Vestibular disorders are difficult to diagnose. Occasionally, a patient with challenging symptoms will be referred for a mental health evaluation instead of additional testing to determine whether there is a physical cause. Amelia Ruzicka discusses whether and when it is appropriate for a medical doctor to label a patient with a mental health diagnosis.
By Amelia Ruzicka Ph.D.
It isn’t hard to find someone who can tell you how frustrating it is to become ill, and then go to the doctor for help only to be told the problem is “all in your head.” Although it has long been known that stress, anxiety, and other mind-based disorders can affect the body, research is increasingly demonstrating that physical disease can affect the mind. Researchers in cardiology, nephrology, rheumatology, and other disciplines are finding that depression, in particular, can be a symptom of a serious physical problem, rather than a reaction to it (Moscavitch, Szyper-Kravitz, and Schoenfeld, 2009; Roy, Rose, Sunderland, Morihisa, and Murphy, 1988; Serrano, Setani, Sakamoto, Andrei, and Fraguas, 2011; Zautra, et al, 2004). Physicians who are quick to dismiss patients as “psych” might be missing early signs of treatable disease before more significant problems develop. Another problem of quick “psych” dismissals is that physicians (who are not psychiatrists) generally are not adequately trained to distinguish between the often subtle differences in mental health issues, and even if they were, the standard ten or fifteen minute appointment is not adequate to make a correct mental health diagnosis. Psychological symptoms must be considered in the context of the patient’s life, and a brief appointment does not allow the necessary time to reach correct conclusions. Unfortunately, in addition to missing early warning signs of serious illness, prescribing the wrong drug for certain kinds of psychiatric disorders can actually make the patient worse.
In my own dissertation research regarding “psych” dismissals that happened to women who really had autoimmune disease, the data suggested that inappropriate psychological diagnosis caused significant and lasting harm to patients (Ruzicka, 2013). In addition to complications resulting from advancing but untreated disease, patients experienced increased anxiety, self doubt, social losses, and inconsistent or inadequate health care as the result of dismissive physician behaviors (Ruzicka, 2013).
Certainly, some psychological conditions do manifest as distress in the body. Also, adjustment to chronic and terminal illness is well-known to result in depression and anxiety. The mind-body relationship is indeed a two way street. Therefore, physicians truly invested in their patients’ best interests do sometimes appropriately make referrals for mental health evaluation. However, considering the risks associated with the “psych” diagnosis, thorough, face-value, consideration of patient complaints and appropriate medical testing generally should occur before a mental-health referral is made. Exceptions to this guideline are when the patient has stated that he or she is going through a time of extreme stress with inadequate support, or when the patient reports inadequate support systems to help them deal with serious illness. Of course, referral for psychological support (not mental health evaluation) is always in order in instances of domestic violence.
Once reasonable medical testing has occurred, the timing of the mental-health referral is largely a matter of clinical judgment. Three important points to consider are that 1.) Many patients are put-off by mental health referrals (“the doctor thinks I’m crazy, but I know I’m not!”), and therefore leave the physician’s care; 2.) Mentally ill patients get sick sometimes, so it is important not to let obvious psychological signs overshadow physical symptoms, and 3.) The physician could be wrong about the need for the referral. Therefore, clear and supportive communication with patients regarding the reason for the referral is important. Physicians can enhance their relationships with patients when making mental health referrals by directly acknowledging the patient’s experience of their symptoms, stating clearly the limits of medicine (i.e., testing and diagnosis is not a perfect science, some diseases must advance to the point that tests can identify them, a particular symptom set can be hard to pin down, etc.), and stating that professional support in coping can be very helpful in dealing with the anxiety caused by being ill and not knowing why. Some participants in my study also stated that it was helpful to them when the doctor admitted not knowing what was causing symptoms, but entered into partnership with the patient by agreeing to work with them until it was figured out (Ruzicka, 2013). Such clear communication not only offers compassion and validation, but removes the possible liability of incorrectly diagnosing or treating a mental health condition.
Unfortunately, some physicians will engage in the practice of drawing conclusions about the patient’s mental health without reasonable investigation into the cause of the patient’s complaint. This can result in the misdiagnoses and “dismissals” that patients experience as frustrating, and that are potentially dangerous. If this happens, patients might consider engaging the physician in a discussion the reasons for his or her conclusion, as well as asking the physician to describe his or her training in mental health. If the physician is either unwilling to engage in the discussion, or responds rudely, it might be time to consult a different doctor.
Moscavitch, S., Szyper-Kravitz, M., & Schoenfeld, Y. (2009). Autoimmune pathology accounts for common manifestations in a wide range of neuro-psychiatric disorders: The olfactory and immune system interrelationship. Clinical Immunology, 130, 235-243. doi: 10.1016/j.clim.2008.10.010
Roy, B., Rose, J., Sunderland, T., Morihisa, J., & Murphy, D. (1988). Antisomatostatin IgG in major depressive disorder: A preliminary study with implications for an autoimmune mechanism of depression. Archives of General Psychiatry, 45(10), 924-928. doi: 10.1001/archpsyc.1988.01800340050007
Ruzicka, A. (2013). Considering the influences of the physician-patient relationship on the patient’s quality of life: An interpretive phenomenological analysis of the experience of being dismissed by one’s physician among women with autoimmune diseases. (doctoral dissertation). Retrieved from ProQuest Dissertations and Theses. (Accession Order No. 2013. 3589680).
Serrano, C., Setani, K. Sakamoto, E., Andrei, A, & Fraguas, R. (2011). Association between depression and development of coronary artery disease: Pathophysiologic and diagnostic implications. Vascular Health Risk Management, 7, 159-164. doi: 0.214/VHRM.S10783
Zautra, A., Yocum, D., Villaneuva, I., Smith, B., Davis, M., Attrep, J., & Irwin, M. (2004). Immune activation and depression in women with rheumatoid arthritis. The Journal of Rheumatology, 31(3), 457-463.