The smell of garbage was strong enough to be disturbing. The young man repeatedly looked for the source but couldn’t find it. “Do you smell it?” he would ask friends. “Do you smell it?” His friends and his brother would exchange that quick glance of exasperation and pity. This had been going on for weeks. No, they didn’t smell it. There was nothing there. It must be all in his head. Becoming increasingly depressed, the young man made an appointment with a highly respected analyst. He went to several sessions every week for five years to try to unearth why he would persist in having these olfactory hallucinations.  Perhaps good therapy did happen. Perhaps he discovered things about himself that were helpful and added depth to his life. But what didn’t happen was a thorough medical exam. An excruciating headache finally sent our young men to a doctor who diagnosed a brain tumor. The operation to remove it was successful but the patient died. And the world lost one of its greatest American composers, George Gershwin. He was only 38 years old.

I’ve imagined Gershwin’s interactions with friends to make a point. The facts are true. He did see an analyst 3 times a week for 5 years for olfactory hallucinations. And he did die from a brain tumor that was diagnosed too late.  Sadly, his story is not that uncommon. Patients with vague, unusual, and/or persistent symptoms that don’t respond to treatment are frequently referred to a psychiatrist or a counselor. But there are many things that can be mistaken for mental illness.  Before you tell someone you love (or yourself) that it’s “all in your head”, make sure that these other bases have been covered.

Underlying Medical Conditions:

Feeling depressed? Low grade anxious all the time? Having memory problems? Diminished sex drive? So preoccupied with sex you can barely think of anything else? Maybe you have some vague aches and pains. Perhaps friends and relatives are getting tired of hearing about it. Maybe they have even suggested that it’s “all in your head” and you should see a shrink. Or they might have suggested that you get some of those antidepressants or anti-anxiety medications that are advertised on TV.

Not so fast.  There are many, many medical possibilities for how you are feeling. Symptoms of depression may be the result of a low grade infection, an over-active or under-active thyroid, a vitamin deficiency, or electrolyte imbalance. Panic attacks may be the result of a tumor that secretes epinephrine or a symptom of hypoglycemia (low blood sugar).  Mood disorders can be caused by a minor stroke, may be the first sign of a neurological condition (such as Parkinson’s or Huntington’s disease), or could be the result of certain cancers (such as pancreatic cancer).  Certain infectious diseases (such as HIV and other autoimmune diseases like multiple sclerosis) can cause personality changes, as can thyroid conditions, a brain tumor, or a blow to the head.  Sexual dysfunction? Before you delve into your deep seated feelings about sex, it may be that this too is a health issue. Endocrine conditions (like diabetes and pituitary dysfunction, for example) can decrease or increase your desire for sex and your ability to orgasm. The list goes on.  Before you see a psychologist for what ails you, see your doctor for a thorough work-up. Explain your symptoms and ask if it is possible that there is something physically wrong.

Medication side effects:  Medications, too, can be the culprit when people start to feel or behave in uncharacteristic ways. Often people forget to mention to their primary care doctor or their psychiatrist that they are taking a cold or allergy medicine. Because they are sold without a prescription, many people don’t think of them as “drugs” but they are. And all drugs can interact with other drugs in unexpected, and sometimes even dangerous ways. The same is true for recreational use of illegal drugs. People who use these substances often don’t report them, either because they don’t want their doctor to know or because it has become such an ordinary part of their lives that they simply fail to realize that talking about it may be important.  Hallucinogens, cocaine, and stimulants can make a person look psychotic! Finally, just because something is “natural” doesn’t make it harmless. Homeopathic remedies, herbal teas, and various nutritional supplements, though usually safe in themselves, can contain ingredients that interact with other medicines. Nicotine and ginseng root, for example, can cause symptoms of anxiety. Further, although some people say they drink because they are depressed, they may not realize that alcohol is a very common cause of depression.

Sleep Disorders: Don’t underestimate the importance of a good night’s sleep. Sleep restores the body and the mind. People who have interrupted sleep or difficulty getting to sleep on a regular basis may start to show symptoms that can be mistaken for mental illness. Irritability, confusion, difficulties with memory and concentration, and lethargy can look like depression. But it may all have to do with the need for regular, restorative sleep.  Be cautious about turning to the sleep medications advertised on TV, too.  Many will get you to sleep but the quality of sleep won’t necessarily be what you need. Work with your doctor to develop a healthy sleep routine that will give your body and mind the rest you need.

A Caution:  Just because you are sick doesn’t mean that you aren’t also suffering from a mental illness. Just because you have a mental illness doesn’t mean you aren’t sick. Sometimes both are true.  When a person has symptoms, it’s essential that whoever is trying to help looks at the total picture. Even though the professions now divide us up into parts, each seen by a different kind of medical specialist, it’s important to remember that the human body is made up of complex interrelated systems that interact with each other. Good care requires a holistic investigation of what is going on.

So why doesn’t everyone deal with symptoms holistically?

The fault lies both with the medical profession and us, the patients. In these days of managed care and tightly controlled costs, time with a medical doctor has become precious. It’s not at all unusual for a doctor to be expected to see an average of three to four patients per hour. The time constraints make it very, very difficult for the doctor to be thorough. Accurate diagnosis of complex medical problems requires a combination of education, commitment, experience and, yes, time, to follow a hunch. In the crush of having to see so many patients and deal with the accompanying paperwork, it’s understandable that things might get missed.  In the stress of having to meet the daily quota of patients, it’s only human if a doctor gives doesn’t probe too deeply or ask lots of questions of a patient who presents what appears to be a simple problem.

We’re also to blame.  In a time when there are commercials on TV for pills for everything from depression to anxiety to sleep disturbance, the public has become increasingly willing to accept the idea that a pill will make it all go away. It’s far easier for many people to think of themselves as a little anxious, for example, than to consider that they might have a serious illness.  In that sense, the pill culture contributes to people’s understandable denial when things begin to go wrong. Sadly, this can also mean that illnesses don’t get caught early and treatment can get delayed.

As consumers, it’s our job to give our doctors the information they need. But people in discomfort and distress aren’t always their most organized, most effective selves. Sometimes a patient might not be assertive about symptoms and be too easily persuaded that the complaint is minor. Or the patient may be shy and not want to share something felt to be deeply personal. Or the patient may not understand that the minor ache here could be related to the major problem there so doesn’t think to mention it. Or the patient just gets flustered by the doctor’s obvious need to move on. 

Our doctors don’t have time to chat. We need to use their time wisely and well. Prepare for an appointment. Bring an organized list of complaints (including when they started, when and how often they happen, and how distressing they are) , a list of all medications and substances being used (including dosages and when you take them), and a brief summary of sleep, nutrition, and exercise habits so the doctor has what he or she needs to investigate the problem.  If you are someone who gets easily rattled when under pressure or who is rather shy, it’s a good idea to bring a trusted friend or relative with you to appointments. There are then two of you to make sure you get through your list and hear accurately what the doctor has to say.

Teamwork:  Getting good care requires teamwork. Each new symptom is a mystery that takes good detective work to solve.  Sometimes it really is “all in your head”. But sometimes, maybe even most of the time, there are other reasons for your distress. When patients and their doctors look at the total picture (body and mind), it is far more likely that a correct diagnosis is made and that appropriate treatment follows.