Psychological Masquerade: Physical Illness and Mental Health

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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

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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 Ive heard doctors
  say
• Thats just the developmental disability.
• Of course hes that way hes autistic and now
  has Tourette Syndrome.
• Shes mentally retarded and 50 years old. Just
  what do you expect?

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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

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First Get A Full Medical Evaluation

• What Trips Us UP?
• Era of HMOs.the safety net has great big
  holes, or waiting for approval is like waiting
  for Godot. Justwaitwaitwaitwait
• 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.

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Seven Slides Based on one of Dr. Ruth Ryans
Diagnostic Exercises (pp. 27-34)
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-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.

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-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.

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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.

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

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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

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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.)

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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.

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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.

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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.

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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!

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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.

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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

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To meet the challenge we must always suspect that
weve been invited to a costume ball.What
illness or disease lies hidden underneath
the behavioral mask?