As practicing physicians, we constantly ask ourselves when and where to alert patients to bad possibilities that may occur in the future. More in this installment of "Why Psychiatrist Are Physicians First," by Sharon Packer, MD.
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.
It was clear that Sam was not ready to return to work. It was equally clear that more than meets the eye was going on. I knew that optic neuritis is the first sign of multiple sclerosis (MS) in almost 1 of 5 persons who go on to get a diagnosis of MS. It is equally well known that MS-related CNS involvement can mimic mania, although depression is even more common in persons with MS. Ruling out MS in everyone with new-onset mania would be a waste of time and resources and could cause panic more than anything else. However, considering that Sam had other highly suspicious symptoms, it seemed prudent to recommend a neurology consult.
A befuddled Sam agreed to a neurology appointment, after I explained that some medical problems cause psychiatric symptoms and that those medical problems may have more specific treatments.
The turning point in MS therapy was still 2 years away when I saw Sam. In 1991, new meds would change MS treatment. Although miracles did not occur then and do not occur now, most MS subspecialists concur that fewer patients have become wheelchair-bound since the medications became available.
After a battery of tests, Sam’s neurologist confirmed the diagnosis. Although many people would be devastated by such a diagnosis and many would go into deep denial, Sam was relieved to learn that he had a medical problem, rather than a mental problem, and that his symptoms were “not his fault.” He was even more relieved when further testing linked his erectile dysfunction to his MS and he found that the treatments were covered by insurance.
Sam’s situation raises many important questions. As practicing physicians, we constantly ask ourselves when and where to alert patients to bad possibilities that may occur in the future. Today, parallel dilemmas surround the diagnosis of mild cognitive impairment, which can be a harbinger of Alzheimer disease (but in only 70%). The difference is that we do not have useful treatments for Alzheimer disease at this time.
When symptoms first developed in Sam, connecting the dots between recurrent optic neuritis and acute-onset mania was not so important because making an accurate diagnosis did not affect clinical care. Neglecting to do a “review of systems”-which would link his neurological symptoms to his psychiatric and ophthalmological symptoms-could have had devastating effects after 1991, when better and targeted treatments became available. Today (in 2013), psychiatrists record observable neurological details in mental status exams, as required for CPT (current procedural terminology) coding. We would take note of his mild motor weakness and “past-pointing” that he showed at the start of the appointment, when he accidentally dropped his briefcase on the floor, but expected to land it on my desk.
Why would these hair-splitting details matter to anyone other than board examiners who probe trainees for their knowledge of medical facts? Is this simply a matter of documenting more details to justify higher CPT codes and to prove that psychiatrists are finally worthy of the same E&M (evaluation and management) codes as other medical specialists? Or do these CPT codes force us to pay closer attention to those neurological symptoms?
Actually, there are even more reasons than that. Today, there is pressure to expand prescribing privileges to non-psychiatrists. That implies that prescribing meds that influence the observable signs and symptoms is sufficient. This approach negates the necessity of looking at the big picture, doing a differential diagnosis, and knowing that some seemingly “medical” symptoms that occur in the presence of seemingly straightforward psychiatric symptoms can carry entirely different meanings-and require different treatments or extra evaluations before beginning any treatment at all.
Yes, some people would rather not know that a disabling illness may develop in their future. But who would not want to know that their symptoms suggest a treatable disorder-and that prompt diagnosis can lessen the odds of becoming bed-bound or wheelchair-bound at a later date? MS may not be a common disorder, but “medical mimics” often occur in psychiatric practice. Those are the times when we really appreciate the value of medical training-but we never know when those times will happen.
Dr Packer is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine in the Bronx, NY. She is also in private practice in New York City. She reports no conflicts of interest concerning the subject matter of this article.