Patients with mental complaints or concerns or disordered behavior present in a variety of clinical settings, including primary care and emergency treatment centers. Complaints or concerns may be new or a continuation of a history of mental problems. Complaints may be related to coping with a physical condition or be the direct effects of a physical condition on the brain. The method of assessment depends on whether the complaints constitute an emergency or are reported in a scheduled visit. In an emergency, a physician may have to focus on more immediate history, symptoms, and behavior to be able to make a management decision. In a scheduled visit, a more thorough assessment is appropriate.
Medical assessment of patients with mental symptoms seeks to identify 3 things:
Physical disorders mimicking mental disorders
Physical disorders caused by mental disorders or their treatment
Physical disorders accompanying mental disorders
Numerous physical disorders cause symptoms that mimic specific mental disorders (see table Selected Mental Symptoms Due to Physical Disorders). Other physical disorders may not mimic specific mental syndromes but instead have an impact on mood and energy.
Many drugs cause mental symptoms; the most common classes of drug causes are
Central nervous system–active drugs (eg, antiseizure drugs, antidepressants, antipsychotics, sedative/hypnotics, stimulants)
Anticholinergics (eg, antihistamines)
Corticosteroids
Numerous other therapeutic drugs and drug classes have also been implicated; they include some classes that may not ordinarily be considered (eg, antibiotics, antihypertensives). Drugs of abuse, particularly alcohol, amphetamines, marijuana (cannabis), , hallucinogens, and phencyclidine (PCP), particularly in overdose, are also frequent causes of mental symptoms. Withdrawal from alcohol, barbiturates, or benzodiazepines may cause mental symptoms (eg, anxiety) in addition to symptoms of physical withdrawal.
Patients with a mental disorder may develop an unrelated physical disorder (eg, meningitis, diabetic ketoacidosis) that causes new or worsened mental symptoms. Thus, a clinician should not assume that all mental symptoms in patients with a known mental disorder are due to that disorder. The clinician may need to be proactive in addressing possible physical causes for mental symptoms, especially in patients unable to describe their physical health because they have psychosis or dementia.
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Patients presenting for psychiatric care occasionally have undiagnosed physical disorders that are not the cause of their mental symptoms but nonetheless require evaluation and treatment. Such disorders may be unrelated (eg, hypertension, angina) or caused by the mental disorder (eg, undernutrition due to lack of motivation to eat resulting from chronic schizophrenia) or its treatment (eg, hypothyroidismhyperlipidemia secondary to atypical antipsychotics).
Evaluation
Medical assessment by history, physical examination, and often brain imaging and laboratory testing (1) is required for patients with
New-onset mental symptoms (ie, no prior history of similar symptoms)
Qualitatively different or unexpected symptoms (ie, in a patient with a known or stable mental disorder)
Mental symptoms that begin at an unexpected age (eg, new-onset psychosis in an older person)
The goal of medical assessment is to diagnose underlying and concomitant physical disorders rather than to make a specific psychiatric diagnosis.
History
History of present illness should note the nature of symptoms and their onset, particularly whether onset was sudden or gradual and whether symptoms followed any possible precipitants (eg, trauma, illness, starting or stopping of a drug or substance). The clinician should ask whether patients have had previous episodes of similar symptoms, whether a mental disorder has been diagnosed and treated, and, if so, whether patients have stopped taking their drugs.
Review of systems seeks symptoms that suggest possible causes:
Vomiting, diarrhea, or both: Dehydration, electrolyte disturbance
Palpitations: Hyperthyroidism, drug effects including withdrawal
Polyuria and polydipsia: Diabetes mellitus
Tremors: Parkinson disease, withdrawal syndromes
Difficulty walking or speaking: Multiple sclerosis, Parkinson disease, stroke
Headache: Central nervous system (CNS) infection, complex migraine, hemorrhage, mass lesion
Fever, cough, dysuria, vomiting, or diarrhea: Systemic infection
Weight loss: Infection, cancer, inflammatory bowel disease, hyperthyroidism
Paresthesias and weakness: Vitamin deficiency, stroke, demyelinating disease
Relapsing and remitting neurologic symptoms: Multiple sclerosis, vasculitis
Past medical history should identify known physical disorders that can cause mental symptoms (eg, thyroid, liver, or kidney disease; diabetes; HIV or COVID-19 infection). All prescription and over-the-counter drugs should be reviewed, and patients should be queried about any alcohol or illicit substance use (amount and duration). Family history of physical disorders, particularly of thyroid disease and multiple sclerosis, is assessed. Risk factors for infection (eg, unprotected sex, needle sharing, recent hospitalization, residence in a group facility) are noted.
Physical examination
Vital signs are reviewed, particularly for fever, tachypnea, hypertension, and tachycardia. Mental status is assessed, particularly for signs of confusion or inattention.
A full physical examination is done, although the focus is on
Signs of infection (eg, meningismus, lung congestion, flank tenderness)
The neurologic examination (including gait testing and weakness)
Funduscopy to detect signs of increased intracranial pressure (eg, papilledema, loss of venous pulsations)
Signs of liver disease (eg, jaundice, ascites, spider angiomas) should be noted. The skin is carefully inspected for self-inflicted wounds or other evidence of external trauma (eg, bruising).
Interpretation of findings
The findings from the history and physical examination help interpret possible causes and guide testing and treatment.
Confusion and inattention (reduced clarity of awareness of the environment, suggesting delirium), especially if of sudden onset, fluctuating, or both, indicate the presence of a physical disorder. However, the converse is not true (ie, a clear sensorium does not confirm that the cause is a psychiatric disorder). Other findings that suggest a physical cause include
Abnormal vital signs (eg, fever, tachycardia, tachypnea)
Meningeal signs and symptoms (eg, headache, photophobia, neck rigidity)
Abnormalities noted during the neurologic examination, including aphasia
Disturbance of gait, balance, or both
Incontinence
Some findings help suggest a specific cause, especially when symptoms and signs are new or have changed from a long-standing baseline:
Dilated pupils (particularly if accompanied by flushed, hot, dry skin): Anticholinergic drug effects
Constricted pupils: Opioid drug effects or pontine hemorrhage
Rotary or vertical nystagmus: Phencyclidine intoxication
Horizontal nystagmus: Often accompanies diphenylhydantoin toxicity
Garbled speech or inability to produce speech: A brain lesion (eg, stroke)
A preceding history of relapsing-remitting neurologic symptoms, particularly when a variety of nerves appear to be involved: Multiple sclerosis or vasculitis
Stocking-glove paresthesias: Possibly thiamin or vitamin B12 deficiency
In patients with hallucinations, the type of hallucination is not particularly diagnostic except that command hallucinations or voices commenting on the patient’s behavior probably represent a mental disorder.
Symptoms that began shortly after significant trauma or after beginning a new drug may be due to those events. Drug or alcohol use may or may not be the cause of mental symptoms; about 10 to 45% of patients with a mental disorder (varies by diagnosis) also have a substance use disorder (dual diagnosis).
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Interpretation of findings reference
1. Toftdahl NG, Nordentoft M, Hjorthøj C: Prevalence of substance use disorders in psychiatric patients: A nationwide Danish population-based study. Social psychiatry and psychiatric epidemiology. Soc Psychiatry Psychiatr Epidemiol 51(1):129-140, 2016. doi: 10.1007/s00127-015-1104-4.
Testing
Testing varies depending on signs and symptoms. If patients with a known mental disorder have an exacerbation of their typical symptoms and they have no medical complaints, a normal sensorium, and a normal physical examination (including vital signs, pulse oximetry, and fingerstick glucose testing), they do not typically require further laboratory testing other than perhaps measurement of therapeutic drug levels.
Although new onset mental symptoms or marked change in the nature of symptoms in patients with a known mental disorder may be due to a medical rather than mental disorder, it is unclear how commonly such a disorder is asymptomatic and there is no consensus on routine laboratory testing of medically asymptomatic patients. Some clinicians do one or more of the following to screen for potential disorders:
Complete blood count
Erythrocyte sedimentation rate or C-reactive protein
Urinalysis
Electrolyte and renal function tests may be diagnostic and help inform subsequent drug management (eg, for drugs that require adjustment in patients with renal insufficiency).
Patients with signs or symptoms of a medical disorder should have testing appropriate to diagnose that disorder:
Head CT: Patients with new-onset mental symptoms or with delirium, headache, history of recent trauma, or focal neurologic findings (eg, weakness of an extremity)
Lumbar puncture: Patients with meningeal signs or with normal head CT findings plus fever, headache, or delirium
> 40 years with new-onset mental symptoms (particularly females or patients with a family history of thyroid disease)
Chest x-ray: Patients with low oxygen saturation, fever, productive cough, or hemoptysis
Blood cultures: Seriously ill patients with fever
Liver tests: Patients with symptoms or signs of liver disease, with a history of alcohol or drug use disorder, or with no obtainable history
Less often, findings may suggest testing for systemic lupus erythematosus, syphilis, demyelinating disorders, Lyme disease, or vitamin B12 or thiamin deficiency, especially in patients presenting with signs of dementia.
Toxicology screening (eg, urine drug screen, blood alcohol level) is done if the patient has a recent history of substance use disorder or physical signs suggesting intoxication or recent drug use (eg, needle marks).
Evaluation reference
1. Anderson EL, Nordstrom K, Wilson MP, et al: American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults: Part I: Introduction, review and evidence-based guidelines. West J Emerg Med 18 (2):235–242, 2017. doi: 10.5811/westjem.2016.10.32258.
