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Troublesome Disguises


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Journal of Psychiatric Practice®: November 2015 - Volume 21 - Issue 6 - p 401
doi: 10.1097/PRA.0000000000000111
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November, 2015. Recently I was asked by Dinesh Bhugra, current President of the World Psychiatric Association, to contribute a chapter for a new edition of a book for which he serves as Senior Editor, titled Troublesome Disguises: Managing Challenging Disorders in Psychiatry.1 I like the title of this book; it reminds us that things are not always what they seem. In the descriptive material about the book, its publisher refers to it as “a warning to beware of diagnostic systems which, despite their many virtues, may become too influential and may perpetuate errors which are to the detriment of patients.” We are now approaching the end of 2015, and in May, 2016 it will be 3 years since the publication of DSM-5. Hard to believe, at least for me! Many of the discussions and debates about proposed revisions are still fresh in my mind, and 1 overriding principle stays with me constantly: any diagnostic system in medicine is a “state-of-the-art/state-of-the-science” language necessary for common understanding and for communication among clinicians and communication with our patients and their families. But it is not gospel, it is not all-inclusive, and its diagnoses do not have airtight validity and reliability. DSM-5 and the forthcoming ICD-11 should contain the best consensus possible about categories of illness, based on scientific data and expert consensus. That said, however, there is still the person-centered reality that no single patient ever quite fits the prototype, and many are far from it.

In this issue of the Journal, Chae and Miller illustrate the complexity of diagnosis and the importance of a “whole body” approach by examining the co-occurrence of neuropsychiatric disorders and one of the most common of bacterial infections, urinary tract infection. They found that 88% of the papers reviewed showed an association between urinary tract infection and psychiatric conditions. The authors emphasize the importance of comprehensive assessment, the recognition that infection may precipitate or exacerbate some psychiatric conditions, and the importance of understanding potential interactions between the immune system and the brain. Also in this issue, Hines and colleagues present a fascinating case of Capgras syndrome (an unusual psychotic condition involving a delusional belief that a family member or acquaintance has been replaced by an identical looking imposter who may have malevolent intent) in a woman with hypothyroidism. Treatment involved levothyroxine to normalize her thyroid hormone levels, in the course of which her delusions rapidly resolved. In a second clinical case presented in this issue by Rasmussen and colleagues, a woman is described who had longstanding depression with psychotic features, which had seemed refractory to treatment. Careful evaluation, however, eventually revealed that this patient was suffering from Cushing disease—that is, secondary hypercortisolism caused by abnormally increased production of ACTH by the anterior pituitary. In this case, a pituitary adenoma was found and successfully removed surgically, following which her psychiatric symptoms gradually disappeared.

In medical school long ago, I recall being warned to rely on the likelihood that “what you see (and hear) is what you get” when taking a patient’s history and examining the patient, and not to waste time looking for “zebras.” Good advice. But we also have to remember that sometimes there are “fascinomas” and surprises!

John M. Oldham, MD

The Menninger Clinic, Houston, TX


1. Oldham JMBhugra D, Malhi GS. Borderline personality disorder. Troublesome Disguises: Managing Challenging Disorders in Psychiatry. Oxford, UK: Wiley-Blackwell; 2015:57–66.
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