Saturday, July 31, 2010

An Analysis of "Preventing Misdiagnosis of Women" (guest post)

by Jessica Hankins


I am a 34 year old Cushing’s patient, amateur writer, and dedicated volunteer to the service of the youth of the United States. Having a devastating disease such as Cushing’s has not been easy for me. After life-long illness, two failed surgery attempts, losing my job and now having no insurance, it is my hope that this information will help those with endocrine issues find the best care possible, and those that don’t – I hope you understand a little better why so many of us have a difficult time
discussing this disease and our mental state.

After my own reading and research, talking to fellow patients and friends, and working with a dedicated endocrinologist, it is my opinion all medical diseases which may cause a psychosocial issue should be ruled out before pursuing a diagnosis of a psychological condition. Many endocrine diseases can be made worse by using medications – sometimes even resulting in death. As health care practitioners, it is your job to rule out complicating conditions. As patients, it’s our job to consider all the avenues possible and to work towards full-time advocacy for ourselves in getting answers.

In the book Preventing Misdiagnosis of Women (Klonof, Landrine), the author quotes a statistic which says 41% to 83% of all people who are treated for psychiatric disorders actually have a physical disorder instead. Briefly, the writer describes Cushing’s Disease, yet does not at all address the issues of focus to which we, as patients, can relate.

It is interesting to note that in this book, the author compares the endocrine system to a symphony of musicians. The hypothalamus interacts as the conductor. The pituitary gland then becomes the baton that everyone follows, and the target glands are the musicians.

Feedback loops are also accurately represented in this model. A musician (the target gland) lets the conductor know that he is performing correctly by his performance. The conductor (the hypothalamus) then can issue new instructions to change something through his baton (the pituitary gland), or continue with the same message.

When an orchestra plays horribly, the problem could be along any step of the way, even though she doesn’t spell this out directly. The conductor could be drunk and send the wrong message to the musicians. Or the musician could have partied too hard the night before and may not be able to stay awake during the performance! So to follow this model, primary dysfunction is a problem with the musicians. Secondary dysfunction is a problem with the baton, and tertiary dysfunction is the fault of the conductor.

Something I didn’t know about anti-diuretic hormone (ADH), but learned reading this book: large amounts of ADH are associated with hypertension. Duh – I could have figured that out if I had been trying! But this causes me to ask the question – could high cortisol affect ADH to cause high blood pressure as well?

This is where we come to my biggest concern about this book. The author states that from her research pituitary disorders are quite rare, and rarely affect focus and mood or can mirror psychological issues. The only disorder she believes comes from the pituitary and is related to psychological issues is hypopituitarism. If she believes that, then perhaps if she understood how pituitary hormones could be hyper instead of hypo, we would be having a different discussion.

The Adrenal Glands/Cushing’s:

I arrived at the discussion regarding the adrenal glands. The writer states that epinephrine and norepinephrine are neurotransmitters and work inside the brain in a variety of ways. What she also mentions is the interesting part, that new theories indicate that those two hormones may be tied to manic and depression issues. Now, if what I have learned is accurate, cortisol is the chaser of these two neurotransmitters, and definitely results in an issue with mood swings!

The writer realizes that Cushing’s syndrome causes a host of psychiatric, neurological and physical symptoms. She also recognizes that the reverse is true, that Addison’s causes these same issues as well. Addison’s disease is discussed in regards to its depressive nature in patients with low cortisol. However, when discussing Cushing’s Syndrome, the author states that 15% of patients with Cushing’s will exhibit “prototypical paranoid or depressive psychosis that includes paranoid or depressive delusions and associated hallucinations.”

This is in stark contrast to the research performed on people with exogenous Cushing’s syndrome, of whom 75% show signs of “euphoria, increased activity level, decreased need for sleep, increased appetite, and increased libido.”

The line between symptoms seems to blur here in anecdotal reality. For those patients looking for diagnosis or have been diagnosed with Cushing’s, there are still issues with a decreased need for sleep, an increased appetite and carbohydrate cravings, and increased activity level. However, many patients are not being diagnosed properly until the physical signs show, and by that time the high cortisol has done its damage, causing other secondary issues such as muscle myopathy, osteopenia and osteoporosis, causing painful muscle loss and bone density issues, respectively.

The book also states that most patients with exogenous Cushing’s do not suffer from the “pressure of speech, flight of idea, expansiveness” or other symptoms. It’s interesting to see these symptoms recognized in writing from a psychologist! Flight of ideas happens to be one of my most uncomfortable issues. As a public speaker and trainer, recalling information and being able to apply it to discussions and questions is a necessity. With Cushing’s, once the information is brought to the front of my mind and I’m ready to use it, the idea will literally flit out of my head and disappear into the ether of space.

I loved this direct quote regarding Cushing’s: “The physical symptoms of Cushing’s syndrome can aid in differential diagnosis but, unfortunately, do not appear until late in the disease. These include weight gain, facial obesity, hypertension, muscle wasting, and amenorrhea. Cushing’s syndrome tends to occur in women (and sometimes in men) ages 20-60 and has no preference for a specific ethnic group.”

The Thyroid:


Thyroid disorders are covered in chapter two of this book. Again, the data is outdated and only refers to the thyroid hormone thyroxine (T4). The book also states the causes for Grave’s Disease are unknown, but there’s much more research out now days that can be discussed with the thyroid experts.

Hyperthyroidism causes manic and hypomanic episodes, and sometimes even bipolar issues. Attention deficit conditions also can occur. Recent memory impairment (as seen with Cushing’s and Addison’s Disease) can also occur with diarrhea, sweating, increased appetite with weight loss, and red puffy eyelids. Talk about clouding the picture! If a woman is seen with bipolar issues and medication is not working for her, it’s probably a case of misdiagnosis. The key here is that when medications are give (especially tricyclic anti-depressants and lithium), these drugs make things worse, not better. The same also goes for hyperthyroid patients and drugs like Haldol used for anti-psychotics. This author cautions that antipsychotic drugs can and will result in fatal dystonic reactions. That’s an “in-your-face” indicator that something isn’t right! Paying extra close attention to physical signs and symptoms is key to making the correct diagnosis in hyperthyroid patients, and that includes asking questions regarding the aforementioned issue.


Hypothyroidism is one of the diseases which can be affected by a dysfunction in the hypothalamus, the pituitary gland, or in the thyroid itself. Unlike other endocrine diseases, hypothyroidism strikes slowly over time, and the symptoms are persistent, but subtle. Most women I know tend to just deal with the symptoms without thinking they are anything out of the ordinary.

The most annoying symptoms include: slowed thinking, impaired memory recall, having to hear things multiple times to comprehend, fatigue and weakness, depression that increases in severity over time, in ability to stay warm, numbness in the fingers, hearing loss, loss of appetite, long menstrual cycles.

Major depression would definitely account for most of the above symptoms, but it is important to note a severely depressed patient should be referred back to their doctor for a battery of thyroid tests to rule out a physical condition before applying psychological techniques! Believe me, most patients would better understand and be open to a physical culprit than having a psychological label over their heads.

This book brings up another interesting point – hypothyroid patients show marked changes when taking neuropsychological tests such as the WAIS Digit Span, the Halstead-Teitan Trailmaking Test, and the MMPI. These changes indicate severe depressive tendencies, but noted the patient only has changes in the depressive information, while the rest of their scales will be normal, itself an abnormality.

According to the literature cited in this book, both kinds of patients should not be treated with anti-depressants, lithium or antipsychotics. Rapid deterioration will follow such drug treatments.

The need to address physical issues accurately before psychosocial treatment is immense. As noted above, if a patient runs into a psychologist or other doctor who would like treat with drugs before running tests for a physical problem, one should trust her instincts and walk away. Physical disorders should be ruled out before pursuing a medical treatment plan for any psychological issue, especially with the overlap in symptoms we as endocrine patients find.

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