Zebra Hunting: Medical Mysteries and When It's Not All in Your Head

name this disease:

Fair warning:  Hypochondriacs should skip this post.

If you live in the valley and are fascinated by medical detective stories, you're in luck this week.  Dr. Lisa Sanders, author of the NYTime's "Diagnosis" column, is speaking as part of the OSU's Program in Medical Humanities lecture series on Tuesday, March 13th, 7:00 p.m. at the LaSell Stewart Center.  Her column inspired the popular TV series "House"; Sanders continues as its medical consultant.  She'll be selling and signing her new book at a reception prior to the lecture.  You can hear an interview with Dr. Sanders and see snippets from her book on NPR at this link:  http://www.npr.org/templates/story/story.php?storyId=111844063

Later this week, I'll be lecturing (in a very loose sense of the word, and without the crowd or book signing) on differential diagnosis at my therapist's continuing education group.  Although most of us aren't doctors, it's important that mental health clinicians have at least a rudimentary understanding of the many diseases and conditions that can present "psychiatrically".   I use the distancing quotes for emphasis.  It's a strange notion to me that so many want to separate disorders of the mind from those of the body.  Where, exactly, do these people think the mind is located?  The brain is an organ.  All organs can have imbalances or diseases.  Furthermore, the problems that affect what we experience as the mind-- eg, those that cause anxiety and depression-- can originate in many other areas of the body.  For example, persons with mitral valve prolapse (a common and usually benign heart condition in which a heart valve does not close properly) may have palpitations and shortness of breath misdiagnosed as panic attacks.   Thyroid irregularities can present as either depression or anxiety, depending on whether there is too little or too much of the related hormones circulating in the system.  Starting (or abruptly stopping) some medications can cause problems in thinking, memory, sleep and certainly in mood.

For many years stomach ulcers were thought of as a psychosomatic illness, caused by the mismanagement of stress.  No one thought bacteria could live in the highly acidic environment of the stomach.  It wasn't until 1982 that two Australian doctors made the connection of between stomach distress and high colony numbers of the heliobacter pylori strain.  Epilepsy is another disorder with a roller-coaster history of (mis)understanding.  Although Hippocrates (400 BC) saw it as a physical ailment, it was considered a sign of demon possession in the New Testament Bible, and a positive symptom of being a witch during the persecutions in the 15th century.  The classic tonic-clonic seizures (also known as "grand mal"--major electrical storms in the brain) were the first to be recognized as clearly organic in origin, though those suffering were still seen as in the grips of a mental illness for at least half of the 20th century.  More subtle electrical brainstorms can cause such varying symptoms as hypersexuality, religious preoccupation, olfactory hallucinations and more.  

Manic, or just immature?

And that lousy memory of yours.  Is it early onset Alzheimer's?  A brain tumor?  That allergy medicine you take year round in our sweet little Valley Of Runny Noses?  Or your Ambien, menopause, seasonal affective depression?  Maybe it's something rarer and more sinister--  that parasite you picked up rafting down the Amazon, or those infiltrating prions from Uncle Bubba's tasty breakfast offering of scrambled squirrel brains.  Even as I type perhaps holes are popping up like yeast bubbles in your gray matter.  But probably not.  Really.  The fact that you can't remember is more likely one of two factors:  those constant electronic interruptions (and training from all that manic transitioning in those Sesame Street shows you weaned on) has whittled your attention span down to the tensile strength of a wet strip of cheap paper napkin, or you are just too tired and/or preoccupied with you busy-ness to be present and attending to the Here and Now. 
Yes, there are lots of possibilities.  But a diagnosis over-stimulation and lack of rest will pretty much trump the likelihood of Mad Cow (or squirrel, for that matter) Disease.  It's not likely you'll be featured on the next episode of "House."

I'm not a doctor, and can't give you medical advice or treatment.  But if you come to see me with complaints of forgetfulness, anxiety, depression and fatigue, I'm going to be using all my senses to help you figure out what's going on.  I'll notice your gait and movements (slowed ones can mean depression, or early symptoms of Parkinson's).  I'll pay attention to the rate and fluency of your speech, and the clarity of your thinking.  Back before my anosmia, I would have noticed distinct smells, if you had them-- too much perfume might mean you're covering up your substance abuse habits, or that you too have lost your sense of smell.  I'll  be asking you when you last saw a doc and what she said; what meds you are on, and what for, whether you have a  history of traumatic injury (especially the old noggin'), how you are sleeping, your drug and alcohol and other significant medical history.  I'll want to know if you see or hear things others don't-- sure, it could be schizophrenia or another serious psychotic disorder, or it could be a detaching cornea, a migraine aura (shimmering changes in the visual field), your carotid artery pulsing loudly in your ear (ear wax blockage?  something more important?).  I'll wonder if your symptoms came on suddenly, and if you had any illnesses or trauma preceding the problem, and if you've felt that way before.  I'll want to know your theory about what is happening to you.

Not Mad, just Cranky

I may also ask you what you eat and how often.  Fluctuating blood sugars can wreak havoc on mood, making you flaky and cranky and shaky.  If you're actually diabetic, that requires vigorous changes in diet and lifestyle because you're going to want those feet, those eyes and that heart later in your life.

If you're female, I may ask about your menstrual history.   Perimenopause (the years leading up to cessation of the cycle) can trigger severe PMS-like symptoms of irritability, anxiety and weepiness for some women.  Premenstrual Dysphoric Disorder can look like Bipolar, with mood swings so severe that some women with it are suicidal several days a month.  While CBT is helpful, sometimes hormonal or other medication therapy is needed.

If you have pre-existing conditions-- diabetes, hormone issues, head injuries, autoimmune disorders-- I will want to know about those too.  Their effects may be causing your mood issues; certainly their stresses will be a factor.  Are you following the medical treatment prescribed?  Many people fail to connect the dots between their poor physical health management and the brain fog, anxiety or other issues that can result.  And as noted, sometimes it is the medication itself that's causing the problem.  For example, steroids can cause mania (and occasionally psychosis).  It's not typical, but it happens. 


Brain tumors and other serious illnesses are the Zebras in our herds of horses at the counseling office.  They happen, and they typically don't get found out until they've started making a ruckus.  Chances of accurate and early diagnosis seem very dependent on who you see, how clearly you can present your symptoms and their progression , and what sort of bureaucracy you run into trying to get adequate testing.  These tests are expensive, and it's hard to convince a strapped system to check out a herd of horses because there may be one very horsey-looking zebra hiding there.  It can help to get back up history from others who have observed and been concerned about the changes in your behavior or pain.  Bring them with you as a second pair of eyes and ears and an advocate if you are really concerned and don't feel you are being heard.  Be nice to the doc, though. Advocacy does not need to be rude.  Listen hard.  You may hear things you don't like or understand,.  Have your questions at the ready but be prepared to accept they may not all get answered.  Get second opinions if your insurance will provide that and you feel uncertain or dismissed.

Many years ago in SE Texas I had a patient who was very country, not very educated but quite organized in her life and thinking.  She seemed perfectly fine except she had an obsession that invisible bugs were crawling on her arm.  She couldn't stop itching.  Her arms were covered with bloody scratches.  She was driving her family crazy trying to get them to see her tormentors with magnifying glasses. She developed lots of obsessive-compulsive symptoms trying to treat the infestation.  But there were no bugs.  I sent her for a physical, telling the doctor things weren't adding up. There was a lesion in her brain; sure enough, when it was resolved the "bugs" disappeared. 

Another woman I saw with fatigue, weight gain, high blood pressure and a long onset depression found relief after she was finally diagnosed with Cushings and treated for her metabolic issue.  The weeks of talk therapy I provided didn't do much at all, though we both enjoyed it.  It was the strange distribution of weight, and facial hair, that clued me to refer her.

Years before that, also in Texas, a man with no previous violent history (family man, former eagle scout) killed his wife, then climbed a tower at the University in Austin and killed several strangers. In his diary, Charles Whitman spoke of having spent two hours with a doctor trying to explain his sudden and overwhelming violent impulses.  It apparently didn't go well, and he never went back.  Writing again, he requested that doctors examine his brain after his death.  He had been convinced for some time that it was changing and these violent impulses were outside of his control.  He was right.  A glioblastoma (tumor) had insinuated itself into his thalamus, hypothalamus and amygdala, hijacking his previous personality. 

The Case of the Collapsed Kelp:  Not drunk, just dehydrated and sun-stroked

The thing is, these are exceptions.  There is so much overlap in cause and disease, and the same symptom of a rushing sound in your ear that could be an aneurysm forming is much more likely to be some flake of ear wax floating around. Neither I nor any other clinician, including your doctor, is going to be hunting for Zebras when it's looking so horse-y out there.  Don't blame us if we forget to ask you something you are worried about' let us know what you are worrying about.   Listen to what we know, and to what we don't.  We will refer you for care if we have suspicions that your chronic fatigue, aches, rapid heart beats or what have you need a doc or a test.  We don't practice medicine.  But we should know enough to point you in the right direction if our expertise and intuition suggest the need for medical consultation.

A lot of these bothersome symptoms will disappear as quickly as they came.  It's tricky to know when to pay attention and when to stop obsessing.  Eye tics, annoying and random but nearly always completely benign, are a good example.  It's POSSIBLE that it's the start of Bell's Palsy, a bran tumor, or hey, demon possession (I don't claim to cover all bases here).  But most likely it's a temporary and meaningless glitch, and it will disappear when you stop attending to it.

If you have a health concern and your doc says "Maybe you should see a therapist", it's not because he or she thinks you're crazy.  It's that the interface between mind and body works both ways, and there are things you may be able to do to heal that are more effective than taking a pill.  Stress-related illnesses are still illnesses, but they can resolve when we get more sleep, nature, sun, exercise and balance and learn to change the panicky way we interpret signals from our body. 


To be continued...and in the meantime, let us reflect on the words inscribed of the guide of famous interplanetary hitchhiker Arthur Dent:  DON'T PANIC!