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Book Forum: Psychotherapy   |    
When Psychological Problems Mask Medical Disorders: A Guide for Psychotherapists
Am J Psychiatry 2000;157:142-a-144.
View Author and Article Information
Providence, R.I.

by James Morrison. New York, Guilford Publications, 1997, 213 pp., $30.00.

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Psychiatry is unique among the medical subspecialties in its rich and important collaboration with nonphysician mental health professionals. With the advent of managed care, the advancing understanding of the neurobiology of psychiatric illness, and the tendency to treat a greater number of patients pharmacologically, the work of the ever-important psychotherapy treatment modalities has fallen to nonphysician therapists. Given their rigorous training and primary focus on psychotherapy, this division of labor is appropriate. However, as more patients seek initial psychiatric care with clinicians who are not medically trained, the evaluation of reversible medical and neurological diagnoses that may account for their presenting mental symptoms may not be adequately considered.

Psychological symptoms are often caused by and can signal the presence of primary medical disease. Indeed, it has long been recognized that identifiable medical and neurological illness can to lead to secondary neurobehavioral symptoms and presentations—including depression, mania, psychosis, and even obsessive-compulsive disorder. Functional psychiatric symptoms and diagnoses, therefore, are best considered diagnoses of exclusion. In this context, Dr. Morrison’s text addresses the issue of and alerts the psychotherapy clinician to the need for medical-psychiatric differential diagnosis in the evaluation of new or changing psychological symptoms.

The text is divided into three parts: part 1 addresses the psychiatric review of systems and the mental status examination as they relate to general and focused observations of the patient, part 2 presents a discussion of 60 medical-neurological disorders that commonly present with neuropsychiatric symptoms, and part 3 is in the form of a summary table that cross-references the occurrence of organ-specific signs and symptoms with the 60 diagnoses elaborated in part 2.

Part 1 emphasizes the importance of a good mental status examination and the value of general observations that precede a more focused psychiatric review of systems. Physicians’ examinations are guided by the directive to "look, listen, and feel." The general observation of a patient (looking) should always precede any more focused, interactive examination that may itself change the observed. As such, it constitutes the first opportunity to collect data relating to a patient’s presenting complaint. Although Dr. Morrison does a nice job of elaborating the role of the mental status examination in the evaluation of the patient, this section could be tighter. For instance, the listing in the text of diagnoses that might account for various findings on the mental status examination appears at times arbitrary. Clinical vignettes in this section make for easy case-based reading but do little to further illuminate the text. Additionally, the content of specific subsections of the mental status examination discussion need better elaboration, including such points as the differentiation between mood and affect and a more accurate labeling of "intellectual resources" as part of the cognitive examination.

A strong point of this introductory section is Dr. Morrison’s emphasis on the need to reevaluate one’s working diagnosis serially in the face of evolving complaints and clinical findings. Identifiable syndromes and diagnoses crystallize from these component signs and symptoms. Regular attention to clinical changes may allow for the recognition of an identifiable syndrome as an explanation for somatic and psychiatric findings earlier undiagnosed. To this end, Dr. Morrison instructs the clinician to remain vigilant to new and changing data that may allow for synthesis of information and more accurate diagnosis.

Part 2 presents brief descriptions of the medical and behavioral signs and symptoms of 60 disorders that Dr. Morrison considers to be responsible for the vast majority of secondary psychiatric presentations. Descriptions are brief, to the point, and arranged alphabetically from adrenal insufficiency to Wilson’s disease. Dr. Morrison does well to balance the cautious message of considering medical causes in the production of mental symptoms with the fact that most mental symptoms are caused by traditional functional psychiatric disorders. Moreover, he points out that the majority of patients with medical and neurological diagnoses will not develop psychiatric symptoms. Dr. Morrison’s message is well summarized by a variation of an old medical adage, "When you hear hoof beats, think horses, not zebras (but always consider zebras)."

The alphabetical organization of part 2 makes for easy reference but does not necessarily treat the content very efficiently. For instance, rather than discussing individually (and under separate headings) the often similar neurobehavioral presentations of specific central nervous system (CNS) processes such as abscess, tumor, stroke, and traumatic brain injury, a more focused approach involving an examination of the neurobehavioral syndromes (aphasia, agnosia, neglect, apathy, abulia, disinhibition, and personality change) caused by disruption of specific parts of the brain, regardless of etiology, would likely be more efficient and informative. Other subjects in this section could be treated in greater depth, including seizures, Parkinson’s disease, and pseudobulbar affect. In the case of seizures, a broader conceptual discussion of ictal, postictal, and interictal states and their relationships to behavior would be helpful. For Parkinson’s disease, further discussion of psychotic symptoms, their relationship to dopaminergic treatments, the use of atypical antipsychotic agents in relation to extrapyramidal symptoms, and a broader elaboration of parkinsonism as a syndrome would benefit the reader. As for pseudobulbar affect, which is discussed with multiple sclerosis, further discussion could have focused on the important differentiation and occasional disconnection between objective findings and subjective mood state in the evaluation of patients with mental symptoms and neurological disorders.

In other areas of section 2, medical terminology and information need to be more carefully presented. In the subsection on kidney disease, glomerulonephritis is referred to as an infection rather than as an inflammatory condition with multiple etiologies. In the subsection on liver disease, the cause of hepatitis B rather than hepatitis A is erroneously attributed to contaminated shellfish. Finally, in the discussion of Wilson’s disease, the author says that it is not clear if the associated psychiatric symptoms are the result of direct CNS toxicity from copper or if they represent the psychological reaction of young patients to debilitating disease. I suspect that most clinicians would argue the former with some certainty.

Dr. Morrison’s writing style is very comfortable and readable. His use of humor helps to keep the reader engaged in the face of large amounts of data presented in part 2. I sometimes wonder, however, if such casual statements as, "the kidney works hard" in reference to diabetes and glucose spilling, "there is hell to pay" in reference to the sequelae of sickle cell disease, and "a disorder to be reckoned with" in reference to systemic lupus erythematosus are unnecessarily light and take away from the quality of his work and the more scientific style with which he approaches most of the text.

In part 3, Dr. Morrison does an excellent job of synthesizing the information presented in part 2 into readable and referenceable tables. The volume of information presented in part 3 is well condensed and made user friendly in this form.

Dr. Morrison has tackled the important topic of psychiatric diagnoses as exclusionary and presented it well. By learning always to consider medical causes in the evaluation of psychiatric-psychological symptoms, the issue becomes less one of psychological problems "masking" medical disorders and more one of medical disorders presenting with psychological symptoms. This requires a shift and a broader conceptualization of psychological symptoms as brain-based and thus more accurately considered neurobehavioral in origin. Dr. Morrison’s text provides a sound introduction to this broader approach. Although the consideration of medical-neurological disease in the evaluation of psychiatric symptoms is important for all mental health clinicians, I assume that most well-trained psychiatrists do so automatically and routinely as part of their approach to the patient. As such, this text is aptly targeted toward and represents a valuable resource for clinicians who are not medically trained but would likely seem somewhat elementary to psychiatrists.




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