Tips for Diagnostic Accuracy: Consider Medical Mimicry

As promised in the previous post, the next several will continue to examine other stumbling blocks to accurate diagnoses that have relatively easy fixes.

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Perhaps the most overlooked diagnostic consideration is that the patient’s presentation is caused, or perhaps exacerbated by, a general medical, physical condition. In fact, at the end of each diagnostic category in the DSM, there is listed a diagnostic code reserved for just such occasions: "Due to Another Medical Condition." Examples may be found on pages 145 and 260 of the DSM-5. In most diagnostic categories, practitioners are also reminded to keep vigilant for this. If you look at criteria for, say, Schizoaffective Disorder (DSM-5, page 105), Criterion D stresses: "The disturbance is not attributable to the effects of a substance...or another medical condition."

How medical etiology gets overlooked

"Due to Another Medical Condition" means acknowledging that some medical problems can mimic mental health conditions. It is not that the person isn’t psychologically suffering, but the symptoms are medically driven and require physician intervention, not a therapist. Of course, someone may need help coping with a certain medical condition, and a therapist can indeed be helpful.

A cursory look at available literature (e.g., Gleason, 2015; McKee & Brahm, 2016; Welch & Carson, 2018) on psychiatric diagnosis, misdiagnosis can reveal numerous articles stressing the importance of assessing for general medical, physical etiology.

Over the years, I’ve heard two frequent excuses for this being overlooked:

1. Even though it is standard practice for intake documents to have a general medical history section that would seem to be a reminder, the first is simply, “I forgot about physical possibilities.” This is understandable, especially for less-experienced practitioners, given we’re largely trained to see the patient’s problems through a psychogenic lens. Because of this reflexive tendency, practitioners move in like a SWAT team, aiming to categorically snipe out symptoms, under the assumption those symptoms are within patient control if only we can reach them with our bags of tricks.
2. The second reason medical etiology often seems to be overlooked is that many clinicians seem to feel they’re overstepping a boundary if medical conditions enter the discussion. However, I have yet to see a rule that says non-medical practitioners cannot address the possibility that a mental health diagnosis is caused, or exacerbated, by a general medical condition. We are not diagnosing or treating a physical problem. Those actions are forbidden barring the appropriate medical degree. We are simply considering what may be causing the psychological suffering. In fact, it would be unethical if we did not consider medical etiology; trying to use talk therapy to manage something that needs medical intervention is neglectful.

To illustrate the second point, when clients complain of panic symptoms, I ask if they have diabetes or if the symptoms seem to occur around mealtimes. While not the norm, sometimes they answer in the affirmative and I suggest they visit an endocrinologist. More than once, symptoms were deemed to be from insulin problems. If I tried to apply CBT-based panic interventions for an insulin problem, they’d be coming to sessions week after week without progress, all the while their medical condition would likely get worse.

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Hopefully, it is now obvious why sound diagnostic practice includes remembering consideration that a person’s symptoms may be influenced by a general medical condition. In Parts 2 and 3 of Medical Mimicry, we'll learn how to evaluate if medical problems may be influencing the clinical picture.