Picture from : https://nypost.com/2009/10/04/my-mysterious-lost-month-of-madness/
What if one day you fell ill and every doctors you met diagnose you with a mental illness without looking for a physiological reason for all of those symptoms? And, on top of that, this mysterious affection you are suffering from is slowly killing you. Doesn’t it look like a bad synopsis of a thriller movie?
This nightmare has been living by Susannah Cahalan and by thousands other people all around the world. It all start in 2009. At the time, she was 24 years old, she worked as a journalist in The New York Post and she was happy. One day, while she was walking to work, everything around her became more intense, even painful : sounds, lights, colors. She felt a general discomfort that wouldn’t leave her. Few days later, the left side of her body started to get numb. She spent her nights wondering what was happening to her.
Day by day, her physical and psychological health were getting deteriorated. She had several convulsion seizures with loss of consciousness, racing thoughts, agitation, sleeplessness. She alternated between euphoria and depression. The doctors she met told her she had mononucleosis, or even alcohol withdrawal. By time, she became agressive and had paranoid thoughts. At the last stage of her disease she was at the hospital and she couldn’t even talked or moved by herself, she became catatonic.
During two weeks, many specialists met her and gave her many tests to do (RMIs, blood tests, X-rays…). All of those were negative and none of them could lead to a diagnosis. Their only one explanation was that Susannah suffered from schizophrenia. But one day, she met Dr. Souhel Najjar, a neurologist who will « find her».
When he met Susannah, he used the neuropsychological Clock-Drawing Test where he asked her to draw a clock. The clock she had drawn highlighted a neurological problem and excluded psychiatric issues. Indeed, all the numbers of her clock were on the right side of the clock circle, with no numbers of the left side.
This new element helped Dr. Najjar to suggest that the right side of Susannah’s brain is inflamed. Other tests, as well as biopsy, allowed to have a diagnosis two weeks later. Susannah suffered from Anti-NMDA receptor encephalitis. This disease became with a non specific viral syndrom. Few weeks later, the installation of neuropsychiatric symptoms is acute. In this affection, we can observe memory, behavior and psychotic disorders, with epileptic seizures (De Broucker, 2011).
Dr. Naajar told her « It’s a death sentence when you’re alive. (…). Many are wasting away in a psych ward or a nursing home. ». After this month of nightmare, she started several treatments. In six months, Susannah has came back home, she has regained 100% of her cognitive abilities and went back to work. Even though, she had to learn how to talk and to walk again. Then, she has decided to write her story « Brain on fire : My month of madness », to help people like her. It has even been adapted in a movie « Brain on fire », directed by Gerard Barrett.
When psychiatric manifestations mask the real problem…
Unfortunately, Susannah is not the first person to be diagnosed with a psychiatric illness when the cause is organic. Several studies has advanced that 10% of psychiatric diagnoses are actually due to organic pathology (Bourla, Ferreri & Mouchabac, 2018). Many organic diseases or troubles can imitate the symptoms of a psychiatric illness. For example, deficiencies in Vitamin B12 can look like schizophrenia, hypothyroidism like depression or hyperthyroidism like maniac syndrom. More dramatic, diagnosis of panic attack or anxiety disorder can be make when the real cause of the symptoms is a heart disease. Even cancer can start with psychiatric symptoms. It is the same thing for limbic encephalitis, the same disease has Susannah Cahalan had suffered from. For example, behavioral variant frontotemporal dementia (bv-DFT) is often confused with psychiatric issues. In that case, biological exams, brain imaging and neuropsychological tests can help to lead to the correct diagnosis (Ducharme, Price, Larvie, Dougherty & Dickerson, 2015). This difficuly can be observed in other neurodegerative conditions.
Sometimes, there’s approximately 10 years between the first psychiatric symptoms and the diagnosis. During this period, patients have to take psychotropic medications, without seeing their condition improved (Bourla et al., 2018).
Another scary story which illustrate this is the Charlotte’s one. She was 27 years old when she had a car accident. After weeks of reeducation, she still couldn’t move her leg. She has started to feel depressed, she couldn’t move or got out of her bed, another pain came in her legs and in her back. The exams she passed revealed nothing. So, the doctors have told her that she suffered from conversion disorder. Then, she was admitted in several psychiatric institutions, took psychotropic medications like antidepressant and antipsychotic… Until the day complementary exams will be done. The doctors discovered a severe inflammatory disease, which was the origin of the members paralysis. After appropriate treatments, Charlotte walked again and came back to her life.
Furthermore, those errors illustrate the importance of multi-disciplinary work and to be in contact with other hospital units. As a future psychologist, it is one of the most important element to take into account in our profession. Indeed, when we met a patient, even if we don’t make a diagnosis, we make hypothesis and it is our responsibility to address a patient to a specialist or a hospital service, or even to talk about it with our pluri-professionnal colleagues when we suspect something strange.
Until 1968, neurology and psychiatry were in the same speciality : the Neuropsychiatry (Bourla, Ferreri & Mouchabac, 2018). Nowadays, those specialities have been separated and more often exercised in different hospital units. Then, they suggested that it would be beneficial if they interact to the maximum, even with other medicine fields to give the best care to patients and avoid, as much as possible, wrong diagnosis of psychiatric illness when the cause is organic.
To conclude and to avoid wrong diagnosis, those authors suggest to detect unusual symptoms or cognitive disorders, a start too early or late of the disease and the inefficiency of a psychotropic treatment. They even add to pay attention to patients who have visual hallucinations. Indeed, in psychiatric illness hallucinations are more often likely to be auditory than visual hallucinations, for example patients will hear voices (Bourla et al., 2018).
Key words: Wrong diagnosis; Mental illness; Encephalitis
Words I have learned:
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- Seizures = crises
- Withdrawal = sevrage
- To get numb = être engourdi
- Encephalitis = encéphalite
- Acute = aigu.
Bibliography:
1- Bourla, A., Ferreri, F., & Mouchabac, S. (2018). Ces maladies psychiatriques qui n’en sont pas : Comment les démasquer ? Cerveau & Psycho, 102, 24-31
2- Cahalan, S. (2009). My mysterious lost month of madness. Retrieved from: https://nypost.com/2009/10/04/my-mysterious-lost-month-of-madness/
3- De Broucker, T. (2011). Encéphalites paranéoplasiques et auto-immunes : quand y penser, comment en faire le diagnostic. Réanimation, 20(3), 242-250
4- Ducharme, S., Price, B.H., Larvie, M., Dougherty, D.D., & Dickerson, B.C. (2015) Clinical approach to the differential diagnosis between behavioral variant frontotemporal dementia and primary psychiatric disorders. American Journal of Psychiatry, 172(9), 827-837.
Amandine Templet, M2 PPCECC