The Mind-Body Divide: As Seen Through a Jaundiced Eye

January 1, 2016

Psychiatrists increasingly recognize that not all treatments for depression are created equal-but in this case, an entirely different diagnosis came to light.

WHY PSYCHIATRISTS ARE PHYSICIANS FIRST

As Mr B started to scratch himself, his golden glow caught my eye. He scratched more than he spoke-but that does not mean much, for he spoke so little. To psychoanalysts (and there were many around me), scratching meant as much as speech. To a newly minted physician like me, just starting psychiatry residency, scratching carried medical connotations as well as veiled analytic meanings.

I squinted to get a better glimpse of his skin. Was it the warm lighting on the ward, or did he really have a yellow tinge? He seemed unconcerned with the itching-which often accompanies icterus. Rather, he spoke of “indigestion” and pain that interfered with eating.

The departing resident had assured me that Mr B was the perfect patient for someone who was just starting out. He had a classic case of “involutional melancholia.” His stomach pains were “somatic preoccupations.” He could not eat, and he lost weight. He paced at night and fretted all day. His sagging skin attested to his weight loss and intensified the furrows on his face as he frowned.

[[{"type":"media","view_mode":"media_crop","fid":"42826","attributes":{"alt":"©CrystalEyeStudio/Shutterstock","class":"media-image media-image-right","id":"media_crop_8926239025277","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5015","media_crop_rotate":"0","media_crop_scale_h":"111","media_crop_scale_w":"175","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"©CrystalEyeStudio/Shutterstock","typeof":"foaf:Image"}}]]Mr B had made no headway through twice-weekly psychotherapy sessions. Months had passed. He could no longer care for himself. No one would say that the sacrosanct psychoanalytic treatment failed-but the “higher-ups” agreed that it was time for a hospital stay and a trial of tricyclics. Should that prove futile, there was always ECT.

Interviewing Mr B was not easy. Establishing rapport was even harder. Open-ended questions, like the ones favored by the analysts, accomplished nothing. Some concrete questions finally did the trick.

When Mr B said that he did not “like” anything anymore, I asked the obvious: “What did your life used to be like?”

“Eat exotic food,” he said. That statement sounded promising and might invite more dialogue.

“Which exotic foods?” I prodded.

As a new arrival in New York City, I was awed by the variety of restaurants in the city-much to the amusement of my office mate, a native New Yorker. There were more restaurants on a single Manhattan street than in most American towns. When Mr B answered, “Chinese,” I felt almost as sad as he did. Even in my Midwestern mind, it was strange to think of Chinese takeout as exotic. It seemed that Mr B had led a limited life all along.

With the ice broken, Mr B elaborated on his background. He spoke slowly and without inflection, confiding that he lived life in an orderly and predictable manner. A rental apartment in a clean and safe neighborhood and a steady government job were plenty, he said. He grew up during the Depression, and he had lower expectations than Baby Boomers who came of age in post-war America. He expressed regret about the family he never had, but without seeming embittered. He had lost his wife years earlier and never remarried. Maybe he entered a depression way back then and never came out of it, I wondered. When life became unbearable, he sought psychiatric treatment at a local clinic.

In spite of the intriguing information about his being widowed and living his life alone, my mind kept returning to his scratching and his continuing complaints about stomachache. It was hard to discern if he was “yellow”-for I could not see his sclera from where I sat. Medical school preceptors stressed the importance of inspecting inside the eyelid when looking for icterus. That was not possible for me.

Soma vs psyche

At that time and place, thinking about lessons learned in medical school seemed heretical. At the very least, it was a sign of “resistance.” American Psychiatric Association Medical Director Melvin Sabshin’s historic exhortation, urging psychiatrists to re-embrace medicine, was still a few years away. In the mid-70s, psychiatrists in training were taught to shed the MD identity so that they could embrace their new role as “doctors of the mind.” The process reminded me of a snake shedding its skin.

In medical school, we learned that liver disease could cause neuropsychiatric symptoms. On medical rotations, we routinely encountered patients who drifted in and out of consciousness, before falling into hepatic coma. Long before I saw extrapyramidal syndrome from then-ubiquitous phenothiazines, I encountered an even more ominous movement disorder, “liver flap,” during medical rounds. Worst of all, pathology books warned that pancreatic cancer could present as depression years before physical symptoms-or lab abnormalities-manifest themselves.

The combination of gnawing stomach pain, a vaguely yellow tinge, and non-stop itching-along with depression-could not be ignored, at least not by me. My office mate, an aspiring psychoanalyst (as well as a restaurant aficionado), felt otherwise and chided me to focus on Mr B’s feelings, like a psychiatrist.

Residency was a time to indulge in debates about the soma and the psyche, and to argue about Descartes’ concepts-and whether his ideas about the separation of the body and mind should be resurrected or cast into the embers. Biological psychiatry was still a twinkle in most analysts’ eyes.

To avoid an argument, we came up with a compromise: if the patient’s chart confirmed that his liver enzyme and bilirubin levels were normal, I would put my worries aside. There was one problem: there were no labs in his chart.

So I ordered labs, amylase and all. The results returned with sky-high serum glutamic pyruvic transaminase and bilirubin to match. I called an emergency gastroenterology consult and ordered whatever studies would expedite matters. There were no MRI scans in the 1970s-just upper and lower GI series-so work-ups were faster and more straightforward (albeit less precise). Contrarily, arguments among psychiatrists-to-be could become more embittered, if one fervently “believed” in biology while the other sanctified the psyche.

The gastroenterologists arrived, flipped through the patient’s chart, and promptly summoned the surgeons. Mr B was whisked away to prepare for what we presumed would be lifesaving surgery. I was not sure how much Mr B understood about the tests ordered or the treatments proposed, for the surgeons took charge. I was optimistic, and my optimistic attitude presumably allayed many of his fears.

When the biopsy report confirmed our suspicions, there was a bittersweet sense of satisfaction. Mr B underwent the Whipple procedure-or pancreatoduodenectomy-for pancreatic cancer. I still believed that this diagnosis-and relatively prompt treatment-would give Mr B a new lease on life, or at least more life than he might have had otherwise.

Mr B returned to the psychiatry ward months later, having spent weeks in the intensive care unit and more time on medical-surgical wards. He was barely recognizable on his arrival. His already sagging skin hung from his bones. He lost 75 lb (and much of his insides) from the pancreatoduodenectomy. Mr B and I also lost time together-for I was starting a new rotation.

Before I left, Mr B made a point of telling me how much he wanted to believe that talk therapy would work-and how angry he was that his bubble had burst. He no longer sounded depressed.

A lifesaving treatment?

It was a spot-on diagnosis-with a horrible outcome. Perhaps the day will come when diagnosing such diseases early offers a survival value-but we don’t know when that day will arrive and we don’t know the specific diagnosis-much less the prognosis-until we attempt to tease out the diagnoses.

As I look back and revisit Mr B’s situation, I ask myself if he would have been better served had the diagnosis been made sooner, before he had grown too ill to appreciate daily life. He might have spent the extra time ruminating about his impending suffering and death-or he might have ordered more of his cherished Chinese food.

Perhaps he would have reconnected with people, activities, or causes that once held meaning for him. Instead, he felt like more of a failure than ever before because he could not find the magical psychodynamic “insight” to stop his depression.

Currently, physicians overall are reevaluating recommendations for supposedly “lifesaving”-but quality-of-life losing-treatments. Psychiatrists increasingly recognize that some psychotherapies are more effective for certain conditions and that not all psychotherapies are created equal.

Ironically, male patients with pancreatic cancer who undergo “curative” surgery have a higher risk of suicide than those who forgo surgery-and men with pancreatic carcinoma have a greater than 10-fold increase in suicide overall.1 As physicians, psychiatrists can weigh these data, when they are available.

We will never know whether Mr B would have opted for surgery had he known then what we know now. We can hypothesize that it was safest for him to return to the psychiatry ward. For all I know, maybe some kind nurse’s aide would have smuggled him some Chinese takeout. Stranger things have been known to happen.

This article was originally posted on 11/02/2015 and has since been updated.

Disclosures:

Dr Packer is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine, Bronx, NY. She is also in private practice in New York City.

References:

1. Turaga KK, Malafa MP, Jacobsen PB, et al. Suicide in patients with pancreatic cancer. Cancer. 2011;117:642-647.