More Than Meets the Eye: Spotting Medical Mimics

Sam hoisted his briefcase up from the floor, but it never reached my desk. It fell to the ground first. The lock popped open and the lid flipped up. Several encyclopedias spilled out and slid across the carpet.

I was impressed by his intent, but not by his dexterity. Then he started to talk . . . non-stop, staccato style. I perked up on hearing his speech pattern. His rapid, pressured, sometimes scanning speech would be easy to describe on the mental status part of Sam’s return to work form.

Sam didn’t mention that he arrived for a return-to-work evaluation. Smiling the entire time, Sam raved about the encyclopedias, praising the price, boasting about the embossed leather binding. His run-on sentences would have been difficult to follow had he not come prepared with props and pamphlets to tout the virtues of his encyclopedia set. He reminded me of the insurance salesman who tormented Woody Allen in Take the Money and Run (1969).

It was no surprise that Sam arrived hypomanic. I knew in advance that he recently spent several weeks at a free-standing psychiatric hospital, one with no medical wards at all. In his coat pocket was a large envelope. His discharge summary and a “release for return to work” form were stuffed inside.

I glanced at the single page supplied by the hospital, noting his meds, his diagnosis, lab studies, even past medical history. Diagnosis: bipolar, single manic episode (no prior history of depression). Age: 34. Recent lithium levels were within range, hovering around 1.1 mEq/L. All other labs were WNL (within normal limits), but a single sentence in the past medical history caught my eye: it was something that we would return to later.

I was not assigned to treat Sam. My job was to determine whether Sam was ready to return to work. This was an employee health center, a day job for psychiatrists who were building their private practices. It could just as easily have been called an “employer protection center” because it did more to protect employers than to ensure employee health. Then, as now, businesses and bureaucracies insisted on “psychiatric clearance” for anyone who went out on medical leave for mental health care. It sounded unfair, on the surface, except for the fact that employees who performed physical labor also needed “medical clearance” before they could resume their duties after equally lengthy absences.

The fact that a salesperson is hypomanic does not necessarily disqualify him or her to work. On the contrary. It is well known that many salespeople perform best when animated by hypomania. Some earn enough during their upswings to compensate for performance dips during episodes of depression. However, there was a problem with Sam’s situation. He did not work in sales at all, and his company had no connection to libraries or reference books. He was employed as an auditor. He reported to the accounting department. His current behavior was completely out of character.

There was another problem: Sam’s medical history. His discharge summary recorded 2 prior admissions for optic neuritis, but no prior admission to the psychiatric service. These facts deserved further exploration, even if they did not immediately impact Sam’s ability to work as an auditor. Once Sam sat down and accepted my assurance that we would examine his encyclopedias after we reviewed the return-to-work requirements, I asked him about the optic neuritis. Perhaps he had been treated with corticosteroids, which can induce mania. Perhaps this was not “real” bipolar at all.

Or, perhaps, something more was amiss, since he had had 2 earlier episodes of optic neuritis and not just one, which was telling. I needed more specifics about Sam’s history, for the shorthand discharge summaries supplied to employers do not necessarily include all pertinent facts.

Sam responded well to structured questions. He stopped his sales pitch, temporarily. He seemed reasonably certain that he had not taken prednisone for at least 2 years, not since the last bout of optic neuritis. He also confirmed that he had never been admitted to a psychiatric hospital before and had only seen a marriage counselor every week or two, for the past 2 years. He was reluctant to reveal why. I later learned that Sam had problems with sexual performance, which his wife attributed to problems in their relationship. She had insisted on couples’ counseling. This detail proved to be important later.

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