Physical Illness and Psychiatric Disorder

Confronted with a patient who has a mental disorder, the psychiatrist must decide whether a medical, surgical, or neurological condition may be the cause. Once the physician is satisfied that no disease process can be held accountable, then the diagnosis of mental disorder not attributable to a medical illness can be made. Although psychiatrists do not perform routine physical examinations on their patients, a knowledge and understanding of physical signs and symptoms is part of their training, which enables them to recognize signs and symptoms that may indicate possible medical or surgical illness. For example, palpitations may be associated with mitral valve prolapse, which is diagnosed by cardiac auscultation. Psychiatrists are also able to recognize and treat the adverse effects of psychotropic medications, which are used by an increasing number of patients seen by psychiatrists and nonpsychiatric physicians.

Some psychiatrists insist that every patient have a complete medical workup; others do not. Whatever their policy, psychiatrists should consider patients’ medical status at the outset of a psychiatric evaluation. Psychiatrists must often decide whether a patient needs a medical examination and, if so, what it should include—most commonly, a thorough medical history, including a review of systems, a physical examination, and relevant diagnostic laboratory studies. A study of 1,000 medical patients found that in 75 percent of cases no cause of symptoms (i.e., subjective complaints) could be found, and a psychological basis was assumed in 10 percent of those cases.

HISTORY OF MEDICAL ILLNESS

In the course of conducting a psychiatric evaluation, information should be gathered about known bodily diseases or dysfunctions, hospitalizations and operative procedures, medications taken recently or at present, personal habits and occupational history, family history of illnesses, and specific physical complaints. Information about medical illnesses should be gathered from the patient, the referring physician, and the family if necessary.

Information about previous episodes of illness may provide valuable clues about the nature of the present disorder. For example, a distinctly delusional disorder in a patient with a history of several similar episodes that responded promptly to diverse forms of treatment strongly suggests the possibility of substance-induced psychotic disorder. To pursue this lead, the psychiatrist should order a drug screen. The history of a surgical procedure may also be useful; for instance, a thyroidectomy suggests hypothyroidism as the cause of depression.

Depression is an adverse effect of several medications prescribed for hypertension. Medication taken in a therapeutic dose occasionally reaches high concentrations in the blood. Digitalis intoxication, for example, may occur under such circumstances and result in impaired mental functioning. Proprietary drugs may cause or contribute to an anticholinergic delirium. Therefore, the psychiatrist must inquire about over-the-counter remedies as well as prescribed medications. A history of herbal intake and alternative therapy is essential in view of their increased use.

An occupational history may also provide essential information. Exposure to mercury may result in complaints suggesting a psychosis, and exposure to lead, as in smelting, may produce a cognitive disorder. The latter clinical picture can also result from imbibing “moonshine” whiskey with a high lead content.

In eliciting information about specific symptoms, the psychiatrist brings medical and psychological knowledge into full play. For example, the psychiatrist should elicit sufficient information from the patient complaining of headache to predict whether the pain results from intracranial disease that requires neurological testing. In addition, the psychiatrist should be able to recognize that the pain in the right shoulder of a hypochondriacal patient with abdominal discomfort may be the classic referred pain of gallbladder disease.

REVIEW OF SYSTEMS

A review of systems is performed by many psychiatrists as part of the initial workup. It often yields information that relates to the patient’s psychiatric complaint.

An inventory by systems should follow the open-ended inquiry. The review may be organized according to organ systems (e.g., liver, pancreas), functional systems (e.g., gastrointestinal), or a combination of the two, as in the following outline. In all cases, the review should be comprehensive and thorough. Even if a psychiatric component is suspected, a complete review of systems may still be indicated.

Head

Many patients give a history of headache; its duration, frequency, character, location, and severity should be ascertained. Headaches often result from substance abuse, including alcohol, nicotine, and caffeine. Vascular (migraine) headaches are precipitated by stress. Temporal arteritis causes unilateral
throbbing headaches and may lead to blindness. Brain tumors are associated with headaches as a result of increased intracranial pressure, but some may be silent for long periods, the first signs being a change in personality or cognition. A head injury can result in subdural hematoma and in boxers can cause progressive dementia with extrapyramidal symptoms. The headache of subarachnoid hemorrhage is sudden, severe, and associated with changes in the sensorium. Normal pressure hydrocephalus can follow a head injury or encephalitis and be associated with dementia, shuffling gait, and urinary incontinence. Dizziness occurs in up to 30 percent of persons, and determining its cause is challenging and often difficult. A change in the size or shape of the head may be indicative of Paget’s disease.

Eye, Ear, Nose, and Throat

Visual acuity, diplopia, hearing problems, tinnitus, glossitis, and bad taste are covered in this area. A patient taking antipsychotics who gives a history of twitching about the mouth or disturbing movements of the tongue may be in the early and potentially reversible stage of tardive dyskinesia. Impaired vision may occur with thioridazine (Mellaril) in high doses (greater than 800 mg a day). A history of glaucoma contraindicates drugs with anticholinergic effects. Aphonia may be hysterical in nature. The late stage of cocaine abuse can result in perforations of the nasal septum and difficulty breathing. A transitory episode of diplopia may herald multiple sclerosis. Delusional disorder is more common in hearing-impaired persons than in those with normal hearing. Complaints of bad odors may be a symptom of temporal lobe epilepsy rather than schizophrenia. Blue-tinged vision may occur transiently when using sildenafil (Viagra) or similar drugs. The teeth of patients with bulimia can be etched as a result of acid vomitus.

Respiratory System

Cough, asthma, pleurisy, hemoptysis, dyspnea, and orthopnea are considered in this section. Hyperventilation is suggested if the patient’s symptoms include all or a few of the following: onset at rest, sighing respirations, apprehension, anxiety, depersonalization, palpitations, inability to swallow, numbness of the feet and hands, and carpopedal spasm. Dyspnea and breathlessness may occur in depression. In pulmonary or obstructive airway disease, the onset of symptoms is usually insidious, whereas in depression, it is sudden. In depression, breathlessness is experienced at rest, shows little change with exertion, and may fluctuate within a matter of minutes; the onset of breathlessness coincides with the onset of a mood disorder and is often accompanied by attacks of dizziness, sweating, palpitations, and paresthesias.

In obstructive airway disease, patients with the mostadvanced respiratory incapacity experience breathlessness at rest. Most striking and of greatest assistance in making a differential diagnosis is the emphasis placed on the difficulty in inspiration experienced by patients with depression and on the difficulty in expiration experienced by patients with pulmonary disease. Bronchial asthma has sometimes been associated with a childhood history of extreme dependence on the mother. Patients with bronchospasm should not receive propranolol (Inderal) because it may block catecholamine-induced bronchodilation; propranolol is specifically contraindicated for patients with bronchial asthma because epinephrine given to such patients in an emergency will not be effective. Patients taking angiotensin-converting enzyme (ACE) inhibitors may develop a dry cough as an adverse effect of the drug. Thiazide diuretics may cause hypokalemia with attendant muscle spasm and generalized weakness that may mimic depression or anxiety.

Cardiovascular System

Tachycardia, palpitations, and cardiac arrhythmia are among the most common signs of anxiety about which the patient may complain. Pheochromocytoma usually produces symptoms that mimic anxiety disorders, such as rapid heartbeat, tremors, and pallor. Increased urinary catecholamines are diagnostic of pheochromocytoma. Patients taking guanethidine (Ismelin) for hypertension should not receive tricyclic drugs, which reduce or eliminate the antihypertensive effect of guanethidine. A history of hypertension can preclude the use of monoamine oxidase inhibitors (MAOIs) because of the risk of a hypertensive crisis if such hypertensive patients inadvertently ingest foods high in tyramine. Patients with a suspected cardiac disease should have an electrocardiogram before tricyclics or lithium (Eskalith) is prescribed. A history of substernal pain should be evaluated, and the clinician should keep in mind that psychological stress can precipitate angina-type chest pain in the presence of normal coronary arteries. Patients taking opioids should never receive MAOIs; the combination can cause cardiovascular collapse. Mitral valve prolapse has been associated with anxiety attacks.

Gastrointestinal System

This area covers such topics as appetite, distress before or after meals, food preferences, diarrhea, vomiting, constipation, laxative use, and abdominal pain. A history of weight loss is common in depressive disorders, but depression may accompany the weight loss caused by ulcerative colitis, regional enteritis, and cancer. Atypical depression is accompanied by hyperphagia and weight gain. Anorexia nervosa is accompanied by severe weight loss in the presence of normal appetite. Avoidance of certain foods may be a phobic phenomenon or part of an obsessive ritual. Laxative abuse and induced vomiting are common in bulimia nervosa. Constipation can be caused by opioid dependence and by psychotropic drugs with anticholinergic side effects. Cocaine or amphetamine abuse causes a loss of appetite and weight loss. Weight gain can occur under stress or in association with atypical depression. Polyphagia, polyuria, and polydipsia are the triad of diabetes mellitus. Polyuria, polydipsia, and diarrhea are signs of lithium toxicity. Some patients take enemas routinely as part of paraphilic behavior, and anal fissures or recurrent hemorrhoids may indicate anal penetration by foreign objects. Some patients may ingest foreign objects that produce symptoms that can only be diagnosed by X-ray.

Genitourinary System

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