Psychiatry is a unique and challenging medical specialty. If I was a cardiologist and a patient presented with chest pain, I would have a number of objective tests at my disposal to evaluate this complaint. A patient presenting to a pulmonologist complaining of shortness of breath and exercise intolerance can be sent for a chest x-ray, pulmonary function tests or a finger oximetry reading. Currently, when a patient comes to a psychiatrist’s office complaining of “depression” there are no definitive blood, imaging or electrophysiological tests to make a psychiatric diagnosis. I am confident that a time will come when psychiatrists will have a Star Trek like scanner that will provide an instantaneous biological readout that will identify the brain abnormality responsible for the patient’s psychiatric symptoms.

That being said, it is important to recognize that not everyone presenting to my office with anxiety, depressive or cognitive complaints suffers from a psychiatric disorder. There are a number of medical mimics that must be considered as the evaluative process unfolds.

For example, psychiatric depression often presents with symptoms that include low energy, lack of drive, sad mood, poor appetite, impaired memory and concentration. A sluggish (hypothyroid) thyroid can result in a similar set of symptoms and mimic psychiatric depression. That is because thyroid hormone status has a direct influence on brain cells. A simple set of blood tests will provide an answer. An overactive thyroid will result in an emotional state that mimics high anxiety.

A number of years ago a landmark scientific study revealed that some individuals complaining of panic anxiety may not be suffering from a psychiatric disorder after all and instead are the victims of caffeinism. Caffeine is a brain stimulant and can result in a state of apprehension and fear, rapid heart rate and shakiness. Limiting caffeine intake in study participants resulted in resolution of their “symptoms”.

Mitral valve prolapse is another medical mimic. Mitral valve prolapse is usually a benign abnormality of a heart valve that rarely results in any medical consequence. But it is not unusual for individuals with this abnormality to experience sudden onset of a rapid heartbeat and state of fear. If one does not know that they have mitral valve prolapse and suddenly experiences the above symptoms it would not be surprising to conclude that these experiences represent anxiety attacks. Once the diagnosis of mitral valve prolapse is made, just the ability to attribute the symptoms to a real problem helps. To then find out that there are medications that can prevent repeat episodes.

Hypoglycemia, or low blood sugar results in symptoms that are indistinguishable from an anxiety attack. The brains’ sole fuel is glucose and a dramatic reduction in glucose availability significantly disrupts brain activity and results in an emergency state. Pursuit of a hypoglycemic diet can dramatically reduce the risk of this reaction.

Another potential source of medical mimics of psychiatric disorders are the medications that are prescribed for bona fide medical disorders. Some medicines used to treat high blood pressure can have side effects that mimic depression. In the elderly, medicines that are used to treat bladder incontinence, congestion, allergies or sinus problems can lead to false fears of failing memory as a consequence of the effects of these medications of brain memory centers, only to cease when these agents are stopped. This age group is also exceedingly sensitive to sedating medications and can lead to a clinical state that mimics dementia. If one does not recognize the mental state altering effects of these medications an expensive and time-consuming dementia neurological workup can follow, only lead to a dead end.

Such examples represent a small sample of medical mimics. A comprehensive psychiatric evaluation must consider such medical mimics before a primary psychiatric etiology is considered. In addition, when an individual with a psychiatric disorder fails to respond to treatment as anticipated it is important to rethink the possibility of an underlying non-psychiatric medical problem responsible for the patient’s symptoms. The medical model that is the core of a psychiatrist’s comprehensive approach to patient assessment serves to consider the potential medical mimics that make my field so challenging.