Patients' symptoms often have an etiology that is actually "all in their head..."
An interesting human behavior is to marginalize or stigmatize anything that elicits feelings of helplessness, frustration, or ignorance. A great example of this phenomenon is the phrase, “It’s all in your head,” which is commonly used when a health care provider, friend, or family member feels helpless or frustrated with a patient’s symptoms that seemingly defy explanation and treatment. Those of us in the psychiatric profession hear this about our patients all too often. Sadly, this judgment commonly extends to individuals with an established psychiatric diagnosis when they present to an emergency department with physical symptoms or complaints.
As psychiatric and medical clinicians, this phenomenon can be very frustrating. As a result, I have sent many patients in different settings back to their referring provider after the cursory medical clearance resulted in the transfer to psychiatry. Ironically, those doctors who told patients, “It’s all in your head” because they could not find a cause with the diagnostic tools available were actually correct. The patient’s symptoms often have an etiology that is indeed in the patient’s head—the symptoms may be due to a process that has gone awry in the patient’s brain and has been missed or was difficult to diagnose.
We still know very little about the human brain. The 80 billion neurons form an integrated circuitry in which each neuron is connected to anywhere from 1000 to 10,000 other neurons. In addition, we are just beginning to understand the microenvironments in which 2 neurons connect, where there is a lot of activity working to maintain a delicate equilibrium for optimal functioning. The presence of inhibitory and excitatory interneurons, astrocytes, microglia, neurotrophic factors, trace amines, autoreceptors, and oppositional postsynaptic effects by the same neurotransmitter binding to different subfamilies of the same receptor type are only some of the processes that can tilt the brain’s equilibrium from healthy functioning to a large range of disordered signs and symptoms.
One example of this complexity is documented in the autobiography Brain on Fire: My Month of Madness by Susannah Cahalan, who tells of an onset of an unusual progression of severe neuropsychiatric symptoms, including erratic behavior, seizures, paranoia, fatigue, depression, anxiety, headaches, and hallucinations. Examinations by medical specialists led to various diagnoses, including bipolar disorder, Capgras syndrome, seizure disorder, postictal psychosis, schizoaffective disorder, and more.
Cahalan underwent weeks of medical and neurological evaluations and diagnostic tests—brain MRIs and CTs, electroencephalograms, extensive laboratory tests, and a lumbar puncture—and ultimately was admitted to a specialty neurology inpatient clinic, yet the clinicians failed to find an etiology to her bizarre symptoms and deteriorating condition. Cahalan’s blood samples were sent to the Centers for Disease Control and Prevention and the New York State labs, all of which returned normal with the exception of some white blood cells in her cerebral spinal fluid (CSF). Her medical team consulted with the resident expert in difficult cases, who ultimately ordered a brain biopsy. It revealed significant inflammation consistent with encephalitis. Samples of Cahalan’s blood and CSF were then sent to the University of Pennsylvania, where neuro-oncologist Josep Dalmau, MD, PhD, was hard at work investigating a series of cases of female patients with similar presentations.
In 2007, Dalmau discovered the etiology: anti–NMDA-receptor autoimmune encephalitis. Cahalan’s CSF tested positive for these antibodies and she became the 217th individual worldwide to receive a diagnosis of this rare disorder. The treatment was plasmapheresis, intravenous immunoglobulin, and steroids. She recovered and returned to work as an investigative reporter.
This case raises many questions and provides many lessons for those of us in the medical profession. What would have happened to Cahalan if she had developed these symptoms before Dalmau’s discovery? What neurobiological, brain-mediated causes of psychotic and severe mood disorders that could be effectively treated once we understand the etiologies remain to be discovered? Why does our visceral feeling about a patient’s diagnosis change so significantly when it is determined to be medical rather than psychiatric?
Despite the necessity of a brain and the presence of at least 1 psychiatric disorder in every human, it is remarkable how stigmatizing psychiatric diagnoses remain. In most hospitals I have visited in the United States, the inpatient psychiatric units are located on the top floor or in some out-of-the-way place. Insurance providers continue to differentiate behavioral treatment from medical treatment. Individuals with serious substance use disorders are often judged as being weak or at fault for their addiction. Medical and social resources remain poor for individuals with persistent serious mental illnesses. More individuals with serious mental illnesses reside in jails or prisons than in hospitals or supportive residential communities.
In addition, although public officials and politicians are quick to blame any destructive behavior on mental illness, funding for treating individuals with serious mental illnesses remains poor. This month’s cover story, “Changing the Narrative: Mental Illness and Gun Violence,” provides an insightful and distressing look into how mental illness is used as a scapegoat for gun violence despite solid evidence to the contrary.
It’s time to use our heads. Let us work together to weave the narrative of mental health and illness into the larger fabric of quality health care. It is asking a lot, but let’s continue to educate politicians and the public about the beautiful brain, the most complex organ in the universe, and be proud and thankful that it is, in fact, all in our head.
Dr Miller is Medical Director, Brain Health, Exeter, New Hampshire; Editor in Chief, Psychiatric Times®; Staff Psychiatrist, Seacoast Mental Health Center, Exeter; Consulting Psychiatrist, Exeter Hospital, Exeter; Consulting Psychiatrist, Insight Meditation Society, Barre, Massachusetts.