When Depression or Anxiety Masks a Medical Problem

It’s perfectly normal for someone to feel anxious or depressed after receiving a diagnosis of a serious illness. But what if the reverse occurs and symptoms of anxiety or depression masquerade as an as-yet undiagnosed physical disorder?

Or what if someone’s physical symptoms stem from a psychological problem? How long might it take before the true cause of the symptoms is uncovered and proper treatment begun?

Psychiatric Times, a medical publication seen by some 50,000 psychiatrists each month, recently published a “partial listing” of 47 medical illnesses, ranging from cardiac arrhythmias to pancreatic cancer, that may first present as anxiety. Added to that was another “partial listing” of 30 categories of medications that may cause anxiety, including antidepressants like selective serotonin reuptake inhibitors, or S.S.R.I.s.

These lists were included in an article called “Managing Anxiety in the Medically Ill,” meant to alert mental health practitioners to the possibility that some patients seeking treatment for anxiety or depression may have an underlying medical condition that must be addressed before any emotional symptoms are likely to resolve.

Doctors who treat ailments like cardiac, endocrine or intestinal disorders would do well to read this article as well lest they do patients a serious disservice by not recognizing an emotional cause of physical symptoms or addressing the emotional components of a physical disease.

For example, Dr. Yu Dong, a psychiatrist at Inova Fairfax Hospital in Virginia, and colleagues pointed out last month that patients with respiratory conditions like asthma, sleep apnea or pulmonary embolism could present with symptoms of anxiety, or those with cardiac symptoms like chest pain or rapid heartbeat could have an anxiety disorder.

The problem of missing the proper diagnosis grows out of a long-ago separation of powers within the medical profession that often limits the ability of practitioners to see the forest for the trees, as it were. Medical doctors like cardiologists or gastro-enterologists are often ill-equipped to recognize and treat emotional symptoms related to a physical ailment, and psychiatrists may not consider the possibility that a patient with symptoms like palpitations, fatigue or dizziness really has a physical ailment.

Indeed, doctors at the Montreal Heart Institute reported in 1996 that about a quarter of 441 patients who came to the emergency room because of chest pain were in fact suffering from panic disorder, not a heart ailment. On the other hand, a woman I know who was being treated for panic attacks turned out to have a cardiac abnormality, and once that was corrected, her panic attacks disappeared.

Furthermore, anxiety is often overlooked as the source of disorders like substance abuse or addiction, or as a contributing factor to symptoms in conditions like migraine headache or irritable bowel syndrome.

The Mayo Clinic lists several factors that suggest the possibility that anxiety may result from an underlying medical disorder:

■ None of your blood relatives has an anxiety disorder.

■ You didn’t have an anxiety disorder as a child.

■ You developed anxiety seemingly out of the blue.

■ You don’t avoid certain things or situations because of anxiety.

Persistent anxiety can cause symptoms like dizziness, nausea, diarrhea and frequent urination. People suffering from anxiety disorders can develop an array of additional physical symptoms as well, like muscle pain, fatigue, headaches and shortness of breath, which can lead to all manner of costly tests in a futile search for a physical cause. Yet nearly a third of people with an anxiety disorder are never treated for it.

The problem affects children as well. Anxiety disorders in children may be expressed as recurrent stomachaches or sleep disorders, including frequent nightmares and teeth grinding.

When people have a chronic physical illness, untreated anxiety can make the symptoms worse and the disorder more difficult to treat. Among patients with chronic obstructive pulmonary disease, for example, untreated anxiety can result in more frequent hospitalizations and more severe breathing difficulties. And those with physical ailments and untreated anxiety are also more likely to die sooner.

Anyone with a chronic ailment who experiences symptoms common to anxiety might consider being checked out for this emotional component and getting treatment, if needed. There are several effective therapeutic approaches for anxiety, including cognitive-behavioral therapy and medication, that can result in a much improved quality of life.

Depression, too, can be an early sign of an underlying medical condition not yet recognized. Among conditions in which this has occurred are thyroid disease, heart attack, cancers of the lung and pancreas, and the adrenal disorder Cushing’s disease.

In a report in the journal Psychotherapy and Psychodynamics, researchers from Italy and Buffalo, pointed out that a neurological disorder like multiple sclerosis or Parkinson’s disease may first show up as a psychiatric problem years before neurological symptoms become apparent that result in a correct diagnosis.

They cited a study of 30 patients with multiple sclerosis at the University of Massachusetts Medical School, three-fourths of whom experienced a delay in diagnosis because they had symptoms of major depression.

“Physicians may not pursue medical work-up of cases that appear to be psychiatric in nature,” the team wrote. “They should be alerted that disturbances in mood, anxiety and irritability may antedate the appearance of a medical disorder.”

Thus, it may be up to patients themselves or their advocates to suggest to therapists that something other than an emotional problem may be responsible for psychiatric disturbances that don’t respond to standard psychiatric remedies.

Keep in mind that human beings are not divided into two different organisms: a physical one and an emotional one. Mind and body are a single construct with two-way communication, and what happens in the body below the head can - and often does - affect the brain and vice versa.

Medical practice has been slow to catch up with what was demonstrated by healers long before the advent of modern medical science. Although these healers may have had nothing to administer more potent than a placebo, they could sometimes successfully treat the body through the mind. Their patients expected the treatment to work, and so it often did.

Nowadays, when researchers study the effectiveness of a new treatment, they routinely include a control group that acts as a placebo to help determine the benefits of the remedy in question over and above those induced by a patient’s belief that the new remedy will work.