The National Council of Psychotherapists
in Ethical Practise: Psychological Presentations of Medical Conditions
Christopher K. Johannes, PhD, HMD
do no harm”
Indulge me with your imagination to the following fictitious though
20-something client is referred to you by her GP with complaints of mild
depression, anxiety, restlessness, poor concentration and a chronic sense of
lethargy and malaise for which no apparent cause has been found. Visits to the
doctor had not revealed anything out of the ordinary.
She reports having had a history of taking the latest anti-anxiety and
anti-depressant medications, with little or inconsistent effect. She reports days and parts of the day when she
experiences exacerbations and ameliorations, and though lacking in energy and
motivation much of the time, she occasionally feels fine and she does not report
feelings of apathy, depressed intent or volition; to the contrary, she has an
eager intent and despite her reported disposition, she assures you that she
maintains an inner enthusiasm for life, her friends and her studies.
Her difficulties, she reports, are in her attention, energy, moodiness,
languor and anxiety, which has, on a number of occasions, already discouraged
her to the point of tears, despondency and social withdrawal. She also reveals
having had a history of counselling and psychotherapy, out of which she reports
having achieved greater self understanding, self-validation, feeling generally
accepting and congruent about her identity and having made significant strides
in coping with the conflicting demands and stresses of her family, her partner
and her own pursuits, career, social, artistic, expressive and academic.
Nevertheless, she reports continuing struggles in managing her stress,
relationships and interests, but insists that the difficulty has nothing to do
with these in and of themselves or her attitude toward them, but rather come
about through her unbidden states of mood, energy and attention.
She feels at the end of her tether and wants desperately to get to the
bottom of it. Since her trusted
doctor found nothing medically wrong with her, and since the prescribed
medication had been largely ineffective, she comes to you for assistance with
the challenges of sorting out the “psychological roots” of her dilemma.
the sixty-four-thousand dollar question is, given this nebulous and
contradictory presentation, what do you do?
What are the first thoughts and questions running through your mind?
You may wish to jot these down, because they may reveal a great deal
about your own diagnostic, ethical, theoretical and professional proclivities,
blind spots and biases.
the following questions: What do
you know? How do you know what you
know and how certain are you? What
don’t you know? What do you feel
you really need to know? How will
you find out? What determines
whether or not you decide to work with her or refer?
If you decide to refer, whom to and for what?
What are your main concern(s) and central responsibilities?
Suppose you consider her condition in psychosomatic/psycho physiological
terms. How is this likely to
influence or guide the nature of the psychotherapeutic relationship (roles) and
possible interventions? Suppose you
consider the doctor may have missed something.
Yet she’s convinced, along with her doctor, that it’s “all
psychological” and requests you not to bother with anything but
psychotherapeutic care. Do you comply?
doctor visits likely took less than 15 minutes to run through the protocol on
deciding how to treat her. You have
an hour with her. As a
psychotherapist, like her doctor, your first concern is the welfare of the
client and above all, “first, do no harm”.
You, like the doctor, are also called upon in your professional ethics to
recognise the limits of your competence and to recognise the gaps in your skills
and training. Optimally meeting the
ethic and responsibility of doing no harm and practising competently require a
certain experiential and knowledge base. Though
most of us are familiar with the psychological influences on physical
conditions, even recognising in a holistic sense that it is difficult to
characterise any condition which is not “psychosomatically” influenced to
some degree, we nonetheless tend to have little background in those conditions
that could primarily be qualified as “somatopsychic”, or rather, medical
conditions with a psychological presentation primarily, symptomatically, or
secondarily in adaptation.
vs. Psychosomatic Presentations
know from research in psychoneuroimmunology that there really is no clear
demarcation between mind (psyche) and body (soma) and that the distinction
between psychological and somatic is in many ways purely academic.
The molecules of thought and emotion that concentrate in and course
throughout the brain are not only everywhere else in our bodies, effecting every
cell, but they are also the very same informational molecules of the soma that
direct the flow of communication and information for all activity in the human
anatomy and physiology (Pert, 2000). The
distinction between mind and body is in this sense purely academic, depending
upon the context and area in which we find these information molecules.
That said, we nevertheless have to direct our focus on not only their
primary places of origin or activity, but also to the results and symptomatic
manifestations of their feedback loops. Though
one might philosophically argue for a treatment focus on either the mind or the
body as a point of possible primary
intervention, the academic distinctions and representations of psyche and soma
as psychosomatic and somatopsychic serve us by providing guiding roadmaps as to
the primary point of intervention and leverage.
Therefor, psychological presentations of somatic conditions need to be
heeded in our concern for the welfare of our client, certainly as much as
physical conditions that contribute to or cause psychological symptoms are not
as rare as they may seem. In a
number of large studies of psychiatric patients, between 9-18% were found to
have a medical disorder causing their psychiatric symptoms (Flaherty, et. al.,
1989). Numerous studies have shown
that previous screening tests and medical examinations offer no absolute
guarantee that the client (patient) is without physical illness, either
independent of the psychological symptoms or directly related to them (Schenkenberg,
1999). In a study of 2090
psychiatric patients, for example, Koranyi (1979) found that 43% were actually
suffering from one or more physical illnesses, out of which 46% of these remained undiagnosed by the referring source.
Similarly, a study (Anderson, et. al. 1989) encompassing some 50,000
autopsied cases over five decades, described the great and worrisome variations
in accuracy of clinical diagnosis depending on disease condition.
The authors concluded with commentary on “necessary fallibility” as a
fact of clinical life. In fact,
this is not too shocking for the medical community, because in the early stages,
many illnesses are very difficult to detect, sharing symptom overlap with a
greater variety of other conditions. This
results in failure to order investigative screening and examinations that might
accurately pinpoint the problem.
when confronted with confusing, contradictory and unclear client presentations
as in the example given, many doctors have been too eager to reach for the
latest vigorously promoted psychiatric medications, such as the latest Selective
Seratonin Re-uptake Inhibitors (SSRIs, like Prozac or Zoloft).
In fact, the majority of “drugs for mental health” are prescribed not
by psychiatrists, who are more familiar with the complexities of psychological
symptom presentation, but by GPs whose expertise in the area is comparatively
limited, despite any posturing to the contrary.
Side effects or treatment failures often complicate the symptom picture
even further, and the changed profile may last for some time after the
withdrawal of any medication or other treatment.
a client presents with what may appear to be clinical or sub-clinical
depression, the first diagnostic question that runs through the doctor’s (or
psychotherapist’s) mind might be, “is this person depressed?”, as opposed
to, “what, if anything, is wrong with this person at this time?”.
The former question may bias the focus to the criteria for depression or
another functional mood disorder, whereas the latter avoids this bias in order
to consider discovery of conditions falling outside the mental health arena as
well. It is widely known that many
general medical conditions produce symptom patterns meeting the criteria for
clinical or sub-clinical depression.
being alert to conditions that masquerade with a psychological presentation, the
psychotherapist is better equipped to ethically and competently serve the
welfare of the client. This
addition to the knowledge base puts the psychotherapist in a better position to
refer judiciously and, as and where appropriate, to actively collaborate with
the physician in arriving at an as accurate an answer to the latter question as
possible. For the welfare of the
client, your professional and aspirational ethics should warrant no less.
Somatopsychic Conditions: Medical Conditions in Psychological Masquerade
there are relatively few workshops or courses dealing with the psychological
manifestations of physical illness. These
would be ideal in the training and continuing education of all psychotherapists.
Not finding formal training, however, does not excuse the psychotherapist
from not picking up a copy of a psychiatric manual on their own and becoming
familiar with the section on ‘Medical Conditions with Psychiatric Symptoms’.
LANGE Clinical Manual of Psychiatry (Flaherty, et. al. 1989) lists 11 different
categories of medical conditions that may present with psychological symptoms.
A brief list and summary of just a few of these are provided below.
The reader is encouraged to follow up to learn more.
It is estimated that 30-50% of epileptics have co-occuring psychiatric
problems, with personality disorders being the most frequent, followed by
psychosis. In addition to possible hallucinations, illusions and dream
like states, interictal psychiatric symptoms can include personality problems,
anxiety, depression, withdrawal, destructive assaultive behaviour,
obsessive-compulsive symptoms, deviant sexual behaviour and euphoria.
Focal Brain Lesions
Patients with supratentorial neoplasms may present with depression,
anxiety and confusion. Those with
frontal lobe disease may present with euphoria, labile affect, disinhibition,
childish behaviour and distractibility. In
its milder forms, basilar artery infarction may present with decreases in
spontaneous activity, delayed response or sleepiness.
In subclavian steal syndrome, the client may present with episodes of
anxiety associated with dizziness and intermittent confusion.
Creutzfeld-Jacob Disease (CJD, as in the headlines recently), for
example, may present with depression and psychosis associated with dementia.
Associated with anxiety and personality changes that can last for months.
Sleep Apnea Syndrome
of these disorders will present with anxieties and depressions, dysphoria,
changes in eating behaviour and fatigue.
Hyperparathyroidism, for example, includes symptoms of dysphoria, loss of
initiative, anorexia and fatigue, in which a normalisation of calcium levels
resolves the symptoms. In
Pheochromocytoma, the initial presentation can be with sudden onset of severe
anxiety, which may progress to acute, but transient psychosis.
Hypercortisolism (Cushing’s Disease)
Hypocortisolism (Addison’s Disease)
Sex Hormonal Disorders
Hyperventilation Syndrome—Is associated with anxiety
Chronic Obstructive Pulmonary Disease—Is associated with depression,
apathy, withdrawal and helplessness.
Sleep Apnea Syndrome—Is associated with fatigue and excessive
somnolence, especially during the daytime, and depression.
may be wise to pay particular attention to this category.
In pancreatic carcinoma, for example, the initial presentation may
revolve around symptoms of depression, loss of motivation, and a sense of doom.
These symptoms can predate the discovery of the tumour by years.
include anemias which pay present as depression and can include symptoms of
anorexia, decreased libido, weakness and fatigue.
include Hepatitis that typically features severe depression in the recovery
and Toxic Disorders
of this is, especially the effects of endocrine disrupters/mimicers, still being
researched. These may be
encountered more than the others and are worth paying particular attention to.
They include hypo and hyperglycemia, which frequently presents with a
combination of anxiety and depression related symptoms that include mood
changes, weakness, fatigue and inability to concentrate.
These also include vitamin deficiencies, such as lack of vitamin
B12—which can produce symptoms of apathy and severe depression; lack of
vitamin B6—often manifested as depression, typically associated with oral
contraceptive use or alcoholism; Folic acid deficiency—can manifest as
fatigue, insomnia, memory impairment, restless legs and depression.
are also essential to learn about, as they can account for roughly 12% of the
medical causes of anxiety.
Systemic Lupus Erythematosus
present with depression and sometimes schizophreniform disorder.
occurring in the elder population and manifested as fatigue and depression,
concomitant with pain and headache.
Mixed Connective Tissue Disease
affecting women and can present as depression and anxiety.
Polymyalgia Rheumatica—Typically presents with fatigue and depression.
symptoms will vary depending on location
Paraneoplastic syndromes—may include psychological presentations of
lethargy, anorexia, memory impairment and confusion.
Carcinoid syndrome—will often involve serotonin-secreting tumours and
may manifest as severe depression, anxiety, confusion or hypomania.
to my studies into the worlds of natural, homeopathic and behavioural medicine,
I have actually encountered clients presenting with profiles not dissimilar to
the one conjured up for you in this presentation.
Their frustration was often enormous.
Was it all in their head, in their body, or some mystical combination of
things? To ferret it out was no
easy task and I we were not always completely successful.
The most common somatopsychic presentations I have encountered in my own
practises were of the Metabolic and Toxic variety, which, after confirmatory
tests as simple sometimes as a Glucose Tolerance Test, resolved rather quickly
with non-invasive ensuing treatments such as dietary, lifestyle, hygienic,
movement or environmental adjustments. Sometimes
restricting sugar, caffeine and a spinal adjustment here and there will indeed
get to the bottom of what seems to be an intractable psychological presentation,
and with a lot less time, expense and grief.
Other times, more sophisticated treatment may be called for that might
just save the clients life!
practise in psychotherapy demands that therapists do no harm, make the welfare
of their clients the priority and recognise the gaps in their competence and
training. The training of
psychotherapists typically does not offer much in the way of formal study that
explores the psychological presentations of medical conditions, psychosomatic
and somatopsychic feedback loops, nor the intricacies of therapeutic leverage in
the treatment of conditions with unclear psyche-soma presentation. In order to
do the utmost to insure the optimal care and welfare of the client, the
psychotherapist needs to be aware of somatopsychic conditions, learn when to
refer in these cases and collaborate with the medical community when there is an
index of suspicion.
clients resisting such referral or treatment, appropriate ethical safeguards of
disclosure and consent must be included in considering further psychotherapy.
Failure to take these steps can be considered professionally remiss.
Referring and collaboration mean that the psychotherapist has a valuable
role to play and which may certainly include continued psychotherapy, as in
psychosomatic conditions, depending on the condition and goals for treatment.
In the absence of formal training or continuing education, the
psychotherapist can independently avail themselves of a number of easy to read
teaching manuals with sections on these conditions.
R.E., Hill, R.B., & Key, C. R. (1989).
The sensitivity and specificity of clinical diagnostics during five
of the American Medical Association, 261, 1610-1617.
J. A., Channon, R. A. & Davis,
J. M. (1989). Psychiatry:
Diagnosis and Therapy—A LANGE clinical manual.
Appleton & Lange, Connecticut, U.S.A..
E.K. (1979). Morbidity and reate of
undiagnosed physical illness in a psychiatric clinical population.
Archives of General Psychiatry, 36,
C. (2000). Your
Body is Your Subconscious Mind. Sounds
True, Boulder, CO, U.S.A..
T. (1999). Neuropsychological
issues in adult psychology. Directions in Mental Health Counseling, Volume 9, No., 63-72.