Separating the subtleties: Mental illness in primary care

Primary care physicians often face diagnostic challenges because of overlapping symptoms and the limited amount of time they have with each patient.

By Kathleen Phalen Tomaselli, AMNews correspondent. Oct. 15, 2007.

Picture a patient throwing $100 bills around the waiting room, urging other patients, "take them, take them." His voice is loud; his affect, frenzied. Another image: The young man who keeps talking about Mr. Maloney. "Mr. Maloney says this, Mr. Maloney says that." Later, his girlfriend reveals that Mr. Maloney doesn't exist. Or what about the concerned mother who calls every day, demanding more of the physician's time. One day overtly complimentary; the next, visibly angry.

It's a familiar refrain of symptoms -- the histrionics, the mania, the auditory hallucinations, the unstable relationships -- common to such mental illnesses and disorders as bipolar, schizophrenia and borderline personality.

"The family doctor is likely to see these people first," says Sheldon Miller, MD, former director of the American Board of Psychiatry and medical director of Timberline Knolls, a residential treatment center near Chicago. "They need to have an incredibly high level of suspicion."

Schizophrenia, bipolar disorder and borderline personality disorder are distinct conditions with separate treatments but similar behaviors.

The classic cases are easy to spot. But unraveling a diagnosis from a subtle set of diffuse clues -- headaches, insomnia, unexplained joint pain, anger -- can be a challenge for time-crunched primary care physicians.

"Often, they have thematic complaints. They don't say, 'I'm depressed,' " says Rick Kellerman, MD, president of the American Academy of Family Physicians and professor and chair of the Dept. of Family and Community Medicine, University of Kansas School of Medicine. "They might be tired, have all sorts of aches. These patients are difficult because they have undifferentiated problems."