - - GO - JANE E. BRODY New York Times News Ser­vice

It’s per­fectly nor­mal for some­one to feel anx­ious or de­pressed af­ter re­ceiv­ing a di­ag­no­sis of a se­ri­ous ill­ness. But what if the re­verse oc­curs and symp­toms of anx­i­ety or de­pres­sion mas­quer­ade as an asyet un­di­ag­nosed phys­i­cal dis­or­der?

Or what if some­one’s phys­i­cal symp­toms stem from a psy­cho­log­i­cal prob­lem? How long might it take be­fore the true cause of the symp­toms is un­cov­ered and proper treat­ment be­gun?

Psy­chi­atric Times, a med­i­cal pub­li­ca­tion seen by some 50,000 psy­chi­a­trists each month, re­cently pub­lished a “par­tial list­ing” of 47 med­i­cal ill­nesses, rang­ing from car­diac ar­rhyth­mias to pan­cre­atic can­cer, that may first present as anx­i­ety. Added to that was an­other “par­tial list­ing” of 30 cat­e­gories of med­i­ca­tions that may cause anx­i­ety, in­clud­ing pop­u­lar an­tide­pres­sants like se­lec­tive sero­tonin re­up­take in­hibitors, or SSRIs.

These lists were in­cluded in an ar­ti­cle called “Man­ag­ing Anx­i­ety in the Med­i­cally Ill,” meant to alert men­tal health prac­ti­tion­ers to the pos­si­bil­ity that some pa­tients seek­ing treat­ment for anx­i­ety or de­pres­sion may have an un­der­ly­ing med­i­cal con­di­tion that must be ad­dressed be­fore any emo­tional symp­toms are likely to re­solve.

Doc­tors who treat ail­ments like car­diac, en­docrine or in­testi­nal dis­or­ders would do well to read this ar­ti­cle as well lest they do pa­tients a se­ri­ous dis­ser­vice by not rec­og­niz­ing an emo­tional cause of phys­i­cal symp­toms or ad­dress­ing the emo­tional com­po­nents of a phys­i­cal dis­ease.

For ex­am­ple, Dr. Yu Dong, a psy­chi­a­trist at Inova Fair­fax Hos­pi­tal in Vir­ginia, and col­leagues pointed out last month that pa­tients with res­pi­ra­tory con­di­tions like asthma, sleep ap­nea or pul­monary em­bolism could present with symp­toms of anx­i­ety, or those with car­diac symp­toms like chest pain or rapid heart­beat could have an anx­i­ety dis­or­der.

The prob­lem of miss­ing the proper di­ag­no­sis grows out of a long-ago sep­a­ra­tion of pow­ers within the med­i­cal pro­fes­sion that of­ten lim­its the abil­ity of prac­ti­tion­ers to see the for­est for the trees, as it were. Med­i­cal doc­tors like car­di­ol­o­gists or gas­troen­terol­o­gists are of­ten ill equipped to rec­og­nize and treat emo­tional symp­toms re­lated to a phys­i­cal ail­ment, and psy­chi­a­trists may not con­sider the pos­si­bil­ity that a pa­tient with symp­toms like pal­pi­ta­tions, fa­tigue or dizzi­ness re­ally has a phys­i­cal ail­ment.

In­deed, doc­tors at the Mon­treal Heart In­sti­tute re­ported in 1996 that about a quar­ter of 441 pa­tients who came to the emer­gency room be­cause of chest pain were in fact suf­fer­ing from panic dis­or­der, not a heart ail­ment. On the other hand, a woman I know who was be­ing treated for panic at­tacks turned out to have a car­diac ab­nor­mal­ity, and once that was cor­rected, her panic at­tacks dis­ap­peared.

Fur­ther­more, anx­i­ety is of­ten over­looked as the source of dis­or­ders like sub­stance abuse or ad­dic­tion, or as a con­tribut­ing fac­tor to symp­toms in con­di­tions like mi­graine headache or ir­ri­ta­ble bowel syn­drome.

The Mayo Clinic lists sev­eral fac­tors that sug­gest the pos­si­bil­ity that anx­i­ety may re­sult from an un­der­ly­ing med­i­cal dis­or­der:

• None of your blood rel­a­tives has an anx­i­ety dis­or­der.

• You didn’t have an anx­i­ety dis­or­der as a child.

• You de­vel­oped anx­i­ety seem­ingly out of the blue.

• You don’t avoid cer­tain things or sit­u­a­tions be­cause of anx­i­ety.

Per­sis­tent anx­i­ety can cause symp­toms like dizzi­ness, nau­sea, di­ar­rhea and fre­quent uri­na­tion. Peo­ple suf­fer­ing from anx­i­ety dis­or­ders can de­velop an ar­ray of ad­di­tional phys­i­cal symp­toms as well, like mus­cle pain, fa­tigue, headaches and short­ness of breath, which can lead to all man­ner of costly tests in a fu­tile search for a phys­i­cal cause. Yet nearly a third of peo­ple with an anx­i­ety dis­or­der are never treated for it.

The prob­lem af­fects chil­dren as well. Anx­i­ety dis­or­ders in chil­dren may be ex­pressed as re­cur­rent stom­ach aches or sleep dis­or­ders, in­clud­ing fre­quent night­mares and teeth grind­ing.

When peo­ple have a chronic phys­i­cal ill­ness, un­treated anx­i­ety can make the symp­toms worse and the dis­or­der more dif­fi­cult to treat. Among pa­tients with chronic ob­struc­tive pul­monary dis­ease, for ex­am­ple, un­treated anx­i­ety can re­sult in more fre­quent hos­pi­tal­iza­tions and more se­vere breath­ing dif­fi­cul­ties. And those with phys­i­cal ail­ments and un­treated anx­i­ety are also more likely to die sooner.

Any­one with a chronic ail­ment who ex­pe­ri­ences symp­toms com­mon to anx­i­ety might con­sider be­ing checked out for this emo­tional com­po­nent and get­ting treat­ment, if needed. There are sev­eral ef­fec­tive ther­a­peu­tic ap­proaches for anx­i­ety, in­clud­ing cog­ni­tive-be­havioural ther­apy and med­i­ca­tion, that can re­sult in a much im­proved qual­ity of life.

De­pres­sion, too, can be an early sign of an un­der­ly­ing med­i­cal con­di­tion not yet rec­og­nized. Among con­di­tions in which this has oc­curred are thy­roid dis­ease, heart at­tack, can­cers of the lung and pan­creas, and the adrenal dis­or­der Cush­ing’s dis­ease.

In a re­port in the journal Psy­chother­apy and Psy­cho­dy­nam­ics, re­searchers from Italy and Buf­falo, pointed out that a neu­ro­log­i­cal dis­or­der like mul­ti­ple scle­ro­sis or Parkin­son’s dis­ease may first show up as a psy­chi­atric prob­lem years be­fore neu­ro­log­i­cal symp­toms be­come ap­par­ent that re­sult in a cor­rect di­ag­no­sis.

They cited a study of 30 pa­tients with mul­ti­ple scle­ro­sis at the Univer­sity of Mas­sachusetts Med­i­cal School, three-fourths of whom ex­pe­ri­enced a de­lay in di­ag­no­sis be­cause they had symp­toms of ma­jor de­pres­sion.

“Physi­cians may not pur­sue med­i­cal workup of cases that ap­pear to be psy­chi­atric in na­ture,” the team wrote. “They should be alerted that dis­tur­bances in mood, anx­i­ety and ir­ri­tabil­ity may antedate the ap­pear­ance of a med­i­cal dis­or­der.”

Thus, it may be up to pa­tients them­selves or their ad­vo­cates to sug­gest to ther­a­pists that some­thing other than an emo­tional prob­lem may be re­spon­si­ble for psy­chi­atric dis­tur­bances that don’t re­spond to stan­dard psy­chi­atric reme­dies.

Keep in mind that hu­man be­ings are not di­vided into two dif­fer­ent or­gan­isms: a phys­i­cal one and an emo­tional one. Mind and body are a sin­gle con­struct with two-way com­mu­ni­ca­tion, and what hap­pens in the body be­low the head can — and of­ten does — af­fect the brain and vice versa.

Med­i­cal prac­tice has been slow to catch up with what was demon­strated by heal­ers long be­fore the ad­vent of modern med­i­cal sci­ence. Al­though these heal­ers may have had noth­ing to ad­min­is­ter more po­tent than a placebo, they could some­times suc­cess­fully treat the body through the mind. Their pa­tients ex­pected the treat­ment to work, and so it of­ten did.

Nowa­days, when re­searchers study the ef­fec­tive­ness of a new treat­ment, they rou­tinely in­clude a con­trol group that acts as a placebo to help de­ter­mine the ben­e­fits of the rem­edy in ques­tion over and above those in­duced by a pa­tient’s be­lief that the new rem­edy will work.

Doc­tors at the Mon­treal Heart In­sti­tute re­ported in 1996 that about a quar­ter of 441 pa­tients who came to the ER be­cause of chest pain were suf­fer­ing from panic dis­or­der, not a heart ail­ment

PAUL ROGERS, NYT

It’s per­fectly nor­mal for some­one to feel anx­ious or de­pressed af­ter re­ceiv­ing a di­ag­no­sis of a se­ri­ous ill­ness. But what if the re­verse oc­curs and symp­toms of anx­i­ety or de­pres­sion mas­quer­ade as an as-yet un­di­ag­nosed phys­i­cal dis­or­der?

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