Mental Problems May Not Be All in Your Head

Date: February 12, 2012      Publication: Bottom Line Health      Source: Barbara  Schildkrout      Print:

Anxiety, depression and out-of-control rage are sometimes caused by physical problems that can be treated.

If you develop anxiety or depression, your first thought might be to call a therapist.

What you should do instead: See your doctor. Many physical problems masquerade as mental health issues. For example, patients with a treatable thyroid disorder often experience intense anxiety. Some seizure disorders may cause intense emotional experiences. And manic behavior could be a medication side effect.

Frightening statistic: Up to 40% of patients in some nursing homes and mental health facilities have mental symptoms that are caused—or made worse—by underlying medical disorders.

To learn more about physical ailments that may be mistaken for psychological problems, Bottom Line/Health spoke with Barbara Schildkrout, MD, a psychiatrist and leading expert on this subject.


Mental/physical issues are often intertwined. For example, a former football player suffering from midlife depression may have suffered multiple concussions in the past. Such head trauma may trigger depression…even years later.

Problem: Many primary care physicians don’t spend enough time with patients to know their psychological histories, and mental health professionals may wrongly assume that a doctor has thoroughly considered a physical cause of mental symptoms. Before you conclude that you have a mental health problem, ask yourself…

Did it start quickly? If you’re fine one day and suffering from depression or another mental health symptom the next, you should suspect that there might be a physical cause.

Does your mood match your life? It’s understandable that someone who is recently divorced or having financial problems might be depressed. But if everything in your life is fine and you still feel lousy, you might have a physical disorder.

Are you experiencing any other symptoms, even if they seem unrelated? Timing is important. A patient who is hallucinating might be psychotic. But hallucinations could also be symptoms of a seizure disorder or the sleep disorder narcolepsy.


More than 100 medical conditions cause symptoms (indicators of a disease or disorder that are detected by the patient) and signs (indicators detected by a physician) that may be misinterpreted to be the evidence of a mental illness. Examples…

  • Drug side effects versus mood disorder. You would expect to experience mood changes when taking a sedating medication, such as codeine. But depression is a common side effect of many medications, including some of those used to treat asthma, elevated cholesterol and high blood pressure. Birth control pills also can cause depression.

Other drugs may trigger mania, a symptom of certain psychiatric conditions, such as bipolar disorder. Mania is marked by racing thoughts, euphoria and lack of sleep. Corticosteroids (such as hydrocortisone and prednisone) may cause mania. Some antidepressants, including selective serotonin reuptake inhibitors, such as fluoxetine (Prozac), and monoamine oxidase inhibitors, such as phenelzine (Nardil), may trigger an episode of mania.

What to look for: The timing of mood changes. If you’ve recently started a new medication and you’re suddenly feeling depressed, talk to your doctor.

What to do: Make a list of all the medications that you take, and ask your doctor if they could be responsible for your mood changes. He/she may advise you to switch medications and/or take a lower dose.

  • Hyperthyroidism versus anxiety. Patients who produce too much thyroid hormone (hyperthyroidism) may experience intense anxiety. Some spend months or even years in therapy before they discover that they have a physical problem. The diagnosis is easy to miss because, unlike many other psychological symptoms caused by physical ailments, the symptoms come on gradually, sometimes over a period of years.

What to look for: Feelings of anxiety that don’t correspond with what’s happening in your life. Patients who suffer from psychological anxiety will usually be worried or concerned about something in particular. One exception is patients with generalized anxiety disorder, who have excessive worry about everyday matters.

The anxiety caused by thyroid disorders will feel physical. Your heart might be pounding…you might sweat a lot…or have shaky hands. Patients interpret these sensations as anxiety even though they may just be physical symptoms.

What to do: If you experience these symptoms or you’ve been told that you have anxiety, make sure that your doctor has considered the possibility of thyroid disease. It’s diagnosed with a blood test. Hyperthyroidism is treated with medication and sometimes surgery.

  • Seizures versus intense emotional episodes. Emotional outbursts are a common symptom of mental illness, including psychotic disorders. But intense emotional experiences—feelings such as fear, a sense of impending doom, rage or déjà-vu experiences—can sometimes be caused by seizures. In addition, seizures can disrupt sleep, which, in turn, may lead to irritability and more likely emotional outbursts.

What to look for: Intense emotional reactions when there’s no clear reason. Patients with mental illness can usually describe what makes them angry, anxious, etc. With seizures, emotional outbursts “come out of the blue.” Depending on the type of seizure, the episodes are usually brief, often only a minute or two. The short duration often indicates a physical rather than a psychological problem.

What to do: Ask your doctor/therapist if you should have an electroencephalogram, a test that measures electrical activity in the brain. A negative test doesn’t mean that you don’t have seizures—it just means that your brain activity was normal at the time of testing. If symptoms continue, a repeat test might be needed. If a seizure disorder is diagnosed, symptoms usually improve with medication.

Important: Certain types of seizures cause only subtle changes in consciousness—for example, a moment of unresponsiveness that may be misinterpreted as, say, a problem with attention. Some seizure disorders are also associated with various types of hallucinations, including auditory, visual and olfactory.

  • Normal pressure hydrocephalus (NPH) versus depression. NPH is an enlargement of the fluid-filled ventricles of the brain that often causes symptoms such as apathy and depression along with cognitive and memory impairments. Some people who are diagnosed with Alzheimer’s disease actually have NPH.

What to look for: NPH symptoms include apathy, depression and mental slowing, along with the development of an unsteady gait and urinary incontinence. With Alzheimer’s, any trouble with walking or incontinence occurs only at very advanced stages of the disease.

What to do: If you or a loved one has any of these symptoms, there’s a chance that the mental health problems have a physical origin. From a simple CT scan, a neurologist can tell whether a person might have NPH. The diagnosis must then be confirmed by further tests including a lumbar puncture in which a small amount of fluid is drained. Doctors then observe whether the patient’s gait improves. If so, the diagnosis has been confirmed, and the condition is treated with the surgical insertion of a shunt to drain fluid from the brain.

Source: Barbara Schildkrout, MD, a psychiatrist and clinical instructor in psychiatry at Harvard Medical School and the Beth Israel Deaconess Medical Center, both in Boston. She is the author of Unmasking Psychological Symptoms: How Therapists Can Learn to Recognize the Psychological Presentation of Medical Disorders (Wiley)