Professional Psychology: Research and Practice

Professional Psychology: Research and Practice
1992, Vol. 23, No. 4, 306-309
In the public domain
Distinguishing Psychological Disorders From Neurological Disorders:
Taking Axis III Seriously
Mark W Bondi
San Diego Department of Veterans Affairs Medical Center
and Department of Psychiatry, School of Medicine
University of California at San Diego
Inasmuch as current efforts in clinical neuropsychology call attention to the difficulty in differentiating psychological from neurological disorders, it is unclear to what extent professional psychologists without expertise in this subspecialty have knowledge of this diagnostic issue. This article
asserts the need for psychologists to have requisite knowledge of neurological disorders that can
initially present with psychological symptoms. Recent developments in professional psychology’s
advancement into hospital settings has prompted examination of such competency issues, and the
abilities of psychologists to accurately differentiate neurological from psychological disorders are
discussed. Examples of neurological conditions that commonly exhibit psychological symptoms
are highlighted, and reference to the elderly is made to exemplify the need for accurate diagnostic
sophistication. Relevant research is reviewed and suggestions for training are offered.
A current professional issue involves the question of psychologists’ competency to function as autonomous professionals
within medical settings and to refer appropriate patients to
such settings (cf. California Association of Psychology Providers et al. vs. Rank, 1989). This concern is most apparent
when considering that more than 10% of the American Psychological Association’s members practice in medical settings, a
percentage that continues to increase (DeLeon, Pallak, & Hefferman, 1982; Enright, Resnick, DeLeon, Sciara, & Tanney,
1990). If psychologists were, in fact, employed as independent
practitioners within such settings, would their professional
diagnostic competencies include the ability to distinguish psychological from neurological disorders? To date, very few empirical studies have addressed this or related questions (cf. Sanchez
& Kahn, 1991; Sbordone & Rudd, 1986). As Geschwind (1975)
pointed out, even if psychological sequelae to neurological disorders were uncommon, this would in no way justify neglect on
the part of mental health professionals in obtaining the requisite knowledge to differentiate such causes.
Historically, estimates have indicated that approximately
30% of all patients initially admitted to psychiatric hospitals
actually have neurological disorders or disease (Maltzberg,
MARK W BONDI received his PhD in clinical psychology from the
University of Arizona in 1991. He is currently completing a National
Institute on Aging postdoctoral fellowship (AG-05561) in neuropsychology at the Department of Psychiatry, University of California at
San Diego, School of Medicine. His research interests include the neuropsychology of dementia and cognitive sequelae associated with substance abuse.
THE AUTHOR THANKS F. Curtis Breslin for his helpful comments on this
manuscript.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to
Mark W Bondi, Psychology Service (116B), Department of Veterans
Affairs Medical Center, 3350 La Jolla Village Drive, San Diego, California 92161.
1959). More recent and conservative estimates, however, indicate that approximately 10% of patients initially diagnosed with
psychological disorders are subsequently found to have a physical basis for their symptoms (see Muecke & Krueger, 1981; Sanchez & Kahn, 1991). Nonetheless, the prognostic and treatment
consequences of inaccurate diagnoses are obvious: Patients
with underlying medical or neurological conditions will likely
go untreated and may deteriorate while in the psychologist’s
care.
Although a recent study by Sanchez and Kahn (1991) found
that mental health professionals were as accurate as medically
trained clinicians in differentiating medical from psychological disorders, another study by Sbordone and Rudd (1986) revealed more troublesome findings with regard to the more specific differentiation of neurological from psychological disorders. They empirically addressed whether professional
psychologists practicing in the community could recognize an
underlying neurological disorder in patients presenting with
disturbed psychological functioning and whether they would
recommend referral of such a patient to a neurologist. Survey
questionnaires were mailed to and completed by 206 psychologists. Four case vignettes were presented containing salient descriptions of an underlying neurological disorder within the
context of a psychological disorder presentation. Their results
indicated that little more than half of those surveyed recommended referral to a neurologist. More than one third of the
psychologists recommended psychotherapeutic treatment
alone. They concluded that these findings argue strongly for
professional psychologists having a better working knowledge
of neurological disorders and closer working relationships with
neurologists and other medical specialists.
The data also suggest that psychologists often may not consider or attempt to rule out neurological conditions that can
present with behavioral symptoms. The findings above are
somewhat disturbing because the current multiaxial diagnostic
system provided in the revised third edition of the Diagnostic
306
DIFFERENTIAL DIAGNOSIS 307
andStatisticalManualofMental Disorders(DSM-IH-R; American Psychiatric Association, 1987) explicitly calls for the clinician to integrate information on physical or neurological conditions into diagnostic formulations.
Clinical Considerations
Given that the average annual incidence of neurological disorders in the general population is approximately 2,500 per
100,000 people, or 2.5% (Kurtzke, 1991), attention to the possibility of clients with such conditions presenting for psychological treatment is certainly indicated. Indeed, a number of neurological disorders can present with psychological symptoms; examples include temporal lobe epilepsy, frontal lobe lesions,
limbic system damage, central nervous system toxicity, traumatic head injury, multiple sclerosis, early stages of Huntington’s disease, and psychoses associated with various endocrine
diseases, to highlight but a few. In addition, false-positive diagnoses of conversion reactions inappropriately applied to persons with physical disease does not appear uncommon (Watson
& Buranen, 1979). Although detailed discussion of these and
other neurological disorders is beyond the scope of this article,
brief descriptions of neurological disorders that commonly exhibit psychological symptomatology are provided, and I refer
the reader to additional sources (e.g., Benson & Blumer, 1975;
Berg, Franzen, & Wedding, 1987; Jefferson & Marshall, 1983;
Kolb & Whishaw, 1989; Pincus & Tucker, 1985; Taylor, 1982).
Neurological disorders can exhibit a multitude of psychological symptoms, including paranoia, hallucinations, attentional
deficits, mood swings, euphoria, sleep disturbance, personality
changes, depression, impaired memory, anxiety, apathy, and violence (Lishman, 1978). Temporal lobe epilepsy (also termed
complex partial seizure disorder), for example, has clear cognitive and affective changes associated with it (Blumer, 1975;
Trimble, 1982; Trimble & Thompson, 1986). Consistent behavioral changes following onset of temporal lobe seizures include
a global diminution in sexual behavior and impulsive-irritable
behavior (Blumer, 1975); yet they often tend to be hyperethical
and display hyperreligiosity, focusing on the qualities of good
and evil, right and wrong, and an overall deepening of emotional experience. Nothing is thought to be trivial, and insignificant details can assume great importance. Hypergraphia (i.e.,
excessive writing) also is common.
Personality changes following frontal lobe damage often include apathy and loss of all initiative; at the other end of the
spectrum, such patients can display euphoria with a lack of
adult restraint or tact (Benson & Blumer, 1975; Stuss & Benson,
1984,1986; Taylor, 1982). The earliest symptoms of frontal lobe
tumors usually involve alterations in behavior consistent with
those of a psychological origin. The apathy displayed by the
patient with a frontal lobe lesion could possibly be mistaken for
the psychomotor retardation of the depressed individual; the
distinction between the two is that the apathy of the frontal
lobe patient has no theme (e.g., empty indifference), whereas
the depressed patient typically reveals a preoccupation with
worrisome thoughts. Incontinence also is a frequent indicator
of frontal lobe pathology.
In a related vein, patients who have sustained traumatic head
injury often exhibit symptoms and behaviors similar to those of
frontal lesion patients, in part because the frontal lobes are
highly susceptible to damage from closed head trauma (see
Butler & Satz, 1988; Grimm & Bleiberg, 1986). Butler and Satz
(1988) have suggested that the clinician be aware that a head
trauma patient may appear depressed, exhibiting symptoms of
memory dysfunction, psychomotor retardation, apathy, lack of
initiation, and blunted or flat affect, in the absence of a major
depressive disorder. This does not imply that such patients may
not, in fact, become depressed. However, when a history of
head trauma has been identified, close attention should be paid
to the subjective, cognitive, and mood-related symptoms of depression; “[njeurovegetative signs such as alterations in sexual
functioning and sleep patterns become less useful as indexes of
depression in head trauma patients” (Butler & Satz, 1988,
p. 537).
Huntington’s disease has two clearly recognizable syndromes: (a) a progressive dementia afflicting all patients, involving motoric dysfunction (i.e., chorea), and (b) an intermittent affective disorder afflicting the majority of the patients (for
discussion, see Albert & Moss, 1988; Folstein, Brandt, & Folstein, 1990; McHugh & Folstein, 1975). The affective changes
often appear before the onset of choreic movements and resemble bipolar or schizophrenic disorders. Paranoia, delusions, hallucinations, and mood swings are a number of such symptoms.
Because Huntington’s disease is an inherited (autosomal
dominant) disease, one parent will have had the disease and
usually die before the child ever develops any symptoms. Therefore, family histories are critical in the determination of this
diagnosis.
Psychiatric and cognitive disturbances are also a common
feature of metabolic and endocrine disorders (Lishman, 1978).
Cognitive deterioration is a fairly consistent finding in pronounced thyroid insufficiency (hypothyroidism). It shares similarities with symptoms associated with progressive degenerative dementia, such as insidious onset and progression of cognitive decline. The patient suffers from sluggishness, lethargy,
poor attention and concentration, and memory disturbances.
However, this condition is indeed reversible with thyroid replacement therapy (Lezak, 1983).
Multiple sclerosis (MS), a progressive degenerative disorder
causing demyelination of cortical and subcortical structures,
can also present with psychological symptoms. Frequent symptoms include muscle weakness and fatigue, double vision,
numbness and paresthesia, pain, bowel and bladder dysfunction, and sexual disturbance (Rao, 1990). Affective disturbances, including both euphoria and depression, can accompany or precede the onset of neurological disturbances in MS
patients (Devins & Seland, 1987; Rao, 1990; Surridge, 1969).
Conversion symptoms, too, may be mistakenly attached to the
initial symptoms of MS.
Another general diagnostic consideration involves physical
symptoms such as headaches, which can be symptomatic of
stress, anxiety, or depression, or the first sign of an organic
disturbance. Within the neurological literature, Pincus and
Tucker (1985) have advised colleagues to fully investigate any
headache that is “the worst, the first, or cursed (by neurological
abnormalities)” (p. 292). That is, if the headache is the worst
ever reported by the patient, if it is a new type of headache, or if
it is associated with neurological signs, it may be of organic
308 MARK W BONDI
etiology. However, if the headaches are dull, generalized, constant for many days in a row, or have been present for more than
a year, they are likely to have no neurological cause (Pincus &
Tucker, 1985).
Conversely, headaches caused by early brain tumors result
from increased intracranial pressure or by traction of the mass
on pain-sensitive structures within the skull (Pincus & Tucker,
1985). Unfortunately, there is no single characteristic of headaches caused by a brain tumor. They may be present in the
morning on awakening and recede as the day continues. Often
the headaches are either bifrontal or bioccipital, lateralized or
localized, and can be exacerbated or relieved by changes in
positioning. Pincus and Tucker (1985) further state that the
single most important feature in distinguishing tension headache from those caused by increased intracranial pressure is
that the patient usually presents to the physician within a few
weeks of headache onset in the latter case. Although these are
general guidelines, properly evaluating headaches is complex.
Thus, any complaint of headaches should be seriously entertained for neurological causes and warrants consideration of a
neurological consultation.
Finally, it should be noted that there is evidence accumulating that previously held “psychiatric” disorders, such as schizophrenia, are now thought to show brain abnormalities and that
the traditional dichotomy between organic and functional disorders may be misleading and misconstrued in some cases.
Certainly an interaction may be possible; for instance, a sequelae to the brain may result in a higher risk of developing
different types of psychiatric disorders (for discussion, see
Crockett, Clark, & Klonoff, 1981). Close attention to recent
advances in the neurosciences will help elucidate more precisely the nature of brain-behavior relationships and ultimately
shed new light on the distinction between functional and organic disorders.
Differential Diagnosis in the Elderly
Another example of this “borderland” (Geschwind, 1975) between neurology and psychology is seen in the elderly. As early
as a decade ago, an estimated 15% to 25% of the elderly were
reported to have significant mental health problems (U.S. President’s Commission on Mental Health, 1978). Of those elderly
who reside outside of long-term care facilities and institutionalized settings, approximately 10% to 15% are cognitively impaired, and an equal number experience significant affective
disorders (Reisberg & Ferris, 1982). In addition, Butler (1975)
indicated that the incidence of psychopathology increases with
age, stating that psychological disorders increase steadily with
each decade of life—particularly depression and paranoid
states. Indeed, the hallmark illness in the elderly, dementia or
“senility,” is inaccurately diagnosed in 10% to 30% of cases
within general medical populations (National Institute on Aging Task Force, 1980). Various intracranial conditions, systemic
illnesses, deficiency states, endocrinopathies, drug effects,
toxin effects, infections, and vascular disorders can present as
dementing illness (Cummings, Benson, & LoVerma, 1980); a
substantial proportion of such cases have potentially reversible
symptoms.
A neurological disorder mistakenly diagnosed as a psychological disorder, or the converse, is not uncommon, partly because
of the inherent difficulty in differentiating these conditions.
Kaszniak (1987) delineated several reasons for difficulty in differentiating dementia from depression in older age. First, there
are changes in cognitive functioning associated with normal
aging, tending to blur the distinction between normal age-related changes and early indicators of dementia. Second, cognitive difficulty frequently accompanies depression in the elderly
and can be of sufficient severity to be confused with dementia.
Third, the signs and symptoms of neurological disorders in
which dementia can occur do have some overlap with those of
depression (e.g., psychomotor slowing, sleep and appetite disturbances). Last, dementia can be accompanied by depression
in some patients. Thus, from the example of elderly populations, it is apparent that the misdiagnosis of treatable neurological disease presenting with psychological symptomatology (e.g.,
reversible neurological illnesses such as hyperthyroidism misdiagnosed as bipolar disorder) is not uncommon despite the
obvious need for accurate assessment of this fast-growing segment of the population.
Clinical Training Considerations
Sbordone and Rudd (1986) underscore that doctoral programs in clinical psychology generally do not include formal
training in the recognition of neurological disorders. Rather,
most training occurs at the general level of instruction of the
biologic bases of behavior, without specific reference to neurological disorders and their concomitant behavioral symptomatology. Berg, Franzen, and Wedding (1987) have also suggested
that such gaps are present in the training of general clinicians,
who are often not taught to recognize when referral to a specialist is appropriate.
Unfortunately, many training programs in neuropsychology, and
especially in clinical psychology, leave the student ill prepared
and inexperienced in this area, and . . . dismayed by both the
number and complexity of central nervous system disorders that
may first manifest themselves through aberrant behavior. (Wedding, 1986, p. 59)
Thus, following their predoctoral or postdoctoral training,
psychologists may not be adequately equipped with the diagnostic sophistication to detect subtle underlying neurological
disorders in clients seeking psychological treatment (for discussion, see Sbordone & Rudd, 1986).
A number of actions may help to achieve such competency,
including thorough histories and behavioral assessments of all
patients, regular screening referrals of patients to physicians,
maintaining referral networks that include clinical neuropsychologists and physicians (such as neurologists and psychiatrists), continuing education programs that focus on differential diagnosis, didactic and experiential training in clinical neuropsychology, research delineating the caveats in psychologists’
knowledge of neurological and other medical disorders, and
development of specialized training within clinical psychology
programs for the recognition of neurological and other medical
conditions.
Finally, the scant literature investigating psychologists’ and
other health care professionals’ competency in this and related
domains should be buttressed. Future research will be crucial
in determining differential diagnostic abilities of practicing clinicians. Such efforts will assure that issues of diagnostic accuracy between mental health professionals are resolved empirically and not through the political arena (for discussion, see
Sanchez & Kahn, 1991). Integral to this end, the statutory au-
DIFFERENTIAL DIAGNOSIS 309
thority to independently practice psychology in hospital settings has been attacked most pointedly around this competency issue: “that only a physician is authorized to render a
diagnosis concerning a mental disorder that is organic in origin
or nature” (Enright, Welch, Newman, & Perry, 1990). As the
California Supreme Court has recently judged professional psychologists to be competent for primary responsibility of diagnosis and treatment of mental disorders, regardless of whether
the mental disorder is of a physical or psychological origin
(Enright et al., 1990), greater attention is warranted on this specific question of competency in distinguishing neurological
from psychological disorders.
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Received July 29,1991
Revision received January 23,1992
Accepted February 3,1992 •

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