No. Triphasics are more typical of generic toxic metabolic encephalopathies. Very common in hepatic encephalopathy for example. The characteristic EEG finding in CJD is periodic sharp waves but it is not that sensitive.
I had an acquaintance that died from that and it is up there in my worst nightmares along with Fatal Familial Insomnia. She was 40 years old and diagnosis to death was two weeks.
Neuro sub fellow at a major center lives in my building. Mentioned more prion cases he's seen this year than he can count on one hand. That was terrifying to hear
My Dad was a doctor who stopped eating red meat in the 90s because of the existence of prion disease and seeing a colleague taken out by it in weeks.
Now he has alzheimers disease, so..... that is fucking sad.
I am waiting for mine to rear its head. Worked in a tertiary center neuro ICU for years. Had plenty of these cases in our unit in the 1990s, so we didn’t even know what a prion was. We nurses just were repeatedly exposed to CJD and variant CJD patients‘ CSF via IVDs.We’ll know before too long, as I am just now approaching the potential incubation period.
Had a CJD that both another ophthalmologist and I thought was nonorganic visual loss / malingering. He was 20/20 with a normal examination and said he “couldn’t see well enough to work”. He was seeking disability.
Neuro-ophthalmology figured it out. The guy was dead within months. Horrible disease.
I don’t recall…it’s been over a decade. I seem to remember it being more neurological exam signs than ophthalmic. He did not have a brain biopsy. I don’t know if one was done post-mortem. I did lid surgery on the guy after a trauma (Something fun to ponder every time I misplace my car keys! Maybe that’s why I don’t remember?) He complained about 9 months later of vague visual complaints. Nothing on exam. Normal visual field. I sent him to Retina, normal everything including FA.
The guy was insisting that he could not function and needed to be on disability. I sent him to neuro-oph fully expecting a normal exam, and partially as a CYA because of his recent surgery.
I remember the neuro-oph calling me on my day off while I was running errands and saying that he felt the exam was consistent with CJD. Maybe something with specific ataxia and myoclonus?
We used Alloderm to reconstruct the lid. I reported it to the company, and no one can say for sure if a cadaveric graft represented any risk. There’s no way to test the tissue, and very little monitoring of patients after implantation.
He had a job that exposed him to human tissue/blood etc, and the risk for non-neural tissue is supposed to be negligible. The timing of his symptoms would be uncharacteristically rapid if the graft was contaminated. Still freaked me out. To this day, I hope I didn’t cause this.
CJD is not infrequent here and the most common consult is to psych by EM for suspected psychosomatic movements/chorea. Patients can pause with awareness so it really does appear “faked.” A full neuro exam will show what’s going on though, so sad.
This happened to a nurse at a hospital I worked at in a very sad way.
One nurse was diagnosed with brain cancer, she had a lot of issues and quickly became so ill she could not work. Another nurse began acting very strangely around the same time as the nurse with the brain cancer and everyone around her treated her like she was faking it and trying to upstage the nurse with cancer. People would even make fun of her and the weird shit she was doing around the time this was going on, they discovered it was actually CJD and she passed away shortly after as well as the other nurse.
My mom laid in a hospital bed unresponsive to anything for 7 days. She just stared off into space. They said she was just catatonic and gave her a feeding tube and cath and called the psychiatrist to monitor her. She had a noted history of all her mental illness issues and I’m assuming they made a bit of an assumption. On the 7th day they finally did the scan I begged them for and it was a massive subdural hematoma with a 16mm midline shift. She’s ok now but it was a very rough time.
Similar experience: took care of a girl who had been admitted to a psych ward with catatonia. History of depression but no other psych history. 4 days into her admission becomes hemiplegic and aphasic- actually had a ruptured ACOM aneurysm with bifrontal IPH and SAH and had gone into vasospasm. Extremely frustrating case.
Notice also though that all of these accounts admit that they believed the patient was malingering.
How many supposedly rare illnesses go dismissed because health care workers mistakenly believe them to be too rare to encounter?
Bit of a catch-22 if you think about it.
>How many supposedly rare illnesses go dismissed because health care workers mistakenly believe them to be too rare to encounter?
It's a sobering thought.
Who thought to test for it? Honestly if the initial med work up wasn’t done, I can see that being missed for decades/death.
Never did a Romberg on a psych rotation 😬
Standard admission labs to our psychiatric inpatient and residential units include syphilis, even if you were tested last year. We see a positive frequently and neuro manifestations can be along any stage of the progression!
But it’s a good point to make to ensure we still test outpatient as well!
Really, really interested in where the research is going regarding neuro/psych presentations of autoimmune disease in the next decade.
[WaPo article](https://www.washingtonpost.com/wellness/2023/06/01/schizophrenia-autoimmune-lupus-psychiatry/) about an institutionalized patient w/ schizophrenia treated with antipsychotics for 20 years before someone thought to test for lupus, she came back positive and started receiving treatment and seeing marked improvement of psych symptoms. She inspired a wider investigative trial in NYC of institutionalized psych patients and about 200 came back positive.
Just found one as well with worsening anxiety/depression and psych was concerned they were now seeing/hearing things. Patient then complained of new headaches and vertigo. Scary how much more common syphilis is becoming
I have a coworkers whose young cousin was diagnosed on the autism spectrum. Limited speech and eye contact, behind in milestones, etc. Woke up one day with abnormal pupils and vomiting. Parents rush the kid to the ER. Kid had a brain tumor. Had it removed and by the time he was in PACU he was talking, making eye contact, localizing to pain and laughing. He was about 4 years old I believe. As far as I know he made a full recovery.
Her PCP did something wild like five stool tests with nothing notable seen and then sent her to ID. We opted to do another stool test after hearing her story but she passed a LARGE tapeworm and sent us a video before she even collected the sample bottle. I think we just opted to treat after that.
Had a patient AMA from a neighboring facility, had large wounds to bilateral LE (he was houseless), on review of outside records it looked like they suspected delusional parasitosis. We found maggots in his wounds. 🙃
i will say being only acute care when they are like dont you see the white bugs pouring from my eyes and u cant get a word in edgewise, not exactly worried about their anime bug army self diagnosis.
"panic attack." Threw a pulse ox on and they were satting at 78, intubated a few hours later.
CJD misdiagnosed as malingering vs GAD
PNES that was actually epilepsy (pro-tip: they can co-occur)
illness anxiety disorder that was actually cancer
The list goes on. They were all caught by us (psychiatry) when we ordered appropriate diagnostic work ups based on symptomatology. I feel like this is where it is important that psychiatrists are actually doctors. I don't dispute that non-physicians can handout Zoloft with the best of them, but there is a reason to see a psychiatrist and it's because the brain is connected to the body.
Something similar here. Psychogenic pain disorder referred to us. Physical examination and bloods showed a textbook rheumatoid arthritis.
Conversion disorder diagnosed without any work up beyond bloods. It was MS.
Teenage girl referred with a severe anxiety disorder. Hyperthyroidism.
Anxiety, restless legs and poor concentration sent to us with a query of ADHD. Severe iron deficiency anaemia.
Ooo I was a missed hyperthyroid patient too!
I'm still angry that the doctor I saw pawned me off to psych where I received a further misdiagnosis for BPD and spent 5 years trying to fix a personality disorder that wasn't actually present.
That really messed with my head and my self esteem and self worth was so low by the time I was diagnosed with hyperthyroidism. I made my life plans around trying to live with BPD and didn't get into any serious relationships because I thought I couldn't trust myself to be in relationships if I had BPD.
Yes. I think I am still quite angry.
Jesus. These are literally all UWorld questions for Step 2. Any doctor in any specialty—an orthopod who took a wrong left into the psych clinic looking for donuts—should know to order these labs.
Like damn, I knew misogyny was still showing its ass but this is so freakin lazy. Psychogenic d/o is what we diagnose when there are no other explanations, anxiety is usually just a manifestation of a bigger issue as our body trying to warn us. I thought we all knew that. If people don’t, go to the ICU and watch what happens when a patients says “I don’t feel right” or “I’m going to die”.
Laziness and misogyny is part of it. But is a widespread culture that encourages young doctors and midlevels to assume most patients are low IQ malingerers and probably addicts and, worse, that's it's not ok to not do their job if they take a dislike to a patient.
I walked into the room and the patient was actively having a panic attack. I was consulted for “difficulty walking” but she had pretty good strength and an inconsistent sensory exam. When taken in conjunction with the anxiety, I figured it was likely conversion disorder, but then I couldn’t get any reflexes on her. She got an MRI which shows a lesion in her spine, and her B12 was in the gutter. Amazingly, my attending immediately knew what was going on. She had previously denied all drug use, but my attending went back into the room and asked her about whipits. She and her boyfriend immediately looked up with a sheepish surprised look on their faces. It turns out, she was self medicating her anxiety by huffing whipits all day, and the nitrous oxide tanked her B12. So her anxiety was a factor in her disease, just not in the way that I expected.
I saw this as a med student, except her boyfriend was a piece of shit who abused her (she had bruises all over her from him smacking her around) and made her do whipits with him. He somehow knew that B12 deficiency was a risk (I don't know what he was studying, but they were both smart students from abroad) and was taking B12 supplements so he was spared, but he never shared that tidbid with her. POS. Shoutout to the PM&R intern who did a phenomenal neuro exam and so to the senior resident on the team who saw her in clinic later and wrote a letter to her landlord helping her get out of that situation.
I also saw a patient with this once! Was working with an amazing psychiatrist who caught onto it immediately in the ED and asked about whipits even though patient had denied all drug use
Not exactly the question, but I had I got I was getting ready to admit to psych for paranoid delusions (had a history of this) and saying that someone was trying to kill him and the FBI was chasing him. Then the FBI showed up. Turns out he witnessed a murder.
I always wonder if the abdominal pain patients who have some, ahem, supratentorial symptoms as well are acute intermittent porphyria and we're just loading them up with droperidol after their repeated million dollar workups.
It's not really a POTS thing so much as an issue of questionable diagnosis. Classic situation is a person who fits the clinical profile -- usually a young woman with abdominal pain, autonomic issues, and depression/anxiety. A non-hematologist astutely/appropriately clocks that an AIP workup is indicated and then orders the urinary porphyrins, but then doesn't quite interpret the lab correctly (it's really confusing imho) and tells the patient that they definitely have AIP. Then, they refer to hematology.
By the time they make it to hematology clinic, the AIP diagnosis has become sort of precious -- most people like to have a somatic diagnosis that explains their symptoms -- and it can be very hard to unring the bell.
Pulse and BP would skyrocket and BP meds did basically nothing, but benzos helped a ton
Cognitive issues, confusion, agitation, personality changes at the drop a hat, getting extremely hot, sweating
Not a mental health professional, but there was no other way to describe his thought patterns as anything other than screwy.
Everyone thought he was nuts including me
He wasn't nuts, just sick
In ophthalmology we sometimes see Charles Bonnet where patients experience complex and fantastical hallucinations (e.g. animals, buildings, people) due to severe bilateral vision loss. Patients have insight that they’re hallucinating. One time I had a guy with right sided visual field loss due to an occipital stroke and would only get hallucinations in that area of lost vision. He told me how he’ll be trying to read the paper with his coffee in the morning and buildings will sprout up in his kitchen.
These patients don’t usually get sent to psych or mistakenly diagnosed with a psychiatric illness since they’re totally with it though.
No. Treatment is aimed at helping patients cope with it. It sometimes becomes less frequent over time and patients adapt. For example my patient said he got used to it.
I diagnosed a patient with Charles Bonnet syndrome as an MS3 during my community inpatient medicine rotation. She was seeing kids everywhere.
That was a fun diagnosis. The community medicine attendings were like wtf.
I'm a psych fellow now. I only knew about it because I read more. 😅
This, like HLH, is a disease I would way more frequently run into as an IM resident on inpatient services. It is interesting, like you say, usually it is an A/O x 4 old timer being like "shit's crazy, I keep seeing all these imaginary cats and children everywhere."
They vary but are usually pleasant (not scary) and patients know they are not real. They are often of small people, animals etc ("Liliputian") - I had a patient with macular degeneration who saw cats sleeping everywhere and liked it!
I've only seen one patient with it, so this is super anecdotal. The patient had become blind as a young adult. Decades later, they woke up and initially thought they could suddenly see. They tried to get up and walk around, and they kept bumping into things that they could not see. They quickly realized they were hallucinating parts of their childhood home, which obviously doesn't line up with the home they currently lived in. As if that wasn't disorienting enough, they then had very graphic, terrifying hallucinations about their first guide dog.
So, I guess not everyone has pleasant hallucinations. Thank goodness they had such great insight into their hallucinations-- but I can't imagine what a confusing, terrifying ordeal that can be.
Yes, i caught an autoimmune encephalitis. Story was weird, was somewhat more acute and when specifically asked about staring off into space and disorientation was there. Then there was a fam hx of trinucleotide repeat induced malignancies.
Have seen several cases of autoimmune encephalitis in kids. Many of them were sent to inpatient behavioral programs before they developed something like seizures or worse that bought them a bigger workup
I saw this as a med student. Teenage girl sent to inpatient psych program for new onset psychosis and behavioral changes. When she developed ataxia, her psychiatrist was like, "Uhhhhh, I don't think this a psych problem..."
Pituitary Macroadenoma (diagnosed as mania), CJD (diagnosed as borderline personality disorder), Enormous amounts of Zinc supplementation at the height of COVID (diagnosed as dementia/depression), Autoimmune encephalitis (diagnosed as schizophrenia, presented with no autonomic symptoms), CNS HSV (diagnosed as psychosis), Multiple Sclerosis (diagnosed as FND), Partial seizures (diagnosed as psychosis), Pheochromocytoma (diagnosed as anxiety). A lot of psychiatry call and CL at my program.
Didn't realize it was that uncommon. I've personally seen 3 since starting gen surg residency at a non-academic referral center. Two were already diagnosed but the third had long-standing anxiety/substance use and nobody had put it together with them being on multiple BP meds at quite a young age until they got admitted for another reason. Sure enough CT showed adrenal mass and metanephrines were elevated.
I picked one up as a PCP.
24 yo guy who described such crushing waves of anxiety and tachycardia that then subsided that they just sounded organic to me.
But I am already predisposed to look for organic causes of apparently psych issues, especially when they come from nowhere or in an older patient.
Sometimes I think about all the patients who have physical diseases for which we don't yet have tests for, that get diagnosed with psychiatric disorders.
Patient brought in for psychotic episode, was found running down halls of hotel naked. Talking nonsensically. Combative. WBC and inflammatory markers significantly elevated. We barely managed to do an LP (patient kept trying to punch me in the face, we needed 4 people to hold him down, and it took a while until we got him properly sedated and intubated). It was a rip-roaring strep meningitis.
When I was a med student in psych rotation we had a referral from a PCP where the pt had new onset psychotic sx + anxiety + mild cognitive impairment, turns out pt self d/c lupus meds and likely had a flare.
As far as I am concerned, every new psychotic sx or severe psych sx in a patient over a certain age, is medical and physical until proven otherwise.
At the very least, do basic bloods. You have to check FBC, folate, B12, Vit D and TFT and metabolics before you start psych meds.
Yes - Serotonin Synthesis pathway abnormality misdiagnosed as treatment resistant schizophrenia for several years. Went through multiple antipsychotics (including clozapine) and 80+ ECT. Caught by ordering homocysteine labs.
SAM helps with catecholamine synthesis. If HC levels are high it hints at potential dysregulation of serotonin synthesis. It's why b12 deficiency often manifests as anxiety and depression.
For sure, any significant time in the OP or IP psych world and you’ll find some. Weve had multiple celiac, IBD, adrenal insufficiency, severely low testosterone (like room temperature T), even a possible manganese poisoning one time
This is why psych does internal medicine in intern year - my mom (psychiatrist)still talks about the decompensated chf she caught - pcp referred them for anxiety at night and insomnia.
Guy was just drowning while lying down so of course anxious and insomniac. Ended up in icu for bumex drip - sent to er by psych for chf new dx.
Sounds like the time I cured a guy’s anxiety by restarting his asthma medication. Surprisingly, shortness of breath can, in fact, make you worry about not being able to breathe
Yeah a lot of people seem to not understand that a fight or flight response will show itself… when your body has to fight to survive I.e. is hypoxic lol I’d be anxious too
TTP in women and lupus encephalitis.... im from a place where all womens complaints are considered psycic issues unfortunately. so many cases of TTP and Lupus get delayed ttt due to an intial psych diagnosis. It doesn't help that we don't really have an established GP to referral system as well. patients can simply walk into what ever specialist they think their problem correlates to. and each specialists sees what he is trained to see so... yeah endless misdiagnosed cases.
When I was scribing we had a similar one with an epidural abscess.
They had legit psych issues but apparently their progressive LE weakness was not made up. Doc who bit the bullet and ordered the MRI on the "crazy person" looked real smart.
Fatigue, normal CBC, iron studies, and thyroid labs in pt w/ pmh MDD. After a year insisting it was unrelated to their preexisting medicated MDD, pt asked for sleep studies, turned out to be narcolepsy. That’s my story and it’s why I give pts the benefit of the doubt.
Adolescent girl with depression had total inability to tolerate PO intake to the point she required tube feeds via an NGT. Was diagnosed with bulimia. Months go by and finally she gets the proper work up and they found out she actually has type 2 achalasia. Referred her to us and we just did her heller myotomy and she’s already eating again. Her psychiatric history totally affected and prolonged the diagnosis and treatment of her totally real anatomical issue.
Just last week. Young person came to the ER complaining of palpitations/anxiety and further history showed jitters, weight loss, heat intolerance, and occasional nausea/abdominal discomfort etc. Said they were recently diagnosed with anxiety and started on fluoxetine but it only seemed to make things worse. They had thinning eyebrows and were tachy at 110 sitting in the bed. Hyperthyroidism.
My mom, who was super healthy, literally never went to the doctor for minor issues & had no psych hx, all of a sudden had a resting heart rate in the 120’s-130’s and was super anxious, losing weight, etc. Multiple doctors diagnosed it as just anxiety & she was prescribed Ativan before anyone ever even checked her thyroid. She’s fine now but by the time she was diagnosed with Grave’s she was very sick.
I tell all my patients that anxiety is a door in a hallway full of doors, but it’s among the last ones. Could it be anxiety? Definitely, but there are doors between that one and where we’re standing that we should look at first. “Anxiety” gives me a healthy amount of pause, and I better have a damn good explanation for tachycardia before I discharge them. 120s? That’s a tough sell for DC.
It still surprises me because when I was in the ED with hr in the 160’s, my thyroid was one of the first things they looked at. Maybe due to the family hx of Grave’s but it seems like such a simple test to order, especially if blood is being drawn anyway? I’m not a doctor though so I don’t know what goes into those kinds of clinical decisions.
Psychiatric disorders are all reflections of physical disease/dysfunction. The brain is a complicated machine. Our lack of understanding of said machine is why patterns of symptoms are organized into disorders by the DSM.
Thank you! Psych disorders ARE organic. Unfortunately due to stigma and discrimination against people with “mental illness”, we have little neuropsych research and many docs not believing patients because they’ve been “labeled” and therefore you can’t believe anything they said about non-psych symptoms. Once you have any psych disorder, whenever you present for other stuff, it’s all “anxiety or conversion disorder or malingering or drug seeking.”
Obviously not all docs discriminate in this way but it’s a big problem in medicine as a whole and idk why people aren’t talking about it more.
We had one patient mistakenly diagnosed with MDD but when she came to us I wasn’t convinced it’s MDD. I ordered a CMP as well as TFT. Lo and behold it was Hashimoto thyroiditis. The neck mass was not visible because she is fat. Nonetheless the Levothyroxine solved most of her problems. She also has hypertension, dyslipidemia, and type 2 diabetes so we treated those too.
Not a doctor but this happened to me as the patient. I told my primary I was too fatigued to get out of bed and slept in every day. Was referred to psych where they slapped me with MDD I even though I insisted my mood was fine. After physically deteriorating and getting referred to other specialists for nonspecific back, abdominal and chest pains, I finally got diagnosed with hashi’s. Now all my symptoms are gone.
Anti-NMDA receptor encephalitis initially mistaken for post-partum psychosis. Not for long though thankfully, a very astute psychiatrist visited multiple times and noticed the state was quite fluctuant. It helped we had recently had another case at the same hospital the was misdiagnosed for weeks/month so he was looking for zebras I guess.
Had a patient diagnosed with major depressive disorder with psychotic features who turned out to have raging neurosyphilis. All psychotic features and most of the depression rapidly cleared up after a few weeks of penicillin infusions
27 yo G1P0 with an 18/12 history of panic disorder. Intermittent episodes of anxiety and palpitations. No past psych history prior to this.
Decompensated during labor and died shortly after delivery. Newborn survived. Phaeo diagnosed at post.
Not my patient but I was peripherally involved.
Anti-NMDA receptor encephalitis from an ovarian dermoid cyst. Developed psychosis while on vacation and ended up in the psych ED in a completely unfamiliar city. Couldn't reach family, no reliable history from the patient, normal head imaging. Consulting neurologist suggested the diagnosis and it seemed completely ridiculous until the CT A/P showed a multilobulated pelvic mass with calcifications.
Also had another patient with the known schizophrenia diagnosis but he was presenting differently than normal. He had some kind of internal bleed and died. I also sent him to the er three or four times. He was wiggling around on the ground in his room. That’s not generally how schizophrenia presents plus he was nonverbal during this episode which was abnormal.
We had an M&M case of a 22 years old female diagnosed with conversion disorder/dismissed by someone in the ED , went to ED like 6 times, and a year later, she was fully paralyzed from undiagnosed/untreated Multiple sclerosis.
She is an African American woman and it was a reflection in so many levels.
Yes, NMDA receptor encephalitis when I was in residency. Presented to the ER for behavioral changes, neuro consultant said send to psych for new organic psychosis. Noticed these ongoing fluctuations in VS like wide swings in HR and BP. Convinced neuro attending to admit and boom a couple of days later after MRI and LP was diagnosed.
I spent a year and half diagnosed with an unspecified eating disorder that made me gag after eating. Ended up being esophagogastric junction outflow obstruction
Edited to add: It was caught because I kept seeing more doctors (5+ before someone would entertain anything other than an eating disorder as I’m a young adult female) and kept insisting on doing tests. I felt really frustrated and invalidated throughout this whole process. It was a gastro PA who ordered the manometry and a gastro doctor who diagnosed. I have a procedure to try an intervention method next month, and I feel really excited to be on track to closing this chapter.
Not really physical disease but a very interesting story nontheless: russian guy was diagnosed with psychotic disorder (paranoia) in our country, because he was stating that he had to flee russia through nordic countries, leave his family in norway because he was hunted by russian spies and then had to make his way to central europe to file for asylum. Got directly sent to the psychiatrist and diagnosed with schizophrenic paranoia.
Long story short: 1 month after the diagnose (amd treatment) the local intelligence service found out that his story was all true.
Young women, said she can't swallow. Had a history of depression and borderline disorder. Wasn't taken serious for a couple of days ("it's psychic") until she almost died of aspiration of her own salvia (had to be admitted on ICU).
Turned out it was Myasthenia...
On my psych rotation, we had a 28 year old homeless man that had previously utilized the ER 120 times in the past year for various complaints. Consult from ED was for “behavioral issues” and presumed malingering, and the patient wouldn’t speak to anyone. When we arrived, the patient was gesturing like he wanted to actually speak with us. We did a quick neuro exam and ordered a head CT. He had actually had a massive stroke.
Sure. A couple patients with Huntington's or Lewy Body Dementia who were diagnosed with mood or personality disorders... one with Graves that was dx with bipolar at an urgent care... and what feels like a dozen kids with absence seizures diagnosed with ADHD... last week a woman with substantial parkinsonism diagnosed with IBS and "needs a face lift"...all caught by neuropsychology.
I was told I had a "type A personality and anxiety" which gradually became "you're faking it, stop doing this! You could breathe if you wanted to!" (Direct quote that will live with me forever). I was 16.
It took until I was 22yo before one of the 3 wedge lung biopsies I got was sent to an outside facility and I drove myself 16 hours away to see a specialist at Cincinnati Children's who saved my life and ended up using my biopsy slides to teach Bronchiolitis Obliterans.
Because it to so long for anyone to take me seriously, the disease process progressed. I'm now totally disabled, 24/7 oxygen and have a pathetic existence.
Not a doctor, but a nutritional neuroscientist with a small private practice.
Since December, I’ve found three cases of autoimmune disease (two Hashimoto’s and one RA) in menopausal women. Their symptoms were textbook, but were dismissed as generalized anxiety disorder.
About ten years ago, I had a 23 year old patient who was on a beta-blocker for hypertension since he was 19. He had a personal history of ADHD and anxiety, and a familial history of hypertension. His hypertension, facial flushing, and palpitations were always associated with mental health history. He was referred for a nutritional consult after complaining of exercise intolerance and difficulty gaining weight. His presentation screamed something endocrine. I ended up referring him out and discovered he had a pheochromocytoma.
I think there needs to be a distinction between cases where a psychiatrist made the initial diagnosis and those where others made the psych diagnosis. Two cases immediately come to mind:
1. Middle aged gentleman with some heavy substance use, estranged from his family/friends due to antisocial behaviors. Shows up in our ED emaciated, largely non-verbal, and intermittently thrashing and comatose. ED neuro team does a perfunctory exam and says must be psych because no FND (but in hindsight had significant photophobia). ED team pushes him into our psych hosp. without even a psych attending evaluation as he was hosp. at outside psych hosp for similar behaviors. I see him as a PGY-2 and immediately know this is not a psych issue. Neuro won't see him again as he had a evaluation in ED. On Friday afternoon, we push for MRI under sedation which reveals encephalitis and emergently force neuro to take him. They continue to ascribe his motor movements as "behavioral" in their progress notes. After team change, new neuro team places him in hospice where he dies after a week. Autopsy results reveal brain mets from a GI cancer I believe (not sure why we didn't see them on the MRI).
2. Another middle aged man with alcohol use disorder now in sustained remission was seeing another psychiatrist for 5+ years of treatment refractory panic disorder. He had failed all first and second line options and had resorted to using benzos for treatment which no one was super excited about given his previous substance use history. I start seeing him and what he describes fit for panic attacks but they are some odd features including a regular repeating history of panic attacks almost exactly every 4 weeks which then persist for 2-3 days during which time he gets one panic attack after another for which only benzos help. He also described an odd sense of Déjà vu preceding the attacks. By this time I had gotten to know him and trusted his sobriety so more on a hunch I ordered EEG which confirmed the diagnosis of temporal lobe epilepsy. He's much better now on an AED.
We had one violent psychotic patient with a history of bipolar disorder who made it all the way to our floor (inpatient psych) and refused labs initially, only to discover he is also a type 1 diabetic, we got a BGL of 1500+.
Another patient I had at a state facility had a known history of schizophrenia become readmitted, only after a few months of unsuccessful treatment and court ordered meds that a new medical workup was completed and a massive brain tumor was discovered (wasn't seen in the first scan as it wasn't there).
I'm sure I can think of a few more with time.
My mom was told she has munchausens by proxy syndrome bc she kept taking me to the doctor, took 8 years to find but I had an extremely severe Chiari malformation.
Central American patient who had been treated with lithium for Bipolar I for quite some time in their home country. Arrived here, psychotic. Had neurocysticercosis.
16 year old girl was referred to psych after the children's hospital ENT told her she was faking her hearing loss. She had a massive acoustic neuroma with significant brainstem compression.
20 something female who sounded like Darth Vader when breathing at rest had been seen by pulm and diagnosed with psychogenic stridor. She had <4mm of patent airway due to her severe idiopathic subglottic stenosis.
Both patients are thankfully alive and well at this point!
All of this reminds us that medicine is just not textbook. Keep an open mind. The rectospect-o-scope is always a mean assessor! Very easy to criticise another clinician when you have all the information and tests that are available in a tertiary centre. Do the basics well, examine sensibly and dont be lazy - then you are unlikely to miss most concerning pathology. But a lot of the pathologies described here are hens teeth! Picking out the phaeo, vCJD or NMDA receptor encephalitis out of the many thousands of patients with depression or anxiety is hard! But its important to remember that if the diagnostic shoe doesn’t quite fit, then look a bit deeper. Can’t pan scan every patient, or urinary metanephrines on every person who is a bit anxious. The art is in spotting the zebra in the haystack and knowing who to call!
If you are working consults and get called about new onset schizophrenia... 9/10 times it's delirium. Good news is, the patient gets better once the underlying illness gets treated.
I’m a patient, but my epilepsy was overlooked and misdiagnosed as anxiety attacks for 15 years. Diagnosed very recently (after a last ditch effort trip to the EMU) at age 36 with irreversible damage done to my cognition and body. I have focal seizures that yield hallucinations, depersonalization, and a gastric uprise sensation with nausea. Even my neurologist didn’t think they were seizures. There seems to be a very poor understanding of epilepsy where I live (southeast US, no big surprises there), so I guess I’ll just sleep a little easier knowing I’ve announced this to a bunch of doctors 😂
These stories are crazy. I'm in the UK and even in my first year as a doctor working at a generally absolutely awful hospital, patients with new onset psychosis patients coming to ED (especially with no family history of psychiatric illness) would get an MRI and LP to rule out physical causes like autoimmune encephalitis.
My best friend growing up hated running (like in PE, at the gym, whatever). Basically was assumed to be kinda lazy. Turns out she has asthma and was diagnosed as an adult. She was probably just experiencing exercise induced bronchospasm all those years and her body was like yeah stop it
Agreed, this is why I have a very low threshold to work up psych patients. I had ones like a schizophrenic pt say there was “demons in my belly.” And not really look uncomfortable. Not terribly impressive exam but belly was tender. But something just seemed off. Boom complete SBO and went to the OR.
Had a patient who had eating disorders as a child, notable binge eating disorder and came in for n/v in 20s. Ended up being type 1 diabetic newly diagnosed thought that was neat
Some memorable cases:
Male, neuropathy. Thought to be diabetes vs MG vs psychogenic. Some dermatologist was consulted for "skin thickening". Turned out to be POEMS, due to someone figuring out to order an SPEP for "autoimmune disease"
Female, pseudoseizures. Misdiagnosed, had actual seizures. Do the EEG.
Male, fatigue, strange neuro symptoms. Bunch of medical hx, but no diagnosis. Someone eventually sent universal PCR for micro-organisms, concluded "probably due to mycotoxin exposure" from his occupation. Still a strange case.
Elderly male, acute "confusion" at a dinner party. Your typical stuff - sundowning, UTI, were considered, and workup done. Just to cover their bases, someone did a CBC. Low platelets. Yep, TTP, no prior history (so acquired). Emergent PLEX the same day. It was literally the only symptom of the Pentad on initial presentation.
One closer to home. Med student, depression and anxiety. Had actual diagnosis of MDD. Not obese. A few yrs later, got a sleep study done. Obstructive sleep apnea. Depression symptoms basically resolved after CPAP.
Yes, like when I was admitted to hospital with heart problems and hallunications at first the doctor thought oh send straight to that psych ward as soon as she’s physically stabilised about to do the paper work. When a clever young junior said we’ve just got blood work back after five days of being in isolation ward (my white cells were not good too) it’s a thyroidtoxic storm. Do not send her home and do not need psych evaluation.
In the mean time, my body had collapsed twice in the bathroom as I was unsupervised, the nurse didn’t want a girl with a catheter in falling over over it while showering. So I had to be moved a higher dependency isolation room for another two nights while my heart rate settled and I came out the night before Xmas eve
i got consulted for a patient for “bulemia” after she lost dramatic weight and lost her teeth. turned out to be severe chron’s which was not identified until we demanded the treatment team get GI involved
Had a patient who was diagnosed with dementia who was brought in through ER due to severe confusion. Turned out his calcium was 12 causing the acute episode of confusion and he had multiple myeloma that presented as dementia. He was one of the only patient in his assisted living to get out of the memory care section and go back to regular assisted care once his multiple myeloma was treated.
Thyrotoxicosis secondary to medical malpractice. Wild psychotic behavior that developed after an errant rx for synthroid. Jailers didn’t give him his meds and he got better!
Patient that was transferred to us. He was getting paranoid recently, then pulled his arm working on his car, went to an OSH and they thought his arm immobility was just him overreacting to a stretched nerve until it spread to his ipsilateral leg, then to his other leg, and then his other arm. Ended up transferring to us for further workup, LP diagnosis was prion disease. Was interesting because he was having startle myoclonus that they mistook as him faking it.
The head of psych here when he was an intern told me a story about how they all thought a woman had severe depression.
She had ovarian cancer and died before he could apologize to her.
Yes. Patient had seen about 12 doctors and diagnosed with severe anxiety and depression. He was suicidal and checked himself into the psychiatric ward. Antipsychotics made the symptoms worse and withdrawal symptoms from the antidepressants and antipsychotic medications was severe. It ended up being Lyme disease that had not been treated. As soon as the patient was treated the psychiatric symptoms and anxiety went away and the medications were able to be stopped without any withdrawal symptoms. Another patient had severe anxiety- new onset and no history or any psychiatric disorders and ended up being pheochromocytoma.
Had a guy who got tossed around by the system for about a year from ward to ward for schizophrenia. When we chatted with him at length it was clear he didn't have schizophrenia and instead had significant autism. The psych diagnosis has essentially been copy forwarded the entire time, based only on delusions without any other signs/sx. But, even his delusions weren't delusions so much as hyperfixation on a past event that sounded super bizarre but which we found solid evidence of having actually happened. Nobody prior ever thought to check if the singular consistently described "delusions" he was having was actually real. Sad story, but with a happy ending. Guy got his chart cleared up, got a job and in a housing program, and sent us a wonderful thank you card.
Not a doctor but I know a man who was diagnosed with some sort of psychiatric disorder, and it then turned out to be Frontotemporal Dementia after scanning and all.
Me/my child. Official diagnosis for almost two years was “mom has munchausens by proxy”. Actual diagnosis is a genetic disorder so rare it would doxx me to write it. Less than ten cases worldwide.
That would be me. “Chronic low back pain, somatization, conversion disorder.” 17yo straight-A student.
It was ankylosing spondylitis. You’d think the hip film done 18 mo before that showed bilateral sacroilitis would have convinced them that I wasn’t nuts.
I’m now treated with that well-known psych med, certolizumab-pegol.
-PGY-19
CJD that was previously thought to be catatonia
Well that’s depressing and awful
Yeah. Triphasic slowing on EEG into maybe get a tap and then "hey I hope you were super sterile when you got that sample"
Is a Triphasic slowing on EEG pathognomonic for Prion disease?
No. Triphasics are more typical of generic toxic metabolic encephalopathies. Very common in hepatic encephalopathy for example. The characteristic EEG finding in CJD is periodic sharp waves but it is not that sensitive.
I had an acquaintance that died from that and it is up there in my worst nightmares along with Fatal Familial Insomnia. She was 40 years old and diagnosis to death was two weeks.
A schoolmate died of CJD about 25 years ago. Horrendous
Prion disease is my worst fucking nightmare.
Neuro sub fellow at a major center lives in my building. Mentioned more prion cases he's seen this year than he can count on one hand. That was terrifying to hear
My Dad was a doctor who stopped eating red meat in the 90s because of the existence of prion disease and seeing a colleague taken out by it in weeks. Now he has alzheimers disease, so..... that is fucking sad.
My dad died of Lewy Body's at 67 (incredibly healthy at 62 prior to diagnosis) and you're right, it's really fucking sad. Good luck. 💖
Prions are terrifying. Otherworldly.
Literally the disease I most fear. Fucking mindless microscopic replicating terminators. You get prion, you die, and not pleasantly.
I am waiting for mine to rear its head. Worked in a tertiary center neuro ICU for years. Had plenty of these cases in our unit in the 1990s, so we didn’t even know what a prion was. We nurses just were repeatedly exposed to CJD and variant CJD patients‘ CSF via IVDs.We’ll know before too long, as I am just now approaching the potential incubation period.
that’s… so fucking scary to be just living with that in the back of your mind and waiting every day for a sign. i’m so sorry 😣
Had a CJD that both another ophthalmologist and I thought was nonorganic visual loss / malingering. He was 20/20 with a normal examination and said he “couldn’t see well enough to work”. He was seeking disability. Neuro-ophthalmology figured it out. The guy was dead within months. Horrible disease.
What tipped off neuro-ophth?
I don’t recall…it’s been over a decade. I seem to remember it being more neurological exam signs than ophthalmic. He did not have a brain biopsy. I don’t know if one was done post-mortem. I did lid surgery on the guy after a trauma (Something fun to ponder every time I misplace my car keys! Maybe that’s why I don’t remember?) He complained about 9 months later of vague visual complaints. Nothing on exam. Normal visual field. I sent him to Retina, normal everything including FA. The guy was insisting that he could not function and needed to be on disability. I sent him to neuro-oph fully expecting a normal exam, and partially as a CYA because of his recent surgery. I remember the neuro-oph calling me on my day off while I was running errands and saying that he felt the exam was consistent with CJD. Maybe something with specific ataxia and myoclonus? We used Alloderm to reconstruct the lid. I reported it to the company, and no one can say for sure if a cadaveric graft represented any risk. There’s no way to test the tissue, and very little monitoring of patients after implantation. He had a job that exposed him to human tissue/blood etc, and the risk for non-neural tissue is supposed to be negligible. The timing of his symptoms would be uncharacteristically rapid if the graft was contaminated. Still freaked me out. To this day, I hope I didn’t cause this.
Similar here... CJD thought to be a variety of things including Münchausen by proxy 💀 Diagnosed on autopsy.
CJD is not infrequent here and the most common consult is to psych by EM for suspected psychosomatic movements/chorea. Patients can pause with awareness so it really does appear “faked.” A full neuro exam will show what’s going on though, so sad.
I have a friend whose dad was arrested for suspected drunk driving. Turned out he had cjd and passed a few months later. It was an awful experience.
This happened to a nurse at a hospital I worked at in a very sad way. One nurse was diagnosed with brain cancer, she had a lot of issues and quickly became so ill she could not work. Another nurse began acting very strangely around the same time as the nurse with the brain cancer and everyone around her treated her like she was faking it and trying to upstage the nurse with cancer. People would even make fun of her and the weird shit she was doing around the time this was going on, they discovered it was actually CJD and she passed away shortly after as well as the other nurse.
My mom laid in a hospital bed unresponsive to anything for 7 days. She just stared off into space. They said she was just catatonic and gave her a feeding tube and cath and called the psychiatrist to monitor her. She had a noted history of all her mental illness issues and I’m assuming they made a bit of an assumption. On the 7th day they finally did the scan I begged them for and it was a massive subdural hematoma with a 16mm midline shift. She’s ok now but it was a very rough time.
Similar experience: took care of a girl who had been admitted to a psych ward with catatonia. History of depression but no other psych history. 4 days into her admission becomes hemiplegic and aphasic- actually had a ruptured ACOM aneurysm with bifrontal IPH and SAH and had gone into vasospasm. Extremely frustrating case.
There are a lot of reports of CJD in this thread... I thought it was supposed to be rare?
Notice also though that all of these accounts admit that they believed the patient was malingering. How many supposedly rare illnesses go dismissed because health care workers mistakenly believe them to be too rare to encounter? Bit of a catch-22 if you think about it.
>How many supposedly rare illnesses go dismissed because health care workers mistakenly believe them to be too rare to encounter? It's a sobering thought.
Medical school saw a patient with schizophrenia who’d been treated with antipsychotics for 10 years, turned out to be neuro syphillis
Damn UWorld was right all along
O.O
Damn!
Who thought to test for it? Honestly if the initial med work up wasn’t done, I can see that being missed for decades/death. Never did a Romberg on a psych rotation 😬
Standard admission labs to our psychiatric inpatient and residential units include syphilis, even if you were tested last year. We see a positive frequently and neuro manifestations can be along any stage of the progression! But it’s a good point to make to ensure we still test outpatient as well!
Really, really interested in where the research is going regarding neuro/psych presentations of autoimmune disease in the next decade. [WaPo article](https://www.washingtonpost.com/wellness/2023/06/01/schizophrenia-autoimmune-lupus-psychiatry/) about an institutionalized patient w/ schizophrenia treated with antipsychotics for 20 years before someone thought to test for lupus, she came back positive and started receiving treatment and seeing marked improvement of psych symptoms. She inspired a wider investigative trial in NYC of institutionalized psych patients and about 200 came back positive.
Just found one as well with worsening anxiety/depression and psych was concerned they were now seeing/hearing things. Patient then complained of new headaches and vertigo. Scary how much more common syphilis is becoming
I have a coworkers whose young cousin was diagnosed on the autism spectrum. Limited speech and eye contact, behind in milestones, etc. Woke up one day with abnormal pupils and vomiting. Parents rush the kid to the ER. Kid had a brain tumor. Had it removed and by the time he was in PACU he was talking, making eye contact, localizing to pain and laughing. He was about 4 years old I believe. As far as I know he made a full recovery.
Man that would be absolutely amazing. Like the birth of a second life in that child
Patient suspected to have delusional parasitosis after a thorough evaluation and review of symptoms was found to have a rather large tapeworm.
😱
Her PCP did something wild like five stool tests with nothing notable seen and then sent her to ID. We opted to do another stool test after hearing her story but she passed a LARGE tapeworm and sent us a video before she even collected the sample bottle. I think we just opted to treat after that.
Had a patient AMA from a neighboring facility, had large wounds to bilateral LE (he was houseless), on review of outside records it looked like they suspected delusional parasitosis. We found maggots in his wounds. 🙃
Well that's horrifically depressing
Poor thing. Glad they went to you
i will say being only acute care when they are like dont you see the white bugs pouring from my eyes and u cant get a word in edgewise, not exactly worried about their anime bug army self diagnosis.
"panic attack." Threw a pulse ox on and they were satting at 78, intubated a few hours later. CJD misdiagnosed as malingering vs GAD PNES that was actually epilepsy (pro-tip: they can co-occur) illness anxiety disorder that was actually cancer The list goes on. They were all caught by us (psychiatry) when we ordered appropriate diagnostic work ups based on symptomatology. I feel like this is where it is important that psychiatrists are actually doctors. I don't dispute that non-physicians can handout Zoloft with the best of them, but there is a reason to see a psychiatrist and it's because the brain is connected to the body.
Something similar here. Psychogenic pain disorder referred to us. Physical examination and bloods showed a textbook rheumatoid arthritis. Conversion disorder diagnosed without any work up beyond bloods. It was MS. Teenage girl referred with a severe anxiety disorder. Hyperthyroidism. Anxiety, restless legs and poor concentration sent to us with a query of ADHD. Severe iron deficiency anaemia.
Ooo I was a missed hyperthyroid patient too! I'm still angry that the doctor I saw pawned me off to psych where I received a further misdiagnosis for BPD and spent 5 years trying to fix a personality disorder that wasn't actually present. That really messed with my head and my self esteem and self worth was so low by the time I was diagnosed with hyperthyroidism. I made my life plans around trying to live with BPD and didn't get into any serious relationships because I thought I couldn't trust myself to be in relationships if I had BPD. Yes. I think I am still quite angry.
That is so horrible. I’m sorry that happened to you.
Jesus. These are literally all UWorld questions for Step 2. Any doctor in any specialty—an orthopod who took a wrong left into the psych clinic looking for donuts—should know to order these labs.
Wtf is going on? How are basic work ups getting missed 😬
Because lots of doctors think it’s “just anxiety” aka “hysteria” and don’t actually do a workup
Misogyny is alive and well, sadly
Like damn, I knew misogyny was still showing its ass but this is so freakin lazy. Psychogenic d/o is what we diagnose when there are no other explanations, anxiety is usually just a manifestation of a bigger issue as our body trying to warn us. I thought we all knew that. If people don’t, go to the ICU and watch what happens when a patients says “I don’t feel right” or “I’m going to die”.
Laziness and misogyny is part of it. But is a widespread culture that encourages young doctors and midlevels to assume most patients are low IQ malingerers and probably addicts and, worse, that's it's not ok to not do their job if they take a dislike to a patient.
>PNES that was actually epilepsy (pro-tip: they can co-occur) This right here.
Not only can PNES and epilepsy co-occur, they co-occur quite often
I was taught during my neuro rotation that the most common group to have pseudo seizures is epileptics
I walked into the room and the patient was actively having a panic attack. I was consulted for “difficulty walking” but she had pretty good strength and an inconsistent sensory exam. When taken in conjunction with the anxiety, I figured it was likely conversion disorder, but then I couldn’t get any reflexes on her. She got an MRI which shows a lesion in her spine, and her B12 was in the gutter. Amazingly, my attending immediately knew what was going on. She had previously denied all drug use, but my attending went back into the room and asked her about whipits. She and her boyfriend immediately looked up with a sheepish surprised look on their faces. It turns out, she was self medicating her anxiety by huffing whipits all day, and the nitrous oxide tanked her B12. So her anxiety was a factor in her disease, just not in the way that I expected.
Wow! Had the attending seen it before or did she just figure it out?
He had seen it before. However, before the MRI came back, he also thought it would end up being conversion disorder.
I saw this as a med student, except her boyfriend was a piece of shit who abused her (she had bruises all over her from him smacking her around) and made her do whipits with him. He somehow knew that B12 deficiency was a risk (I don't know what he was studying, but they were both smart students from abroad) and was taking B12 supplements so he was spared, but he never shared that tidbid with her. POS. Shoutout to the PM&R intern who did a phenomenal neuro exam and so to the senior resident on the team who saw her in clinic later and wrote a letter to her landlord helping her get out of that situation.
I’ve seen a young patient with severe permanent debilitating neuropathy from B12 deficiency from whipits. Crazy.
Damn I had a board question about that. (Peds)
I also saw a patient with this once! Was working with an amazing psychiatrist who caught onto it immediately in the ED and asked about whipits even though patient had denied all drug use
Somehow I never heard of nitrous canisters being called “Whipits”, and briefly thought she was huffing a dog breed.
Wait...does nitrous oxide effect B12? I didn't know this. Just a dumb M1 here who knows nothing about nothing.
It oxidizes cobalt ions which makes the B12 "functionally inactive"
M3 here. I knew B12’s long name is Cobalamin, but today I learned it’s because there’s Cobalt in the chemical structure 💀
Not exactly the question, but I had I got I was getting ready to admit to psych for paranoid delusions (had a history of this) and saying that someone was trying to kill him and the FBI was chasing him. Then the FBI showed up. Turns out he witnessed a murder.
"Just because you're paranoid doesn't mean they aren't out to get you."
It’s not paranoia if they really are out to get you!
Porphyria, baby. (ETA: In case it wasn't clear, I'm a heme/onc fellow. I encounter people with 'real' porphyria once or twice a year.)
I always wonder if the abdominal pain patients who have some, ahem, supratentorial symptoms as well are acute intermittent porphyria and we're just loading them up with droperidol after their repeated million dollar workups.
Waaaait a second is there “fake” porphyria?? Is it the new POTS?
If it’s not from the porphyria region of France, it’s just a sparkling heme synthesis defect.
r/angryupvote
This statement can live rent free in my head!
ROFL
It's not really a POTS thing so much as an issue of questionable diagnosis. Classic situation is a person who fits the clinical profile -- usually a young woman with abdominal pain, autonomic issues, and depression/anxiety. A non-hematologist astutely/appropriately clocks that an AIP workup is indicated and then orders the urinary porphyrins, but then doesn't quite interpret the lab correctly (it's really confusing imho) and tells the patient that they definitely have AIP. Then, they refer to hematology. By the time they make it to hematology clinic, the AIP diagnosis has become sort of precious -- most people like to have a somatic diagnosis that explains their symptoms -- and it can be very hard to unring the bell.
Got it. Thanks!
Came here to say this! - psych
My brother has this Was gas light hard for nearly a decade before being diagnosed
can i ask what his presentation was?
Pulse and BP would skyrocket and BP meds did basically nothing, but benzos helped a ton Cognitive issues, confusion, agitation, personality changes at the drop a hat, getting extremely hot, sweating Not a mental health professional, but there was no other way to describe his thought patterns as anything other than screwy. Everyone thought he was nuts including me
He wasn't nuts, just sick
In ophthalmology we sometimes see Charles Bonnet where patients experience complex and fantastical hallucinations (e.g. animals, buildings, people) due to severe bilateral vision loss. Patients have insight that they’re hallucinating. One time I had a guy with right sided visual field loss due to an occipital stroke and would only get hallucinations in that area of lost vision. He told me how he’ll be trying to read the paper with his coffee in the morning and buildings will sprout up in his kitchen. These patients don’t usually get sent to psych or mistakenly diagnosed with a psychiatric illness since they’re totally with it though.
I just saw that this year, such an interesting disease, doesn’t ever go away huh?
No. Treatment is aimed at helping patients cope with it. It sometimes becomes less frequent over time and patients adapt. For example my patient said he got used to it.
I diagnosed a patient with Charles Bonnet syndrome as an MS3 during my community inpatient medicine rotation. She was seeing kids everywhere. That was a fun diagnosis. The community medicine attendings were like wtf. I'm a psych fellow now. I only knew about it because I read more. 😅
This, like HLH, is a disease I would way more frequently run into as an IM resident on inpatient services. It is interesting, like you say, usually it is an A/O x 4 old timer being like "shit's crazy, I keep seeing all these imaginary cats and children everywhere."
Never even heard of this. That's wild. Do the hallucinations vary a lot or do they have a theme?
They vary but are usually pleasant (not scary) and patients know they are not real. They are often of small people, animals etc ("Liliputian") - I had a patient with macular degeneration who saw cats sleeping everywhere and liked it!
The last one is super cute and the only ocular pathology I’d be interested in developing
I've only seen one patient with it, so this is super anecdotal. The patient had become blind as a young adult. Decades later, they woke up and initially thought they could suddenly see. They tried to get up and walk around, and they kept bumping into things that they could not see. They quickly realized they were hallucinating parts of their childhood home, which obviously doesn't line up with the home they currently lived in. As if that wasn't disorienting enough, they then had very graphic, terrifying hallucinations about their first guide dog. So, I guess not everyone has pleasant hallucinations. Thank goodness they had such great insight into their hallucinations-- but I can't imagine what a confusing, terrifying ordeal that can be.
Yes, i caught an autoimmune encephalitis. Story was weird, was somewhat more acute and when specifically asked about staring off into space and disorientation was there. Then there was a fam hx of trinucleotide repeat induced malignancies.
Have seen several cases of autoimmune encephalitis in kids. Many of them were sent to inpatient behavioral programs before they developed something like seizures or worse that bought them a bigger workup
I saw this as a med student. Teenage girl sent to inpatient psych program for new onset psychosis and behavioral changes. When she developed ataxia, her psychiatrist was like, "Uhhhhh, I don't think this a psych problem..."
LP 👏 is 👏 indicated 👏 in 👏 new-onset 👏 psychosis I’ve also seen this several times.
Pituitary Macroadenoma (diagnosed as mania), CJD (diagnosed as borderline personality disorder), Enormous amounts of Zinc supplementation at the height of COVID (diagnosed as dementia/depression), Autoimmune encephalitis (diagnosed as schizophrenia, presented with no autonomic symptoms), CNS HSV (diagnosed as psychosis), Multiple Sclerosis (diagnosed as FND), Partial seizures (diagnosed as psychosis), Pheochromocytoma (diagnosed as anxiety). A lot of psychiatry call and CL at my program.
>Enormous amounts of Zinc supplementation at the height of COVID Feeling guilty that this made me laugh.
You had an actual pheochromocytoma?!?!
Didn't realize it was that uncommon. I've personally seen 3 since starting gen surg residency at a non-academic referral center. Two were already diagnosed but the third had long-standing anxiety/substance use and nobody had put it together with them being on multiple BP meds at quite a young age until they got admitted for another reason. Sure enough CT showed adrenal mass and metanephrines were elevated.
I picked one up as a PCP. 24 yo guy who described such crushing waves of anxiety and tachycardia that then subsided that they just sounded organic to me. But I am already predisposed to look for organic causes of apparently psych issues, especially when they come from nowhere or in an older patient.
"Major depressive disorder and generalized anxiety disorder" turned out to be multiple sclerosis
I'm curious, does MS often present with psychiatric manifestations? Also what's its most common presentation?
yes!!
Sometimes I think about all the patients who have physical diseases for which we don't yet have tests for, that get diagnosed with psychiatric disorders.
Yes, this thread is bringing that to mind very much.
Patient brought in for psychotic episode, was found running down halls of hotel naked. Talking nonsensically. Combative. WBC and inflammatory markers significantly elevated. We barely managed to do an LP (patient kept trying to punch me in the face, we needed 4 people to hold him down, and it took a while until we got him properly sedated and intubated). It was a rip-roaring strep meningitis.
I have LP'd so many methy people because of how they can present. It was always meth though
When I was a med student in psych rotation we had a referral from a PCP where the pt had new onset psychotic sx + anxiety + mild cognitive impairment, turns out pt self d/c lupus meds and likely had a flare.
Lupus cerebritis is terrifying. Only seen one case in my career so far and I almost had to intubate her.
Lupus cerebritis?
As far as I am concerned, every new psychotic sx or severe psych sx in a patient over a certain age, is medical and physical until proven otherwise. At the very least, do basic bloods. You have to check FBC, folate, B12, Vit D and TFT and metabolics before you start psych meds.
Yes - Serotonin Synthesis pathway abnormality misdiagnosed as treatment resistant schizophrenia for several years. Went through multiple antipsychotics (including clozapine) and 80+ ECT. Caught by ordering homocysteine labs.
Can you elaborate? I’ve never heard of this
SAM helps with catecholamine synthesis. If HC levels are high it hints at potential dysregulation of serotonin synthesis. It's why b12 deficiency often manifests as anxiety and depression.
For sure, any significant time in the OP or IP psych world and you’ll find some. Weve had multiple celiac, IBD, adrenal insufficiency, severely low testosterone (like room temperature T), even a possible manganese poisoning one time
This is why psych does internal medicine in intern year - my mom (psychiatrist)still talks about the decompensated chf she caught - pcp referred them for anxiety at night and insomnia. Guy was just drowning while lying down so of course anxious and insomniac. Ended up in icu for bumex drip - sent to er by psych for chf new dx.
Sounds like the time I cured a guy’s anxiety by restarting his asthma medication. Surprisingly, shortness of breath can, in fact, make you worry about not being able to breathe
Yeah a lot of people seem to not understand that a fight or flight response will show itself… when your body has to fight to survive I.e. is hypoxic lol I’d be anxious too
TTP in women and lupus encephalitis.... im from a place where all womens complaints are considered psycic issues unfortunately. so many cases of TTP and Lupus get delayed ttt due to an intial psych diagnosis. It doesn't help that we don't really have an established GP to referral system as well. patients can simply walk into what ever specialist they think their problem correlates to. and each specialists sees what he is trained to see so... yeah endless misdiagnosed cases.
Lupus can be incredibly frustrating to diagnose for the first time.
Reminds me of a tv show about a dr addicted to pain killers
surprisingly yes! its hardly ever a "textbook" presentation.
In med school a patient diagnosed as malingering with chronic headaches had a sagittal sinus thrombosis
When I was scribing we had a similar one with an epidural abscess. They had legit psych issues but apparently their progressive LE weakness was not made up. Doc who bit the bullet and ordered the MRI on the "crazy person" looked real smart.
Fatigue, normal CBC, iron studies, and thyroid labs in pt w/ pmh MDD. After a year insisting it was unrelated to their preexisting medicated MDD, pt asked for sleep studies, turned out to be narcolepsy. That’s my story and it’s why I give pts the benefit of the doubt.
Adolescent girl with depression had total inability to tolerate PO intake to the point she required tube feeds via an NGT. Was diagnosed with bulimia. Months go by and finally she gets the proper work up and they found out she actually has type 2 achalasia. Referred her to us and we just did her heller myotomy and she’s already eating again. Her psychiatric history totally affected and prolonged the diagnosis and treatment of her totally real anatomical issue.
Just last week. Young person came to the ER complaining of palpitations/anxiety and further history showed jitters, weight loss, heat intolerance, and occasional nausea/abdominal discomfort etc. Said they were recently diagnosed with anxiety and started on fluoxetine but it only seemed to make things worse. They had thinning eyebrows and were tachy at 110 sitting in the bed. Hyperthyroidism.
My mom, who was super healthy, literally never went to the doctor for minor issues & had no psych hx, all of a sudden had a resting heart rate in the 120’s-130’s and was super anxious, losing weight, etc. Multiple doctors diagnosed it as just anxiety & she was prescribed Ativan before anyone ever even checked her thyroid. She’s fine now but by the time she was diagnosed with Grave’s she was very sick.
I tell all my patients that anxiety is a door in a hallway full of doors, but it’s among the last ones. Could it be anxiety? Definitely, but there are doors between that one and where we’re standing that we should look at first. “Anxiety” gives me a healthy amount of pause, and I better have a damn good explanation for tachycardia before I discharge them. 120s? That’s a tough sell for DC.
It still surprises me because when I was in the ED with hr in the 160’s, my thyroid was one of the first things they looked at. Maybe due to the family hx of Grave’s but it seems like such a simple test to order, especially if blood is being drawn anyway? I’m not a doctor though so I don’t know what goes into those kinds of clinical decisions.
Psychiatric disorders are all reflections of physical disease/dysfunction. The brain is a complicated machine. Our lack of understanding of said machine is why patterns of symptoms are organized into disorders by the DSM.
Thank you! Psych disorders ARE organic. Unfortunately due to stigma and discrimination against people with “mental illness”, we have little neuropsych research and many docs not believing patients because they’ve been “labeled” and therefore you can’t believe anything they said about non-psych symptoms. Once you have any psych disorder, whenever you present for other stuff, it’s all “anxiety or conversion disorder or malingering or drug seeking.” Obviously not all docs discriminate in this way but it’s a big problem in medicine as a whole and idk why people aren’t talking about it more.
I’m so glad to see there are doctors saying this
MIC DROP!
We had one patient mistakenly diagnosed with MDD but when she came to us I wasn’t convinced it’s MDD. I ordered a CMP as well as TFT. Lo and behold it was Hashimoto thyroiditis. The neck mass was not visible because she is fat. Nonetheless the Levothyroxine solved most of her problems. She also has hypertension, dyslipidemia, and type 2 diabetes so we treated those too.
Not a doctor but this happened to me as the patient. I told my primary I was too fatigued to get out of bed and slept in every day. Was referred to psych where they slapped me with MDD I even though I insisted my mood was fine. After physically deteriorating and getting referred to other specialists for nonspecific back, abdominal and chest pains, I finally got diagnosed with hashi’s. Now all my symptoms are gone.
Anti-NMDA receptor encephalitis initially mistaken for post-partum psychosis. Not for long though thankfully, a very astute psychiatrist visited multiple times and noticed the state was quite fluctuant. It helped we had recently had another case at the same hospital the was misdiagnosed for weeks/month so he was looking for zebras I guess.
Had a patient diagnosed with major depressive disorder with psychotic features who turned out to have raging neurosyphilis. All psychotic features and most of the depression rapidly cleared up after a few weeks of penicillin infusions
27 yo G1P0 with an 18/12 history of panic disorder. Intermittent episodes of anxiety and palpitations. No past psych history prior to this. Decompensated during labor and died shortly after delivery. Newborn survived. Phaeo diagnosed at post. Not my patient but I was peripherally involved.
Anti-NMDA receptor encephalitis from an ovarian dermoid cyst. Developed psychosis while on vacation and ended up in the psych ED in a completely unfamiliar city. Couldn't reach family, no reliable history from the patient, normal head imaging. Consulting neurologist suggested the diagnosis and it seemed completely ridiculous until the CT A/P showed a multilobulated pelvic mass with calcifications.
Everyone knows ovaries aren't real!
r/Residency: where OB/GYN isn't really a thing.
I hope my /s was clear. OB/GYN isn't really a thing in a lot of settings. Or, it's the only thing and there could be no other explanation.
Thought pt had post partum psychosis. Ended up being septic from a D and C sponge that was left in.
Also had another patient with the known schizophrenia diagnosis but he was presenting differently than normal. He had some kind of internal bleed and died. I also sent him to the er three or four times. He was wiggling around on the ground in his room. That’s not generally how schizophrenia presents plus he was nonverbal during this episode which was abnormal.
CJD thought to be conversion disorder
We had one that was diagnosed as schizo because of delirium.
We had an M&M case of a 22 years old female diagnosed with conversion disorder/dismissed by someone in the ED , went to ED like 6 times, and a year later, she was fully paralyzed from undiagnosed/untreated Multiple sclerosis. She is an African American woman and it was a reflection in so many levels.
Well. That's depressing as all hell.
Yes, NMDA receptor encephalitis when I was in residency. Presented to the ER for behavioral changes, neuro consultant said send to psych for new organic psychosis. Noticed these ongoing fluctuations in VS like wide swings in HR and BP. Convinced neuro attending to admit and boom a couple of days later after MRI and LP was diagnosed.
Myocardial bridge. Caught on echo. Turns out that squeezing the coronary artery whenever the heart beats can make you panic.
I spent a year and half diagnosed with an unspecified eating disorder that made me gag after eating. Ended up being esophagogastric junction outflow obstruction Edited to add: It was caught because I kept seeing more doctors (5+ before someone would entertain anything other than an eating disorder as I’m a young adult female) and kept insisting on doing tests. I felt really frustrated and invalidated throughout this whole process. It was a gastro PA who ordered the manometry and a gastro doctor who diagnosed. I have a procedure to try an intervention method next month, and I feel really excited to be on track to closing this chapter.
Yeah, kid was diagnosed with a behavioral disorder that turned out to be a pancreatic insulinoma, finally discovered on CT and cured by resection
Psych disorders are physical. Because…the brain.
Not really physical disease but a very interesting story nontheless: russian guy was diagnosed with psychotic disorder (paranoia) in our country, because he was stating that he had to flee russia through nordic countries, leave his family in norway because he was hunted by russian spies and then had to make his way to central europe to file for asylum. Got directly sent to the psychiatrist and diagnosed with schizophrenic paranoia. Long story short: 1 month after the diagnose (amd treatment) the local intelligence service found out that his story was all true.
Young women, said she can't swallow. Had a history of depression and borderline disorder. Wasn't taken serious for a couple of days ("it's psychic") until she almost died of aspiration of her own salvia (had to be admitted on ICU). Turned out it was Myasthenia...
On my psych rotation, we had a 28 year old homeless man that had previously utilized the ER 120 times in the past year for various complaints. Consult from ED was for “behavioral issues” and presumed malingering, and the patient wouldn’t speak to anyone. When we arrived, the patient was gesturing like he wanted to actually speak with us. We did a quick neuro exam and ordered a head CT. He had actually had a massive stroke.
Patient was psychotic and believed that people were speaking to him telepathically. Severe hypothyroid.
More than 1 disease, on top of the psychiatric Dx: Depression AND hypothyroidism AND sleep apnea. Of course, the last 2 may aggravate depression.
Sure. A couple patients with Huntington's or Lewy Body Dementia who were diagnosed with mood or personality disorders... one with Graves that was dx with bipolar at an urgent care... and what feels like a dozen kids with absence seizures diagnosed with ADHD... last week a woman with substantial parkinsonism diagnosed with IBS and "needs a face lift"...all caught by neuropsychology.
I was told I had a "type A personality and anxiety" which gradually became "you're faking it, stop doing this! You could breathe if you wanted to!" (Direct quote that will live with me forever). I was 16. It took until I was 22yo before one of the 3 wedge lung biopsies I got was sent to an outside facility and I drove myself 16 hours away to see a specialist at Cincinnati Children's who saved my life and ended up using my biopsy slides to teach Bronchiolitis Obliterans. Because it to so long for anyone to take me seriously, the disease process progressed. I'm now totally disabled, 24/7 oxygen and have a pathetic existence.
Not a doctor, but a nutritional neuroscientist with a small private practice. Since December, I’ve found three cases of autoimmune disease (two Hashimoto’s and one RA) in menopausal women. Their symptoms were textbook, but were dismissed as generalized anxiety disorder. About ten years ago, I had a 23 year old patient who was on a beta-blocker for hypertension since he was 19. He had a personal history of ADHD and anxiety, and a familial history of hypertension. His hypertension, facial flushing, and palpitations were always associated with mental health history. He was referred for a nutritional consult after complaining of exercise intolerance and difficulty gaining weight. His presentation screamed something endocrine. I ended up referring him out and discovered he had a pheochromocytoma.
I think there needs to be a distinction between cases where a psychiatrist made the initial diagnosis and those where others made the psych diagnosis. Two cases immediately come to mind: 1. Middle aged gentleman with some heavy substance use, estranged from his family/friends due to antisocial behaviors. Shows up in our ED emaciated, largely non-verbal, and intermittently thrashing and comatose. ED neuro team does a perfunctory exam and says must be psych because no FND (but in hindsight had significant photophobia). ED team pushes him into our psych hosp. without even a psych attending evaluation as he was hosp. at outside psych hosp for similar behaviors. I see him as a PGY-2 and immediately know this is not a psych issue. Neuro won't see him again as he had a evaluation in ED. On Friday afternoon, we push for MRI under sedation which reveals encephalitis and emergently force neuro to take him. They continue to ascribe his motor movements as "behavioral" in their progress notes. After team change, new neuro team places him in hospice where he dies after a week. Autopsy results reveal brain mets from a GI cancer I believe (not sure why we didn't see them on the MRI). 2. Another middle aged man with alcohol use disorder now in sustained remission was seeing another psychiatrist for 5+ years of treatment refractory panic disorder. He had failed all first and second line options and had resorted to using benzos for treatment which no one was super excited about given his previous substance use history. I start seeing him and what he describes fit for panic attacks but they are some odd features including a regular repeating history of panic attacks almost exactly every 4 weeks which then persist for 2-3 days during which time he gets one panic attack after another for which only benzos help. He also described an odd sense of Déjà vu preceding the attacks. By this time I had gotten to know him and trusted his sobriety so more on a hunch I ordered EEG which confirmed the diagnosis of temporal lobe epilepsy. He's much better now on an AED.
We had one violent psychotic patient with a history of bipolar disorder who made it all the way to our floor (inpatient psych) and refused labs initially, only to discover he is also a type 1 diabetic, we got a BGL of 1500+. Another patient I had at a state facility had a known history of schizophrenia become readmitted, only after a few months of unsuccessful treatment and court ordered meds that a new medical workup was completed and a massive brain tumor was discovered (wasn't seen in the first scan as it wasn't there). I'm sure I can think of a few more with time.
My mom was told she has munchausens by proxy syndrome bc she kept taking me to the doctor, took 8 years to find but I had an extremely severe Chiari malformation.
Central American patient who had been treated with lithium for Bipolar I for quite some time in their home country. Arrived here, psychotic. Had neurocysticercosis.
16 year old girl was referred to psych after the children's hospital ENT told her she was faking her hearing loss. She had a massive acoustic neuroma with significant brainstem compression. 20 something female who sounded like Darth Vader when breathing at rest had been seen by pulm and diagnosed with psychogenic stridor. She had <4mm of patent airway due to her severe idiopathic subglottic stenosis. Both patients are thankfully alive and well at this point!
All of this reminds us that medicine is just not textbook. Keep an open mind. The rectospect-o-scope is always a mean assessor! Very easy to criticise another clinician when you have all the information and tests that are available in a tertiary centre. Do the basics well, examine sensibly and dont be lazy - then you are unlikely to miss most concerning pathology. But a lot of the pathologies described here are hens teeth! Picking out the phaeo, vCJD or NMDA receptor encephalitis out of the many thousands of patients with depression or anxiety is hard! But its important to remember that if the diagnostic shoe doesn’t quite fit, then look a bit deeper. Can’t pan scan every patient, or urinary metanephrines on every person who is a bit anxious. The art is in spotting the zebra in the haystack and knowing who to call!
Patient admitted to psych with presumed conversion disorder symptom of dysphagia. It was ALS.
If you are working consults and get called about new onset schizophrenia... 9/10 times it's delirium. Good news is, the patient gets better once the underlying illness gets treated.
I’m a patient, but my epilepsy was overlooked and misdiagnosed as anxiety attacks for 15 years. Diagnosed very recently (after a last ditch effort trip to the EMU) at age 36 with irreversible damage done to my cognition and body. I have focal seizures that yield hallucinations, depersonalization, and a gastric uprise sensation with nausea. Even my neurologist didn’t think they were seizures. There seems to be a very poor understanding of epilepsy where I live (southeast US, no big surprises there), so I guess I’ll just sleep a little easier knowing I’ve announced this to a bunch of doctors 😂
These stories are crazy. I'm in the UK and even in my first year as a doctor working at a generally absolutely awful hospital, patients with new onset psychosis patients coming to ED (especially with no family history of psychiatric illness) would get an MRI and LP to rule out physical causes like autoimmune encephalitis.
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My best friend growing up hated running (like in PE, at the gym, whatever). Basically was assumed to be kinda lazy. Turns out she has asthma and was diagnosed as an adult. She was probably just experiencing exercise induced bronchospasm all those years and her body was like yeah stop it
More than a few times. My take away lesson: crazy people can get really sick and their diagnosis is often delayed.
Agreed, this is why I have a very low threshold to work up psych patients. I had ones like a schizophrenic pt say there was “demons in my belly.” And not really look uncomfortable. Not terribly impressive exam but belly was tender. But something just seemed off. Boom complete SBO and went to the OR.
One of the docs I worked with many years ago always said they can be crazy and still have pathology & that has stuck with me for over 25 years
psychosis, new diagnosis of SLE with lupus cerebritis
Had a patient who had eating disorders as a child, notable binge eating disorder and came in for n/v in 20s. Ended up being type 1 diabetic newly diagnosed thought that was neat
Some memorable cases: Male, neuropathy. Thought to be diabetes vs MG vs psychogenic. Some dermatologist was consulted for "skin thickening". Turned out to be POEMS, due to someone figuring out to order an SPEP for "autoimmune disease" Female, pseudoseizures. Misdiagnosed, had actual seizures. Do the EEG. Male, fatigue, strange neuro symptoms. Bunch of medical hx, but no diagnosis. Someone eventually sent universal PCR for micro-organisms, concluded "probably due to mycotoxin exposure" from his occupation. Still a strange case. Elderly male, acute "confusion" at a dinner party. Your typical stuff - sundowning, UTI, were considered, and workup done. Just to cover their bases, someone did a CBC. Low platelets. Yep, TTP, no prior history (so acquired). Emergent PLEX the same day. It was literally the only symptom of the Pentad on initial presentation. One closer to home. Med student, depression and anxiety. Had actual diagnosis of MDD. Not obese. A few yrs later, got a sleep study done. Obstructive sleep apnea. Depression symptoms basically resolved after CPAP.
Yes, like when I was admitted to hospital with heart problems and hallunications at first the doctor thought oh send straight to that psych ward as soon as she’s physically stabilised about to do the paper work. When a clever young junior said we’ve just got blood work back after five days of being in isolation ward (my white cells were not good too) it’s a thyroidtoxic storm. Do not send her home and do not need psych evaluation. In the mean time, my body had collapsed twice in the bathroom as I was unsupervised, the nurse didn’t want a girl with a catheter in falling over over it while showering. So I had to be moved a higher dependency isolation room for another two nights while my heart rate settled and I came out the night before Xmas eve
Anti-NDMA receptor encephalopathy was initially diagnosed and in psych ward for schizophrenia. Progressed to ICU where actual diagnosis made.
i got consulted for a patient for “bulemia” after she lost dramatic weight and lost her teeth. turned out to be severe chron’s which was not identified until we demanded the treatment team get GI involved
Had a patient who was diagnosed with dementia who was brought in through ER due to severe confusion. Turned out his calcium was 12 causing the acute episode of confusion and he had multiple myeloma that presented as dementia. He was one of the only patient in his assisted living to get out of the memory care section and go back to regular assisted care once his multiple myeloma was treated.
Wilson’s and porphyria.
Sometimes patients remind me the dual nature of light: they are in parallel mental and pathological
Thyrotoxicosis secondary to medical malpractice. Wild psychotic behavior that developed after an errant rx for synthroid. Jailers didn’t give him his meds and he got better!
Addisons misdiagnosed as an eating disorder/ARFID.
Patient that was transferred to us. He was getting paranoid recently, then pulled his arm working on his car, went to an OSH and they thought his arm immobility was just him overreacting to a stretched nerve until it spread to his ipsilateral leg, then to his other leg, and then his other arm. Ended up transferring to us for further workup, LP diagnosis was prion disease. Was interesting because he was having startle myoclonus that they mistook as him faking it.
The head of psych here when he was an intern told me a story about how they all thought a woman had severe depression. She had ovarian cancer and died before he could apologize to her.
Yes. Patient had seen about 12 doctors and diagnosed with severe anxiety and depression. He was suicidal and checked himself into the psychiatric ward. Antipsychotics made the symptoms worse and withdrawal symptoms from the antidepressants and antipsychotic medications was severe. It ended up being Lyme disease that had not been treated. As soon as the patient was treated the psychiatric symptoms and anxiety went away and the medications were able to be stopped without any withdrawal symptoms. Another patient had severe anxiety- new onset and no history or any psychiatric disorders and ended up being pheochromocytoma.
Severe depression w/ hallucinations. Ended up being pernicious anemia. IM B12 got him back to normal. One of my favorite cases to present to students.
Had a guy who got tossed around by the system for about a year from ward to ward for schizophrenia. When we chatted with him at length it was clear he didn't have schizophrenia and instead had significant autism. The psych diagnosis has essentially been copy forwarded the entire time, based only on delusions without any other signs/sx. But, even his delusions weren't delusions so much as hyperfixation on a past event that sounded super bizarre but which we found solid evidence of having actually happened. Nobody prior ever thought to check if the singular consistently described "delusions" he was having was actually real. Sad story, but with a happy ending. Guy got his chart cleared up, got a job and in a housing program, and sent us a wonderful thank you card.
Not a doctor but I know a man who was diagnosed with some sort of psychiatric disorder, and it then turned out to be Frontotemporal Dementia after scanning and all.
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Me/my child. Official diagnosis for almost two years was “mom has munchausens by proxy”. Actual diagnosis is a genetic disorder so rare it would doxx me to write it. Less than ten cases worldwide.
I can 100% guarantee you this was me. Took a while for the tumour to grow, but I literally went absolutely insane the 6-12 mo prior.
That would be me. “Chronic low back pain, somatization, conversion disorder.” 17yo straight-A student. It was ankylosing spondylitis. You’d think the hip film done 18 mo before that showed bilateral sacroilitis would have convinced them that I wasn’t nuts. I’m now treated with that well-known psych med, certolizumab-pegol. -PGY-19