I was browsing through the excellent blog I have featured on my blog roll called Wheelchair Kamikaze, where I came across an amazingly interesting post he did that included a link to a 2007 article on The Differential Diagnosis of MS that has a long discussion on MS and Psychiatric Disease. After reading it, I now understand why neurologist #3 continued to send me back to my GP when I asked questions about my sinus infection or my desire to get the source of my pain identified . When I saw him after my hospitalization for severe malnutrition on February 14, 2012, he asked me why they thought I had post-herpetic neuralgia. I told him that I had no idea but that was what twigged me to the fact that I should get a copy of my records so I could see what other errors/fiction had been written. At least he did that for me. So, all of these things happened after my stay in hospital where I was given a whack of psychiatric diagnoses — anxiety, depression, conversion disorder . . . The neurologist obviously thought I was just wasting his time.

Early on in the article it talks about Red Flags and the Differential Diagnosis of MS.

The diagnosis of MS should be questioned when clinical or laboratory findings are unexpected or atypical. These unusual features or “red flags” should raise suspicion that MS is not present. Rare patients with these red flags do have MS .

So, going down the list of red flags, there are three prominent ones that apply to me:

1. Normal neurologic examination

4. Onset in childhood or over age 50

11. Lack of typical symptoms: no optic neuritis, bladder problems, Lhermitte sign, sensory level, etc.

The glaring omission in the diagnostic procedure was the lack of information from an MRI. Once he had that, indicating lesions consistent with demyelinating disease, he had a responsibility to follow up on it.

Back to the fascinating article.

Psychiatric Disease and Normal People
By far the most important disease confused with MS is psychiatric illness. Most patients referred to a neurologist for consideration of possible MS who do not have the disease instead suffer from some form of psychiatric disorder: somatization, hypochondriasis, malingering, depression, anxiety, or similar problems. In the few instances where the differential diagnosis of MS patients has been documented (as summarized in Table 6), psychiatric diseases emerged as the foremost problem. . . Across diverse settings and referral patterns, over 3 decades, with or without MRI, the most common conditions mistaken for MS were psychiatric.
The second largest diagnostic category of “non-MS” patients is normal people describing everyday sensations that are misconstrued as abnormal. In one study, 32% of normal people between the ages of 20 and 45 reported transient neurologic symptoms, such as visual changes, loss of power, poor balance and coordination, and speech difficulty. Care thus must be taken not to overemphasize the multitude of transient disturbances that plague all normal people: itches, twitches, “falling asleep” limbs, and fleeting visual obscurations.

The end of the article is somewhat patronizing in tone. This is common in medical literature when they talk about clinical interactions with ‘patients’.

HOW TO INFORM PATIENTS THAT THEY DO NOT HAVE MS
After a complete workup, often a diagnosis of MS, or any serious neurologic disorder, will not be established. The manner in which patients should be informed of this conclusion largely depends on their psychologic status. At one end of the spectrum are patients who, apart from understandable concern about the possibility of a disabling illness, are essentially normal psychologically. For these patients, the neurologist may explain the circumstances that led to the initial suspicion of MS (eg, over-reading of an MRI scan or misplaced concern about benign paresthesias) and the objective findings which have shown that MS is not present.
An intermediate class of patients consists of persons who have mild but persistent anxiety or mood disorder (“the worried well”), either constitutionally or because of the lingering suspicions on their part or the part of their neurologist that organic disease might be present. These patients will benefit from infrequent but regularly scheduled (eg, q. 3–6 months) return visits to the neurologist for reassurance and reevaluation. Eventually, these patients usually reach a point where they can be returned to the long-term supervision of their primary physician, always with the offer of a repeated neurologic assessment if needed.
At the other end of the psychologic spectrum are patients who have severe underlying mental disturbance and whose symptoms frequently evoke very negative emotions in physicians. For example, in an analysis of 300 new outpatient visits, Carson and colleagues found that patients whose symptoms were not explained by organic disease were consistently rated as most difficult to help by neurologists. In this regard, O’Dowd coined the term “heartsink patients” for persons who exasperate, defeat, and overwhelm their doctors by their behavior. Patients presenting with psychogenic symptoms often suffer from somatization disorder, anxiety disorder, hypochondriasis, depressive disorder, or an attachment to illness as a way of life.

Very few neurologists have the resources and skills to effectively manage patients with chronic psychogenic disorders. A major mistake for the neurologist in this circumstance is to attempt too much; for example, to try to cure the incurable by endeavoring to reverse an ingrained pattern of psychogenicity in one brief conversation. So if most patients with psychogenic symptoms reject immediate referral to a mental health professional and if the neurologist is usually not the best person to provide continued management, who is? The medical literature provides a consistent and positive answer to this question, namely, that the primary care physician, who deals with a high percentage of nonorganic or embellished complaints during each practice day is usually well qualified by experience and training to help these patients. Several authoritative guidelines endorse short, frequent visits to a primary care physician for a program based on reassurance and support; limiting of testing and subspecialty referrals to those that truly are necessary; first-line treatment of depression and anxiety; and a gradual, nonthreatening shift of focus to consideration of stress and other psychologic factors. Eventually, psychogenic patients often reach the point that they will accept expert psychiatric referral. In summary, while the best hope for fundamental change over the long term lies with psychiatric treatment, in the short term, optimal management is usually based on supportive care with a primary care physician. Obvious exceptions to the recommendation for delayed psychiatric management are the rare patients who are psychotic or who are a danger to themselves or others.

Dr. Kastrukoff told me that many women with MS get to the MS Clinic after having been diagnosed with a psychiatric problem. After reading this, it all becomes crystal clear . . . the neglect, the empty promise of making sure I saw ‘the best’ neurologist at the MS Clinic. I was very careful in all of my meetings to be respectful and cooperative. He had no intention of doing anything to help. He wasted a year and half of my time and let me suffer. How does a person forgive that?