How do you differentiate between psychiatric and non-psychiatric symptoms during a follow-up medication management appointment?

Differentiating Psychiatric from Non-Psychiatric Symptoms During Medication Management Follow-Up

The most critical first step is to systematically investigate medical causes through targeted history, physical examination, and selective testing, as 46% of patients with apparent psychiatric symptoms have underlying medical illnesses directly causing or exacerbating their presentation 1.

Structured Assessment Framework

Step 1: Characterize the Symptom Precisely

• Avoid vague descriptors like "agitation" or "confusion" - drill down to specific behaviors, timing, triggers, and fluctuation patterns 1.
• Document temporal relationship to medication changes, including dose adjustments, new medications, or missed doses 2.
• Assess for fluctuating course and acute onset, which strongly suggests delirium or medical etiology rather than primary psychiatric illness 1.
• Determine level of consciousness and attention - intact awareness with psychotic symptoms suggests primary psychiatric disorder, while altered consciousness points to medical causes 1.

Step 2: Investigate Medical Contributors Systematically

Medication Review (Highest Yield)

• Compile complete medication list including over-the-counter drugs and supplements by having patients bring in bottles 1.
• Identify anticholinergic medications and drugs with CNS effects that commonly cause psychiatric symptoms 1.
• Consider pregabalin (Lyrica) accumulation in patients with renal impairment, as this causes reversible mental status changes 2.
• Evaluate for drug interactions and polypharmacy effects, particularly in elderly patients 2.

Targeted Medical Workup

• History and physical examination have 94% sensitivity for identifying medical causes and should focus on 2:

  • Pain assessment (uncontrolled pain frequently manifests as agitation) 1
  • Infection symptoms (UTI, pneumonia) 1
  • Constipation and dehydration 1
  • Sensory impairments (vision, hearing) 1

• Selective laboratory testing based on clinical findings 1:

  • Metabolic panel (glucose, electrolytes, renal function) 1
  • Complete blood count 1
  • Urinalysis (especially in elderly with behavioral changes) 1
  • Routine screening labs without clinical indication have low yield (only 0.8-1.4% contribute meaningfully to diagnosis) 1

Patient-Specific Factors

• Evaluate pre-existing psychiatric conditions (schizophrenia, bipolar disorder) that may require optimization of existing regimens 1.
• Assess functional limitations and cognitive severity that may contribute to behavioral symptoms 1.
• Consider sleep hygiene as poor sleep exacerbates both psychiatric and behavioral symptoms 1.

Step 3: Distinguish Primary Psychiatric from Secondary Medical Presentations

Features Suggesting Medical/Non-Psychiatric Etiology

• Acute onset with fluctuating course throughout the day with lucid intervals 1.
• Inattention as cardinal feature (cannot maintain focus during examination) 1.
• Temporal correlation with medication changes or medical events 2.
• Improvement when medication doses are missed or reduced 2.
• New onset psychosis in elderly without psychiatric history warrants thorough medical workup 1.
• Somatic delusions may indicate specific conditions like C9orf72 mutations 1.

Features Suggesting Primary Psychiatric Disorder

• Intact level of consciousness and awareness despite psychotic symptoms 1.
• Presence of concern or insight about symptoms (though absent in severe psychosis/mania) 1.
• Consistent symptom pattern without fluctuation 1.
• History of similar episodes with psychiatric diagnosis 1.
• Depressed mood, suicidal ideation, or specific mood symptoms captured by structured scales like MADRS 1.

Step 4: Environmental and Caregiver Factors (Especially in Dementia)

• Assess caregiver communication style - harsh tones, complex commands, and unrealistic expectations exacerbate behavioral symptoms 1.
• Evaluate environmental triggers - overstimulation, understimulation, safety hazards, lack of routine 1.
• Identify caregiver misattributions - belief that patient is "doing this on purpose" indicates need for education 1.
• Pain during caregiving activities (bathing, transfers) commonly manifests as aggression 1.

Critical Pitfalls to Avoid

• Do not assume psychiatric symptoms are purely psychiatric - 46% have medical causes, and 28% have complete resolution with medical treatment 1.
• Do not order routine screening labs without clinical indication - false positives (8 times more common than true positives) lead to unnecessary workups 1.
• Do not miss medication-induced delirium - this is often reversible unlike other causes 2.
• Do not overlook pain as a cause of behavioral symptoms, especially in patients with limited verbal communication 1.
• Do not proceed with psychiatric treatment without addressing medical contributors first 1.

Practical Algorithm for Follow-Up Visits

1. Review medication changes since last visit - new medications, dose adjustments, adherence issues 2.
2. Characterize symptom timeline - acute vs. chronic, fluctuating vs. stable, triggers identified 1.
3. Perform targeted physical assessment - vital signs, pain evaluation, neurological signs 1, 2.
4. Order selective labs only if clinically indicated by history/exam findings 1.
5. Consider diagnostic trial - temporarily reduce or discontinue suspect medication if safe 2.
6. Address medical issues first - treat pain, infection, constipation, dehydration before escalating psychiatric medications 1.
7. Optimize existing psychiatric regimen if underlying psychiatric disorder confirmed 1.
8. Refer for specialized evaluation if diagnostic uncertainty persists despite workup 2.