Misdiagnosing POTS As Psychiatric Disorders

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Misdiagnoses in the medical world are quite common especially if the medical officer in charge is not familiar with the patient's presentation (signs and symptoms related to their illnesses).

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It has been planted deep inside the thought process of a medical doctor regarding steps in diagnosis and if everything seems off (every symptom didn't account for any specific medical condition), they should have referred such patients to the psychiatric department (the symptoms might have been psychosomatic) after a thorough investigation. This would mean that people who were having psychiatric condition might have been subjected to various procedures and frequently deal with frustration due to being diagnosed differently in every visit. In this article, I would like to emphasise a few things about misdiagnosis specifically related to the Postural Orthostatic Tachycardia Syndrome (POTS) which is usually known as the Orthostatic Intolerance and how it can affect the patient.

Let's Talk About Mrs T

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Now, Mrs T has been suffering from an unknown disease for a very significant amount of times. There were a couple of standard gastrointestinal symptoms like abdominal pain and nausea but the main complaint is a headache which would become worse when she was standing up. It is up to the level of fainting but usually compensated by a quick reaction of sitting that would calm her down. Diagnosing something which we are not familiar with, especially if the symptoms weren't manifested as physical, is difficult. Misdiagnoses are relatively common when we are trying to figure out what kind of disease the patient is having, and when we were approaching the land of the unknown, treatment and management quickly turn experimental.

Mrs T was only 23 when she went to a doctor for treatment and after a detail history taking, the doctor (which is kinda confused about the patient's presentation) asked whether Mrs T has been referred to a psychiatrist before. The doctor started to fell the symptoms experienced by Mrs T was, in fact, a form of somatisation (psychological problems which are manifested as physical symptoms). You must have experienced this at least once in your life when you were experiencing backache during a stressful situation; well, that's a form of somatisation and I would say a mild one. There were a few known cases which resulted in transient complete paralysis of the upper or lower limbs or even transient reversible blindness as a result of stress which is reversible if the stress level reduces. The diagnosis is called "Conversion Disorder" and it is, to any patient, one form of a hellish experience.

The doctor (who treat Mrs T) was actually good but he was certainly missed diagnosing which is pretty much different from misdiagnosing. What's the difference? The diagnosis was not yet established. If he had confirmed the diagnosis by documenting it, discharge the patient with a couple of anti-depressants, then, it is a misdiagnosis. Mrs T however, was very persistent. She insisted on retesting and thank god, she did because later, after a series of test which involved taking her blood pressure while she was sitting and standing, compare the value, she was diagnosed with Postural Orthostatic Tachycardia Syndrome (POTS). It is a group of abnormal symptoms manifested by patients due to the changes in gravity. It's like Benign Paroxysmal Positional Vertigo in which you were experiencing some sort of spinning sensation when you were changing your head as a result of abnormal functions assumed by one of the organs in the ear which are responsible to align any sort of gravity-dependant movement with the head (like when lying down).

Gravity is a bitch but with healthy and fully functional organ systems, we are shielded from any damaging sensation caused by gravity. Having POTS really affected Mrs T quality of life. She stopped going to work because let's face it, it will be difficult for her to move around and sitting in the wheelchair only make her prone to social and workplace stigma which eventually cause other kinds of problems like ostracisation, depression and anxiety.

Psychological Effect and The Quality Of Life Of People With POTS

In the psychiatric department, we have all kind of survey forms which are created to check patient's risk towards developing a specific kind of illness. For example, Beck Depression Inventory is a multiple choice, self-reported questionnaires which are been given to the patient to access their mental state health on the day of their visit to the clinic. It's not always accurate but it does help in giving some sort of the first impression regarding how does the patient feel for the past couple of days/weeks/months so that the direction of discussion can be determined by a psychiatrist. In 2009, a psychiatric profile was conducted on 21 POTS patients trying to identify any sort of psychiatric problems specifically anxiety and major depressive disorder by using some criteria documented in DSM-IV (which is considered the latest in 2009).

Anonymous - Wikimedia (CC0)

They might seem anxious waiting in numerous clinics, hoping for a definite diagnosis but after they have been diagnosed, the anxiety level is high but not pathological. The only thing which is discovered among them which can be considered as a form of disability is inattentiveness. They have low attention threshold making it difficult for them to function normally especially if their daily activities required them to be so. It is practically debilitating especially if they were students which usually required to have a certain level of attentiveness in order to be able to accomplish certain tasks. People with POTS were especially anxious if they didn't know what's wrong with them. This can lead to frustration and doctor-shopping behaviour which is usually manifested among people with illness anxiety disorder. In 2014, a study conducted by Singh H. et al have found that every year, at least 12 million adults that were living in the United State were misdiagnosed. It is a relatively big figure and can potentially lead to a few harmful conditions or illnesses.

You Me - Flickr (CC BY 2.0)

One of the major problems imposed by POTS which affect the quality of life of patients is sleep. They weren't able to sleep adequately (7-9 hours per day) which can lead to agitation, fatigue and daytime somnolence. In 2002, Benrud et al. demonstrated a study which measures the quality of life of people with POTS and compared them with the quality of life of people who were diagnosed with congestive heart failure. They were almost similar! There were a few domains tested which include:

• Physical, social and role functioning
• Pain score
• General state of health
• Vitality

All of them were impaired and relatively similar to patients that were having heart problems. This is particularly serious consequences and patients should be diagnosed and treated well. Numerous sleep studies have demonstrated below-average results when comparing the quality of sleep between patients with POTS and the general healthy population.

Management of POTS

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Like what has been discussed in my previous articles, management contained two important steps which are investigations and treatment modalities. Standard workups such as full blood count, renal and liver function tests should be carried out to screen any other pathologies which might have been causing symptoms in patients. Patients with POTS were often confused with a patient who was having a disease called the phaeochromocytoma; I would discuss it tomorrow if I weren't busy with works. An electrocardiogram can be a useful tool to rule out cardiac abnormalities as patient with POTS often presented with tachycardia (it can be due to POTS or anxiety of having POTS). There were a few other tests that can be carried out like measuring the amount of norepinephrine in the supine (lying down) and standing position to demonstrate abnormalities in neural sympathetic tones, but it is rarely carried out.

There were a few non-pharmacological approaches but most of the time, medical officers would focus more on exercise. Patients are required to perform a few postural exercise to recondition themselves with upright posture. For some patients, there might be some sort of debilitating effects after the exercise regime but in a long-term, a study conducted by Fu et al in 2010 has found that it will improve patient's autonomic functions thus a chance at a complete cure. Patients might become demotivated at first but later they would feel better; it is important for them to have a good support system that could motivate and push them further, towards recovery; in the case of Mrs T, she was supported by her husband. Oh yeah, as most of POTS patients would be bed-bounded, they were required to wear a pair of Thrombo-Embolic-Deterrent (TED) stockings to prevent blood clots.

There was no known pharmacological treatment which has been approved by the FDA to treat this condition. Most of the drugs catered for this condition were experimental and some doctors just treated symptoms while encouraging patients to exercise more as currently, it is one of the most effective treatment.

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Sources

• This Mysterious Blood-Flow Disorder Is Often Misdiagnosed As Depression
• A doctor said it was all in her head, but it was 'the most common condition you've never heard of'
• The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations
• Postural Tachycardia Syndrome (POTS)
• Quality of life in patients with postural tachycardia syndrome.
• Cardiac origins of the postural orthostatic tachycardia syndrome.
• Psychiatric profile and attention deficits in postural tachycardia syndrome.

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