Psychological Masquerade: Physical Illness and Mental Health

1. Psychological Masquerade: Physical Illness and Mental Health Leonard L. Magnani, M.D., Ph.D. Medical Consultant and Staff Physician Alta California Regional Center Sacramento, California

2. Psychological Masquerade • Term I first heard in 1968; first read it in a formal journal article in 1976. • Behavioral changes can “mask” serious physical diseases; etiology is not psychological but due to physical disease. • Once the physical disease or condition is treated, the aberrant behaviors lessen, recede or vanish.

3. Handbook of Mental Health Care for Persons with Developmental Disabilities • By Ruth Ryan, M.D. (2001, The Community Circle, Glendale, Colorado). • Focus on delayed diagnosis; I’ve heard doctors say: • “That’s just the developmental disability.” • “Of course he’s that way; he’s autistic and now has Tourette Syndrome.” • “She’s mentally retarded and 50 years old. Just what do you expect?”

4. Our Focus Today • When abnormal psychological behaviors (“mental illness”) have physical causes that can be diagnosed and treated. • But there is a big stumbling block for caregivers and mental health professionals:

5. First Get A Full Medical Evaluation What Trips Us UP? • Era of HMO’s….the “safety net” has great big holes, or waiting for “approval” is like waiting for Godot. Just…wait…wait…wait…wait… The strategy to now follow: • Unless a patient has rapid access to physical diagnosis and care, go treat the apparent mental health problems; odds of a favorable result are high.

6. Seven Slides “Based” on one of Dr. Ruth Ryan’s “Diagnostic Exercises” (pp. 27-34):

7. -1- • Mr. O.P. is a 33 year-old with a diagnosis of moderate to profound mental retardation. • Since childhood he is reported as “aggressive” and “destructive.” • An “assault” brought him, via squad car, to a mental health clinic or hospital.

8. -2- • His childhood history: Treatment with Ritalin for ADHD. • As dose increased, it made him worse. • Other drugs (Tofranil) →almost explosive. • Mellaril helped the most.

9. -3- • Behavioral analysis by an ABA: • Mr. P. is a sociopath. • Aversive conditioning is urged. • Board and care and day program have all “finally had enough.” (Beware of selective recall)

10. -4- • If presented at our bi-monthly Psych/Med/Behavior Conference we would suggest the gradual withdrawal of high-dose Mellaril…. • …instead consider Paxil with Depakote, or Risperdal, or…..

11. -5- • The history from reliable observers: • Mr. P. may stamp his feet and wildly flail both of his arms. • He destroys favorite possessions. • He punches and pulls hair of those nearby. • If anyone moves away, he never pursues. • The attacks seem “unplanned;” they are not “altercations” or social conflicts.

12. -6- Everyone is fearful, especially since the attacks are “unprovoked” and unanticipated: O.P. becomes wild-eyed. He “stares blindly with a mean grimace.” He punches, pinches, scratches and pulls at the clothing and hair of others.

13. 7. The Mask Removed: • After all these years, an EEG was done. • A seizure disorder was clearly diagnosed. • The MRI was entirely negative. • Were Mr. O.P. evaluated for seizures at any time prior to his third decade of life, the “psychotic rages” would have been treated.

14. What Medical Conditions Might Masquerade as Mental Illness or as Behavioral Dis-ease?

15. General Behaviors and Illness • Only “sluggishness” and diminished activity/involvement are sensitive indicators of some underlying and non-specific physical illness • Sustained diminution in self-care or other adaptive areas also may be due to an underlying pathophysiology

16. Spotting Trends or Sustained Changes • Self-injurious behaviors • Non-compliance • Anger, aggression or hostility outbursts • Diminished attention span • Increased restlessness • Disregard for boundaries • Increased vocalizations or gestures

17. Some Physical Diseases Have a Predilection for Certain Masks • Anemia • Endocrinopathies • Epilepsy • Esophagitis • Chronic Systemic Infection (Lyme Disease) • Prostatitis, Urethritis, Vaginitis • Pica • Drug Addiction • Angina Pectoris • Puritis • Pain

18. Anemia Can Wear the Mask of Depression, Dysthymia, or Apathy and Avoidance. • To rule it out simply requires a Hct or HGb • CBC or RBC (cell morphology is the key) Diagnosing the cause might require a • Fe, iron binding capacity, ferritin, etc. • B12 level and Folate level (Diet should not be confined to a skillet or can.)

19. Endocrinopathies • Hypothyroidism may cause depression, lethargy, moodiness, irritability, violent outbursts, hyperactivity, OCD behaviors. Atypical may be the “typical” in DD pop. • Needs a TSH and T4, etc. • Individuals with Down syndrome are at risk for hypothyroidism. That risk increases to 1 out of 2 (50%) with advancing age.

20. Endocrinopathies (cont.) • Raging and simmering hormones can produce behavioral problems: • Adolescent males:  testosterone→ anger, tantrums, acting out, non-compliance; ADHD worsens this scenario. • Females: PMS depression, anger, non-compliance, verbal/physical assaults, etc. • Perimenopausal phase: disinterest, confusion or depression, all slowly progressive.

21. Epilepsy and Brain Masses • Violence, non-compliance or disinterest (depression), moodiness, anger, head banging, refusal to comply, profanity, destructive acts, paranoia, delusional psychosis, OCD behaviors or untreated Tourette syndrome. • When suspected this requires a neurology consultation, an EEG and/or brain scan.

22. Reflux Esophagitis • Chewing of hands • Jamming fingers into mouth • Rocking back and forth to relieve pain • Pseudo-bulimia • May need a specialist evaluation and perhaps an upper GI endoscopy

23. Lyme Disease • Generalized anxiety and panic attacks • Disorientation, confusion, hallucinations and extreme agitation • Impulsive behaviors or directed aggression • Frank mood swings and mania • Obsessive compulsive behaviors (Borrelia burgdorferi) • Paranoia and schizophrenic-like states

24. Prostatitis or Urethritis • Masturbation and exposure • Grabbing at others • Refusal to comply • Rocking back and forth • Needs a U/A and culture

25. Vaginitis • Masturbation and exposure • Grabbing at others • Refusal to comply • Scratching of legs or abdomen, but no rash is observed to be present • Needs a GYN consult or a complete female exam by the primary care physician

26. Pica Pica pica • With or without lead toxicity • Cigarette butts, dirt, rocks, etc. • Presents as a generalized anxiety disorder. • Needs close monitoring, SSRI therapy and ABA evaluation with lots of B-mod.

27. Drug Addiction • Alcohol, illicit drugs, nicotine intoxication, diet pills, etc. • Everything behaviorally aberrant that is conceivable or possible. • Unless it is logistically unimaginable, it should at least be considered.

28. Angina Pectoris • Grabbing of chest • Refusing to let go • Pounding of chest • Refusal to do anything “active,” even eating meals (non-compliance equals pain) • EKG in appropriate age groups, and more!

29. Puritis • Pinworms are very common. • Eczema may be hidden underneath the scratches and areas of rubbing (redness). • Allergies, occult hives and their continual itching can “drive someone crazy.” • Tearing at skin may not be “mutilation.” • Fussiness may not be “anxiety.”

30. Pain • Joints, ribs, teeth, ear canal, head, eyes, back, etc. • If chronic and untreated, one can do crazy things→ head banging, talking to self, simply the works. • Hard to diagnose even by a concerned doctor if not indicated by the hurting individual. • Close observation and good preventive medicine are essential. In DD population, former may be achieved but the latter is our great challenge.

31. Caregiver Observations • Close up and objective; a set or sets of knowledgeable eyes • Able to see trends and changes away from the prior baseline • Since interactions are daily, data collection and record keeping can suggest a tentative diagnosis to an astute clinician and help pull the mask off, cure the disease, and end the dysfunctional behaviors

32. To meet the challenge we must always suspect that we’ve been invited to a “costume ball.”What illness or disease lieshiddenunderneaththe behavioral mask?