Re: Pain from physiological vs psychiatric cause....

Posted By HFHS M.D.-TB on April 21, 1999 at 22:02:12
Topic Area: Mental Health (other)
I am rather frustrated.  I have had a lot of medical problems including underactive thyroid (now on .3 mg synthroid), asthma and allergy problems with frequent bronchitis, carpal tunnel syndrome, bursitis in various joints, heel spurs, neuropathies, some kind of sleeping disorder (can't sleep without medication) and some kind of connective tissue disease plus fibromyagia is probable.  My TSH remains at 10.4 hence the increase of the synthroid, that dx is not being questioned, but the doc refused to refer me to endocronologist.  My ANA started at 1:640 and has steadily increased...now 2 yrs later it is 1:2560.  However, all other labs are normal (borderline rheumatoid factor) but perfectly normal CBC, blood chemistry, cholesteral, SED rate (ESR), and all additional antibody testing, also lip biopsy was normal, despite dry eyes confirmed by eye doc.  I have a lot of pain and stiff joints, but no swelling nor erosion.  I was on prednisone for 20 months, but am now off completely.  It was a low dose and I still had pain but at least it was tolerable.  Now that I am off all the way, the pain has increased.  It is limiting my ability to exercise, although I have tried to be faithful to the exercise program I set up in January....this week I was physically unable to exercise.  Although I have Ultram, I do not use them....the only med I take to try to control pain is Celebrex, which doesn't seem to work (history of NSAID induced gastric ulcers and colitis precludes the use of most NSAIDS).  There is a lot of stress in my life as a divorced mother of two teenagers and I have a demanding full time job....but I strive to maintain a good attitude and a sense of humor.  I am also experiencing memory problems and what seems to be a decline in cognitive function, which seems to be very slowly progressing.  On occasion I have forgotten my address, my phone, don't recognize familiar routes, lose things constantly, etc.  I am having trouble understanding my children's homework, despite the fact that I should be able to do it.  I have been taking Ambien for 30 days to sleep...so far it is the only thing that has succeeded in increasing nighttime sleep from 1-2 hours to 5-6 hours without increasing daytime sleepiness.
With only the ANA and no confirming labs, my internist refuses to consider the possibility that I have a connective tissue disease.  He does not want me treated for CTD.  He also says fibromyalgia is a non-existent disease...he says it is just made up and that people that have it are psychiatric patients.  He says I should not keep listening to the other doctors....he says they will kill me with all the meds they have either prescribed or talked about.  He says there is no reason I should have such a thick chart, that I have had expensive tests, and everything is normal (he says he puts no value on a pos. ANA).  Therefore he says the only doctor I really need to see is a psychiatrist.
The pain and stiffness I feel are very real, regardless of what this internist says.  I don't understand why, in the light of current rheumatological findings, a ANA at 1:2560 would be dismissed as nothing, and how fibromyagia is totally discounted as being solely psychiatric.  This internist had me change specialists to people he knew, yet when they recommended to continue the same treatment, now he is trying to change it.
I have nothing against psychiatrists.  I was treated by one long ago for clinical depression which was first started following the horrible breakup of my marriage, and they helped me.  I am willing to consider the possibility that depression may be a factor, and that a psychiatrist might be able to help.  However, I am reluctant to completely discount the physical nature of the bulk of my complaints.  If there is depression, or stress related illness, I am much more likely to believe that it is an integral part of a larger physical illness, probably autoimmune, some kind of connective tissue disease....I believe the pain and fatigue may contribute to causing the depression rather than the other way around.  I am interested in knowing your perceptions as to the problems that I am having...and whether it is more likely that a physical problem may contribute to psychiatric, or whether the internist is correct, in which case I should stop my meds, forget about all these other specialists that are trying to treat me (I also am on plaquenil to try to change the course of the autoimmune illness), and just attack the psychiatric problem head on.  I am also interested in knowing your take on some of the newer illnesses and whether they are "real" or not...such as fibromyalgia, and chronic fatigue syndrome.  Thank you for giving me your "spin" on the issue.
Deb




Dear Deb, I can see that you are frustrated with your situation.  Regarding a physical problem contributing to depression, this can certainly happen.  Physical problems for example can sometimes cause people to function less optimally than normal or cause pain, which can lead to stress.  It has been shown that stressors may alter the neurochemicals in the brain, which could lead to depression.  
I can not say whether or not your internist is correct or not regarding your having a conective tissue disease.  Fibromyalgia is a recognized disease and is a form of nonarticular rheumatism.  The core feature is widespread pain and tenderness.  One of the medications shown to be somewhat effective is amitriptyline, a tricyclic antidepressant.  Chronic fatigue syndrome is also a recognized diagnosis and is characterized by debilitating fatigue and other symptoms, many suggestive of Ebstein-Barr virus infection.  The prevalence of psychiatric illness is increaesed considerably in patients with chronic fatigue syndrome although it is not clear whether it has a psychiatric etiology.  
You also described memory problems and decline in cognitive function, which could possibly be symptoms of depression.  The medication you are taking, Ambien, can possibly cause anterograde amnesia the day after taken, which is amnesia after a certain point in time.  These problems should be mentioned to your physician so that the cause of your symptoms can be addressed.
I hope that his information has been helpful for you.  It is provided for educational purposes only and should not replace consultation with your physician.  If you wish to see a mental health professional at Henry Ford Hospital, please call 1-248-689-7476.  
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