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Comorbidity Conundrums and Other Brain Teasers

Comorbidity Conundrums and Other Brain Teasers

  • Here: An update on emerging trends in psychosomatic medicine to help clinicians address mental health stressors in psychiatric and medical settings. Scroll through the slides for this Special Report collection. Links to detailed articles can be found in the captions.

  • Seize the Opportunity. Psychogenic non-epileptic seizures (PNES) may be a symptom of a variety of processes rather than a specific disorder, thereby requiring personalized treatments instead of a one-size-fits-all intervention. Although PNES are events that appear to be similar to seizures, they are not caused by abnormal electrical brain activity. Instead, they are thought to have an underlying psychological cause. It is important to recognize when seizure-like symptoms are being volitionally produced for the purpose of maintaining a sick role or for secondary gain. The authors shed light on a disorder that is difficult to diagnose and manage, and offer insights on how to develop an appropriate treatment plan. See: Psychogenic Non-Epileptic Seizures: Clinical Issues for Psychiatrists

  • SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST: Did you know . . . early-onset (adolescence) PNES has been associated with bullying? Furthermore, late-onset PNES has been associated with health-related trauma. After reading this article, psychiatrists will have greater insight on how to assess patients and diagnose PNES. In addition, the authors shed light on the current challenges of treating such illnesses so clinicians can develop an appropriate treatment plan. For a mobile-friendly view of the monarch notes, click here.

  • The Catatonia Conundrum. Catatonia, described in 1874 by K. L. Kahlbaum, is a distinct and heterogeneous neuropsychiatric syndrome, with both motoric and behavioral signs. It may be hypokinetic, hyperkinetic, or mixed and includes volitional signs, such as mutism, negativism, and automatic obedience. It was formerly relegated to a schizophrenia subtype, or considered extinct after the advent of modern psychopharmacology. Renewed interest and emerging systematic data have highlighted the frequency and pattern of catatonic presentations in psychiatric and medical settings, including in critical illness. See: Update on Medical Catatonia: Highlight on Delirium

  • SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST: Of particular interest and potentially of great clinical significance is the relationship between catatonia and delirium. While atypical antipsychotics with benzodiazepines have been considered for psychiatric catatonia in those without fever or autonomic signs, there is no evidence that these agents are safe or effective for medical catatonia or delirium with catatonia. This article presents examples of other medical conditions associated with catatonia. For a mobile-friendly view of the monarch notes, click here.

  • Special Considerations. Patients go through an adjustment period for about 4 to 6 weeks after diagnosis of cancer. For many patients, cancer is synonymous with death and debilitating treatments, with images of a prolonged painful dying process. Patients often say they feel overwhelmed trying to assimilate medical information and make treatment decisions Although most cancer centers provide some psychosocial services, increased attention to the psychosocial needs of patients with cancer may result in increased referrals to mental health professionals in other settings. Some basic knowledge about a patient’s cancer and treatment are essential for psychiatric management. See: Depression and Anxiety Disorders in Patients With Cancer

  • SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST: Concurrent with advances in cancer treatment, the importance of psychosocial care of individuals with cancer is being increasingly recognized. Psychiatrists are learning more about a patient’s cancer diagnosis, staging, treatments and their adverse effects, and prognosis to appreciate the challenges the patient is coping with throughout treatment as well as survivorship or end-of-life. For a mobile-friendly view of the monarch notes, click here.


On the other hand, there is a tendency by many practitioners to erroneously label patients with "too complex symptoms" as having Somatisation Disorder or Anxiety induced symptoms.
This is usually preferable by many doctors instead of admitting their failures at not knowing the diagnosis,or preferable to having to deal with the frustration of a patient with unusual symptoms which do not fit the box, especially when one is time constrained.

This is problematic particularly for two reasons:
1.The so-called Somatisation disorder diagnosis is usually given without any evidence base.
Ie:it is often given as a diagnosis of exclusion once numerous tests for Organic causes have been ruled out,however,lack of evidence is not evidence of lack.
2.Patients often view this diagnosis as being highly stigmatising and they do not agree with it.
Many patients have stated that having a Somatisation or Anxiety label has prevented them from receiving quality healthcare in the future and the label and presumptions about them have followed them around on their health records -in turn influencing their treatment and care.

Diagnosing a patient with Somatisation disorder or Anxiety due to feeling frustrated or being at the end of ones tether is no more scientific based than for example Homeopathy.
In addition sometimes it has led to tragic outcomes.
Eg: Women with Cardiac conditions have wrongly received these diagnoses and had their symptoms dismissed as being Psychiatric based,only to go on later having a Cardiac Arrest.

m @

This is such an important issue - I watched a good friend who died from leukemia, repeatedly ask her oncologist for something to help her sleep, or for anxiety, and he said he did not believe in providing those treatments. He did not refer her to a psychiatrist, and her HMO did not allow for self referrals. She suffered from severe anxiety until the day she passed.

Kelli @

That doctor should be referred to a psychiatrist. He needs proper advice and behaviour therapy.
Doctors are supposed to treat their patients and their families humainely and do their best to provide every possible treatment , comfort and refer the patients to appropriate specialists for help. It is their utmost duty to listen to the patients' concerns and relieve their anxity and tension.
We cannot allow our patients to keep suffering and we simply set aside and do nothing.


Many physicians are very reluctant to speak of death. However, I keep on trying with my doctor as I believe it is a normal reaction for my doctor to be upset about a patient passing on their watch. Doctors are humans trained to save lives not to watch them end. They also experience our youth oriented culture in the US and their attitudes anx feelings must be considered as well.

Susan Ross @

Sigh. Our bodies still thought of in separate and distinct sections where never the twain shall meet. Perhaps Oncologists fear bringing the conversation with the patient to the point of "real" as that will require a likewise real response from them. When my Mom was dying of cancer, the word death was never put on the table for an open discussion. Instead, it was " we are sorry but we can't do anything more for you. Let us know when you're ready for Hospice" thereby overlooking the stages of dying and grief when simply asking the patient if they'd care to talk to someone about dying would be so much kinder. Each patient Is in a different place but each can be assisted in their journey home if physicians could maintain a more holistic and mindful attitude. Very sad that MD's are ill prepared in medical school for such matters though this is very much a part of life and assisting in maintaining the quality of that life as much as chemo does. Likely more.

Marcella @

Likewise I had not received a single referral from an oncology practice though the patients themselves have came seeking help and my panel has several in various stages of treatment/recovery. Sad thing is that the family identified the need often late into their suffering and it was this insight that brought them too us.

Wayne MacKenzie PMHNP-BC

Wayne @

From personal experience I can say that oncologists hardly ever refer patients with a diagnosis of cancer for psychiatric intervention. I had 4-5 referrals in 30 years of practice and my office was one floor above a large oncology group. I had cordial relationships with several members of that group. The pattern has continued in several other practice settings. My offers to provide input to cancer support groups have been routinely ignored and I no longer make such offers.
Very sad and very difficult to understand.
Peter Berndt, MD

Peter @

On the other hand, from personal observation, not all adult patients with cancer, on dialysis, and other life threatening illnesses/medical conditions are going to agree to attend counseling even if there is a transitional program between the medical aspect and the counseling department. This is sad too.

Sherri @

It is surprising that the psychiatrists will not raise the issue with the oncologists. I believe the psychiatrists should organise meetings and invite the nearby oncologists to attend. Its very important for the oncologists to prepare their patients, relieve their pains and anxiety and refer themto psychiatrists when appropriate.
Not every patient will agree to be seen by psychiatrists but many more will be helped.
The worst thing is when a doctor refuses to help, relieve anxiety, provide sleep medications and co


The most important message in this review is the need for psychological/psychiatric care for the cancer patient.Some well intentioned oncology devices an d practice provide no referral or mental health consuling to their patients.Some institutions only have a social worker who is overwhelmed by a case load and deposition of the patients.
Unfortunately the fellowships in oncology and psychiatry rarely intersect .
John J OConnor,MD PhD

John @

I agree with all the above colleague comments made about mental health needs for the chronically ill and dying patients. I attempted to do the GDS in a doctor's clinic with flyers out and shared publically. Not one showed up. Sadly insurance would probably not cover a consultation with a mental health practitioner unless a Psychiatrist and medication was induced. Keep trying though...some places even managed care provide behavioral health support to insured members. D.W.,LCSW

David @

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