When Psychological Problems Mask Medical Disorders A
Guide for Psychotherapists - 2nd Edition
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provide information that is complete and generally in accord with the standards
of practice that are accepted at the time of publication. However, in view of the
possibility of human error or changes in behavioral, mental health, or medical
sciences, neither the author, nor the editor and publisher, nor any other party
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Library of Congress Cataloging-i n-P ublication Data
Morrison, James.
When psychological problems mask medical disorders : a guide for
psychotherapists / James Morrison. — Second edition.
pages cm
Includes bibliographical references and index.
ISBN 978-1-4625-2176-0 (paperback) — ISBN 978-1-4625-2177-7 (hardcover)
1. Psychological manifestations of general diseases. 2. Medicine,
Psychosomatic. I. Title.
RC455.4.B5M67 2015
616.08—dc23
2015015975
For Thomas Flanagan, MD—a world-class friend
and one of the finest clinicians I have ever known
About the Author
James Morrison, MD, is Affiliate Professor of Psychiatry at Oregon
Health and Science University in Portland. He has extensive experi-
ence in both the private and public sectors. With his acclaimed prac-
tical books—including, most recently, DSM-5 Made Easy; Diagno-
sis Made Easier, Second Edition; and The First Interview, Fourth
Edition—Dr. Morrison has guided hundreds of thousands of mental
health professionals and students through the complexities of clinical
evaluation and diagnosis.
vi
Contents
Introduction 1
Definitions, 3; Using This Book, 4; In Appreciation, 5
Part I A Review of Symptoms 7
The Need for Evaluation, 8; Observing
the Mental Status, 12; Appearance and Behavior, 15;
Mood (Affect), 26; Speech, 30; Content of Thought, 32;
Intellectual Resources, 36; Insight and Judgment, 39;
Personality Change, 39; Diagnostic Principles, 40
Part II 66 Disorders 43
Adrenal Insufficiency, 44; AIDS, 47;
Altitude Sickness, 51; Amyotrophic Lateral Sclerosis, 54;
Antidiuretic Hormone, Inappropriate Secretion, 56;
Brain Abscess, 58; Brain Tumor, 60; Cancer, 63;
Carcinoid Syndrome, 66; Cardiac Arrhythmias, 68;
Celiac Disease, 71; Chronic Obstructive Lung Disease, 73;
Congestive Heart Failure, 76; Cryptococcosis, 78;
Cushing’s Syndrome, 80; Diabetes Mellitus, 82;
Epilepsy, 85; Fibromyalgia, 89; Heavy‑Metal Toxicity, 91;
Herpes Encephalitis, 94; Homocystinuria, 96;
Huntington’s Disease, 97; Hyperparathyroidism, 100;
Hypertensive Encephalopathy, 103; Hyperthyroidism, 105;
Hypoparathyroidism, 107; Hypothyroidism, 110;
vii
viii Contents
Kidney Failure, 112; Klinefelter’s Syndrome, 115;
Liver Failure, 118; Lyme Disease, 121;
Ménière’s Syndrome, 123; Menopause, 125;
Metachromatic Leukodystrophy, 127; Migraine, 129;
Mitral Valve Prolapse, 132; Multiple Sclerosis, 133;
Myasthenia Gravis, 137; Neurocutaneous Disorders, 139;
Normal‑Pressure Hydrocephalus, 141; Parasitism, 143;
Parkinson’s Disease, 146; Pellagra, 149;
Pernicious Anemia, 150; Pheochromocytoma, 153;
Pneumonia, 155; Polycystic Ovary Syndrome, 157;
Porphyria, 158; Postoperative Delirium, 160;
Premenstrual Syndrome, 162; Prion Disease, 165;
Progressive Supranuclear Palsy, 167;
Protein Energy Malnutrition, 169;
Pulmonary Thromboembolism, 172;
Rheumatoid Arthritis, 173; Sensory Deficit, 177;
Sickle‑Cell Disease, 179; Sleep Apnea, 181;
Stroke (Cerebrovascular Accident), 183;
Substance Intoxication and Withdrawal, 187;
Syphilis, 191; Systemic Infection, 194; Systemic
Lupus Erythematosus, 197; Thiamine Deficiency, 199;
Traumatic Brain Injury, 203; Wilson’s Disease, 208
Part III Symptom Summaries 211
Suggested Readings 235
Index 241
Introduction
Almost always, physical illness has some kind of emotional impact.
It stands to reason that having a serious illness will cause anxiety
or depression. Yet of the thousands of medical disorders to which
humankind is heir, there are just a few that directly cause mental
symptoms. This relative handful makes up the subject matter of this
book.
The sort of diagnostic problem I have addressed can arise in a
variety of contexts:
• The situation often arises when you, the clinician, must
determine whether depressive symptoms are caused by a
physical disorder, in contrast to a depressive disorder. An
exactly analogous case can be made for symptoms of anxiety
or psychosis.
• In another common scenario, you need to know whether a
patient’s already proven physical illness can account for a
given set of mental symptoms. Examples might be drawn
from the entire contents of this book.
• The diagnosis of somatization disorder (in current diagnos-
tic parlance, somatic symptom disorder, though I prefer the
earlier term) and other similar conditions has been a staple of
1
2 When Psychological Problems Mask Medical Disorders
mental health differential diagnosis for many years. Unhap-
pily, this is still an area where far too few practitioners,
whether in medical or mental health arenas, have adequate
training and experience.
• Over a period of days or weeks, or even longer, you notice a
change in your patient’s behavior (it’s less reserved, perhaps,
or you note some mannerisms). Is the change caused by the
gradual onset of a primary mood disorder or by physical ill-
ness?
• Altered appearance, which may be quite external, such as
changes in the condition of your patient’s skin, or (by infer-
ence) internal, as hinted by the beginnings of a limp or
tremor, can herald either physical or mental disease. How do
you determine which interpretation is correct? For that mat-
ter, how do you even know where to go to find out?
• Your patient is being treated for “typical” symptoms of, say,
a depressive disorder but doesn’t get well. Could the cause of
these symptoms actually be a physical disease?
• Finally, in my experience with well over 15,000 mental health
patients, it is distressingly easy—perhaps it is the norm—to
see a patient for several months, long enough to become
comfortable with the mental health diagnosis for which you
are providing treatment. So it is another goal of this book to
stimulate practitioners to think outside the mental health box
and consider other diagnoses for patients with whom they
have had long acquaintance.
In each of the situations above, knowledge of disease and the diagnos-
tic process can be critical for a patient who, with less careful consid-
eration, might retain an inaccurate diagnosis until incapacitated—by
a disease that, with earlier detection, could have been corrected.
I don’t plan to discuss those conditions (such as uncomplicated
asthma) that may be worsened by stress but do not cause mental
symptoms themselves. And I have omitted the genitourinary diseases,
whose emotional symptoms are primarily sexual; of course, they are
important, but these sexual problems are a bit specialized for most
mental health practitioners. Although drugs and other toxins need
entire books to do them justice, their importance to our patients and
to the diagnostic process requires their mention here.
Introduction 3
Definitions
I have tried to define the more specialized medical terms I’ve used;
usually, I’ve redefined them for each section of the book. In this
regard, I apologize for omissions and redundancies.
Several terms deserve special explanation. I have been a bit cava-
lier with symptom. Strictly speaking, a symptom is what a patient
complains of (back pain, swollen joints, an anxiety attack, hearing
voices), whereas a sign is what an observer notices about the patient
(reddened skin, swollen joints, worried facial expression, clenched
fists). In this book, I have allowed symptom to refer to either; it seems
perfectly understandable and a bit more relaxed. Until late in the
19th century, the two terms were used more or less interchangeably.
Even today, the distinction is not razor-sharp: Note that “swollen
joints” appears on both of the lists just given as examples.
The term syndrome I have used in the traditional sense, to mean
a collection of symptoms that commonly occur together. (The word
has Greek roots, and it means “running together.”) Most patients
who have any given syndrome will experience some, but not all, of
the symptoms usually associated with it.
In assigning degree of rarity to the illnesses described in Part
II, I confess to a certain arbitrariness. But epidemiology has yet to
become an exact science, and for many of these diseases the data are
sparse, contradictory, or even nonexistent. Often the numbers must
be estimated. Nevertheless, for better or for worse, I have tried to
categorize all of these illnesses as follows:
Common. Most adults have at least one friend or acquaintance
who has, or will have, the condition in question. The preva-
lence ranges to as low as 1 in 200.
Frequent. A town or small city will be home to one or more of
these people. Frequency ranges downward from 1 in 200 to
1 in 10,000.
Uncommon. There will be at least one such person in a large
city (or small state). These patients occur as infrequently as
1 in 500,000. When one is identified, it is often cause for a
grand-rounds presentation in a hospital or medical school.
Rare. Less frequent than 1 per million. When encountered, such
a patient is likely to be written up in a medical journal.
4 When Psychological Problems Mask Medical Disorders
Keep in mind that the frequencies stated are those of the illnesses
themselves; mental complications will generally occur in only a
minority of cases. Also note that most frequencies are given in terms
of lifetime prevalence—the likelihood that a person will develop the
illness at some time prior to death.
In discussing evaluation, I have tried to indicate only the one
or two tests that are the simplest, most helpful, or most commonly
used. Of course; the workup of most patients will include far more
tests and procedures than can be usefully described in a book of this
nature.
Using This Book
You can use this book in a number of ways.
1. Use the first portion of Part I as a guide to the sorts of obser-
vations you can make that might indicate a physical disorder. I have
arranged these within the framework of the typical mental status
examination (MSE), familiar to any mental health professional. The
descriptions* given here will point the way to some of the illnesses
discussed later in the book.
2. Part II discusses some 66 disorders that can have important
implications for mental health patients. You can learn something
about the typical appearance (physical and mental) of patients who
have these disorders. Of course, the disorders can include many symp-
toms besides those I have detailed in this section, which attempts
only to list those that are most important, common, or prominent.
3. Part III cross-
tabulates every disorder discussed in Part II
against the mental and physical symptoms discussed. At a glance,
you can see how, for example, typical neurological symptoms of
hypo- and hyperparathyroidism compare.
4. You can also use Part III as an index to the disorders in which
any given symptom might be found. But heed the warning that almost
* In discussing the various symptoms, syndromes, and disorders, I have described
patients who are composites of the people I have known throughout my profes-
sional life; any similarity to an actual, individual person is unintentional.
Introduction 5
anything is possible in medicine, and that any compilation of symp-
toms can be neither exhaustive nor exclusive.
5. Finally, I have included a brief list of Suggested Readings.
I hope that by the time you finish this book, you will have
become:
• More aware of mental symptoms that occur in the course of
physical disease.
• More alert to the physical symptoms (and signs!) that could
indicate the need for a medical intervention.
• Increasingly curious about illness beyond the usual interests
of the mental health practitioner.
In Appreciation
For their help with the first edition of this book, I want to express my
appreciation to several people. They include V. Kay Hafner, Andrew
Henry, Barbara Nicholson, and Mary Walters, who have helped me
realize anew why I so appreciate librarians; the anonymous critics
who contributed their time and wisdom; and Mary Morrison, for her
usual and unusual support and advice. I especially want to thank G.
Arul, MD, Arthur Swislocki, MD, and the many mental health pro-
fessionals whose after-class comments and requests provided much of
the inspiration for the first edition.
For this edition, I’ve added some text and made many alterations,
often occasioned by changes in our understanding and treatment of
the syndromes themselves. I also want to express my appreciation for
the contributions of my editors at The Guilford Press, especially Anna
Brackett, Editorial Project Manager; Marie Sprayberry, ace copy edi-
tor; and of course Kitty Moore, my editor and long-time friend.
Pa r t I
A Review of Symptoms
Melissa Block had her therapist worried. She had been completely
healthy until 9 months earlier, when at age 42 she had gradually
developed anxiety, nausea, and episodic vomiting. She had also
begun to complain of depression, and she seemed to worry obses-
sively about her health and her family. Abdominal pain, weight loss,
and mild lethargy led to several medical evaluations. A physical
exam and routine lab studies were all normal, so her family doctor
referred her for psychotherapy. At her first appointment, she cried
and paced nervously around the room, complaining of depression
and trouble sleeping at night.
But 2 months of therapy (combined with an antidepressant drug
in doses that would be adequate for most people) had yielded no
improvement. Melissa’s depression continued unabated, and, truth-
fully, it did not seem excessive in light of her continuing abdomi-
nal pain. Recent family problems—her husband had confessed to a
long-standing affair with the woman who had once been their real
estate agent—suggested an emotional component to her difficulty.
Melissa had never been one to complain much about her health.
As a matter of fact, in the past she had shrugged off worse problems
than those she had now—notably the combat death of her first hus-
band and the loss of a baby to sudden infant death syndrome. But
with no history of manic symptoms, no family history of mood dis-
order, and little improvement with treatment, of course her clinician
was worried. This illness did not seem at all like a primary mood
disorder. Back to her internist went Melissa for more tests.
7
8 When Psychological Problems Mask Medical Disorders
Another physical exam and more blood tests were normal, but
a repeat of an earlier radiological examination finally provided a
lead. An upper gastrointestinal (GI) series, this time with small-
bowel follow-through, revealed a slight shrinking of the lining of
the small intestine. It was enough to justify an exploratory laparot-
omy, which revealed a pancreatic cancer that had invaded Melissa’s
small intestine.
Happily, most of the disorders that can produce mental symp-
toms are less serious than pancreatic carcinoma (Melissa died only
a few months after the diagnosis was made). Although research has
yet to determine what percentage of patients have mental symptoms
that are caused or exacerbated by physical disease, it seems safe to
guess that every mental health practitioner with an active caseload
will encounter such patients. The lifetime prevalence of the medical
disorders described in this book is such that most of us will at some
time or other contract at least one—though, as previously stated, in
most cases they will not produce mental symptoms.
The Need for Evaluation
If your patient starts convulsing or coughing up blood, you realize
at once that something is wrong. But many symptoms of physical
illness are far less obvious. If they develop gradually enough, even
life-threatening symptoms may not seem alarming.
At first, the patient may not even have physical symptoms. Early
manifestations may be strictly emotional or behavioral, and, like
Melissa Block’s, they may have been previously investigated and dis-
carded as unimportant. To counteract the potential for confusion,
you can use several principles to help determine which symptoms
demand attention:
• New symptoms. Of course, the ideal time to detect a new
disorder is with the patient’s first symptom. The trouble is
that the first time a symptom occurs, it may be relatively mild
and go unnoticed.
• More symptoms. This principle seems pretty obvious.
A cough may escape your notice; you will pay far more
