It's that time of year again. Like no other month of the year, October reminds us that all is not always as it seems. The masks and costumes come out so we can pretend for a day, to masquerade as someone we are not. Scary and fun at the same time, we hide behind disguises to enter a temporary pretend, trick-or-treat escape before getting serious about giving thanks, gift-giving, love, leprechauns, faith, memorials, independence, and labor before starting all over again.
The purpose of this editorial is to remind readers that all is not always as it seems at first glance. Health care professionals must potentially reveal physical problems for what they are, even if the physical diagnosis is presenting primarily with psychological signs and symptoms, such as hallucinations and disorientation.
Identifying Tricky Disease Processes
Some disease processes can be tricky—overtly sporting their psychological symptoms and side effects, trying to trick providers down the yellow brick road of a seemingly mental illness diagnosis. The temporal nature of symptoms should also be considered, as symptoms may, and often do, resolve. The deception of easy recognition and the temptation to apply a convenient label of a mental health diagnosis can be a missed opportunity for urgent treatment. A recurring example is the application of a diagnosis of delusions as a result of a urinary tract infection, which, instead of a course of antibiotics, can lead to a permanent false record of mental health diagnosis.
Most mental health professionals use the Diagnostic and Statistical Manual of Mental Disorders, currently in its fifth edition (DSM-5; American Psychiatric Association, 2013), to diagnose mental health disorders. This manual contains criteria for hundreds of different disorders; psychiatric nurse practitioners, clinical nurse specialists, psychiatrists, psychologists, or therapists determine which criteria best fit the signs and symptoms that the client is exhibiting.
But wait, not so fast; remember, all is not always as it seems.
The DSM-5, despite its widespread use, is a guide that allows for a categorical approach to diagnosis. In this approach, however, it limits categorization of symptoms and generalizes case formulation. This focused use of the DSM-5 inevitably creates the opportunity for a missed physical diagnosis. Although this is a guide, the responsibility of the health care professional is to do exactly that—use the tools available as a guide, while concurrently using each encounter to strip away the presenting facade and apply an initial primer of evidence.
Evolution of Knowledge
Mirroring society as a whole, medicine and health care continue to develop and evolve. This evolution of knowledge (or knowledge evolution) is a direct result of research. Scientific research results in the empirical evidence that guides practice. Evidence-based practice is the standard for the most informed and best client care. The provision of the best health care requires an application of evidence with a systematic consideration of the individual. It cannot be a broad-brush stroke approach. It therefore requires us to ask the question, “How does the evidence we have apply to the individual in question?” That is the process that can allow for evolution of knowledge.
Making the Right Diagnosis
Diagnosing illness is detective work; providers skillfully prioritize the clues discovered through a thorough health history and presentation of client signs and symptoms so as not to be tricked by the potentially first-glance-masked appearance.
For an accurate diagnosis, leading to appropriate, successful, cost-effective, and streamlined medical and/or psychological treatments, it is critical for providers to be on the lookout for physical illnesses that masquerade as psychological disorders. For example, before the pathophysiology of hypothyroidism was discovered around 1886, patients were diagnosed as depressed. We now know differently; with hypothyroidism or Grave's disease, the extreme sluggishness of body and mind are due to lack of thyroid hormone triiodothyronine and thyroxine T4 production by the thyroid gland (Schildkrout, 2014). Thyroid cells need iodine as well as tyrosine (i.e., an amino acid [amino acids combine to form proteins]) to make these thyroid hormones. Similarly, the unfolding discoveries of hyperglycemia from a malfunctioning pancreas, later called diabetes, dates as far back as the Egyptian pharaohs.
“In diagnosis, think of the easy first.”—Martin H. Fischer (access https://www.brainyquote.com/topics/diagnosis)
When attempting to unmask the tricky goblin, it is important to start with the most common culprit and work from there, and not the other way around. That is, do not first consider the most obscure diagnosis, such as Whipple disease caused by the rare microorganism, Tropheryma whippelei, the brain and multiorgan-system thief. Even the deer tick spreading Lyme borreliosis, causing short- and long-term multiorgan symptoms of Lyme disease, is more common than T. whippelei. Lyme psychosis can masquerade as schizophrenia just as third-stage syphilis can mimic dementia.
Schildkrout (2014) does a masterful job of revealing the top 100 physical illnesses that can present as psychological disorders. From acromegaly to Wilson's disease and 98 diseases in between, Schildkrout (2014) alphabetizes and skillfully dissects these physical illness culprits and psychological manifestations using language all members of the health care team can understand. Common and familiar physical diagnoses, such as thyroid disorders, sleep apnea, Alzheimer's disease, and Parkinson's disease initially manifest with psychological signs and symptoms, such as anxiety.
The most common physical disease culprits that present with mental illness signs and symptoms originate in malfunctioning of the endocrine system (Schildkrout, 2014). The endocrine system comprises eight glands that produce and secrete the hormones that regulate the activity within cells that contribute to every organ system. The endocrine system, as well as external pathogens, are the primary culprits in this who-done-it of potentially mistaken diagnoses.
Along with the masquerade, keep in mind that physical and psychological diagnoses can be intertwined and layered as can be the case with migraines, insomnia, chronic pain, and depression (Reich & Savitt, 2018; Silberstein, 2016; Stanos et al., 2016). Depression symptoms can indicate a comorbidity, outcome of prolonged symptoms, or worsening prognosis. Remember, the work doesn't stop at diagnosis, it continues throughout treatment.
As health care team providers, nurses need to be collegial sleuths and be on the lookout for classic psychological signs and symptoms that can be misdiagnosed as mental illnesses. Being aware of the more obscure physical illnesses that present as psychological masqueraders make nurses valuable health care team members. After all, observing symptoms and discerning physical or physiological concerns began with Hippocrates (Kleisiaris et al., 2014).
Deb Stanford, MSN, RN
Assistant Clinical Professor
The University of North Carolina Greensboro
Greensboro, North Carolina
Catherine Ling, PhD, FNP-BC, CNE, FAANP,
Tamar Rodney, PhD, RN, PMHNP-BC, CNE
Mona Shattell, PhD, RN, FAAN
Associate Dean for Faculty Development
Johns Hopkins School of Nursing
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). doi:10.1176/appi.books.9780890425596 [CrossRef]
- Asogwa, K., Buabeng, K. & Kaur, A. (2017). Psychosis in a 15-year-old female with herpes simplex encephalitis in a background of mannose-binding lecithin deficiency. Case Reports in Psychiatry, 2017, 1429847 doi:10.1155/2017/1429847 [CrossRef]
- Kleisiaris, C. F., Sfakianakis, C. & Papathanasiou, I. V. (2014). Health care practices in ancient Greece: The Hippocratic ideal. Journal of Medical Ethics and History of Medicine, 7, 6 PMID:25512827
- Reich, S. G. & Savitt, J. M. (2019). Parkinson's disease. The Medical Clinics of North America, 103(2), 337–350 doi:10.1016/j.mcna.2018.10.014 [CrossRef]
- Schildkrout, B. (2014). Masquerading symptoms: Uncovering physical illnesses that present as psychological problems. Wiley.
- Silberstein, S. D. (2016). Considerations for management of migraine symptoms in the primary care setting. Postgraduate Medicine, 128(5), 523–537 doi:10.1080/00325481.2016.1175912 [CrossRef]
- Stanos, S., Brodsky, M., Argoff, C., Clauw, D. J., D'Arcy, Y., Donevan, S., Gebke, K. B., Jensen, M. P., Lewis-Clark, E., McCarberg, B., Park, P. W., Turk, D. C. & Watt, S. (2016). Rethinking chronic pain in a primary care setting. Postgraduate Medicine, 128(5), 502–515 doi:10.1080/00325481.2016.1188319 [CrossRef]