524
Occasional
Survey
PSYCHOGENIC ILLNESS WITH PHYSICAL MANIFESTATIONS AND THE OTHER SIDE OF THE COIN*
ing it?" Unexplained physical complaints accompanied by changes in at least two of these three areas are strong evidence of a depressive illness. Confirmation may be provided by a past history of similar symptoms possibly attributed to physical illness. Sometimes the patient will add that this time he cannot shake them off. COMBINED PHYSICAL AND PSYCHIATRIC ILLNESS
A Practical Approach
study of hidden psychiatric illness in general that, because of social conditioning, papractice3 tients bring a physical offering to their doctors, and this A recent
RALPH SHULMAN
shows
Vancouver General Hospital and Department
University of British Columbia,
of Psychiatry,
Canada
A DOCTOR’S greatest concern is that he will misdiagA diagnosis is a statement about probabilities, and when mental symptoms mimic, accompany, or mask physical disease, this range of probability may lie between certainty and inspired guesswork. Every day a family doctor may expect to see several patients with vague complaints, particularly of feeling tired or needing a tonic. Such symptoms are often due to mild depression or anxiety, but any one of them may be due to serious organic disease requiring early diagnosis. The practitioner, limited by time, must be selective, and his choice is bound to be affected by non-medical factors, such as his frame of mind, irritation with the patient, or the circumstances of the visit.1 A source of diagnostic error is the law of parsimony, which tries to subsume all the patient’s complaints under one diagnosis. However, illnesses tend to coexist and cluster in at least 25% of patients.2 Hence the question, "Is this organic or functional?". The interaction between physical and psychosocial factors in disease can be complex, and diagnostic errors or delays are especially likely when physical symptoms are the presenting manifestations of psychiatric illness, when there is psychiatric presentation of organic disease, and when combined disease is present. In this paper I make some suggestions for a practical approach to these diagnostic problems. These suggestions are based on my experience with diagnostic referrals in a large general hospital. nose.
PHYSICAL PRESENTATION OF PSYCHIATRIC ILLNESS
presenting with problems of diagnosis, the largest group are those with recurring physical complaints for which there is no obvious cause. In such cases one should be alerted to the possibility of hidden depression. This is especially likely when the complaints are of tiredness, gastrointestinal symptoms, weight-loss, or insomnia. A major problem is that these patients may not acknowledge their depression or may attribute their despondency or anxiety to their physical symptoms. A direct inquiry is therefore necessary, and replies to the following questions may unmask a hidden depression. "Have you noticed ... loss of interet-in work, family, hobbies, or social activities, loss of zest for life, loss of sex drive; slowing-in memory, concentration, reading, thinking, decision-making; mood change—irritability, anxiety, depression, crying spells, unusual fears, overconcern with health, with cancer, with dying; wonder if life is worth while, occasional thoughts of endOf patients
*
Shortened version of a paper presented at a symposium ’Bridging Family Medicine and Psychiatry’ held in Vancouver, April 29, 1976.
may include symptoms which have been present for
a
long time but are only now distressing because of emotional turmoil. This partly explains the diagnostic difficulties presented by patients with known physical disease who are also in acute emotional distress or have a mood disorder, and by patients whose illnesses are perpetuated because they provide some secondary gain (of which the patients themselves may be unaware). Patients should be asked about their interpretation of what is wrong with them. This may reveal that their primary disability is psychogenic rather than physical and has been caused by fear of disease based on ignorance, or by fantasy, perhaps fed by overzealous investigations. PSYCHIATRIC PRESENTATION OF ORGANIC DISEASE
as
Organic disease may have shown below:
a
psychiatric presentation,
Presentation
Disease
Anxiety
Thyrotoxicosis Hypoglycasmia Phecochromocytoma Temporal-lobe epilepsy
state
Conversion reaction
Carcinoid tumour Left-heart failure Focal stroke (speech) Endocrine disease Brain tumour
Epilepsy Neurologiclil
disease chronic physical disease Complications of medical drugs Latent
Depression
or
In order to recognise such patients, a high index of clinical suspicion is essential. Patients tend to have characteristic responses under stress--such as mood disorders or psychophysiological symptoms-and these responses are generally established before midlife. In addition, there is a consistency in symptom patterns,
including physical complaints, in recurring episodes of depression. In anxiety there is arousal of the autonomic nervous system, with either a sympathetic or a parasympathetic pattern of dominance. As a consequence, an individual’s psychophysiological responses tend to remain the same to a variety of external stresses. Thus, when patients present their symptoms one has to ask oneself whether this is new or part of the old repertoire. If new, further inquiries and investigations beyond the psychosocial are required. A GUIDE FOR THE PERPLEXED
This
guide
is illustrated with
examples from my own
practice. 1. The Data Base A good history is the
cornerstone
of
accurate
diag-
525 nosis. This clinical axiom has been validated in a study which examined the relative contribution from the patient’s history, the physical examination, and the laboratory investigations.4 The history should be concerned with the patient’s present illness as well as his biography. A useful practice is to complete a "life chart" for every new patient. This is a chronological summary since birth, with the key dates in the patient’s life arranged under three headings, representing significant personal events and past physical and psychiatric ill health. The last should include a review of the patient’s characteristic responses to stress and, when there is anxiety, the vulnerable psychophysiological target organ. Inspection of this life chart makes a comprehensive diagnosis easier and alerts one when the present complaints are not part of an established pattern. The history should also include an inquiry into the patient’s understanding of his symptoms or illness. Case 1.-A
housewife and part-time schoolteacher presented with recurrent chest and abdominal pain which had developed after a cholecystectomy 3 yr earlier. Subsequent investigations, including coronary angiography, cardiac catheterisation, and pulmonary-function tests, had all been normal. Her pain was now being attributed to a hiatus hernia, although oesophagoscopy was normal. At interview she appeared to be obsessional, with a longstanding pattern of psychophysiological muscle-tension pain. She expressed concern over her husband’s dangerous assignments in the Royal Canadian Mounted Police. She was preoccupied with pain in her right axilla. On close questioning I discovered that she thought her pain was due to multiple sclerosis and that for years she had been afraid to disclose this fear to her doctors. She confided that a twin sister had this disease and with it similar pain. She improved after talking about her fears and with reassurance that she did not have multiple sclerosis.
41-year-old
2. Complaints
versus
Disabilities
We seldom ask patients how their symptoms interfere with their everyday lives. If there is incongruity between the assumed pathology and the patient’s reply, then one should look for a diagnosis other than that suggested by the patient’s presenting complaint. For example, in a patient with a known hiatus hernia and abdominal pain, the answer, "I am afraid to go out in case I faint", drew attention to her life situation, and eventually depression was
diagnosed.
3.
"WhyHaveyou Come Now?" This question may reveal interpersonal crises, problems in living, or secondary gain from illness, such as relieving the patient from painful obligations or postponing unpleasant decisions. It may also draw attention to the presence of depression producing undue pessimism about known physical disease. Case 2.-A Scottish widower in his fifties had emigrated to Vancouver to be with friends after his wife’s death 3 years earlier. He had moderate chronic bronchitis and had become disproportionately disabled, although his physical health was not deteriorating. At interview he described a normal grief reaction when his wife had died but was nevertheless found to be depressed. When asked, "Tell me about Vancouver, what does it mean to you?" he began to cry and described his first visit to Vancouver in 1954 as a member of the Scottish cycling team at the Empire Games. He had been a reserve then and had not participated in the games, much to his disappointment. Returning to Vancouver was a painful reminder of lost opportunities and of declining health. When the significance of this
was
grasped he was rehabilitated successfully with physical a bicycle.
exercise on
4. Onset
of Change While attending to the primary complaint it is also important to ask, "When ’did you last enjoy good health?" or, "How long is it since you were your normal self?" This may reveal that the patient has been unwell for years, often with a masked depression hidden by multiple investigations uncovering disease which only partially explains the initial complaints. This is especially likely when the somatic symptoms have been referred to the gastrointestinal system. 5. Recurrent Illness with New Symptoms
This should alert
one to
the
possibility
of organic dis-
ease.
60-year-old lawyer was being investigated for a history of depression treated with electroconvulsive therapy. He was obviously depressed and was waking early. As his diarrhoea was most troublesome on waking, it had been attributed to his agitation. On inquiry there was no history of diarrhoea in his earlier depression, and for this reason I suggested that it had an independent cause. Further investigations revealed localised ulcerative colitis, which responded well to steroids. Case 3.-A
severe
diarrhoea. He had
6. First
Psychiatric Illness after Mid-life
Army officer was referred because of pelvic pain thought to be hysterical because of normal investigations and her inappropriate emotional reactions. As Case 4.-A Salvation
severe
her age was 54 and she had never had a hysterical illness before, this seemed an unlikely primary diagnosis. After an interview I found no evidence of psychiatric illness. Her medical records showed removal of a breast carcinoma 8 years earlier. During her present admission an abnormally high alkalinephosphatase level had been overlooked because of the dramatic quality of her presenting pain. A tactful suggestion that further investigations for bone secondaries be carried out proved tragically correct, and she died 3 months later.
7. No
Adequate Psychogenesis
It is preferable to admit that the diagnosis is uncertain than to speculate prematurely on a plausible psy-
chogenesis. Case 5.-A medical resident was referred with persistent He had asked to be excused from attending necropsies because of longstanding uneasiness in the post-mortem room. This request had been refused. The nausea became generalised, and the resident was unable to function in clinical or social situations. A gasteroenterologist and a neurologist found no evidence of physical disease. The psychiatric history revealed a preoccupation with death dating back to early childhood and a later decision to enter the Church. However, he had reluctantly entered medicine partly because his father was an eminent physician. The psychiatric diagnosis was anxiety neurosis with psychogenic nausea. When headaches became prominent, further radiological studies revealed an operable brain tumour. The assumed psychogenesis of this illness failed to take into account that the fear of dying had been present since childhood and had not previously interfered with the patient’s functioning as a physician. nausea.
Groups of Patients Among groups of patients vulnerable to misdiagnosis are those with a past psychiatric history. Such patients are often assumed to be "old crocks" and may be given
8. Vulnerable
526 a psychiatric label prematurely. This may lead to their underinvestigation and undertreatment. Doctors are doubly endangered both as victims of mental illness and also as patients with organic disease, being apt to con-
ceal their condition until it becomes too obvious for anyone to ignore. Also at risk are the bereaved with complications of physical and psychiatric illness during the grief period. Case 6.-A widow of 54, whose husband had died 6 months earlier, had been befriended by a former associate of her husband. Her children thought this relationship was untimely. She became anxious and guilty and developed palpitations. Clinical examinations and electrocardiograms were normal, and she was referred for a psychiatric opinion. On entering my room she was so unsteady that I thought she had taken a drug overdose. However, examination revealed uncontrolled atrial fibrillation with combined right and left heart-failure. She was admitted to hospital and was found to have mitral stenosis, for which she had a successful valvotomy. It was concluded that her paroxysmal atrial fibrillation had been precipitated by the stress of her grief reaction and that a final prolonged paroxysm, perhaps related to her anxiety about seeing a psychiatrist, had triggered her into rapid heart-failure.
premature and
"-,
the pancreas.
10. Reliable
Information Finally, since diagnosis depends from as many sources as possible, remains in doubt information. Case 8.-A
man
one
’
upon reliable data when the diagnosis should review the reliability of the
in his mid-fifties
was
admitted
to a neuro-
logy unit with a diagnosis of early dementia. A psychiatric consultation was requested, and the striking clinical features were those of a Korsakoff’s psychosis. He denied being an alcoholic, and his denial was confirmed by his wife and by three adult children. Further investigations were normal, and the cause of his Korsakoff’s psychosis remained unknown. Fortunately he improved and was discharged home. During a preparatory visit to his home the social worker was surprised to find an accumulation of empty whisky bottles. The family indicated that they had been so ashamed of their father’s drinking that they had decided to conceal it. It was emphasised that the father’s recovery depended on his abstaining from alcohol. CONCLUSION
A doctor needs to concede that hidden knowledge, crucial for diagnosis, is often locked up in his patient and that to gain access to this a special kind of psychotherapeutic relationship has to be developed. To achieve this one has to tolerate ambiguity rather than risk
to
accept that
answers
1W3, Canada. REFERENCES
Elliott-Binns, C. P. E. Br. med. J. 1958, ii, 271. Lipowski, Z. J. Compreh. Psychiat. 1975, 16, 105. Goldberg, D. P., Blackwell, B. Br. med. J. 1970, ii, 439. Hampton, J. R., Harrison, M. J. G., Mitchell, J. R. A., Prichard, J. S., Seymour, J. S. ibid. 1975, ii, 486. 5. Bacon, F., cited by Lewis, A. Lancet, 1958, i, 171.
1. 2. 3. 4.
Emergency Action COMPARISON OF RESULTS FROM A CARDIAC AMBULANCE MANNED BY MEDICAL OR NON-MEDICAL PERSONNEL
Weight-loss on Antidepressants Because antidepressants promote carbohydrate craving, patients on these drugs will usually gain weight, although they may not recover from their depression.
"
closure,
end in certainties."5 Requests for reprints should be addressed to R.S., Department of Psychiatry, University of British Columbia, Vancouver, B.C. V6T
9.
Case 7.-A 34-year-old woman with marital and sexual problems had been diagnosed as having an irritable-bowel syndrome by an experienced gastroenterologist. Thorough investigations, including radiological studies, a sigmoidoscopy, and tests for malabsorption, were normal. She was severely depressed and was admitted for inpatient psychiatric care. She continued to complain about her diarrhoea, which was explained to her on the basis of her irritable-colon syndrome. She was treated -with marriage counselling and antidepressants, and after 2 months she was discharged from hospital essentially unchanged. However, I had overlooked that on antidepressants she had lost weight. This should have been an ominous sign. Several months later she died with carcinoma of
erroneous
always clearcut and that symptoms do not fit into neat conceptual systems according to specialty. "If a man will begin with certainties he shall end in doubts but if he will be content to begin with doubts he shall are not
J. R. HAMPTON
MARY DOWLING
CHRISTINE NICHOLAS
Nottingham University Department of Medicine, General Hospital, Nottingham
Summary
During a 20-month period a "cardiac" ambulance was manned on alternate days by specially-trained ambulance personnel only, or by such personnel plus a doctor. The presence of a doctor did not lead to any reduction in the mortality of patients with heart-attacks. Although transport to hospital by the special service was associated with a low pre-hospital mortality, this was balanced by a high pre-hospital mortality in the group of patients brought to hospital by routine ambulances at times when the special vehicle was manned, but for some reason was not used. There was evidence of unintentional selection of low-risk cases for transport by the cardiac ambulance. The number of lives saved by the special service was too small to cause any significant reduction in the overall mortality from heart-attacks in Nottingham. INTRODUCTION
Joint Working Party of the Royal College of Physicians and the British Cardiac Society recornmended that special ambulance services for the transport to hospital of patients suspected of having heartattacks should be further developed; this THE
recommendation was based at least in part on very low death-rates that have been claimed to result from the use of such special services.2 However, the only attempt so far made to compare the results of a special "cardiac" ambulance with those of a routine service3 suggested that, while a special service might save a few lives, it would be unlikely to have any significant effect on the overall mortality from heart-attacks. "Cardiac" ambulance services have been developed using either medical staff45 or specially trained ambulance personnel. 36 It is possible that disappointing results from the second type of service result from inadequate training of the ambulance crews, or from restrictions on the type of care they are allowed to provide.
Occasional
Survey
PSYCHOGENIC ILLNESS WITH PHYSICAL MANIFESTATIONS AND THE OTHER SIDE OF THE COIN*
ing it?" Unexplained physical complaints accompanied by changes in at least two of these three areas are strong evidence of a depressive illness. Confirmation may be provided by a past history of similar symptoms possibly attributed to physical illness. Sometimes the patient will add that this time he cannot shake them off. COMBINED PHYSICAL AND PSYCHIATRIC ILLNESS
A Practical Approach
study of hidden psychiatric illness in general that, because of social conditioning, papractice3 tients bring a physical offering to their doctors, and this A recent
RALPH SHULMAN
shows
Vancouver General Hospital and Department
University of British Columbia,
of Psychiatry,
Canada
A DOCTOR’S greatest concern is that he will misdiagA diagnosis is a statement about probabilities, and when mental symptoms mimic, accompany, or mask physical disease, this range of probability may lie between certainty and inspired guesswork. Every day a family doctor may expect to see several patients with vague complaints, particularly of feeling tired or needing a tonic. Such symptoms are often due to mild depression or anxiety, but any one of them may be due to serious organic disease requiring early diagnosis. The practitioner, limited by time, must be selective, and his choice is bound to be affected by non-medical factors, such as his frame of mind, irritation with the patient, or the circumstances of the visit.1 A source of diagnostic error is the law of parsimony, which tries to subsume all the patient’s complaints under one diagnosis. However, illnesses tend to coexist and cluster in at least 25% of patients.2 Hence the question, "Is this organic or functional?". The interaction between physical and psychosocial factors in disease can be complex, and diagnostic errors or delays are especially likely when physical symptoms are the presenting manifestations of psychiatric illness, when there is psychiatric presentation of organic disease, and when combined disease is present. In this paper I make some suggestions for a practical approach to these diagnostic problems. These suggestions are based on my experience with diagnostic referrals in a large general hospital. nose.
PHYSICAL PRESENTATION OF PSYCHIATRIC ILLNESS
presenting with problems of diagnosis, the largest group are those with recurring physical complaints for which there is no obvious cause. In such cases one should be alerted to the possibility of hidden depression. This is especially likely when the complaints are of tiredness, gastrointestinal symptoms, weight-loss, or insomnia. A major problem is that these patients may not acknowledge their depression or may attribute their despondency or anxiety to their physical symptoms. A direct inquiry is therefore necessary, and replies to the following questions may unmask a hidden depression. "Have you noticed ... loss of interet-in work, family, hobbies, or social activities, loss of zest for life, loss of sex drive; slowing-in memory, concentration, reading, thinking, decision-making; mood change—irritability, anxiety, depression, crying spells, unusual fears, overconcern with health, with cancer, with dying; wonder if life is worth while, occasional thoughts of endOf patients
*
Shortened version of a paper presented at a symposium ’Bridging Family Medicine and Psychiatry’ held in Vancouver, April 29, 1976.
may include symptoms which have been present for
a
long time but are only now distressing because of emotional turmoil. This partly explains the diagnostic difficulties presented by patients with known physical disease who are also in acute emotional distress or have a mood disorder, and by patients whose illnesses are perpetuated because they provide some secondary gain (of which the patients themselves may be unaware). Patients should be asked about their interpretation of what is wrong with them. This may reveal that their primary disability is psychogenic rather than physical and has been caused by fear of disease based on ignorance, or by fantasy, perhaps fed by overzealous investigations. PSYCHIATRIC PRESENTATION OF ORGANIC DISEASE
as
Organic disease may have shown below:
a
psychiatric presentation,
Presentation
Disease
Anxiety
Thyrotoxicosis Hypoglycasmia Phecochromocytoma Temporal-lobe epilepsy
state
Conversion reaction
Carcinoid tumour Left-heart failure Focal stroke (speech) Endocrine disease Brain tumour
Epilepsy Neurologiclil
disease chronic physical disease Complications of medical drugs Latent
Depression
or
In order to recognise such patients, a high index of clinical suspicion is essential. Patients tend to have characteristic responses under stress--such as mood disorders or psychophysiological symptoms-and these responses are generally established before midlife. In addition, there is a consistency in symptom patterns,
including physical complaints, in recurring episodes of depression. In anxiety there is arousal of the autonomic nervous system, with either a sympathetic or a parasympathetic pattern of dominance. As a consequence, an individual’s psychophysiological responses tend to remain the same to a variety of external stresses. Thus, when patients present their symptoms one has to ask oneself whether this is new or part of the old repertoire. If new, further inquiries and investigations beyond the psychosocial are required. A GUIDE FOR THE PERPLEXED
This
guide
is illustrated with
examples from my own
practice. 1. The Data Base A good history is the
cornerstone
of
accurate
diag-
525 nosis. This clinical axiom has been validated in a study which examined the relative contribution from the patient’s history, the physical examination, and the laboratory investigations.4 The history should be concerned with the patient’s present illness as well as his biography. A useful practice is to complete a "life chart" for every new patient. This is a chronological summary since birth, with the key dates in the patient’s life arranged under three headings, representing significant personal events and past physical and psychiatric ill health. The last should include a review of the patient’s characteristic responses to stress and, when there is anxiety, the vulnerable psychophysiological target organ. Inspection of this life chart makes a comprehensive diagnosis easier and alerts one when the present complaints are not part of an established pattern. The history should also include an inquiry into the patient’s understanding of his symptoms or illness. Case 1.-A
housewife and part-time schoolteacher presented with recurrent chest and abdominal pain which had developed after a cholecystectomy 3 yr earlier. Subsequent investigations, including coronary angiography, cardiac catheterisation, and pulmonary-function tests, had all been normal. Her pain was now being attributed to a hiatus hernia, although oesophagoscopy was normal. At interview she appeared to be obsessional, with a longstanding pattern of psychophysiological muscle-tension pain. She expressed concern over her husband’s dangerous assignments in the Royal Canadian Mounted Police. She was preoccupied with pain in her right axilla. On close questioning I discovered that she thought her pain was due to multiple sclerosis and that for years she had been afraid to disclose this fear to her doctors. She confided that a twin sister had this disease and with it similar pain. She improved after talking about her fears and with reassurance that she did not have multiple sclerosis.
41-year-old
2. Complaints
versus
Disabilities
We seldom ask patients how their symptoms interfere with their everyday lives. If there is incongruity between the assumed pathology and the patient’s reply, then one should look for a diagnosis other than that suggested by the patient’s presenting complaint. For example, in a patient with a known hiatus hernia and abdominal pain, the answer, "I am afraid to go out in case I faint", drew attention to her life situation, and eventually depression was
diagnosed.
3.
"WhyHaveyou Come Now?" This question may reveal interpersonal crises, problems in living, or secondary gain from illness, such as relieving the patient from painful obligations or postponing unpleasant decisions. It may also draw attention to the presence of depression producing undue pessimism about known physical disease. Case 2.-A Scottish widower in his fifties had emigrated to Vancouver to be with friends after his wife’s death 3 years earlier. He had moderate chronic bronchitis and had become disproportionately disabled, although his physical health was not deteriorating. At interview he described a normal grief reaction when his wife had died but was nevertheless found to be depressed. When asked, "Tell me about Vancouver, what does it mean to you?" he began to cry and described his first visit to Vancouver in 1954 as a member of the Scottish cycling team at the Empire Games. He had been a reserve then and had not participated in the games, much to his disappointment. Returning to Vancouver was a painful reminder of lost opportunities and of declining health. When the significance of this
was
grasped he was rehabilitated successfully with physical a bicycle.
exercise on
4. Onset
of Change While attending to the primary complaint it is also important to ask, "When ’did you last enjoy good health?" or, "How long is it since you were your normal self?" This may reveal that the patient has been unwell for years, often with a masked depression hidden by multiple investigations uncovering disease which only partially explains the initial complaints. This is especially likely when the somatic symptoms have been referred to the gastrointestinal system. 5. Recurrent Illness with New Symptoms
This should alert
one to
the
possibility
of organic dis-
ease.
60-year-old lawyer was being investigated for a history of depression treated with electroconvulsive therapy. He was obviously depressed and was waking early. As his diarrhoea was most troublesome on waking, it had been attributed to his agitation. On inquiry there was no history of diarrhoea in his earlier depression, and for this reason I suggested that it had an independent cause. Further investigations revealed localised ulcerative colitis, which responded well to steroids. Case 3.-A
severe
diarrhoea. He had
6. First
Psychiatric Illness after Mid-life
Army officer was referred because of pelvic pain thought to be hysterical because of normal investigations and her inappropriate emotional reactions. As Case 4.-A Salvation
severe
her age was 54 and she had never had a hysterical illness before, this seemed an unlikely primary diagnosis. After an interview I found no evidence of psychiatric illness. Her medical records showed removal of a breast carcinoma 8 years earlier. During her present admission an abnormally high alkalinephosphatase level had been overlooked because of the dramatic quality of her presenting pain. A tactful suggestion that further investigations for bone secondaries be carried out proved tragically correct, and she died 3 months later.
7. No
Adequate Psychogenesis
It is preferable to admit that the diagnosis is uncertain than to speculate prematurely on a plausible psy-
chogenesis. Case 5.-A medical resident was referred with persistent He had asked to be excused from attending necropsies because of longstanding uneasiness in the post-mortem room. This request had been refused. The nausea became generalised, and the resident was unable to function in clinical or social situations. A gasteroenterologist and a neurologist found no evidence of physical disease. The psychiatric history revealed a preoccupation with death dating back to early childhood and a later decision to enter the Church. However, he had reluctantly entered medicine partly because his father was an eminent physician. The psychiatric diagnosis was anxiety neurosis with psychogenic nausea. When headaches became prominent, further radiological studies revealed an operable brain tumour. The assumed psychogenesis of this illness failed to take into account that the fear of dying had been present since childhood and had not previously interfered with the patient’s functioning as a physician. nausea.
Groups of Patients Among groups of patients vulnerable to misdiagnosis are those with a past psychiatric history. Such patients are often assumed to be "old crocks" and may be given
8. Vulnerable
526 a psychiatric label prematurely. This may lead to their underinvestigation and undertreatment. Doctors are doubly endangered both as victims of mental illness and also as patients with organic disease, being apt to con-
ceal their condition until it becomes too obvious for anyone to ignore. Also at risk are the bereaved with complications of physical and psychiatric illness during the grief period. Case 6.-A widow of 54, whose husband had died 6 months earlier, had been befriended by a former associate of her husband. Her children thought this relationship was untimely. She became anxious and guilty and developed palpitations. Clinical examinations and electrocardiograms were normal, and she was referred for a psychiatric opinion. On entering my room she was so unsteady that I thought she had taken a drug overdose. However, examination revealed uncontrolled atrial fibrillation with combined right and left heart-failure. She was admitted to hospital and was found to have mitral stenosis, for which she had a successful valvotomy. It was concluded that her paroxysmal atrial fibrillation had been precipitated by the stress of her grief reaction and that a final prolonged paroxysm, perhaps related to her anxiety about seeing a psychiatrist, had triggered her into rapid heart-failure.
premature and
"-,
the pancreas.
10. Reliable
Information Finally, since diagnosis depends from as many sources as possible, remains in doubt information. Case 8.-A
man
one
’
upon reliable data when the diagnosis should review the reliability of the
in his mid-fifties
was
admitted
to a neuro-
logy unit with a diagnosis of early dementia. A psychiatric consultation was requested, and the striking clinical features were those of a Korsakoff’s psychosis. He denied being an alcoholic, and his denial was confirmed by his wife and by three adult children. Further investigations were normal, and the cause of his Korsakoff’s psychosis remained unknown. Fortunately he improved and was discharged home. During a preparatory visit to his home the social worker was surprised to find an accumulation of empty whisky bottles. The family indicated that they had been so ashamed of their father’s drinking that they had decided to conceal it. It was emphasised that the father’s recovery depended on his abstaining from alcohol. CONCLUSION
A doctor needs to concede that hidden knowledge, crucial for diagnosis, is often locked up in his patient and that to gain access to this a special kind of psychotherapeutic relationship has to be developed. To achieve this one has to tolerate ambiguity rather than risk
to
accept that
answers
1W3, Canada. REFERENCES
Elliott-Binns, C. P. E. Br. med. J. 1958, ii, 271. Lipowski, Z. J. Compreh. Psychiat. 1975, 16, 105. Goldberg, D. P., Blackwell, B. Br. med. J. 1970, ii, 439. Hampton, J. R., Harrison, M. J. G., Mitchell, J. R. A., Prichard, J. S., Seymour, J. S. ibid. 1975, ii, 486. 5. Bacon, F., cited by Lewis, A. Lancet, 1958, i, 171.
1. 2. 3. 4.
Emergency Action COMPARISON OF RESULTS FROM A CARDIAC AMBULANCE MANNED BY MEDICAL OR NON-MEDICAL PERSONNEL
Weight-loss on Antidepressants Because antidepressants promote carbohydrate craving, patients on these drugs will usually gain weight, although they may not recover from their depression.
"
closure,
end in certainties."5 Requests for reprints should be addressed to R.S., Department of Psychiatry, University of British Columbia, Vancouver, B.C. V6T
9.
Case 7.-A 34-year-old woman with marital and sexual problems had been diagnosed as having an irritable-bowel syndrome by an experienced gastroenterologist. Thorough investigations, including radiological studies, a sigmoidoscopy, and tests for malabsorption, were normal. She was severely depressed and was admitted for inpatient psychiatric care. She continued to complain about her diarrhoea, which was explained to her on the basis of her irritable-colon syndrome. She was treated -with marriage counselling and antidepressants, and after 2 months she was discharged from hospital essentially unchanged. However, I had overlooked that on antidepressants she had lost weight. This should have been an ominous sign. Several months later she died with carcinoma of
erroneous
always clearcut and that symptoms do not fit into neat conceptual systems according to specialty. "If a man will begin with certainties he shall end in doubts but if he will be content to begin with doubts he shall are not
J. R. HAMPTON
MARY DOWLING
CHRISTINE NICHOLAS
Nottingham University Department of Medicine, General Hospital, Nottingham
Summary
During a 20-month period a "cardiac" ambulance was manned on alternate days by specially-trained ambulance personnel only, or by such personnel plus a doctor. The presence of a doctor did not lead to any reduction in the mortality of patients with heart-attacks. Although transport to hospital by the special service was associated with a low pre-hospital mortality, this was balanced by a high pre-hospital mortality in the group of patients brought to hospital by routine ambulances at times when the special vehicle was manned, but for some reason was not used. There was evidence of unintentional selection of low-risk cases for transport by the cardiac ambulance. The number of lives saved by the special service was too small to cause any significant reduction in the overall mortality from heart-attacks in Nottingham. INTRODUCTION
Joint Working Party of the Royal College of Physicians and the British Cardiac Society recornmended that special ambulance services for the transport to hospital of patients suspected of having heartattacks should be further developed; this THE
recommendation was based at least in part on very low death-rates that have been claimed to result from the use of such special services.2 However, the only attempt so far made to compare the results of a special "cardiac" ambulance with those of a routine service3 suggested that, while a special service might save a few lives, it would be unlikely to have any significant effect on the overall mortality from heart-attacks. "Cardiac" ambulance services have been developed using either medical staff45 or specially trained ambulance personnel. 36 It is possible that disappointing results from the second type of service result from inadequate training of the ambulance crews, or from restrictions on the type of care they are allowed to provide.
