Medical Misogyny or Following the Differential Dx?

Medscape

2 days ago

I recently presented a clinical scenario of a young woman who presented with fatigue and had a long history of nightmares. I was concerned that she might have posttraumatic stress disorder (PTSD), and I asked readers whether they agreed with my management of this patient.
Thank you for the comments on this case. The majority of the comments focused on a workup for the patient's symptoms beyond mental illness, which is completely appropriate for this patient. First, a targeted history should be completed to include the following elements:
Menstrual history to evaluate the possibility of anemia due to irregular menses and pregnancy
Cold intolerance or skin and hair changes, as a potential sign of hypothyroidism
Any alterations in appetite and diet, which could indicate disordered eating and/or a possible vitamin deficiency
Medication use, including supplements
Substance use
I would also recommend the following basic laboratory evaluation:
Other labs may be ordered, as needed, based on the patient's targeted history.
But adding all those elements to this case would yield quite a lengthy document to read online! And of course, there are always more questions to ask of patients and more studies to be ordered, but the pressure of time in primary care dictates that we be judicious with our fact-gathering.
Although my decision to ask the patient about past events that might relate to her fatigue and bad dreams was the most popular answer selected in the reader poll, some commenters disagreed with my approach. I was surprised by multiple comments that suggested my consideration of a potential psychological disorder would be considered patronizing or offensive to this patient, and one commenter recommended 'physiology before psychiatry.' I respectfully disagree.
First, a mental health or sleep disorder is at the top of the differential diagnosis of an otherwise healthy young woman with fatigue. When a physician fails to address a potential mental health disorder for fear of offending said patient, they risk delayed diagnosis, worsening symptoms, diminished treatment options, and a breakdown of trust in her care, all of which could have devastating consequences. As mentioned in my original article, PTSD negatively affects multiple domains of function and is associated with an increased risk for suicide.
I completely understand that patients can feel marginalized by the idea of a mental health diagnosis. And it's entirely understandable that a woman presenting with persistent fatigue might fear that a psychological explanation simply repeats historical patterns of medical sexism; after all, attributing women's health complaints to 'hysteria' is a real historical wrong. Yet when that same fatigue is coupled with a decade-long history of recurring nightmares — symptoms strongly suggestive of an underlying mood or stress ‐ related disorder — a thoughtful clinician must expand the differential diagnosis to include those possibilities. By transparently describing how each symptom fits into a broader clinical picture, the doctor honors the patient's concerns and makes a diagnosis based on comprehensive evidence, not gender bias.
In responsible practice, a physician uses validated screening questions, explains the medical rationale clearly, and invites open dialogue with the patient (at their own pace). That way, mental health issues are assessed objectively, based on clinical need and symptom presentation. We, as a society, need to move away from stigmatizing mental health diagnoses, and that starts with the patient encounters we have every day.
There is no reason that mental health diagnoses should be placed at some level below other diagnoses. Mental health diagnoses incur significant amounts of morbidity and are risk factors for other diseases, such as coronary heart disease. Patients who are diagnosed with mental health disorders should not feel any different from patients with a diagnosis of type 2 diabetes or rheumatoid arthritis.
It is up to us, as clinicians, to lead insightful, evidence-based, empathic evaluations of our patients to accurately diagnose their conditions and treat them appropriately. I hope that this case reminds you of that calling.