How do you differentiate between psychological and psychiatric concerns in a patient's chief complaints?

Differentiating Psychological from Psychiatric Concerns

The distinction between psychological and psychiatric concerns is fundamentally clinical: psychiatric concerns represent medical conditions requiring medical evaluation and treatment (e.g., major depression, schizophrenia, bipolar disorder), while psychological concerns are emotional or behavioral responses to life stressors that don't meet criteria for a psychiatric disorder—and the key to distinguishing them lies in a focused history and physical examination to rule out organic medical causes before attributing symptoms to either category. 1, 2

Primary Assessment Framework

Begin with vital signs and targeted clinical evaluation:

• Abnormal vital signs (fever, tachycardia, hypertension) suggest underlying medical causes masquerading as psychiatric symptoms 2
• History has 94% sensitivity for identifying acute medical conditions in patients presenting with psychiatric complaints 1
• Physical examination adds 51% sensitivity beyond history alone 1

Critical Historical Elements to Elicit

New-onset versus chronic symptoms is the single most important distinction:

• First-time psychiatric presentations have a 63% likelihood of having an underlying medical etiology 1
• Patients with established psychiatric history and stable symptoms are far less likely to have new organic causes 2
• Document whether symptoms represent acute change from baseline or chronic pattern 2

Specific red flags in the history that mandate medical workup:

• Disorientation or altered cognition (60% of confused patients with "psychiatric" complaints had medical causes) 1
• Substance use history (30% had toxicologic etiologies for behavioral changes) 1
• Current medications that could cause psychiatric symptoms 2
• New medical complaints accompanying psychiatric symptoms 1, 2

High-Risk Populations Requiring Enhanced Medical Evaluation

Four groups warrant more extensive medical assessment regardless of presentation: 1, 2

• Elderly patients (≥65 years)
• Patients with substance abuse history
• Patients without prior psychiatric history
• Patients with concurrent medical complaints or lower socioeconomic status

Physical Examination Priorities

Focus on neurologic, cardiac, and respiratory systems: 2

• Comprehensive neurologic examination is the most commonly deficient component of psychiatric evaluations 1
• Mental status examination assessing orientation, cognition, and thought processes 2
• The neurologic exam should be thoroughly documented in every case 2

Laboratory Testing Strategy

Selective testing based on clinical findings, not routine batteries: 1, 2

• Routine laboratory testing carries only 20% sensitivity for organic causes and produces false positives 8 times more often than true positives 1
• In alert, cooperative patients with normal vital signs and noncontributory history/physical examination, routine laboratory testing is not indicated 1
• Laboratory abnormalities not predicted by history and physical examination are exceedingly rare (only 2 cases of mild hypokalemia in one 345-patient series) 1

When to order targeted tests:

• Order tests only when history or physical examination suggests specific medical conditions 1, 2
• Consider thyroid testing in elderly patients with affective disorders 1
• Pregnancy testing in women of childbearing age when clinically indicated 1

Substance Intoxication Considerations

Urine drug screens have limited utility in medical decision-making: 1

• Routine toxicologic screening does not change disposition or management in alert, cooperative patients 1
• Self-reporting has 92% sensitivity for substance use 1
• Clinical judgment about substance use is highly accurate (88% of those admitting use had positive screens) 1
• Some psychiatric facilities require drug screens for admission regardless of clinical utility 1

Alcohol intoxication specifically:

• Acute intoxication impairs valid psychiatric examination and may mimic psychiatric symptoms 1
• As blood alcohol decreases, psychiatric symptoms (particularly suicidality) often resolve 1
• Most psychiatric facilities will not accept intoxicated patients 1

Medical Conditions That Mimic Psychiatric Disorders

Common organic causes to consider: 2

• Neurologic disorders (CNS tumors, seizures, delirium) 3
• Metabolic/endocrine disorders (thyroid disease, hypoglycemia, diabetes insipidus) 1, 3
• Respiratory conditions 1
• Medication effects or substance intoxication/withdrawal 1, 2

Documentation Best Practices

Avoid the term "medically cleared"—instead document "medically stable for psychiatric evaluation" 2

• Document specific findings from history, physical examination, and vital signs 2
• Clearly document rationale for any laboratory or imaging studies ordered 2
• Note mental status at triage and throughout evaluation 1

Common Pitfalls to Avoid

Critical errors in psychiatric patient evaluation: 2

• Ordering routine laboratory panels without clinical indication 1, 2
• Failing to perform or document thorough neurologic examination 1, 2
• Missing medical causes in younger patients (younger patients have 4 times greater chance of missed medical diagnosis) 1
• Anchoring on referral information rather than conducting fresh evaluation 4
• Accepting vague symptom descriptions without clarifying precise complaints 5

Only 4% of psychiatric patients required acute medical treatment within 24 hours of admission, and 83% of these cases should have been identified by history and physical examination alone 1