When Anxiety or Depression Masks a Medical Problem

How long might it take before the true cause of the symptoms is uncovered and proper treatment begun?

Comments: 240

  1. And anxiety is addictive.

    Our consumer culture is based on cultivating a habit of anxiety.

  2. The drug ads on tv alone could give a dog anxiety

  3. The US New Zealand are the only developed nations that allow DTC (direct to consumer) advertising. The Supreme Court ordered drug advertisers to list all potential side effects with every ad. The Food and Drug Administration (FDA) oversees prescription drug advertising with the Federal Food, Drug, and Cosmetic Act and related regulations.

  4. They gave my dog anxiety and I don't even have a dog.

  5. For over 35 years, I have provided psychiatric consultation to the medical services at a large teaching hospital. Too often, when a physician learns that the patient has a history of psychiatric treatment, they do not take the patient's problems seriously, & are slow to order a work-up because "it's all in their head." This causes unnecessary delays in arriving at the proper diagnosis & treatment plan. Many doctors are reluctant to diagnose a disorder which falls outside their area of greatest expertise, since they prefer to diagnose conditions they are comfortable treating rather than something hey may not feel competent to treat. Only when we look at the whole person are we best able to correctly interpret the meaning of our patient's symptoms. Since many patients will not go to see a psychiatrist even when given a referral, it is incumbent upon all primary care physicians to develop competence in treating anxiety & depression. Regrettably, not all physicians are receptive to the education & training necessary to attain this level of competence.

  6. The article made me wonder about this, what about the poor patients who have a pre-existing psychiatric disorder that signals one of these physical disorders and who are then unlucky enough to also get the physical disorder?

  7. Could be one of the reasons many people won't follow up w/a psychiatrist "even when given a referral" is because their insurance won't cover the cost. Even for those w/ok health insurance, mental health parity may not exist.

    Surely won't under the GOP plan.

  8. garnet - an appointment to a psychiatrist won't help someone who suffers from a physical illness which has been misdiagnosed as mental. In fact, that is the worst thing for someone with a physical illness manifesting as "mental"--it perpetuates the cycle of misdiagnosis.
    In this article, we're talking about misdiagnosis of physical as opposed to mental. Not the other way around.

  9. A friend of mine was experiencing symptoms similar to anxiety for at least two years before being treated for kidney and adrenal cancer. She had never had any type of psychiatric symptoms in the past.
    There were many delays in appropriate treatment since the first medical diagnosis was cardiac due to irregular heart beat. The cancer was at an advanced stage when finally detected. Sadly, she died a few months later.

  10. Lorraine: You gave the differentiating point: "Never had any type of psychiatric symptoms in the past."

    Sudden onset of anxiety or depression without a precipitating event or history...is the red flag for another issue.

    The biggest problem for those who have had anxiety/depression for many years is discerning when an uptick is actually something else. But for those without this problematic history, or a major precipitating event, have your doctor run blood tests and rule out other causes.

  11. Can treated thyroid disease be the cause of anxiety, even with the thyroid ablated and thyroid hormone readings in the "normal" range after daily intake of synthroid?

  12. Yes. Go to the 'stop the thyroid madness' website. As they point out, it's not in the range, but where in the range that counts.

  13. Blood levels of T3/T4/TSH are NOT good diagnostic tools. If it's not being absorbed properly, it doesn't matter what's circulating in the blood.

    Additionally, other drugs (such as statins) can interfere with the blood tests and with cellular uptake. Hypothyroidism can lead to increased cholesterol levels, so statins are often prescribed for hypothyroid patients.

    Take your temperature every morning, and get a blood-pressure monitor. My doctor has agreed to prescribe thyroxin at levels that keep my heart rate and temperature in normal ranges. At 125 micrograms, my morning temperature was 97. At 150 mcg, it's at 98.2 or thereabouts.

  14. An excellent book for hypothyroid information on symptoms and treatment options is "From Hypothyroid to Healthy". It is well organized, easy to follow, and provides a helpful guide to understanding multiple medication types and options for hypothyroidism. I have purchased multiple copies for friends and family members and I recommend it highly.

  15. Many women are diagnosed with anxiety and depression when they have medical issues that are causing anxiety and depression. I have been treated for depression INSTEAD of thyroid problems. The depression and anxiety disappeared when I got proper treatment.

  16. Maybe it would help if MDs actually listened to their patients. I was born with spina bifida and a tethered spinal cord which literally tortured me 20% of my first 50 years. During that time I kept saying, IT IS THE PAIN! The professional kept saying I had an emotional problem. But I kept insisting IT IS THE PAIN!

    They did not know such a thing as an ingrown spina bifida could happen. Finally, when I was 50, which was 20 years ago, they diagnosed me correctly. But still, since they do not understand the problem and seem to have no interest in learning----, they do not listen.

  17. Since 1970 medical students have been allowed to skip further training in internal medicine and start a psych. residency right out of med. school. You can't see what you're not trained to look for. I completed a year of postdoctoral training in internal medicine, a year of neurosurgery and then I entered a psychiatry training program. I specialize in patients that other psychiatrists don't want or can't help. You get what you pay for.

  18. It sounds like you were well trained. Remembering my internship, I am not sure that in the hospital setting, I would have seen the types of patients who would have prepared me to deal with the diagnostic puzzles that are the subject of this article. It often requires seeing the same patient over several visits spanning a few months before the physician with the prepared mind will root out what is at the bottom of the symptoms.

    I certainly agree the physician psychiatrist cannot begin to consider a diagnostic possibility unless he/she has seen it or learned about it and seeing it is the best way to remember it.

  19. If you get what you pay for: are you saying only the wealthy plus those who closely review a potential health care providers CV (or pay someone else to do it if they're wealthy) get good care?

  20. Dr. Bill,
    You have things backwards. Until the late 70s, psychiatrists didn't have to do a year of training in medicine before starting a three year psychiatry residency. Since then they have been required to do so.
    apparently you have been around a psychiatry residency in the past 40 years.

  21. This is why good mental health practitioners always want to be sure someone has a personal physician and gets regular checkups.

    I learned in my training that Depression can be one of the first signs of Pancreatic Cancer.

  22. I've begun searching for a functional medicine MD, and have discovered they aren't terribly plentiful. The two that I've found on the north side of Chicago, within a reasonable drive for me, do not take health insurance. I really wish that functional medicine was more widespread. If I present with a particular condition, I'd like to have a doctor who doesn't immediately prescribe a pill for it but wants to find the underlying cause. Example: An individual could have a blocked artery, is successfully treated, and then takes statins. But the cause could be something like gluten sensitivity that has created a permeability in the gut. This article touches on this in a way - the presenting illness doesn't always lead back to the most logical or obvious origin.

  23. There a a few functional medicine practitioners near me, and they were recommended to my husband but none take insurance and all are beyond our financial means. Again it seems that to maintain optimum health and find a doctor who practices in any kind of humanistic way is only for the wealthy.

  24. Sounds good in theory. Unfortunately many so called "functional providers" order unnecessary and unproven tests and extrapolate "treatments' from limited or preliminary science. Beware of "I know something the rest of medical world does not".

  25. Kimberly,
    the problem is that for many of the most common problems for which people go to see docs including back pain and headaches we have no idea as to the etiologies.
    You apparently have the misconception that enough tests are done, an etiology can always be identified.

  26. With mental health benefits being put on the table on the new health plan, the real diagnoses may never be found. Mental health professionals are the first line of assessment for people with anxiety and panic. Compared to other specialists they cost the medical system relatively little compared to the crucial benefit they provide. Most insurance plans limit the number of visits for mental health but not for skin health or hearing health etc. It's time they are treated equally with other medical professionals.

  27. Excellent article. It would be very useful it psychiatrists/psycologists thought to have patients tested for illness and vice versa.
    I had extremly low levels of b12. I was depressed and exhausted. With weekly shots, I am my high energy self once again! I did have physical symptoms too-dizziness, heart palpitations, blurred vision and the inability to concentrate on anything but it was thought that i was periomenopausal.
    A simple but thorough blood test was the answer.

  28. I've two endoscopies, one colonoscopy and no doctor could figure out what was waking me up with pain and burning sensation. I tried all PIP's. I finanlly went to Clevalad Clinic and the doctor prescribed me amitriptyline 25mg and that helped the most. Now I could sleep till 3:30 am. Then doctor said she could not help me anymore and said to see a Primary Care Physician. She checked my B12 and it came in at 385. The report said 200-1100 is normal except people over 50 who has it lower than 500. Then they gave me monthly shots of B12 and that has made all the difference. The new Gastro told me to stop after 3 months and tested and it came back at 453. So he said do not take it until I see him in 3 months. However, after a month and hal of stopped taking B12, I started to wake up around 3 am again. So I am going to the doctor today and I think he will give me the shot again. It is a very simple and inexpensive thing. Hope B12 is the missing link to fix my condition. If doctors listened instead of see the patients as an assembly line of next patient, many things would be so much better for the the system and the doctors and the patients.

  29. Have you tried sublingual B12 tablets? If so, did they work? Just wondering if the monthly shots could be switched to daily vitamins.

  30. This may be why anti-depressive medicines only help approximately 30% of the population taking it.

  31. Anxiety rules the day, no one is calm, relaxed and happy anymore.

  32. @The Iconoclast - How can people with an underlying medical problem just decide to be "calm, relaxed and happy"? It's an undiagnosed, untreated medical problem, you can't wish it away.

  33. The good psychiatrists I know check screening labs for medical conditions and refer to others for sleep evaluations, etc., if needed.

  34. The real test of any good doctor is his/her diagnostic skills. The doctor either cares enough about a patient to find out what's wrong or doesn't. Our health care system says get them in and out. Spending time is wasting money.

    We must change the culture that health care is only for profit. When a diagnosis is a "quick fix" tool for the doctor but wrong for the patient, something is very wrong. Will the US ever put Patients First?

    The drug ads on TV perpetrate the problem. The drug for "opiod-induced constipation" is a classic example, covering up the real diagnosis of addiction.. While addiction becomes an epidemic, the ad treats it like an annoying inconvenience, ignoring the reality of addiction and zero diagnosis of the guy's back problem.

    Anyone diagnosed with anxiety goes into the insurance records as having "mental health issues" for time immemorial. It doesn't matter if the doctor is too lazy or stupid to diagnose correctly.. You'll be denied coverage or pay dramatically increased premiums.

    Profit, not proper diagnoses. That's the real problem with health care in America. The Republican "health care" bill would carve that in stone.

  35. The diagnosis of opioid-induced constipation does *not* somehow mask an addictive disorder. Anyone prescribing a medication for this knows what's caused it and whether or not the cause is being treated.

    And please don't regard this sort of constipation as a minor problem, as it afflicts cancer patients and people (like me) who have neurological conditions for which an opioid is the medication of last resort.

    Insufficiently treated, opioid-induced constipation can lead to bowel impaction, which in turn can result in intestinal blockage, and then perforation or sepsis, major surgery, and possibly death.

  36. M.L. Chadwick is correct that opioid induced constipation does not have any relationship to addiction.
    However, it should be noted that very few patients would require the new and expensive drugs being advertised for OIC if their docs knew enough to treat the constipation prophylactically with a stool softener or an over-the-counter laxative (you need to ask your doctor which of these to take as there are different types and some such as Metamucil can actually exacerbate it)

  37. Anxiety is not a diagnosis. There are anxiety disorders that require specific diagnostic criteria to be diagnosed.

  38. This article reinforces the case for fully integrating "physical" health care and "mental" health care, by mitigating the "separation of powers", as the article puts it. I would include "oral" health care as well. In addition to the "co-location" of these services, a one-stop shop, so to speak,"cross-training" of all health care professionals must be cross-trained outside their specialization and they must have access to consultations from physicians, psychiatrists and dentists (and the like.) As the article says "mind and body are a single construct..." I would add "mouth" to that as well. This is why health care professionals MUST be in the practice of addressing the health of the whole person, and why we must have reimbursement models for health care services that place responsibility for attending to the health of the whole person on a team of caregivers - like the patient-centered medical home model.

  39. An excellent observation, HIgh Desert Rat. I am surprised the NYT article didn't mention fibromyalgia. For years, it went undiagnosed or else thought to be a product of women's "hysteria" or imagination, although they complained of depression and widespread pain. I'm not sure how many men suffer from fibromyalgia. It seems that only within the last 10 years fibromyalgia has become accepted as an illness or condition that can be caused by physical trauma. But I'm still not sure if a person with depression would be recognized as having fibromyalgia, or whether the disease itself causes depression.

  40. Same with chronic fatigue syndrome (or whatever name some people are applying to it these days).

    I don't how many men suffer from it either, but I do know at least one for whom it is a severe problem and has been for quite some years.

  41. Rat,
    Psychiatrists are physicians. They must have graduated from medical school and be licensed to practice medicine. If you don't consider this to make one a physician, perhaps you could explain what you do.

  42. This makes for a medical team case. When all of your doctors collaborate to treat the whole patient better medical care is provided for the patient. It is very important that your primary care physician be in contact with all of your other providers too coordinate your personal treatment plan.

  43. Great idea, in my experience, it rarely happens. Even if chartnotes/treatment notes are cc'd to any other treating providers, they still must be read by the recipients. Maybe even thought about.

    In the days of employee MDs, who have quotas for how many people they're expected to see/day, there's not much time for review of treatment notes, etc.

  44. From your mouth into God's ear. Doctors do not cooperate with each other when it comes to patients. They don't send out reports to your primary doctor even if they say they do or the primary doctor doesn't read them. Either way, patients are the ones that lose time, money, and health when doctors don't work together on their behalf. Medical care has become a labyrinthine undertaking in America whether it's for something simple like an ear infection or something more complex like cancer or heart disease or recovering from a serious infection.

  45. I consulted a specialist who had observed signs of what he believed might
    be a malignancy.For reasons best known to him. he did not share this with me during the exam, the office consultation that followed, or during a follow-up
    call during which he review lab work with me and told me that I was fine.
    He send a letter to my internist, in which he shared his concerns. My internist did not relay this to me.

    I learned of this by requesting that a copy of my medical records be sent- my psychologist,, as I have learned that doctors charge me for medical records, but do not charge when they send my medical records to other doctors. My psychologist learned from one of these reports that tests results had revealed that it was likely that I had a malignant liver tumor,and left him to break the bad news to me.It turned out that the liver tumor was not malignant. After this,I asked him not to read the reports, to spare him the anxiety, so I found myself reading the letter that the specialist had send my internist which relayed that he believed that I might have cancer.I had to wait until after the Sabbath to call an Orthodox friend who is a psychiatrist whose husband is a radiologist. Now, I have all my medical records send to them. I am fortunate that my best friend and her husband are M.D.s. and that they are kind enough to review my test results and interpret them.

  46. I am a family doctor. Many years ago I saw a nice patient of mine who complained of tiredness. Right off the bat I could tell she was depressed. Antidepressants were not as well accepted then, as they are now, and I was explaining to her the type of medication I was likely to prescribe for the problem. Then I listened to her heart and found she was in rapid atrial fibrillation, which can cause a decrease in cardiac output, certainly a cause of marked fatigue. I abandoned the diagnosis of depression and sent her to a cardiologist who easily resolved and the rhythm disturbance. But a month later she was suddenly admitted to the psychiatric unit with a serious depression from which she recovered after a few weeks Let me say I learned to consider all of the possibilities. The head is attached to the body. Need I say more?

  47. It seems you are suggesting that a physical and psychiatric maladies may co-exist. You are correct however, it seems no one truely explores a holistic approach to the wellness of an individual. Thanks doctor and please don't ever stop practicing medicine. You get it.

  48. An undiagnosed brain tumor can also cause personality changes. Years ago a story in a medical journal told of a patient who laughed uncontrollably when he looked to the left. He decided to seek medical help ahis mother's funeral when a piece of paper blown by the wind caught his eye and caused him to burst out laughing.

  49. Consider that their patients could be victims of crime, "not yet recognized".

  50. As an endocrinologist I am not surprised when I see thyroid disease with psychological symptoms. But last year I was diagnosed with PTSD and depression-- I was quite humbled when it turned out to be do my malfunctioning pituitary-- low ACTH- the hormone that drives cortisol production from the adrenal. Steroid replacement totally controls the psychological symptoms.

  51. I would wake up in the middle of the night screaming with my heart pounding. I was told it was a symptom of my PTSD. Well, yes and no. My boyfriend noticed that I wasn't breathing well at night. I started using prescription nose spray and put two pillows under my head. Lo and behold, I stopped waking up screaming. All I can figure is that I couldn't breathe and my brain interpreted that as a nightmare while I was dreaming in order to wake me up. When I was trying to figure this out, my psychiatrist referred me to a sleep doctor who just said that I have a delayed onset circadian rhythm and that I should find a different line of work. So glad I didn't listen to her! I would still be falling asleep at my desk!

  52. I had a similar experience, only I finally figured out that my middle-of-the-night panics weren't anxiety but obstructive sleep apnea!

  53. Parsing out the nuances of the overall physical and mental health issues in a typical Primary Care patient takes a lot of training experience, dedication and TIME. Which is not highly appreciated respected or reimbursed under the current system. Those of us dedicated to doing it right inevitably make significant concessions. Don't like the current system of "procedures first"?
    Work for major change. And be prepared for pus- back from the US mentality of "profit Trumps everything else".

  54. I had an endocrinologist in the US who was born and trained as an MD in Germany. He told me that in Germany, internists and primary care specialists are paid highly, because they need to know so much about so many systems of the body, whereas specialists only had to focus on one thing and so were paid lower. Would that this were the case in the USA! A good primary care doctor who actually can spend time with a patient is often worth a dozen specialists only looking for their part of the puzzl.e

  55. In 1928 my sister, age 12, had polio and was put into a body cast for one year.
    She had to learn to walk again. By age 40 her aches and pains were significant
    but doctors always told her, "It's all in your head". In 1985 an article in a
    magazine prompted her to contact the Dr. doing a study on what has since
    become known as Post Polio Syndrome (which, of course, was what she had).
    What a relief it was for her to know that her pain was indeed real, and not
    just "imagined".

  56. All pain is "in your head" as you experience pain in your brain.

  57. I mistook my diabetes for an exacerbation of my existing major depression for at least a year. My doctor went right along with me. So, yep. Bodies are confusing and many symptoms overlap significantly.

  58. Can we also please discuss the fact that some medications can cause both physical and emotional disorders? Fluoroquinolone antibiotics carry this risk.

  59. My "anxiety disorder" had consumed my life until about three years ago, as countless medications had failed to resolve my problem. An astute psychiatrist told me to see a new doctor for a physical because "there has to be something else going on with you -- get a fresh set of eyes". So, I did.

    After a few simple questions about my medical history and some cursory physical examinations, this new doctor diagnosed me with Vascular Ehlers Danlos Syndrome -- an extraordinarily rare cardiovascular genetic condition -- one whose signs often mimic anxiety disorder.

    It turns out my body's autonomic nervous response was constantly "on" due to vascular laxity and cardiac stress -- so therefore the "Fight/Flight" response was over-reactive. Turns out my anxiety wasn't anxiety at all -- it was adrenal fatigue. A common blood pressure medication has very literally changed my life. I am no longer depressed and my physical symptoms have almost disappeared. I haven't had a panic attack in nearly three and a half years. I still have other, often disabling symptoms of this rare condition, but I am better able to manage them and cope.

    Curious doctors saved my life. Cheers to them!

  60. Jen - very happy you are now doing better. As someone with another form of Ehlers-Danlos, I completely understand. I live with POTS--posterior orthostatic tachycardia misdiagnosed for years and years as "anxiety" and treated abominably by the psychiatric community.

  61. sorry to hear of your POTS. That's really rotten to deal with. I get mildly faint sometimes, but not regularly. I always reflect on the fact that I likely would have taken my own life had I not been properly diagnosed. Many doctors are too quick to look for horses, not "zebras". in other words, they lean on Occams' razor. Curious doctors, on the other hand, want to learn from their patients and therefore, help others.

  62. I had endometriosis in my late 20s and early 30s. It hurt and it left me exhausted and depressed. I was put on the pill to control the symptoms. And the doctor told me that he believed me when I said I was in pain. Yet he gave me no advice for how to deal with the pain or what to expect. My guess is that he thought that the pill would solve the entire problem. It didn't but because of how brusque he and his staff were I never asked about how to handle it even though I was seeing him every 6 months. I stopped taking the pill when I realized that it left me with severe body odor and not feeling like myself.

    The sad part about this interaction is that it's quite common for women. Doctors, even female doctors, downplay women's pain and depression. They accuse us of being manipulative, drug seeking (and for some pain one does need a strong drug), and hormonal. The distrust this brings about is hard to overcome particularly when doctors don't spend enough time with us, when insurance companies limit what doctors can do to help, and when we know something is wrong but nothing helps. It's frustrating to be asked by your doctor "What do you want me to do? All your tests are negative." The obvious implication being that you are making yourself sick.

  63. Confusing article. Shouldn't the second sentence read "But what if the reverse occurs and symptoms of anxiety or depression MASK an as-yet undiagnosed physical disorder?"
    Based on the headline, the thrust should be that certain emotions might mask an underlying disorder. But it goes back and forth between "What if your symptoms are caused by your emotions? No wait, what if your emotions are caused by your disorder? No, wait ..."

  64. Your insurance may pay for every possible test a doctor could order, but not for more than 15 minutes of her/his time.

  65. Exactly. It's hard to pay even overhead if you actually spend time with patients. This is wrong.

  66. @Ed, @Irene - You're both going to the wrong doctors. There are doctors out there (more than you think) who try to see the patient as a whole and spend time listening and asking questions. Try either an internist with a holistic approach, or a D.O. (Osteopathic doctor) whose medical training teaches with that view in mind. Or as @Jen noted, a curious one.

  67. These things are what we Consultation-Liaison psychiatrists have been diagnosing, treating, and also teaching our medical and surgical colleagues for decades. More are needed in outpatient settings.
    Nice overview

  68. We need a "Consultation-liaison psychiatrist? Aren't all of you in the medical field supposed to communicate with each other directly as needed?

  69. Endocrine disorders -most often- have a 'depression' element to them. Hypothyroidism is the most obvious, but a poorly functioning endocrine system predictibly will involve depression of some level as well as mood swings.

  70. The second sentence of this article is poorly written. Didn't the author mean to say "But what if an as-yet undiagnosed physical disorder masqueraded as anxiety or depression"?

  71. My depression/anxiety disorder was actually hypogonadism - the failure of the body to produce testosterone - which was treated with SSRIs. Far from not being effective, they made matters much worse. Not only was my actual condition not being treated, but I had persistent "pops" in my brain and periods of feeling that my head was full of spinning, electrified steel wool. A SIMPLE medical examination would have indicated the true problem. I had one testicle removed for cancer when I was a teenager and the remaining testicle had shriveled due to radiation to treat that cancer. Yes, this may be TMI but physiatrists are MDs - MDs who rarely perform medical examinations. And it cost me. Five years of unemployment, misery, and a deteriorating cognitive state later, a urologist ran my blood for testosterone and properly diagnosed my condition.

    Thus I don't think it's asking too much to demand that MDs practice medicine.

  72. Just curious-how did you end up seeing a psychiatrist in the first place. You seem to indicate you weren't refer by your internist or family doctor.
    And what is a "pop" in the brain"?

  73. This speaks to the imperative for doctors to leave room for their patients to tell their stories. There is time in even a brief appointment to ask open-ended questions that encourage the patient to provide the doctor with sufficient information to truly read between the lines and catch medical problems like these.

  74. Shouldn't the title be "masks" because the anxiety OR depression creates a singular subject?

  75. Hannah, your concentration indicates that you are not suffering from Attention Deficit Disorder. Well done!

  76. Yes, From OWL at Purdue "When two or more singular nouns or pronouns are connected by or or nor, use a singular verb. The book or the pen is in the drawer." This goes to underscore that the NYTimes need to keep their copy editors.

  77. The artificial (and inaccurate) separation of psychiatry from other branches of "physical" medicine has been a bone of contention for decades for those of us who see people and healing more holistically. One does not have to subscribe to any complementary medicine, however, to advocate for parity and inclusion of "both types" of symptoms in putting together a differential diagnosis and treatment plan. The mind-body paradigm does NOT serve us; neither our energy nor our functions are divided up like that!

  78. Thank you! One day we will be out of the late medical middle ages.

  79. It also doesnt help that prior to the ACA, mental health care was not covered at the same level as medical care by health insurers (go mandates! God help us if the ACHA passes and they can go back to being excluded). I think this might play a big part in the divided treatment we still see.

  80. For five years I was treated for depression by a number of physicians. They told me my job was stressful and it was normal for me to be depressed. I was started on multiple anti-depressants, none of which worked.
    One day, a routine blood glucose showed that I had extremely low glucose. I was sent to an endocrinologist who discovered I had a goiter and Hashimoto's thyroiditis.
    Starting levothyroxine was like a miracle. All of my symptoms resolved. Unfortunately the five years of missed diagnosis led to strains in my marriage and divorce. My ex-husband couldn't understand why I wasn't the happy person he had married.
    There can be many consequences to a missed diagnosis.

  81. I've taken several psych courses during my masters programs for both education and coaching programs and have found them to be extremely helpful in my life and career. Pardon my ignorance but are standard medical (GP) degrees requiring any substantial number of psychology courses in their programs? I can't tell you the number of times I've walked into my GPs office sometimes sad and other times clinically depressed and I don't recall us having 'the talk' about that. (I was in the care of a therapist not mentioned to the GP, also not asked about.)

  82. It is up to you to reveal to your doctor the fact you are seeing a therapist. If patients don't disclose their entire range of health problems, how can a cdoctor help them? My mother used to tell the doctor she felt fine even though she didn't because she thought that was what the doctor wanted to hear. The doctor believed her. Why wouldn't he?

  83. Family physicians are required to do psychiatry rotations during their residencies. Unfortunately, these are usually relatively brief especially considering a significant part of their practices involve patients with mental disorders. This not only results them in not correctly diagnosing these patients but providing inappropriate medication management to them. Most of the inappropriate prescription of psychiatric medications is not by psychiatrists, who receive extensive training in them, but by family docs and internists who don't.

  84. Katherine Cagle--Once you mention you have been seeing a therapist and/or psychiatrist, the medical community will write you off as "psychosomatic" and you will have a really tough time convincing anyone that your symptoms are physical as opposed to "in your head."

    So if you want to get problems resolved (the non-psychiatric ones), mentioning psychiatry is a death wish. I know, it's happened to me, and lots of other people I know--many women don't get taken seriously once "psychiatric" issues are brought up.

  85. Reading this article gave me a panic attack. Not only have I dealt with constant anxiety for the past 3 years that I've managed to control with CBT but now i can worry constantly that I'm actually dying of cancer.

  86. If you are worrying constantly that you are actually dying of cancer, it is an anxiety disorder. Especially given that you controlled your panic attacks with CBT.

    Cheers. (from one who knows of which I speak from personal experience).

  87. Anxiety and depression can have many physical causes--not only cancer. Just because some worries doesn't mean there isn't an actual physical cause to anxiety--and I'm not talking about the nebulous "chemical imbalance" of mental illness.
    Just because someone worries, it doesn't always mean it's "in their head." It could very well be caused by a multitude of physical origins. This should NOT be so easily dismissed.
    Yes, trust me, I also know this from personal experience.

  88. I have long suspected a connection between my daughter's gut and her frequent bouts with anxiety. Her heart races, she feels faint, sometimes tingling in her arm (left arm, of course!). Then she'll have a bowel movement and everything is better. This has been going on for a year. I don't know what started it. And I don't know what to do with this information! Our doctor thinks she's stressed from school, the CBT therapist pushed and pushed "but no, what's REALLY going on with you ..." to the point my daughter was like "nope, not going back." But the brain-gut test (described above) is 100 percent the same outcome. So what to do? How do I get doctors to say they want to look at her gut?

  89. not a doctor, but look into Ehlers Danlos syndrome. those symptoms all sound very familiar. www.ednf.org

  90. She might have leaky gut syndrome. Try to find a functional MD.

  91. my son had same, add in migraines as well...finally .....diagnosed as a milk protein allergy.

  92. Promoting a better appreciation of anxiety has been a long time in coming. Depression screening (w/o consideration of anxiety) has been promoted by several stakeholders in healthcare, and this was an important step forward for population health. However, collectively, the anxiety disorders are more prevalent than depression. Bipolar disorder, also too often overlooked, has arguably even stronger adverse effects on overall health. These very facts were what spurred us on at M3 Information to develop a EHR-compatible, fully validate screen for 4 common mental health conditions: depression, anxiety, bipolar and PTSD. It also evaluates risk of alcohol and substance misuse. Now available through LabCorp as a standard test, the can measure and track response to treatment over time, we hope to incorporate consideration of these widespread conditions in the treatment of all medical patients. Gerald Hurowitz, MD Chief Medical Officer, M3 Information.

  93. Bipolar disorder can be especially difficult to diagnose because until a manic episode occurs it is impossible to determine if the depression is due to this disorder or is major depression.

  94. At least I can't focus on my anxiety or depression when I'm busy twitching with irritation at the absence of basic subject-verb agreement in a headline.

  95. It is in agreement. "Or" is a singular nominative conjunction.

  96. I'm on the autism spectrum. When I brought this up to my primary care physician when asking for help with GI trouble (often associated with autism), he just waved his hand and said, "I'm an internist. I don't deal with psychiatric issues." But, autism is not a "mental health problem." It is caused by anomalous physical and physiological aspects of the brain (and, as more widely theorized now) could even originate from issues in our guts (the "second brain"). The "mental health" symptoms (anxiety, depression, etc.) that many autistics experience are just secondary to the autism itself. It's frustrating and saddening how few medical professionals I have encountered know much, if anything, about the autism spectrum.

  97. Have a look at the GAPS diet. The Gut And Psychology Syndrome book by Dr Natasha Campbell-McBride goes into detail about various conditions, like schizophrenia, that can be helped by a diet that takes you back to a healthy gut with the flora and fauna re-initialised. She mentions autism and the colitis that often accompanies the condition. The depressive symptoms are more likely to result from poor digestion and absorption of vitamin B, etc. Might be worth contacting her.

  98. Yes, yes, yes, and yes--we need many more articles like this. Maybe then it will stick in society's mind that any number of physical illnesses can present as "mental" and thus are misdiagnosed on an alarmingly regular basis.

    I see that some commenters are confused. This is an article about PHYSICAL illnesses which present as anxiety and depression but, as such, are not. They can include, but are not limited to, cancer, rare genetic illnesses, thyroid and endocrine malfunction, etc. This list is extensive and if it were up to me, I would demand that before anyone sees a psychiatric they first get a complete work-up.

    I almost lost my life to misdiagnosis. If I had not dumped the psychotropics and the psychiatrists, I would for sure have been institutionalized forever, if not dead. That is the honest truth and not an exaggeration.

    Even then, it took another 13 years to unravel my complicated genetic illness as well as a more common endocrine disorder. Both contributed to "depression and anxiety" symptoms which were misdiagnosed as "mental" illness, when in fact, they are part and parcel of my physical disorders.

    For those who still don't "get it" I hope you never have to suffer being misdiagnosed. It destroyed my life.

  99. The number of people who are misdiagnosed with physical illnesses who actually suffer mental disorders far exceed those who have physical disorders misdiagnosed as mental disorders.
    There are many people who repeatedly go to emergency departments with chest pain who are actually suffer from an anxiety disorder.

  100. I am happy that you made it; that you were finaly able to find the right diagnosis and help.

    Much anxiety and depression are also PHYSICAL, btw, being related to brain chemistry.

  101. Steve-- the whole purpose of this article is that there are those of us who have misdiagnosed--and it can be deadly.
    Let me put it another way: If you suffered from congestive heart failure, but your doctor decided to send you to a podiatrist for treatment of heart failure--would that be okay with you?
    Well, that applies to those people who have been misdiagnosed--and some have died as a result. Is that still okay with you?

    I don't care how many people go to the ER with chest pain and it turns out to be anxiety. What does that have to do with people who have been misdiagnosed--and suffered because of it? Don't we count? Apparently not in some people's psychiatric-centric world.

  102. When I became ill with chronic fatigue syndrome following a flu, I saw several doctors to try and find the cause of a host of new, debilitating symptoms. Vertigo, muscular and joint pain, nausea and brain fog were only some of my symptoms. Where I was previously extremely healthy and active, I was forced to drop courses and quit one of my part-time jobs, and was no longer able to go to the gym -- something I had loved. Blood tests showed nothing out of the ordinary, but months went by and I didn't get better. As a young woman, this wasn't easy to understand or accept, and it caused me much worry and anxiety. Which was then all any doctor could focus on. As soon as a physician learned I had a history of depression, this became the only possible cause for my devastating physical illness. I was told it was all in my head, and to exercise more -- something that eventually rendered me bedbound when I decided to "show" the doctor how real my illness was. Depression and anxiety are serious, and should be taken seriously. But a patient's depression or anxiety should never be a reason to stop looking for a cause to their very real physical complaints.

  103. I have finally decided that medicine---particularly at the General Practice level---is the bastion of misplaced certitude. In Doctor speak, "Ican't find the problem, in fact I don't want to see it---so it must be in your head."

  104. If you don't believe depression and anxiety are "real" illnesses, you speak to those who suffer from these disorders. Or perhaps you believe when people with depression who commit suicide they aren't really dead either.
    As to disorders being all in the person's head, it might interest you to know that the brain is where you experience pain. And if the brain isn't in your head, you've got major problems.

  105. I understand. After having chicken pox and mono in rapid succession my freshman year of college, I remain chronically tired. My seasonal allergies also morphed into year-round allergies, and testing hasn't shown a good reason for that. I had a very proactive nurse practitioner acknowledge that they could well be related, but that seemed to be the end of it.
    Unfortunately there is a lot about the human body that we have yet to figure out. Witness the sudden appreciation for our microbiome in the last few years.

  106. This is why psychiatrists have MD degrees and spend 1/2 year training in neurology and psychologists should not prescribe medicines.

  107. As far as I know, only psychiatrists, and not psychologists, can prescribe med school. I liked the response from the FASTRACK who states there are too may specialists and not enough practitioners who know the whole person.

  108. If this is true then why do so many psychiatrists have a problem diagnosing a child with PANS or PANDAS which is an auto immune neurological disorder that presents as psychiatric one?

  109. I don't know where you live but where I live, psychologists can't prescribe medicine. Regular MDs shouldn't but sometimes do.

  110. 1) All my blood relatives on the paternal side had an anxiety disorder;
    2) At twelve I was breaking out into hives and deemed anxious;
    3) Confronted with environmental depressive life situations, I was told by age 17 how amazing it was that I was so well grounded and contained (here a psychologist on hearing some of these anecdotes would have thought all this is going to come back one day to haunt her);
    4) Today past 60, if I were to have a social panic attack with some of these symptoms described in front of company, I would explain that I was having a panic attack and to ignore it);

    Rather than go on a 'Catcher in The Rye' story and the ironies of destiny, I am more interested in reading what others have to say and with this in mind, recommending the work of Dr. Claire Weekes, a pioneer in the field of Nervous Suffering, while thanking Jane Brody for uncovering the difference between environmental and clinical depression, other emotional disorders and how to look to one's physical health.

  111. There are many causes for hives.I am suffering from Chronic Auto-Immune Hives. I am grateful that my dermatologists never suggested that my chronic itching was psychiatric, though they missed the auto-immune diagnosis for decades. At least they didn't tell me it was "all in my mind".

  112. It is perfectly valid to urge physicians to pursue all efforts to identify physical problems when a patient is identifying with anxiety and/or depressive symptoms. At the same time, these seesaw arguments give some people the idea that major depression can be whisked away by tinkering with one's diet, or sleeping with the latest brand of scuba-gear designed to eliminate apnea, or any of the latest fashions in body-over-mind. The anti-pill zealots, whose agenda is inseparable from bigotry toward "mental illness", have got to be warded off from interfering with the few tools we have to deal with the enormous scale of human suffering involved in depression and related disorders.

  113. Have you considered that a great part of the surge of anxiety & depression might directly be linked to our present lifestyles - poor nutrition, little movement, not enough sleep, and tons of stressors like the onslaught of political bad news, the ever greater pressure to perform at work and in bed, the insecurities about old age, disability and sickness in this country?

  114. Physical and mental conditions often arise as a result of dietary imbalances. The connection between brain and gut is becoming more understood. Gut problems can cause defence in vitamin B complex and can give rise to depressive type symptoms. Lack of magnesium can result in a whole host of physical and mental disabilities. My 'anxiety', panic attacks and heart palpitations, were a direct result of severe anaemia but it took several YEARS for a doctor to think about a simple blood test instead of prescribing anti depressants and beta blockers. Sometimes I think that doctors are far too lazy and fob patients, especially women, off with expensive pharmaceuticals. No doubt doctors have shares in big pharma. Conflict of interest?

  115. Last year I walked into an ER with a red blood cell count of 3.9. That is one fifth the normal amount your body needs to live. The diagnosis? Anemia. I was previously misdiagnosed three times: one doctor told me I had asthma, and two others diagnosed anxiety after my ekgs were normal. I knew I was near death and made the last doctor write how I felt into my record for posterity. He treated me like I was a hysterical woman. Fortunately, that same doctor ordered a blood test and sent me to the ER as soon as he got the results. With all our technology something as simple as anemia was missed. The anxiety was the main clue.

  116. Same thing happened to me. For years I was fobbed off with anti-depressants and beta blockers when all I needed was a simple blood test to show I was anaemic. It wasn't until my rbc went down to 4 that suddenly I was given several blood tests and admitted to ER for urgent blood transfusion. Lack of energy, therefore feeling low, and heart palpitations are classic symptoms of anaemia. But being a woman I was considered to be emotionally unstable. Women are probably more likely to suffer from anaemia for obvious reasons but doctors seem unable to think of this simple explanation and instead continue to discriminate against women.

  117. It is hard to believe that any good doctor wouldn't order a battery of blood tests that would include blood counts. I have that done at least once a year and sometimes more often. If I go to my doctor with an infection he orders blood tests. When my white count soared, it was pneumonia even though I wasn't terribly sick. In my sister's case her red blood count was extremely low and her white count was extremely high. She had leukemia. If your doctor doesn't order these tests, find a new doctor.

  118. Do you see a gynecologist every year? Ordinarily an ob/gyn appointment includes a hematocrit that will immediately diagnose anemia, which is fairly common in women.

  119. As an FP (General practitioner) the problem is...specialists.

    I am both a family practice doc and general surgeon as were most of us who graduated in the 1960s and early 1970s from med school.

    I delivered the babies of the babies I delivered. I knew every family member. I made house calls. My patients could come to my home in the evenings. I put them in the hospital as needed, I made rounds before clinic and sometimes at lunch... then after clinic.

    If they needed to go to the ER, I would call and say “Mrs. G has had acid reflux for years. She always overdoes it with too much food on holidays. Can you just check that and get back to me?”

    No more! All become expensive sub sub specialists and NONE OF THEM know the patient! They see a patient for 90 seconds then order a battery of very expensive tests, MRIs, procedures because the specialists OWN the MRI machines and other expensive equipment!

    Doctors from India and Pakistan have BETTER outcomes as they see patients as a whole person, not a sum of parts.

    1) We HAVE to make medical school cheaper--if a doc wants to be an internist and be the primary care giver? He gets free tuition.

    2) Change our schools. There is NO reason to take 4 years of pre-med then ANOTHER 4 years of med school. Why take 2 years of inorganic and organic chem when you can take a semester of biochemistry. MDs don’t make their own home made poultices anymore!
    A total of 6 yrs is enough.

    3) Cut down the # of specialists!

  120. Thanks for this. I know I must go back and finish the article, but must admit I stopped dead in my tracks, when during its very opening I found myself once again reading, from a supposed top source, which I expect the NYT to be, about a supposed distinction between "mental" and "physical" illness. That's also part of the problem, right there!

  121. You did not mention depression or anxiety being mistaken for physiological
    medical conditions anywhere in an extremely lengthy comment. I would have thought you would have at least made mention of the topic of the article.

  122. I am in complete agreement.
    US Medical degrees take enormous time compared to any other country and after taking degree they spend another few years as interns and Residents.

  123. Add to the internal causes of depression are the external factors - poverty, family issues, job loss, healthcare bills, Trump,...

    It is a good thing the pharmaceutical industry does not sell placebos - we could not afford it!

  124. The brain does both neurology and psychiatry.

    The first time a patient seems a physician, (for other than a routine check up) they are anxious. The 2nd and all subsequent times, they are anxious and depressed.

  125. We need to start understanding depression and anxiety as symptoms, not diseases. When one is depressed or anxious, that person's body is saying that something is off balance and needs to be examined. It could be medical. It could be psychological. It could also be environmental or situational. Prescribing a pill will only mask the symptoms, not treat the underlying causes. Couple that with hormonal birth control, which is given out like candy to women, and we've got a real mess.

  126. I have to note that "underlying causes" are sometimes not treatable. For me, antidepressant medication was a lifesaver. All the talk therapy in the world didn't get me there. Others I'm sure have had different experiences.

    Regarding hormonal birth control, I am among the many women who have found it very useful in both decreasing the severe menstrual pain I used to suffer as well as greatly reducing my premenstrual emotional lability.

    Broad generalizations about complex entities are generally unhelpful, I think.

  127. As a retired neuropsychiatrist, the problem is stress. "Anxiety" is the word we use to describe the physical and psychological feelings associated with our activated stress response. Walter Cannon, MD, Harvard Professor of Physiology, named this ancient neuro-endocrine reflex, "the Fight or Flight Reaction" over 100 years ago, which was much more accurate and descriptive than Freud's "anxiety", which has dominated the dulled medical imagination ever since. Ironically, our over-active stress response is responsible for all of the "medical illnesses" listed in this article and every other human "disease". Most of the FDA approved medications for "anxiety" actually exacerbate the already over-active stress response and INCREASE "anxiety" symptoms. The two best and safest "anti-anxiety" meds I used in my 40 year practice were the alpha 2 agonist clonidine (in very small doses) and elemental Magnesium, although beta-blockers and pure SSRI's (escitalopram) are also effective. Score another for the psychiatric publishing world and newspaper science editors. Stress R Us.

  128. I know several individuals who were diagnosed as suffering from mental illnesses when the actual cause of their symptoms were brain tumors. One of my friends had been placed in a psych ward, and was slated for a group home, when doctors discovered the grapefruit sized brain tumor.

    The second woman was treated with anti-depressants for a metastatic brain tumor.

    I ,as a layperson with an undergraduate degree in psychology, realized that these diagnoses did not make sense. Mental illness does not typically manifest out of the blue in women in their 40s and 50s who have no history of mental illness. Such illnesses would ordinarily manifest in the late teens or early. 20s.

    I had a friend who suddenly started to experience crushing chest pains, sweating and a racing heart beat. Doctors told him that he was suffering from panic attacks. This man was an extremely calm individual who had no history of anxiety. Finally, doctors realized he was suffering from a cardiac problem. He suffered terribly. and could have died due to misdiagnosis.

    My sister, developed severe pains while breathing.Her doctor told her that the cause was emotional. .Finally,her husband insisted that she see another doctor .That doctor told me that my sister would have been dead within 24 hours of the time he saw her, had she not been hospitalized. Her "emotional breathing pain "was a pulmonary. embolism.

    The list goes on.

  129. While I was working full-time at a high stress job I was always told that I suffered from anxiety and depression, even though I never felt either anxious or depressed, just overworked. Now that I am working part-time in a low stress environment I'm told that all of my issues must be arthritis with absolutely no consideration of other possibilities... because at my age it must be arthritis…I spend a lot of time researching symptoms to determine the likely true issue and appropriate course of treatment.

  130. This column demonstrates why psychologists and social workers can't provide the same services as psychiatrists. Before their four year psychiatry residencies, psychiatrists also had to have already graduated from medical school. Social workers and psychologists aren't required to have any training in medical illnesses.
    And it's interesting that the general popular view is that neurosurgeons, i.e,. "brain surgeons," are the smartest docs and psychiatrists the least intelligent. In reality, virtually all the cases neurosurgeons treat are diagnosed by various forms of x-ray studies while psychiatrists must use their knowledge and intelligence to diagnose the cases they see.

  131. A couple of points in response:

    Non-physician mental health professionals should definitely work with psychiatrists/psychopharmacologists as indicated. That said, my experience is that both MSWs and clinical psychologists have provided far superior psychotherapeutic services for me and other members of my family than busy, costly MDs. MDs and non-MDs and mental health do not do the same work: they do complementary work, particularly today with greatly restricted reimbursement for MD psychotherapy.

    Second point: it is news to me that psychiatrists are "generally considered the least intelligent doctors." (I should note that my ex is a neurosurgeon; both of my siblings are physicians; and my best friend of 30 years is a physician, as are many others of my close friends. My roommate from Harvard days, a brilliant student, went on to become a psychiatrist. My own impression is that those to go into psychiatry are, in general, considered to be deeply thoughtful people – – interested perhaps in a broader variety of topics than the med students who are attracted to more narrow, technical specialties.

    Regarding neurosurgeons, they deserve their reputation for brilliance regardless of modern diagnostic modalities. Everyone knows neurosurgery is the toughest residency to get. Only the top in the class are even in the running. (I admit that Ben Carson may be the rare exception.)

  132. The reality, however, is that psychiatrists are mainly focusing on medication management and don't even bother to actually TALK to their patients about what is going on with them. Now not all psychiatrists practice this way, and for the ones who do, there are various reasons why. But social workers and psychologists are arguably doing more for their clients because they are actually addressing the underlying causes of their symptoms. Depression and anxiety are often symptoms of other problems. And the first thing a competent social worker or psychologist will do is explore with a client about their medical health and whether they've ruled out an underlying physiological issue. Moreover, many physiological issues manifest as a result of something environmental or psychological. In reality, psychiatrists are actually doing their patients a disservice by not using their medical knowledge and training in their day to day practice. Simply masking a problem with a pill may bring relief to a patient, but it often does nothing to address the etiology of the problem.

  133. As a licensed (CA and NY) clinical social worker without "any training in medical illnesses" and who worked in hospitals for 20 years, I present this quick anecdote. A woman in her 30s passed out at the elevators that lead to the prison unit. The vaunted ER docs decided she was "hysterical" and were moving her along to psych. She was holding her 3 year old when she lost consciousness and had no ID, which is the reason I was called, the peds social worker. I kept looking at her - well put together--and kept harping at the docs not to think it was psych- this is not a psych problem. They finally agreed to pacify me and do some blood work and she was diabetic and dangerously sick.

    When she passed out someone stole her purse...

    All's well that ends well but don't put it on social workers.. we may look dumb, but.....

  134. I was diagnosed with a locally advanced pancreatic neuroendocrine tumour six years ago. Prior to diagnosis I experienced uncharacteristic, and unexplained, low moods together with unplanned weight loss. My gastroenterologist said: you're a teacher, subject to stress. Go on holiday. Alarming blood test results took me to the ER where I was told that a low blood cell count of 3 (among other things) didn't justify extra tests or admission; I was asked whether I suffered from psychological issues.

    Enough said.

  135. Yep, no different in the 25 years before I was diagnosed with lupus at aged 38 - starting suffering depression at aged 14. Now knowing being born in 1954 with lupus with the typical neonatal rash ('barley rash' according to the birth doctors) - but not diagnosed/recognized/understood then - changes many things. AND then a late life - aged 60 - of under active thyroid - turns on the 'light bulb' moment.

  136. I'm glad to see this receiving more public attention. This happened to me. In my case it was GERD causing asthma and sleep disfunction that amped the anxiety. I went years being told by medical professionals that I was a hypochondriac and in need of "serious professional help". When I got that help that mental health professional kept encouraging me like crazy to get the doctors to find the physical source. She insisted I wasn't crazy and that my doctors were refusing to acknowledge the mind-body link. That therapist (not even phd) is the best doctor I ever had. After seven years of struggle I went on to a stomach acid medication to try to diagnose GERD and poof the anxiety disappeared. The MDs still knowing my results refuse to acknowledge that the medication helped (it doesn't do that they say) or that there is any connection between GERD and anxiety but I KNOW because I got my life back. Also, I know it's the curing of the condition and not the medication that helped because once the medication related my system I went off it and I continue to be anxiety free.

    Knowing about the mind body connection and how integrated we are may help you work with your doctors and get better results.

  137. This is a good article. But Ms. Brody should have also noted that combined anxiety/depression, or anxiety combined with a kind of chronic low-level depression called dysthymia, often is a result of undiagnosed adult ADHD. Many adults with ADHD have had it all of their lives but were never diagnosed because they never had any prominent hyperactivity or impulsivity. Anxiety and depression medications won't help these people very much if their ADHD isn't treated as well. But as soon as the ADHD is recognized and treated (typically though not exclusively with stimulant medications), the anxiety and depression symptoms abate significantly, or even go away entirely.

  138. These symptoms also correspond to those of bipolar disorder.
    It takes a well-trained mental health professional to differentiate between the two disorders.

  139. Fifty years ago my husband graduated from med school. He took boards in Psychiatry and Neurology - in those days it was mandatory. He had a rotating internship and three year residency plus 2 years mandatory service in the Navy thanks to Uncle Sam's law. Training! Especially the rotating internship in internal medicine, surgery and psychiatry were expected in 1967. Psychiatrists were more than psychopharmacologists! They could diagnose mind and body with the best. And by the way, the brain is part of the body! The med schools have to change their programs. And it does take more than the years put in now. A differential diagnosis seems to be a lost art and one that was expected to be mastered without a battery of MRI's and tests. In all but the length of training, I agree with "Nuschler" below.

  140. Kathryn,
    Since 1977 psychiatrists have had to perform a year internship before they can enter a psychiatry residency.

  141. "A differential diagnosis seems to be a lost art..."
    I couldn't agree with you more. As a practicing clinical psychologist and mother of a child with chronic (physical) illness, I have had many opportunities to observe the limitations and problems with the "silo-like" medicine that is practiced today. Although I am not a medical doctor, I approach my work as a psychologist in as comprehensive a manner as I can; meaning I always try to consider what else might explain the difficulties the person I am working with is having. As a result, I have referred a few patients for comprehensive neurological workups that yielded significant neuro/chronic health diagnoses for problems that all of the MDs and PhDs before me viewed only as mental health issues. It is all intertwined, for sure. But it is also critical to treat all of the pieces to the puzzle. Sadly, there are many mental health patients who are repeatedly written off by MDs (and/or viewed only through a mental health lens by psychologists/therapists) and comprehensive diagnostic evaluation is not even considered much less conducted.

  142. The headline is interesting and most of the comments seem to indicate people believe that it is always physical illnesses that are misdiagnosed as mental illnesses.
    Curiously almost 60 years ago, George Engel, one of the leaders in the field of psychosomatic illness, presented his belief that much of chronic pain is actually masked depression. Considering that certain of the antidepressants are excellent analgesic and that we still can identify a physical cause in most people with chronic pain, it is quite likely he was right.
    And if you don't believe me, then tell me why there is no correlation between findings on MRIs and the presence or severity of back pain.

  143. More people ought to be tested for elevated homocysteine. People with this condition cannot properly absorb the B vitamins, which are known to regulate mood. Prescription strength B vitamins like Folgard (now OTC) are usually the remedy and can make a huge difference in terms of managing depression and anxiety.

  144. My daughter has this condition, but because it has a genetic basis the only way to diagnose it is with quality genetic testing. Just saying "take this supplement and you will feel better" leads to too many placebo results and often misses the true cause of a person's ailment.

  145. The article highlights an important issue and purports to emphasize that mental and physical illnesses are intertwined. But you and some of the sources you cite persist in differentiating "medical" illnesses from psychiatric disorders.

    Both physical and mental illnesses are medical issues. Ignoring or downplaying this fact contributes to the ongoing stigma against mental illlness. It does little to discourage the idea that mental illness reflects a failure of will or, worse, a fundamental personal flaw.

    Language matters. You, as a respected health journalist, have great power to influence how people speak and think about psychiatric illnesses -- and that includes doctors. You could do a great service by using "medical" in a way that doesn't unnecessarily separate the brain from the rest of the human body.

  146. Lois--the differentiation between psychiatric and physical illness is an important one. If you are misdiagnosed with, let's say, bipolar but you really have a brain tumor--would you really want a psychiatrist, as opposed to an oncologist and/or neurologist treat you? You might say, ideally, both; however what if the psychiatrist insists you need psychotropics, not cancer treatment (because, of course, you are misdiagnosed with a mental illness, and cancer is not even in the picture). Would you rather die, just so you could hang on to the false notion that there is "no difference" between the two?

  147. I was told from the time I was a teenager that I was depressed and that's why I needed inordinate amounts of sleep and fell asleep in public all the time. Been taking various psych meds with various diagnoses for more than 20 years before a new psychiatrist said, "well, maybe you are depressed but the sleeping thing can be treated." Confirmed to have a central nervous system sleep disorder 9 months ago and I feel like a new human -- and I'm off the mood stabilizers. I wasn't sleepy because I was depressed. I was depressed because I couldn't stay awake.

  148. The most common mutation in caucasians of northern european (particularly irish) ancestry is an iron overload condition with the clumsy name of hemochromatosis. It is very silent, and usually misdiagnosed as type 2 diabetes, heart enlargement, or liver malfunction. Important symptoms can include exhaustion, depression, irritability, and brain fog.

  149. Genetic research has come a long way, but it's still in its infancy.
    There are a number of conditions (such as this one) that can be diagnosed with genetic testing, but most doctors still aren't doing these tests. Insurance coverage plays a role (some policies still classify it as 'experimental' medicine). Also, medical schools didn't include this training when many went through school so they're uncertain about when the tests are worth the cost.
    This situation will change, but it's going to take time - and current patients need whatever help their doctors can offer until that knowledge base expands.

  150. Three years ago I was seeing a cardiologist for symptoms including severe fatigue, heart palpitations and a slow pulse (in the low 40's). But after I saw a psychiatrist, the cardiologist suddenly refused to make any more appointments for me. I insisted and got in a couple of times, but I was only given appointments to see the nurse practitioner - not the doctor himself.

    Fortunately, my primary care physician referred me to a heart arrhythmia specialist located about 2 hours away. After a year of testing, they've found that my heart problems are caused by an electrical malfunction plus an artery that's more than 50% blocked. NOT something my psychiatrist could have fixed!

  151. The history of anxiety in your family? I'm pretty sure Anxiety was just recently invented by the drug companies and the shrinks. In my parents time there was no such malady. Nor ADD. Nor a lot of these normal states of mind which are all now considered pathological.

    Amazing that children can't sleep. That is another malady that is a recent phenomena. The growing human body will do just about anything to get sleep. The problem is it can't stand up to the modern road blocks we throw at it -- junk food, screens, screens, screens, constant contact with peer groups. There is a reason recess was limited in school -- kids need to learn how to interact with their peers in dosages that are easier to swallow. Then there is the matter of regular bedtimes *for all* regular meal times *for all*, fresh air and moving around instead of being forced to sit in one position all day from the age of 5 until retirement by which time you can only sit in that position so you get a recliner and do it at home.

    Read Andrew Weil is my prescription.

  152. No, there wasn't anxiety in my family. Chronic worry about everything was regarded as a natural part of being a human being. It was a relief to learn about anxiety and that it is (at least to a certain extent) optional.

  153. For what it's worth, my mother in law (in her 70s) has had anxiety attacks since her early teens. She claims she was told to "deal with it". No meds for her. She wouldn't have taken them anyways - too much stigma.

  154. No, the problems existed, but they were considered moral failings. My father was not diagnosed as bipolar until he was in his 60's, although it probably developed in his late teens. But his family considered everything a result of lax morals, including my mother, who was aleady a registered nurse when they married in 1961. I can't help wonder how different my own life would have been if he had been diagnosed when young and then treated. I probably wouldnt have half the problems I currently experience as a result of living with his untreated mental health issues.

  155. I think this is an extremely important column as, more often than not, anxiety and/or depression may be symptomatic - indeed, the only symptom - of an underlying medical condition. Certain low-grade infections can go unnoticed for months - or even years - as they cause little-to-no pain. Ear infections (otitis media; mastoiditis) for example, can be especially tricky as patients become "habituated." Chronic inflammation (bursitis, etc) can also bring on symptoms of depression. This is why a medical exam should probably precede any psychiatric intervention.

  156. I would think that brain tumors could present as a variety of psychological disorders.

  157. This happened to me just recently. I have developed severe mold and pollen allergies, after decades of exposure but no allergic reaction. Before I was able to sort out all the triggers and symptoms, I was begging my doctor for help. I had insomnia, brain fog, recurrent sinus infections, debilitating fatigue, and terrible depression that was either a direct symptom of allergen exposure or a side effect from being so sick with the physical allergic reaction and infections. Because I continued to be quite sick even after taking antibiotics for a sinus infection, my doctor decided that my entire issue was depression, and she refused to have a conversation about why that might not be the case. I was very clear, having had depression in the past, that this was different. She wouldn't listen. I went to my allergist, and she confirmed that the allergic reaction often includes all the symptoms I was experiencing. I have switched doctors, and so far the new doctor is a better listener.

    As others have pointed out, the second sentence in this article is obviously backwards--the author should fix it.

  158. I have seen many people with mild asthma who do not wheeze but experience chest tightness relieved easily with inhalers. I cannot tell you how many of them have been treated for "anxiety" instead of asthma..often for years or more before I see them.

  159. I have seen this repeatedly., and most primary doctors aren't equipped to recognize what is psychological versus what is physical - they are stuck in the physical alone.
    It is amazing how the human body functions, each 'division' works alone and with the others. In my life coaching and counseling work, I realized that there is a fantastic explanation or description for it: Heart (emotions), soul (spirituality), mind (thoughts), and strength (body, physicality). When I research each one and start putting those pieces' information together, I get a fuller and better picture of the client and can better help them, referring when necessary.

  160. Physicians get much more money for a five minute procedure than 45 minutes of detailed evaluation. Often the second is what will get to the correct diagnosis. But merely seeing patients and getting them diagnosed and treated doesn't even pay the office overhead. It's sad.

  161. Thank you, Ms. Brody. When my husband exhibited behavior that was unusual, and I contacted two of his doctors, they ignored me. It was three years of considerable family suffering before he was diagnosed with Parkinson's Disease. The information in your column may help a family to receive help in a much more timely manner.

  162. Jane is perfectly correct to point out that physical problems can cause emotional symptoms. As an Internal Medicine physician who sees patients with tick-borne infections, I can attest to the high incidence of anxiety, depression and irritability (sometimes resulting in rage episodes) that occur with Lyme Disease and its coinfections, especially Bartonella and Babesia. The neuropsych symptoms resolve with appropriate antimicrobial treatment. A previous study which tested for Lyme Disease in people in an in-patient psych ward found an incidence of 30% positivity, with a control population that was near zero. Mental health professionals should be tuned in to possible organic issues that can cause psychiatric problems.

  163. This is the most interesting comment I've read in a while. I hope it prompts NYT to do a follow up article about the potential link between microbes and psych symptoms. We know the "bugs" can cause cancer, ulcers...makes sense they can cause anxiety and depression too. My guess is that hand sanitizer and antimicrobial soaps just make us more susceptible, not less, but I'd love to learn more.

  164. Modern research is finding that the Lyme spirochetes have a wide variety of ways to alter their host's immune responses and physical structures in order to survive and eat/thrive. The same is true of the co-infections, and all of them cooperate with parasites and viruses. Some of the most common neurological effects of these infections appear to be due to disruption of cytokine balance, caused by the microbes. The books by herbalist Stephen Buhner include summaries of huge amounts of this research, and some of the best and most experienced Lyme-literate doctors also publish information about how this happens. Relatedly, look up the NYT article on how parasites can pretty much take over your brain function in order to get what they need. Frankly, it's beginning to seem likely that most or all psychiatric problems stem from infection or from physical/genetic imbalances.

  165. I didn't know I was having panic attacks when I was having them, I only knew the onset of fear precipitated by an unknown reason. until I happen to read a book about anxiety. I felt better to know I wasn't the only one experiencing these feelings.
    I learned about how the mind bluffs the body into believing something ominous is about to happen. I learned to accept these unnatural fears, not fight them.
    I was fortunate to have been exercising for a number of years which help me cope with anxiety, for me it's impossible to be anxious lifting weights or on a ride on my Me-Mover.
    Love the endorphins that our body gives us while exercising, that feeling of well being you can't find pills for.
    I know we cannot forget anxiety, we must accept the triggers, and realize that big bluff is just what it is, pretend fears.

  166. I would have liked to have seen SOME guidance for people who do have a personal or family history of anxiety and depression, beyond "get treated!" The bulletized list copied from the Mayo clinic and the other content of this article are written as if only people with no prior history of anxiety or depression ever develop heart problem, cancer, or endocrine disorders. That's obviously not true. Some guidance on how those of us who do have a personal or family history of anxiety or depression can tell whether that recent uptick in anxiety, headaches, dizziness, angina, or shortness of breath is a sign of a new medical problem, and not simply a new manifestation of anxiety -without going on an expensive, lengthy medical goose chase - should have been provided here.

  167. Interesting article but takes me back to when medical training was not limited to specialties only. In the "good old days", Interns rotated thru ALL specialties including ER, Psych, Ob/GYN, Surg., Medicine, dermatology, etc. When they finished that first year, they all had at least a working knowledge of the whole spectrum afflicting the human body. I acknowledge science has grown by leaps and bounds since that time. But I do think our physicians were better prepared to recognize disease out of their speciality.

  168. The headline is SERIOUSLY misleading. Anxiety and depression ARE medical problems. Unfortunately, the mental health "care" system chooses not to view them as such.

  169. My mother experienced unexplained anxiety 27 years ago. Her doctor gave her prozac which she said had horrible side effects. Three months later she was diagnosed with pancreatic cancer and 3 months after that she was dead.

  170. More attention on this, please! My Prinzmetal angina went undiagnosed for nearly a decade because it was clearly the product of a middle-aged woman's anxiety-filled brain. It wasn't till I had a serious heart attack that it was recognized - and after years of being told everything was in my head, I almost ignored the symptoms myself.

  171. Could we please get over the "physical vs. psychological" false dichotomy? It's all physical.

  172. Like most medical issues, there is no one size fits all. Disorders, illnesses, diseases: Science has proved they are all physical. The brain is an organ like the liver or pancreas is. Science has proven that our mental and emotional health has a direct impact on our physical health as a whole. Emotional stress is probaby the best example as it can lead to a list of serious health problems. Feeling depressed is a common symptom of an underactive thyroid (hypothyroidism) while clinical depression (which changes the physical structure and chemical activities of the brain) can cause hypothyroidism. A lot of it has to do with methabolic imbalances so, ideally, will will appraoch our mental and physical health as one.

  173. Omlink -- I have to disagree with the idea that "clinical depression" can cause hypothyroidism. We can't think our thyroid into malfunctioning--it's an autoimmune attack (Hashimoto's) which causes most hypothyroidism. Then there's Grave's - which is definitely autoimmune.
    Okay, sure, my thyroid disintegrated as a result of "depression" as opposed to strong family history and environmental factors (I grew up close to a active nuclear power plant).
    Are you also one of those who believes that cancer is a result of "faulty thinking?" If you believe that, I have a bridge for sale . . .
    I could not "think myself" out of thyroid dysfunction any more than I could move the earth's axis by "positive thoughts."

  174. "clinical depression (which changes the physical structure and chemical activities of the brain)"

    Nothing in there says anything about "Thinking" yourself into or out of thyroid dysfunction. Your thyroid dysfunction was likley because of all of those factors. Not everyone with thyroid issues has that background, however, everyone is subjected to the chemicals and hormones in their own body.

  175. Celiac disease is another one that can show up as anxiety. Anxiety + headaches + stomachaches + gender ===> years of delayed diagnosis and misdiagnosis.

  176. Good illustration, awful ( dumb) title which epitomizes a non-existent mind-body split. Anxiety must be another way our body warns us of trouble brewing - inside or outside.

    The content could be helpful to many patients, especially if their physicians and other medical professionals read this or the studies or articles underlying the reports.

  177. As a certified counselor for some years, I treated many patients who presented with anxiety and/or depression. Before assuming that the diagnosis was psychiatric in nature, I always asked them when they last saw their primary doctor for their symptoms. If simple measures like adding exercise to their routine did not help, I referred them for a physical before psychiatric medication. This is only common sense. However, many physicians have relatively little psychiatric training, so if someone truly needed antidepressants or anti-anxiety medication, I referred them to a specialist, a psychiatrist. Nowadays better psychiatrists ask about physical well-being as well as mental and behavioral well being. If yours doesn't or isn't interested when you mention it, find another doctor.

  178. Under the proposed changes to the ACHA many patients will lose coverage for mental health services. The information in this article supports the fact that mental health is, as a previous commenter wrote, physical health, and removing coverage for one will result in increased costs in attempting to treat the other.
    Write/call your representatives and show your opposition to any reductions in medical coverage, in this case particularly for mental health services:

  179. I work at a community health center as a mental health therapist and can attest to the fact that there is an interplay between mental and physical health. After all, the mind resides in the body. I have also had personal experience with being diagnosed with hypothyroidism about 10 years ago by my then primary care provider who wanted to prescribe an antidepressant. I went on thyroid medication and my depressive symptoms lifted.

  180. A positive story that relates: when I, a generally sunny person, became intensely lackluster and sad, my exceptional gyn nurse-practitioner suggested that i look into thyroid levels. Mine were within average range but my doctor was persuaded to let me try -- and within a month or so i was sunny again. It was definitely a physical cause.

  181. Was persuaded to let you try what?

  182. Kate--you are really, really fortunate that your doctor (I presume he/she gave you thyroid hormones) treated you for thyroid disease even though your levels were "average."
    I went for years and years being told my thyroid symptoms were the result of "depression". I ended up with a malfunctioning thyroid that had to be removed (along with a carcinoma). Yes, more doctors need to be aware that optimal, not "average" levels is the key when it comes to treating thyroid dysfunction.

  183. There is too much emphasis placed on testing and not enough placed on the patient, who ostensibly knows their body better than anyone else. You know if something is amiss or doesn't feel right. Symptoms warrant testing, but I have a hard time with the words "normal" and "average"- what may be right for one is never right for all.

  184. Don't forget Addison's Disease, which my son has, and which was misdiagnosed as depression.

  185. Why do we continue to separately group 'mental' and 'physical' illnesses? Many 'mental illnesses' are now known to be heritable and/or can be successfully treated with drugs that support GABA, reduce serotonin uptake, etc. If a 'mental illness' can be managed by drugs, why isn't it labelled a physical disorder similar to diabetes (for example).

  186. I love that you're taking this up.

    I have never had problems like that, misdiagnosis and such, but it's something I think about quite often. There's a lot of things that can be labelled as anxiety-symptoms: stomach ache, head ache, heart palpitations, insomnia, difficulty breathing - or just the feeling of being vaguely ill.

    What if it's really an illness behind, and not just anxiety?

    Once you've gotten that diagnosis of anxiety, anything can be explained away alongside that.

  187. Excellent article. An important addendum - or follow-up - would describe the ways that institutional sexism and racism affect the missed diagnoses and misdiagnoses you describe here. Or, to put it more gently, would describe how disparities in diagnosis and treatment intersect with race and gender. There is a good body of research work investigating this. Women's anxiety symptoms more likely to be ignored, black males with depression being diagnosed as schizophrenic, etc.

  188. Agreed- this is huge. There is so much implicit bias in diagnosis and treatment, not just in psychiatry but all areas of medicine. Pain assessment and pain control being another area with wildly biased mismanagement.

  189. The book "Black Man in a White Coat" is about the interactions between black people and medicine. How black people are treated, health issues that black people tend to suffer from, etc.
    As for women and medicine - I get the impression that women are much more likely to be treated as if their health issues are actually psychological problems. And suspected of exaggerating their symptoms for emotional reasons. Like people are less likely to believe what women say about their experience.

  190. I spent years with a GP who kept telling me my anxiety, rashes, alarming weight and hair loss were a result of being a working-mom with two children.-- it was stress. Years later, a thorough nurse-practioner diagnosed my Lupus. It was a relief. Now treated, I have yet to have another Lupus flare.

  191. please let the psychiatrist Laurie in Chicago know of your experience as she denigrates the care provided by mid levels.

  192. If you constantly had a highly elevated level of cortisol in your body, wouldn't you think that would cause anxiety? Yes, it does, and it's called Csuhing's syndrome. It also causes depression, high blood pressure, high blood sugar, muscular weakness, weight gain, among other symptoms. Often caused by a tumor in the pituitary or adrenal glands, it is treatable. And prompt diagnosis is essential, because without treatment, Cushing's can be fatal. Having survived pituitary Cushing's myself, I am glad to see that psychiatrist are being encouraged to consider a non-psychiatric cause for psychiatric symptoms. The word needs to get out to psychologists, social workers, and other mental health professionals as well.

  193. In my doctoral training in clinical psychology it was the standard of care to check that medical assessment had been done -- I think the word is already out with most clinicians. I don't know any who don't at least consider if not make referrals to rule out medical explanation for psychological symptoms.

  194. The problem isn't physicians. Insurance companies and Pharma are the ones who really control what is happening in any physician's office. Insurance companies and Pharma are purely profit driven. When I started training in Psychiatry prozac and zoloft just came out. They changed people's lives. People who had been in psychotherapy for years. Shortly thereafter, Insurance decided they would not reimburse me to do psychotherapy. Since then they only reimburse me to do 'medication management', 15 minutes to talk to the patient, figure out what is going on and come up with a plan. Insurance finds most tests I want to do are 'not medically necessary'. Insurance prefers midlevel practitioners who they can reimburse the same or even less which limits the quality of the care delivered. In order for me to practice medicine and psychiatry the way it needs to I have to step outside of insurance. For me to use all of my education for the good of the patient I have spent endless hours receiving additional training through Institute For Functional Medicine (to give me a framework to scientifically think holistically) and pursuing different business practices. There are a lot of good physicians out there who have become pawns of the system(Insurance and Pharma).

  195. Laurie, thank you for your honest and educational comments. Too many people blame doctors. In my opinion, patients should be required to pay more and more out of pocket in order to appreciate all that doctors do. If a person gets their medical care for free (for example, because they have Medicaid) they take good medical care for granted. They assume it is all coming to them, as if the doctor is their servant.

  196. @Fatso - You appear to make a lot of generalizations about what various people think of their health care providers, and you seem particularly prejudiced toward lower income groups receiving Medicaid.

  197. Fatso--most people now are struggling to pay "more and more" out of pocket--and that's in addition to their premiums. People on Medicaid cannot pay more --that's the whole point of Medicaid; they don't have money to spend on doctors (and their basic living expenses). Would you rather that people die because they cannot afford to see the doctor (happening right now, actually). Do you honestly think that most people (talking about the middle class here as well) could afford more? Pretty delusional, imo, but on the other hand, "good" medical care is also hard to find--at any price.

  198. Scary to think you have been treated for an assumed diagnosis, even if successful initially, only to find out it delayed urgent treatment for a more serious condition. Indeed, we can be lulled into complacency, once a given symptom or diagnosis is given, underscoring the imperfection of our knowledge and understanding of a human condition (mind and body). Perhaps, unless we can be sure that our hint is corroborated by evidence, a second opinion without the new diagnostician being led astray by 'our' thoughts, may be the way to go. Even so, our gut feeling may come into play, and remain on the alert, in spite of so much technology at our fingertips. In a professional's busy schedule, there may be a tendency to objectivize a patient (a fellow human being) and call him/her "an appendix", or a "gallbladder", or 'a psychiatric case' when we failed to suspect a brain tumor in a schizophrenic or paranoid personality...by way of an MRI. Trouble is, in an attempt to cover all bases, for legal defense or not, it becomes an expensive proposition. Judgement derived out of experience, and some humbleness, may go a long way to minimize mistakes...recognizing that the only one not missing things, off and on, is the one sitting in a chair, and doing nothing to begin with. Clear as mud, right? Just don't get paralized by the anxiety and depression that may ensue.

  199. About a year after her father died suddenly, my sunny six-year old daughter started to suffer from severe separation anxiety. She cried every morning and clung to me as I tried to leave her with her first grade teacher. She often cried during recess and sat on the sidelines during games. She put her head on her desk during class and at lunch time. Her teacher and principal suggested that I seek professional counseling for her. First, I wanted to be sure there was not an underlying physical cause for the change in her personality. I had to persuade my pediatrician to run the blood tests. A simple CBC revealed that my daughter was severely anemic. We never discovered what caused her iron levels to drop, but after several months of iron drops in apple sauce, she was back to her energetic and engaged self. She is now 17, and has not had an issue with iron deficiency -- or anxiety -- since.

  200. Interesting, but what's up with the bizarrely ignorant headline? Is the author implying that depression is not a medical problem? Don't you think it should be "...Masks a DIFFERENT Medical Problem" or something to that effect?

  201. It was last summer when my 82 year old husband began feeling out of sorts - among his symptoms a lack of interest or enthusiasm for things that usually interested him or any of his household jobs. He also complained of a persistent sense of fogginess in his head. First his doctor guessed (and treated him) for depression. Then he grew increasingly anxious and was treated for that. He developed a deep feeling of dread and was frequently beset by terrible chills and all over shaking and was afraid he was going to fall over and die. We saw specialist after specialist - a cardiologist for suspected atrial flutter, a rheumatologist who suggested Parkinson's, a neurologist who doubted that diagnosis but had no answer either. After nine months, I persuaded my husband to see a new GP who sent us immediately for a brain MRI. Diagnosis: brain tumor. He had surgery three weeks later and is currently in the hospital in Hartford recovering from a frontal lobe glioblastoma.

  202. My Graves Disease was not diagnosed for over 5 years despite me begging doctors that there had to be something physically wrong beyond mental health diagnosis. A nurse practitioner told me to see an endocrinologist but instead of a referral from my GP I got a prescription for antidepressants. I begged a shrink to do a blood test- anything to figure out why the meds weren't working but he took out a model of the human brain with a Prozac logo and explained how SSRIs worked and why I needed to give them more time. 5 years later and a switch to PPO insurance, a qualified endocrinologist diagnosed me with severe hypothyroidism and Graves Disease, I had no choice but to do RAI twice, it was malpractice plain and simple. Too many shrinks make big money on 5 minute med appointments dolling out pills that do not work and making patients feel any issues with the treatments are their failings.

  203. I suffered from depression for years. Then my doctor and I talked about a thyroid test. Mine was within a normal range, but the range is very broad for normal. She prescribed additional thyroid and within 8 weeks, the clouds began to lift.
    All those years of feeling sadness for no reason, when there was really an underlying, and minor medical condition, not life threatening, but life affecting.
    And just a dab 'll do ya too. Not an extreme solution at all, but one that has lasted and changed my life.
    We really are one Being, not mind and body, but one mind/body.

  204. Back in 2003 I started to experience severe reactions to a variety of foods when I tried them after doing an elimination diet. Along with physical symptoms like being in a stuporous state for several days, joint pain, etc., I had psychological symptoms: a lot of anxiety, tension, rage, depression.
    I went to a gastroenterologist to see if I might have celiac disease. But they wanted to refer me to an environmental medicine doctor. Because my food reactions had those emotional aspects.
    But food reactions are gastroenterologist territory par excellence. And food reactions that include emotional states should be gastroenterologist territory as well. Our emotions aren't just "in our heads" - they're connected, sometimes very powerfully, to what goes on in our bodies. Surely a gastroenterologist could deal with that.
    And I didn't like the idea of seeing an environmental medicine doctor, because they might push possibly harmful treatments on me.

  205. I suffered with severe depression, anxiety, brain fog, physical pain, and low energy for decades. About 6 years ago, on the advice of a chiropractor, I eliminated wheat from my diet. It made a huge difference. Both my mental and physical health improved. Then, 3 years ago, I did an elimination diet and discovered food sensitivities that also reduced symptoms of both my physical and psychiatric illnesses. Subsequent "tests" of my sensitivity to wheat, corn, and cane sugar resulted in a myriad of psychiatric symptoms from brain fog, to sudden and extreme rage, to sudden depression and exhaustion. You would think a gastroenterologist should be prepared to understand and recognize problems like this, but apparently many are not. It took an Osteopath and a Chiropractor to figure these things out with me.
    Recent studies demonstrate that depression is an inflammatory disease, as are many auto-immune disorders. Other members of my family have had bacterial infections that caused auto-immune disorders that included neurological and behavioral symptoms.
    The fact that we still see behavioral and emotional problems as less than real medical problems is a huge problem.

  206. I haven't read through all of the comments, so maybe someone else made this point. Anxiety disorders and depressions ARE medical problems. Many times there are other medical problems that have anxiety and depressive symptoms associated, but anxiety disorders and depressions/mood disorders are very often discrete illnesses and we need to be careful not to re-stigmatize them, please.

  207. We also need to be careful not to medicalize people's feelings and their experiences. Maybe a person has anxiety because of traumatic past experiences, for example. Maybe they're depressed because they feel stuck in a bad job.

  208. Ms. Brody:
    There is a glaring hole in you summation of the different kinds of physical afflictions that present as (psychiatric) anxiety: You omitted dysautonomia. Dysautonomia is not rare. Over 70 million people worldwide live with various forms of it.

    In your article you state
    " psychiatrists may not consider the possibility that a patient with symptoms like palpitations, fatigue or dizziness really has a physical ailment."

    This is exactly the problem people with dysautonmia face: they have all the symptoms of "psychiatric" anxiety, but the cause is due a malfunctioning autonomic nervous system: most neurologists/physicians are blithely unaware and unfamilar with this affliction, and assume "it's all in the patient's head," and send them to a psychiatrist. They are told the symptoms are psychiatric in nature, when in reality their autonomic nervous system is out-of-whack.

    I suggest you watch this video by Dr. Alan Pocinki:
    “Psychiatric Misdiagnoses in EDS: When is Anxiety not Anxiety?”

    I also suggest you check out the Dysautonomia International webpage:

    (note: Despite the title, dysautonomia is not inextricably linked to EDS. )

  209. 'This is exactly the problem people with dysautonmia face: they have all the symptoms of "psychiatric" anxiety, but the cause is due a malfunctioning autonomic nervous system: most neurologists/physicians are blithely unaware and unfamilar with this affliction, and assume "it's all in the patient's head," and send them to a psychiatrist.'

    You're looking at a 1% disease occurrence rate worldwide and expecting a doctor, who's exposure might be infinitely less likely by geography, gene pool, economic status, and so on, to alter their largely positive outcome strategies?

    There has to be some sort of cost/benefit calculus for the system to even function. Start with the most likely...

  210. That is exactly the problem with our medical system today. People's lives should not be broken down by cost/benefit calculus. Doctors should listen to patients, carefully consider ALL possibilities, perform tests to help clarify diagnoses, and treat according to the needs of each patient. Costs for the health of all human beings should be shared so that those with illnesses are actually able to live full, productive lives that help contribute to the greater good.
    Doctors, whose experience and knowledge are limited by the human condition, need to quit assuming they always have the final answer, and that patients' reported symptoms are less valid for not fitting the assumed diagnosis, or not responding to the 'appropriate' treatment. When doctors dismiss patients' reports of their experience as 'mental illness' or 'hypochondria', they contribute to the growing distrust of the medical industry.

  211. Has anyone studied why everyone is now being diagnosed as "anxious"? It's beyond ridiculous that this many people need therapy and drugs. I have school teacher friends who have no problems who all of a sudden need therapy and meds to keep them calm. What is that about? I think this country has never had to deal with real problems and that "anxiety" is another money-maker for the greedy drug companies and doctors.

  212. Did you notice the results of the 2016 presidential election? A major source of anxiety is right there...

  213. Have you ever had every symptom of a heart attack? Felt the room spinning? Not been able to get words out?---then feared the above and more. I never let any of this stop me from doing but I'm older now and had every test conceivable this past year. In my case the extreme anxiety was probably caused by an undiagnosed invisible neurological disorder. Meds let me live a very productive happy life for many years. They don't work as well anymore and I live in a part of the country where it's easier to see a pulmonary doctor than a psychiatrist---a year wait. I hope nobody you love ever suffers with extreme anxiety. You'll be singing a completely different song

  214. I believe that I have had an underlying anxiety disorder most of my life. Since I was a teenager I have had trouble sleeping, and though I could cope (and somewhat succeed) in life, it seemed that I was more "stressed" than others, struggling with inner anxiety that I had a hard time putting into words. I was tense, most all of the time. I jogged, I swam, I meditated, all primarily as a way to get some control over my anxiety. I went to therapists for awhile, and was taught some things -- like expressing my feelings honestly, being more assertive, etc. But the anxiety remained, seemingly an inherent to how I was made. On a whim, once, a physician prescribed a low dose of Zanax to help with ringing in my ears. I was amazed at what it felt like to be "rested", to be able to sleep through the night, to be calm. I continue to take a very low dose of zanax most every night. I do not abuse the drug, but I have not been able to rid myself of anxiety without it.

  215. Such a timely article! After 25 years of being treated for anxiety and depression, I was recently diagnosed with a serious sensory processing disorder. Despite having constantly lodged complaints that all pointed to something underlying my symptoms, the real condition was never identified. Hiding in plain sight, as it were.

    Ironically, my treatment maxim has always been that Occam's Razor cuts both ways: If the most probable explanation fails repeatedly, perhaps it's time to start looking for less probable explanations. Having been right is somewhat vindicating, but far better would have been a psychiatric community that - like me - continued to look "outside the box."

  216. I think the article could include an even stronger caution against dismissing symptoms as "psychological." The point may seem too crude and obvious to bear repeating, but I personally know people who have died as a result of such misdiagnoses. As we can see from some of the comments, the bad old days when such things happened routinely are not over.

  217. You're absolutely right. Especially when the patients are women. Far too often, women's complaints are seen as 'much ado about nothing', or chalked up to emotional reactions. Misogyny kills women in this way far too often.

  218. As a psych undergrad, one of my professors who was also a practicing psychologist stated that any therapist at any level should start the first session with "When was the last time you had a medical exam?" Further probing should determine how thorough any exam was. In my years of practicing and attending I have yet to hear of any therapist who regularly does this.

  219. One would assume they'd just scan the file from a patient's referring physician.

  220. I don't think most clinical psychologists (and certainly not most MA-level therapists) ask for a release and get medical records faxed over. There's no reimbursement for records review. They have to depend on the patient's self-report.

    I'm a retired neuropsychologist. I routinely asked got releases, and I can tell you that even for a child with behavior problems (let alone an adult referred due to bewildering emotional problems), I often wound up studying an inch or more of records.

    Indeed, a neuropsychologist is often the only clinician a patient sees who puts his or her whole history together.

    (That's getting harder and harder to achieve, though, due to insurers who reimburse for too few hours, and randomly declare assessment of certain disorders not to be reimbursable at all... which is one reason why I retired.)

  221. First, keep in mind that 50% of all physicians graduated in the bottom half of their class. I developed anxiety after dealing with doctors who were inept and misdiagnosed or otherwise failed in their assessments. When one has to rely on a person scarcely more adept than a witch doctor, anxiety is a reasonable response. So while anxiety may be the precursor to an ailment, it may also be the result of seeing doctors who are mediocre.

  222. "First, keep in mind that 50% of all physicians graduated in the bottom half of their class."-Elizabeth

    I first take comfort in the knowledge that the bottom half of any graduating medical class is still a few ticks higher than the people who made my pizza. Lighten up. You'll live longer.

  223. it doesn't really matter if doctors graduate in the top or bottom half of their classes, since medical schools do not systematically teach students what they need to know to be effective physicians. Instead, students are taught basic sciences, which provide minute details of cellular functioning more appropriate for research scientists to know. Training in diagnosing and treating diseases is done in the clinical years and is haphazard at best. Pretty much no medical student graduates with any competence in clinical practice, as all their time has been spent learning worthless information. Many students at the bottom of their classes in medical school make the best, most attentive and careful clinicians, as they are far more interested in and skilled at caring for the whole person than in memorizing the irrelevant details of their basic science classes.

  224. Until 8 years ago I was a very self sufficient professional woman. Then all of a sudden even leaving home, made me uneasy and sick to my stomach. Doing my taxes made my heart race, my hands shake, I could not hold papers or write legibly. I could no longer clear dishes for fear of dropping something. Cooking became frightening. What if I dropped the broiler, or quarts of boiling water ? Everything I enjoyed became a chore, and tasks like taxes nightmares.
    I had gotten to a point where I could barely function, by my standards, and sorry, but therapists didn't help. In fact they increased my anxiety and depression. I had little funds, and owing people made me more anxious, and therapists in general care more about getting paid.
    Long story short, 'found a great doctor and asked how do I shake for 3 - 4 hours having a Raynaud's attack, and why does sleep and warmth abate it?
    All extensive tests came back negative, blood flow too.
    But one day a M. J. Fox Foundation researcher asked me had anyone suggested I had Parkinson's. I was floored, he said I was shaking all over. Something I felt, but no one said.
    My doc sent me to top rated neurologist and I got the good news and bad. I did not have Parkinsons, but I had Essential Tremors at a very advanced stage. It's a progressive neurological disorder, it will not kill me. It will make my life progressively more difficult. Anxiety and depression are symptoms. Hindsight is 20/20.
    Doctors are humans, too.

  225. Essential tremor is what causes my typos. The cooking problems are very real. My grandfather had it. My brother and I both have it; because of grandpa we self-diagnosed early on. My older niece does, too, although she probably would not be noticing it yet if she had not been observing her father and me.

    The thing that calms my tremors best is about 2 ounces of gin or vodka. Unfortunately that is not conducive to writing lucidly or doing one's tax return. It does allow me to have dinner out without dropping food off forks or spoons.

  226. I spent approximately 10 years in therapy with a psychiatrist (some of that time not insured) and taking antidepressants for major depression. Not only was I obviously unhappy but, as a self-employed person, my income also suffered. Eventually tremors in one hand were bad enough that I went to a doctor who diagnosed Parkinson's Disease. My antidepressants were changed to ones more suitable for my dopamine-depleted condition and my depression began to lift. So many years wasted on inappropriate treatment for depression and delayed treatment for Parkinson's. I thought that the first thing a health care provider is supposed to do is check for possible physical causes of the mental illness.

  227. In my case a physical illness caused thought and behavioral changes that were diagnosed as depression. Treating the depression and leaving it at that contributed to the real diagnosis being missed for over 20 years. Having to perform an exam in under 15 minutes because of reimbursement issues makes for a lot of mistakes with terrible outcomes.

  228. I don't understand this article. The topic seems to be physical illnesses that manifest themselves as emotional distress. But the author keeps referring to the opposite phenomenon: emotional illnesses that manifest themselves with physical symptoms. It's all muddled up. I want to know about emotional distresses that are signs of, or products of, an underlying physical ailment, like the woman with the cardiac abnormality.

  229. As an infant in 1950, my thymus was deemed too large and irradiated, during that period that we were fascinated with the power of radiation and unaware of the dangers. I spent my teens anxious and depressed. The final recommendation from my college advisor (head of the Theater Department and ultimately President of the college) was to get my thyroid checked. Diagnosed with goiter and Hashimoto's disease, I took a low dose of thyroid medicine, still dealing with mild depression and anxiety while complaining of sinus infections to obtain antibiotics to deal with persistent low grade fevers. It was not until my cancerous thyroid was removed (at 39) did I learn what it was like to feel normal. No more fevers, depression lifted and finally, over many years able to lose a significant amount of weight. I'm grateful for talk therapy, which kept me going, and understand that doctors did their best a every point, but had the dose of thyroid medication been larger and given earlier, life would have been significantly easier and more joyful from ages 15 to 40.

  230. My daughter has an auto immune condition and has had ongoing issues with fatigue. postural orthostatic tachycardia syndrome, headaches and the list goes on. However, in high school and by doctors, friends she was always being told she just had anxiety issues, that there wasn't really anything wrong. I am certain many, many people have been in the same situation and it is in itself depressing. It affected her to the point where she couldn't attend school because she got so fed up with having to defend herself. She is an adult now and still struggles with her health but she has an understanding family and friends and very supportive physicians. She may well need medicaid in the future so just a shout out for single payer. Having to deal with chronic illness which inevitably leads to feeling depressed and the so called health care fiasco will inevitably lead to a lot more people feeling depressed.

  231. I suffered from "depression" and "anxiety" off and on since high school. Psychiatrists threw every psychiatric medicine in the book at me; the meds either didn't work or I couldn't tolerate the side effects. I developed insomnia and completely lost my libido for several years, due to Prozac. I spent a lot of money and many hours on psychotherapy that worked minimally.

    In my late 40s, I developed endometriosis, had a hysterectomy/oophorectomy, and put on an estrogen patch. And, what do you know: my depression and anxiety decreased 95%. Just like that! Apparently my mood problems were actually untreated hormone problems.

    Luckily I only suffered from the wrong diagnosis for 35 years.

  232. Its not news to me that the brain and body are not just connected but one and the same!!!

    There is a brilliant holistic medicine group at UCSF. Top notch mind/body medicine.
    Massage as part of cancer treatment. Acupuncture as part of pain treatment. Mediation as part of autoimmune treatment.

    Its not so much a no brainer, its a whole person.

  233. Always, always pay attention to your own instincts and gut feelings. You know our body. There are so many publications, newspapers and magazines now that devote weekly space to "medical mysteries" and the patient has usually gone to a great number of doctors. Insist no matter what. move on to the next doctoro when unsatisfied and find someone who knows what they're doing. Doctors no longer do differential diagnosis. I've been through this myself. It isn't easy but delayed treatment can cause great damage.

  234. Cushing's disease is not an adrenal disorder. Cushing's disease is caused by a tumor on the pituitary gland that secretes too much ACTH, which causes the adrenal glands to produce too much cortisol. The actual disorder is in the pituitary gland. However, Cushing's syndrome (not disease) could in fact be an adrenal disorder, as tumors on the adrenals can cause increased cortisol production. A small clarification for anyone reading. I am a Cushing's disease survivor and now I advocate for awareness of this disease.

  235. Shouldn't the title of this story have been "When Anxiety or Depression Masks Another Medical Problem"? Anxiety and depression are both legitimate "medical problems" in their own right.

  236. Absolutely. And herein lies the problem. Until researchers find the physiological causes of mental illness (and this is happening today), the general public will continue to misunderstand that mood disorders are real, patients fail to seek help due to the tremendous stigma and our insurance companies will continue to discriminate against patients who have brain based illnesses.

  237. "The problem of missing the proper diagnosis grows out of a long-ago separation of powers within the medical profession that often limits the ability of practitioners to see the forest for the trees, as it were."
    Hence this endeavor: http://www.focusdiagnosticmedicine.com

  238. Actually, this is an example of the law of unintended consequences. In the 80s and 90s, the mental health service and research communities became concerned about depression being missed in the rest of the medical community, while depression was found to be a leading cause of the global burden of disease. There are not enough mental health professionals to manage all the depression in the country, let alone the world. So they set about training medical students and all physicians to screen for depression in their patients using simple questionnaires and scales that could be self-reported or administered by a less highly paid practitioner. Scores on these scales were believed to represent potential depressive illness and intended to trigger more in-depth evaluation and treatment, but instead (with a lot of help from the pharmaceutical industry) they triggered the prescription of antidepressant drugs. Over time, these drugs have become over-prescribed, boosted by direct marketing of expensive new antidepressants to consumers who then show up in their primary care doctors' offices and demand these drugs. What got lost in all this was exactly what the article is about; physicians were not trained to understand that people can have depression as well as another disorder and one might or might not be the cause of the other. Hence, in the spirit of not missing depression, physicians are missing other "comorbid" disorders that might be causing depression.

  239. In the early 1980's I published a review of the then vast body of literature showing the link between mental illness and physical health problems. This link has been know for decades and yet our fragmented healthcare "system" has failed to find ways to integrate behavioral health and physical health services. I suspect at least one cause for this failure is the lingering stigma associated with depression, substance abuse, and all forms of mental illness. But it cannot be cost because we have long known that integrating mental and physical health services will lead to substantial cost savings.

  240. I think that it is not stigma but the strict compartmentalization of western medicine. This begins in medical school, continues through all phases of physician training, and is reinforced by medical office practices and insurance billing policies.

    Last time I saw my internist I was handed an information sheet while waiting for my appointment. It explained that I might see multiple billing codes on my insurance statement. If you talk about the single issue you are booked for, it said, you will see one charge. If you go off script and bring up anything else, you'll get a second billing code, and so on. For anyone with a high deductible or poor insurance coverage, this is alarming. If we are thus warned not to mention any vague concerns, how are we to track down the source of health problems that don't present as immediately definable?