Is It Disease or Delusion? U.S. Takes on a Dilemma

That's the title of href="http://www.nytimes.com/2006/10/24/health/24cons.html?ex=1319342400&en=e370af46c3a1c13b&ei=5090&partner=rssuserland&emc=rss">an
article in the New York times.  It is about clusters
of illness that are discovered by people posting on the Internet.
 The concern is that some of these might by "psychosomatic,"
more properly known as href="http://psyweb.com/Mdisord/jsp/somatd.jsp">somatoform
disorders.  In the article, they describe a group of
persons who believe they have rel="tag">Morgellons Disease.



Personally, I would be skeptical of the assumption that these are
psychiatric illnesses.  Some of them may be.  If so,
it is more likely to be a manifestation of depression with psychotic
features, than somatoform disorder.  



I realize it is risky to say that, without having met any of the
persons involved.  But the reason for saying it is simple.
 Depression is extremely common, one of the most common
psychiatric conditions.  While psychotic features are present
in a minority of cases, such features are more common than many people
realize.

When they do exist, the depression is not likely to respond to
treatment with an antidepressant alone.  It is one thing I
think of when people do not get decent results with standard treatment.
 



Having said that, I would alway be reluctant to attribute mysterious
medical symptoms to a psychiatric condition.  Even when it
seems there is no other explanation, is is a hazardous assumption to
make.  The correct approach is for the doctors to admit that
they do not understand what is happening.  It is easy to do.
 You just look at the patient and say, "I'm sorry, but I do
not understand what is happening."  Then you tell the patient
that you (the plural, collective "you") need to figure out how to
proceed, even though you do not know what is causing the problem.
 Often, the best solution is to treat it as though there is a
psychiatric problem, while simultaneously making incremental,
reasonable efforts to find a medical diagnosis.  



I have seen some cases that I really do think are delusions
related to somatoform disorders, or psychotic depression, but I have
also seen cases of people with brain tumors or some such, that were
initially dismissed as psychiatric.  Examples include href="http://www.americanhs.org/" rel="tag">hemochromatosis,
rel="tag">Addison's disease, and href="http://www.emedicine.com/NEURO/topic365.htm">temporal
lobe epilepsy.  I also saw a person with depression
who also happened to have href="http://www.nlm.nih.gov/medlineplus/ency/article/000662.htm">tertiary
syphilis, one with schizophrenia who had href="http://www.multiplemyeloma.org/">multiple myeloma,
and so on.  



People who are mentally ill do get other illnesses.



One thing you want to avoid, is doing aggressive medical procedures.
 If you end up doing things like biopsies and exploratory
laparotomies and lumbar punctures, you end up being more likely to do
harm than good.  If you send the patient flying around the
country to all kinds of specialists, you burn up time and money
needlessly.  But it does make sense to take your time and
think it through, keeping an open mind the whole time.



The problem with that, of course, is that insurance companies do not
pay you to think; they pay you to do procedures.  But that is
another issue.