Somatic illness in psychiatric patients

ERWIN K. KORANYI, M.D.

Somatic illness in psychiatric patients ABSTRACT: The author reviews a dozen studies conducted over a period of 40 years and shows that approximately half of a total of over 4,000 psychiatric patients had major medical illnesses. Somatic conditions were directly related to the psychiatric symptoms in 9% to 42% of the cases. Approximately half of the patients' referring physicians had not diagnosed their physical illnesses. These findings and five brief case reports point up the need to follow a medical model on psychiatric services.

Disorders of mood, behavior, and perception either may signify a primary, distinct psychiatric illness, or else they may be the secondary, entirely nonspecific indicators of a physical disease or toxic state. While these alternative diagnoses have been known for a long time, they are still not sufficiently appreciated. Frequently, the recognition of a somatic illness and the secondary nature of the consequential psychiatric symptoms is not a difficult differential diagnostic problem because, typically, other recognizable clinical signs precede or ac-

company the psychiatric ones. Strictly psychiatric manifestations might, however, precede even by years the first symptoms of some physical illnesses. Thus, misleading and persuasively "psychiatric" clinical presentations may conceal a wide variety of somatic diseases. Many physical illnesses are known to cause several psychiatric manifestations, such as personality change, anxiety, depression, hallucinatory or delusional states, aggressive behavior, and sexual pathology. With failure to detect the underlying somatic pathologic con-

Dr. Koranyi is professor ofpsychiatry at the University of Ollawa, health sciences faculty, and director ofeducation at the Royal Ollawa Hospital. Reprint requests to him at the Hospital, Department of Psychiatry, /145 Carling Avenue, Ollawa, Ontario KIZ 7K4. NOVEMBER 1980' VOL 21' NO II

dition, treatment will be exclusively psychiatric and therefore futile. But when the true cause of psychiatric symptoms is identified and treated, the patient will respond favorably. Appropriate intervention may be medical or surgical. Patients may require such medication as cortisone, digitalis alkaloids, or vitamins, or they may require the discontinuation of drugs, such as antihypertensive agents or diuretics, that may have produced adverse effects. Distinguishing between primary and secondary psychiatric syndromes is at times an arduous task, demanding an open mind and a thorough knowledge of pathophysiology. Categorizing syndromes as purely primary or secondary may be justified, as long as it is remembered that diagnosing a psychiatric disorder does not exclude the presence of physical illness; physical and psychiatric conditions frequently overlap. I·) A naive eitheror concept of illness was rejected in favor of a balanced, holistic visualization of the total clinical picture by Weiss and English4 at the dawn 887

Somatic disease

of psychosomatics and more recently by Leeman. 5 The present study grew out ofconcern about the unfortunate disregard of the significance of the somatic element in psychiatric illness by psychiatrists and general practitioners, an oversight that has been lamented by Engel,6 McIntyre and Romano,? Brill,s Sandifer,9 Romano,1O Johnson, II and others. A few brief clinical cases may help to clarify the problems: Case 1 A 31-year-old social worker with a history of long-standing ~pathy, and a conflict over authority more recently had anxiety attacks and complained of impotence and "immaturity." He came to our clinic mainly for investigation of his sexual dysfunction. A five-hour glucose tolerance test showed fasting levels of 94 mg/100 ml; at one hour, 74 mgl100 ml; at two hours, 53 mg/100 ml; at three hours, 15 mg/100 ml; at four hours, 64 mg/ 100 ml; and at five hours, 51 mg/100 ml. On his hospitalization in the metabolic unit, hypopituitarism and an insulin-producing lesion in the abdomen were demonstrated. Subsequent to surgical treatment, the patient did not return to our clinic, and his psychiatric status is not known. Case 2 A 37-year-old unemployed woman had a 13-year history of arthritis and a five-year history of "accumulating personal problems." She had entered dynamic psychotherapy on the referral of a family physician three years previously when "anhedonia, anxiety, and withdrawal" developed after an ended love affair. The therapy was nonproductive, and the patient terminated it after four months. Apart from her mood disorder and inability to work when referred to our clinic, she also complained of lost senses of taste and smell, chronic fatigue, and arthritis of the jaw. Proteinuria was found,

888

although kidney function was unimpaired. A positive anti-nuclear antibody in a titer of 1:320 and other laboratory findi ngs confirmed the presence of systemic lupus erythematosus, and the woman was referred for medical treatment. Case 3 A 37-year-old unemployable woman had a seizure disorder that developed when she was 13 years old, recurring psychotic episodes, and organic deterioration. She was treated with haloperidol and high dosages of phenytoin sodium, phenobarbital, and primidone, all of which failed to provide sufficient seizure control. Numerous psychiatric hospitalizations and longterm institutionalizations resulted in erosion of her family ties and social relationships. She had bilateral cataract operations two years earlier. On admission she was psychotic-confused and disoriented-and organically blunted with impaired memory, frequent seizures, and incontinence. Phenytoin and phenobarbital blood levels were in the toxic range. The patient was deficient in folic acid, and a calcium level of only 6.4 mg per dl was found. (A search of her medical records failed to show any previous calcium determination.) Chvostek's sign was positive, and Trousseau's sign, negative; her history included one episode of "muscular spasm." Repeated calcium determinations and other tests confirmed that the patient had primary hypoparathyroidism. Treatment with vitamin o and extra milk in her diet cleared the patient's mental state without any psychotropic medication. Minimal dosages of anticonvulsants were administered to prevent withdrawal seizures. She was seizure-free when she was discharged, and was preparing to return to a shared apartment and to a fulltime job. Case 4 A 49-year-old construction worker was treated with various benzodiaze-

pines for "nervous, mild hypertension," irritability, insomnia, anxiety, and weight loss for one year by his family physician. Referred to a psychiatrist, he was given the same medication along with psychotherapy, but he was poorly motivated for this treatment. On initial assessment, a "free" T4 index of 25.5 was found among other typical laboratory and clinical signs, demonstrating a distinct case of thyrotoxicosis, which responded excellently to 1131 . The patient's psychiatric symptoms subsided completely. CaseS A 44-year-old mother of seven children, recently separated from her husband, had a five-year history of periodic aggressive behavior, jealousy, and paranoid ideas. One previous psychiatric hospitalization, a more recent day hospital admission, and psychotropic medications failed to alleviate these symptoms. Her children were removed by the Children's Aid Society because of her abusive attitude. In addition to her social and behavioral problems, the patient complained of headaches and blurred vision. Her EEG showed bursts of focal and generalized slow wave abnormalities, and a brain scan led to suspicion of a subdural hematoma. After her referral to a neurosurgeon, an angiogram of the left common carotid artery demonstrated an aneurysm in the anterior cerebral artery. Following surgery, there was improvement in the presenting symptoms.

Background Far from being an exotic rarity, somatic disease, as Lipowski 12 documented, is a major cause of psychiatric morbidity. The causal relationship of physical illness to psychiatric manifestations is well supported by epidemiologic surveys and clinical studies. Long before the golden age of psychosomatic medicine, and before the insulin era, Bonhoeffer,13 PSYCHOSOMATICS

near the tum of the century, masterfully portrayed the perplexity of somato-psychic interrelationships in his studies of "diabetic psychosis." But it was Malzberg '4 in 1934 and later Odegard l5 who drew attention to the high morbidity and mortality rates in the psychiatric patient population. Phillips '6 in 1937 reported on the first systematic study of the rate of physical disorders among mental patients admitted to a hospital. Of 164 consecutive patients, the article listed 39 (24%) as having physical conditions with a "direct" relationship to their mental disorders and an additional 35 patients (21%) with an "apparent" association of this kind. Thus, a total of 45% of these psychiatric patients had physical illnesses. Later studies have supported Phillips' findings (Table). Apart from numerous case studies and descriptions documented mainly in various textbooks of medicine, neurology, and endocrinology, no further systematic re-

search was conducted until 1949 when Marshall I7 reported a 44% physical morbidity rate in psychiatric inpatients. Herrige 18 in 1960 found a 50% rate of physical disease among 209 patients, some of their illnesses directly related to their psychiatric symptoms. Davies l9 in 1965 investigated 36 consecutive psychiatric outpatients and found only 15 patients free of physical illnesses. Of the 21 physically ill patients (58%) in this series, the somatic pathology in 15 of them (42%) was directly related to the psychiatric illness. Maguire and Granville-Grossman 20 three years later found that of 200 consecutive first-time psychiatric inpatients, 33.5% had significant physical pathologic conditions. Almost half of these patients had not had their physical illnesses diagnosed previously. In the same year Johnson 21 studied 250 psychiatric patients and found that 60% of them had physical illnesses, the majority (80%) of which, again, had not been

diagnosed before. Of the physically ill patients, 12% were found to have illnesses causally related to the psychiatric symptoms. In a pilot study of 100 consecutive psychiatric outpatients22 in 1972, the author found 49% suffering from various physical illnesses. In ten (20%) of the 49 patients, the somatic pathology was found to be the direct cause of the psychiatric symptomatology. Nonpsychiatric medical referring sources, mainly general practitioners, had not diagnosed the physical pathologic condition in close to one third of the physically ill patients they referred, and psychiatrists had similarly failed in 50% of such patients. Social agencies did not recognize the physical illnesses in 87.5% of their referred patients with physical illnesses. Only 14% of the selfreferred patients correctly diagnosed their physical illnesses. Burke23 in 1972 found that 43% of his 202 psychiatric inpatients suffered from significant physical

Table-Physlcallllnes_ln 12 Psychiatric Patient PopulaUona Senior author

otltudy Phillips Marshall Herrige Davies Maguire Johnson Koranyi Burke

Eastwood Burke Hall Koranyi

Yr.tudy Psychlldrlc Rate of phplClll DlNCIIy reIatIMI to Previous., published petlenta studied (N) 111...... (..) peychopetholog, (") undllllnoMd (")

1937 1949 1960 1965 1968 1968 1972 1972 1975 1978 1978 1979

164

45

24

•

44

•

209 36 200 250 100 202 124 133 658 2,090

50 58 33 60

49 43

•

•

• •

42

•

12

49 80 71

•

20

•

("High")·

•

50

•

•

9

43

18

• • •

46 46

'Data not shown ,n study_

NOVEMBER 1980' VOL 21' NO II

889

Somatic disease

pathologic conditions. Eastwood 24 also found a high rate of major medical illnesses in his sample. Further, when they compared 124 medical clinic patients who had psychiatric histories with a matched group of patients with no such background, they found a high number of patients with multiple physical illnesses in the psychiatric group, particularly in the male population. In a 1978 study of 133 psychiatric day hospital patients, Burke 25 found that half of them suffered from a variety of physical illnesses, including only five cases of organic brain syndrome. However, there were 33 patients with diverse neUrologic diseases. One third of these patients had previously been diagnosed as having hysteria, a finding similar to that of Slater26 in his famous follow-up study of such cases in 1965. Hall and associates 27 in 1978, screening a sample of 658 psychiatric outpatients, found that 9.1 % of this population had physical disorders directly accounting for their psychiatric symptoms; 46% of these patients had not been diagnosed beforehand. Unfortunately, Hall's report does not clarify the total number of physically ill patients. In i979 this author; reporting on 2,090 psychiatric clinic patients, found a 43% rate of physical illness. Almost half (46%) of the physically ill patients had been previously diagnosed by the referring practitioner. Confirming the results of the author's pilot study, this larger investigation showed that physiciarls other than psychiatrists missed one third of the physical diagnoses and psychiatrists missed one half of the major medical illnesses of their referred patients. In 18% of the physically ill, the somatic pathologic

condition caused the psychiatric symptoms. In some instances, medical investigations have uncovered rather unusual physical pathologic conditions. 28 Other studies in progress or not yet fully reported are arriving at comparable results. Etemad 29 found a 50% rate of physical illness in his psychiatric patients, the same number cited in the Annual Report of the Western Psychiatric Institute in 1978. Additional studies at the Maclean Hospital in Belmont, Mass. are in progress.

Discussion the reasons physical illnesses so frequently are missed in the psychiatric population are manifold. The prejudice against the psychiatric patient is only one aspect of the problem. Importantly, physical and psychiatric illnesses may coincide. Furthermore, unscreened selfreferred patients are readily accepted for psychiatric treatment, as are patients referred by general practitioners. Johnson 30 demonstrated that one half to one third of referring physicians are using psychiatry as a primary-care resource, often neglecting to take histories or give their patients physical examinations. In addition, McIntyre and Roman07 found that only 8% of psychiatrists did physical examinations on "selected" outpatients, and Patterson 3) reported in 1978 that not one of 100 psychiatrists surveyed performed routine physical examinations on their ambulatory patients. Sometimes psychiatrists do not feel confident enough to confront their medical colleagues about doubtful diagnoses. And all physicians, the author included, tend to unquestioningly "sell" their diagnoses to other practitioners. Al-

though they are equipped to do so, psychiatrists often are reluctant to discontinue such drugs as antihypertensive agents, anticonvulsant medications, digitalis, diuretics, and oral antidiabetic agents. Yet, in the author's experience, these drugs are sometimes unnecessary and may cause adverse effects. Many psychiatrists try to solve the problem by routine referral for physical examination, by and large a reasonable practice. Among the problems, however, is failure to inform the consultant about why he is seeing the patient. "Health questionnaires," as Knox 32 pointed out, "are but mere ancillary aids or preludes to a physical examination." Significant symptoms may develop under misleading or peculiar circumstances. A somewhat insecure middle-aged bridegroom having transient monocular blurred vision, weakness, and facial numbness cannot actually be manifesting his first symptoms of multiple sclerosis on the second day of his honeymoon. Or can he? Patients often are said to complain about the "wrong things," and they do. Sometimes they replace or minimize their symptoms by elaborating on their psychosocial situation. The complaints may be circumstantial, or the patient may be elderly, unattractive, or have poor hygiene, which can arouse a negative response in the physician, as Detre and Jareckj33 pointed out. The mechanism of how physical illnesses cause secondary psychiatric disorders is more complicated. In the light of current research, Groddeck's34 proposition that "the actual pathology is the result of a symbolic representation of a preexisting conflict" now belongs to the realm of the psychiatric historian. The answers to our questions PSYCHOSOMATICS

have to be sought on other levelsin the neurology of the limbic system, along the lines of current theories of emotions. Some forms of homeostatic imbalance, concomitant with various disorders, will ultimately cause "emotion" or cognitive distortions. How such changes affect the central nervous system may not as yet be completely understood. The question is not unlike the puzzle of why some nonmetastatic peripheral neoplasia will cause cerebellar atrophy and dementia. 35-37 Regressive behavior readily results, and coping devices wear out. The mechanism between the cognitive and affective components of emotion is elaborated on

by Schachter and Singer38 and more recently by Candland 39 and Freedman,40 who provide insight into this complex problem. Also of interest is the work of Leshner'" and Levi.42

Conclusion The conclusion for application to everyday practice is that behavioral and mood alterations often are entirely nonspecific in nature, and that half of those patients presenting with such symptoms suffer from significant medical illnesses. Nothing will replace a pathophysiologic approach and a thorough history. Particular emphasis must be placed on the chronologie sequence of

symptom development. Nor will anything replace a complete physical examination, appropriate laboratory tests, and the recognition of "atypical" signs that do not coincide with the natural course of a hastily diagnosed psychiatric condition. Unfortunately, there are no short cuts. Harrison's43 statement in Principles of Internal Medicine is apt: "Any symptom, however trivial or remote, may yet hold the key to the solution of a medical problem." Such symptoms, which are frequently manifested as disordered mood or behavior, support the usefulness of a medical model on psychiatric services. 0

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