In Defense of Zebras
Sometimes, when physicians hear that there may be a tick-borne cause for the mental symptoms of one of their patients, it prompts a lecture - perhaps an attempt to be helpful. A favorite strategy is the recounting of amusing old medical proverbs: "You know, when you hear hoof beats, you should look first for horses, not zebras," or, "Remember, if you hear barking it usually turns out to be dogs and not foxes."
What really is implied by the lecturer is that, while the evidence is clear to this psychiatrist that someone's brain and nervous system are on fire from chronic tick-borne infections, it ought to be kept in mind that people have had "nerves" since the beginning of time. The use of the maxims suggest that there is no sense in speculating that some new, rare, or exotic cause (hear Lyme disease, ehrlichiosis, and babesiosis, amongst others) is needed to explain a patient's symptoms. Nor is it worth considering the possibility of tick-borne cerebral vasculitis or encephalitis that is suspected by the psychiatrist.
One of the problems with being amused at the zebra-deficiency of many doctors nowadays is that what used to be thought unusual and exotic - late stage tick-borne diseases - is now commonplace. It seems that many doctors are so used to seeing "horses" and "dogs" that they have zebra blind spots and CAN'T see "zebras" at all, despite being surrounded by them and by some "foxes" as well. Perhaps scheduling pressures from managed care/HMOs have led to the substitution of rigid dogma for the medically investigative mindsets of yesteryear. This change sacrifices physicians' abilities to attend to their patients with open-minded medical curiosity. "I will always follow Dr. X's lead in the diagnosis and treatment of Lyme disease because he will always be right." These words were actually spoken by a noted infectious disease lecturer to the staff and medical students of a local teaching hospital.
Taking the time to listen to their patients with real curiosity intact would enable doctors to see that we now are, infiltrated by entire herds of "zebras" and "foxes." They could witness that in the immense geographic areas infested with infected ticks, it is much less common than it used to be to find a "horse" or a "dog" in the diagnostic pasture.
Actually, the fact is that widespread, chronic tick-borne diseases (TBDs) can cause or stir up and precisely imitate almost every problem in the medical encyclopedia in the very people who, having no ideas of them-selves as being infected, are waiting, undiagnosed, in these doctors' offices. The enormity of this concept is overwhelming for physicians, generally.
The most difficult thing for doctors to understand may be the fact that any emotional, behavioral, or mental symptom may be a "zebra" related to, for example, Lyme disease. Should they become open to the concept, there are some tip-offs that are so easy and obvious that every doctor, (psychiatrists especially), social worker, nurse, cleric and psychologist should paste them under a photo of a zebra on the wall over their telephone.
In the original call for help, one can hear the special sense of urgency of a patient with chronic TBD. Whether they are calling about themselves or a loved one, they often are desperate. What one also needs to listen for in the adult is a history of a PERSONALITY CHANGE. When a spouse says that his/her usually reasonable mate has broken down the bathroom or the screen door in a rage and that they have never acted that way before, it's time to think of "zebras."
When the caller mentions that his mate was always a good housekeeper but now is spending three hours a day scrubbing a perfectly clean floor, "zebras" should come to mind.
When one asks patients to say a few words about their physical health, and if they first say they are physically well but then go on to mention their many unusual physical problems, one needs to listen for hoof beats.
Patients may volunteer that they had no intention of talking about their physical symptoms because these problems have made no medical sense. The bizarre, fluctuating, shifting symptoms are interpreted as embarrassing examples of "hypochondriasis" and anxiety. It seems then that the doctor might hear a distant neighing.
When someone in an endemic area says on the phone that he or she has been diagnosed for the first time as having panic attacks and they fear they are going to go out of their minds, one must not think of "horses" so quickly these days. The most likely cause of Panic Disorder in the area of this Pennsylvania psychiatric office, an area that is loaded with nearly invisible nymphal deer ticks of which up to 94% may be infected, is Lyme disease and its co-infections, primarily babesiosis and ehrlichiosis. In the old days, a panic attack was serious enough, but it did not have the same quality of desperation and immediacy that is manifest today. And the panic attacks from chronic, neurologic TBDs are prolonged-often outlasting the duration usually associated with the historic Panic Disorder. Another clue to the origin of spirochetal panic is the presence of symptoms (an example would be joint pains) that do not usually accompany the classical panic attack.
In the past, people were willing to agree that their ER doctor was probably right - that this was "just" an emotional problem. Generally, this is not what is heard from the sufferers of panic attacks from chronic TBDs. They come to the office because they have been told that they should see a psychiatrist, but they keep saying, quite correctly, "I know that there is something physically wrong with me." These hoof beats may carry something striped one could think to oneself.
When depressed persons call in, it is always important to ask up front if they are aware of any outstanding physical symptoms. Usually, now one will hear about insomnia - not rare in depression - but such a TOTAL insomnia! And then, for example, it comes out about the night sweats and the strange episode in which the face, throat, eyelid, tongue, or limb wouldn't wait right. The troublesome symptom may have gone away, but the worry remained that this had been a partial stroke leaving the patient exhausted and feeling as if he is probably doomed to fall apart. Thus, the first clues occur even before one meets the adult patient in person. They are the hints of desperate fear - even terror, fatigue, road or other rages, extreme marital discord, general irritability, a Tourette's-like tendency to spew abusive words, obsessions, aggression, phobias, compulsions, weakness, memory impairments, and/or weird shifting pains. But they always involve a major PERSONALITY CHANGE. As an example, Lyme-infected adults with strange memory impairments usually were well known for their efficiency before they developed major cognitive organizational handicaps from their infections and began to avoid the newly stressful tasks and responsibilities.
When the patient is due to be in the office, the doctor frequently will observe the first concrete evidence of brain involvement; typically, most new Lyme patients get very lost on the way to the office, even despite having been given careful directions beforehand. Psychiatrists usually start sessions about on time, but it is not rare that new patients will arrive, lost and frustrated, after the session time is over, and they may be in a state of fury. They struggle to hide this, but often they are furious because lateness is not their usual style and they can't make sense of why they are not on time. It does not seem fair to them and they are overwhelmed.
So, in the first interview one may get a discomforting experience with the cognitive problems and the irritability. Often, suggesting to new patients that they need sophisticated testing for TBDs stirs up anger, too. Not so much for the cost, but because they tend to feel that there hasn't been enough attention paid to their oven analysis as to why they are there. Some undiagnosed people come to see a psychiatrist because, eager to make sense out of their confusing symptoms, they decide they must have arisen in response to the anniversary of a loved one's death long ago, or that they may be reliving an old trauma, or that it is due to marital stresses, or to their doctor-documented hypochondriasis. However, these factors are too simple to explain the plethora of symptoms. Office experience may teach the doctor that any stress can stir up the effects of the spirochete Borrelia burgdorferi, the cause of Lyme disease, as well as the infection is able to magnify the old stresses. If the patient proceeds with anti-microbial treatment, the past trauma fades to greater obscurity.
Of course, it is vital to care about the patients opinions, but it is more important to keep in mind that they are not going to get well until any underlying infections are properly diagnosed and treated as quickly as possible.
Maybe the analogy about hoof beats could be utilized in a positive way. Imagine the impact of Dr. Paul Revere riding on a zebra, carrying an early warning system to arouse the citizenry to be on the alert for a forthcoming assault on their nervous systems by tick-borne infections.