What disorders should be screened for during a comprehensive psychiatric review of systems?

Psychiatric Review of Systems: Essential Disorder Screening

A comprehensive psychiatric review of systems should systematically screen for eight major categories of psychiatric disorders: depression, anxiety disorders, psychotic disorders, bipolar disorder, substance use disorders, eating disorders, cognitive disorders, and personality/behavioral disorders. 1

Core Screening Categories

Depression and Mood Disorders

• Screen with two initial questions: Ask about persistent depressed mood and loss of interest or pleasure in activities (anhedonia) over the past two weeks 2
• Use the Patient Health Questionnaire-9 (PHQ-9) for quantitative assessment, with scores ≥10 indicating clinically significant depression requiring further evaluation 2, 3
• Critical pitfall: Before diagnosing depression, you must screen for bipolar disorder risk by asking about distinct periods of elevated mood, decreased need for sleep, and increased goal-directed activity 4, 5
• Assess family psychiatric history, particularly for mood disorders and suicide, as this significantly impacts diagnostic formulation 4

Anxiety Disorders

• Screen for generalized anxiety disorder, panic disorder, social anxiety disorder, and post-traumatic stress disorder using the GAD-7 questionnaire, with scores ≥10 warranting detailed diagnostic assessment 3, 6
• The GAD-2 (two-item version) serves as an efficient initial screen, with scores ≥3 triggering full evaluation 3
• For public safety personnel and high-risk populations, use the Brief Panic Disorder Symptom Screen-Self-Report and Short-Form PTSD Checklist-5 6

Bipolar Disorder

• Ask specifically about: "Have you ever had distinct periods, lasting at least 4 days, when your mood was abnormally elevated or irritable, you needed much less sleep than usual, and you were much more active or talkative than usual?" 4
• Differentiate episodic mood changes (bipolar) from chronic irritability (other disorders) by mapping symptoms on a life chart showing temporal patterns 4
• Critical distinction: Bipolar symptoms must represent a clear departure from baseline functioning, not reactions to situations or temperamental traits 4
• Screen for decreased need for sleep (not just insomnia), psychomotor activation, and spontaneous mood elevation—these are hallmark features 4

Psychotic Disorders

• Evaluate for hallucinations (particularly auditory), delusions, disorganized thinking, and formal thought disorder through mental status examination 7
• Screen for prodromal symptoms: social isolation, bizarre preoccupations, unusual behaviors, academic/occupational decline, and deteriorating self-care 7
• Assess family psychiatric history with specific focus on psychotic illnesses 7
• Rule out medical causes first: CNS infections (meningitis, encephalitis, HIV), CNS lesions/tumors, seizure disorders, metabolic disorders, and acute intoxication 7

Substance Use Disorders

• Use the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) for alcohol screening 6
• Ask directly about: tobacco, alcohol, marijuana, cocaine, hallucinogens, prescription medication misuse, and over-the-counter medication abuse 4
• Obtain toxicology screening when substance-induced psychiatric symptoms are suspected 7
• Critical consideration: If psychotic symptoms persist >1 week after documented detoxification, consider primary psychotic disorder rather than substance-induced psychosis 8

Eating Disorders

• Screen for anorexia nervosa, bulimia nervosa, and binge eating disorder as part of the systematic review 1
• Assess body image concerns, restrictive eating patterns, binge eating episodes, and compensatory behaviors

Cognitive Disorders

• Use the Montreal Cognitive Assessment (MoCA) or Addenbrooke's Cognitive Examination-III (ACE-III) for general cognitive screening 7
• Add executive function testing (Frontal Executive Screen or Institute of Cognitive Neurology Frontal Screening) if general screening is normal but clinical suspicion remains 7
• Assess attention, memory, language, visuospatial function, and executive function domains 7
• For suspected dementia: Perform formal neuropsychological testing including Trail Making Test Part B, Stroop Test, Hayling Sentence Completion Test, and verbal fluency tasks 7

Personality and Behavioral Disorders

• Screen for patterns of interpersonal dysfunction, emotional dysregulation, impulsivity, and maladaptive coping strategies 1
• Assess for disruptive behavior disorders, particularly in children and adolescents 4

Medical Conditions Mimicking Psychiatric Disorders

Neurological Causes to Rule Out

• CNS pathology: stroke, intracranial hemorrhage, tumors, infections (meningitis, encephalitis, brain abscess, HIV, syphilis), seizure disorders, hydrocephalus 7
• Neurodegenerative disorders: multiple sclerosis, Huntington chorea, tuberous sclerosis 7
• Obtain neuroimaging, EEG, and CSF analysis when clinically indicated based on history and physical examination 7

Metabolic and Endocrine Causes

• Screen for: hyponatremia, hypocalcemia, hypoglycemia, hyperglycemia, ketoacidosis, uremia, hyperammonemia 7
• Thyroid disorders: hyperthyroidism, thyroid storm, hypothyroidism 7, 8
• Adrenal disorders: Addison disease, Cushing disease 7
• Other endocrine: pituitary dysfunction, parathyroid disorders, pheochromocytoma 7
• Order comprehensive metabolic panel, thyroid function tests, calcium, magnesium, and liver function tests 8

Medication and Toxin-Induced Disorders

• Drug withdrawal: alcohol, benzodiazepines, barbiturates, opioids 7
• Drug intoxication: phencyclidine, cocaine, amphetamines, MDMA, LSD, "bath salts" 7
• Prescription medications: steroids, birth control pills, antihypertensives, statins, anticonvulsants, anticholinergics, antibiotics, cardiac medications (digoxin) 7

Respiratory Causes

• Hypoxia, hypercarbia, and respiratory failure can present with psychiatric symptoms 7

Practical Screening Approach

Initial Questions Using Normalization Technique

• Transition smoothly between topics rather than abruptly changing subjects 1
• Use normalization: "Many people experience periods when they feel down or anxious. Have you noticed any changes in your mood?" 1
• Use symptom assumption: "How much alcohol do you typically drink in a week?" (assumes drinking occurs, making disclosure easier) 1

Systematic Algorithm

1. Start with depression screening (PHQ-2 or PHQ-9) 2, 3
2. If positive for depression, immediately screen for bipolar disorder before considering antidepressant treatment 4, 5
3. Screen for anxiety disorders (GAD-2 or GAD-7) 3
4. Assess substance use (AUDIT-C and direct questioning) 6
5. Evaluate for psychotic symptoms through mental status examination 7
6. Screen cognitive function if age >65 or clinical concerns present 7
7. Assess eating disorders and personality patterns 1

Essential Laboratory Workup

• Baseline tests for all patients with new psychiatric symptoms: complete blood count, comprehensive metabolic panel, thyroid function tests, urinalysis, toxicology screen 8
• Additional tests based on clinical presentation: HIV testing (if risk factors), vitamin B12/folate, RPR/FTA-ABS (syphilis), Lyme antibody, ESR, chromosomal analysis (if developmental features) 8

Critical Pitfalls to Avoid

• Never diagnose depression without screening for bipolar disorder first—antidepressants can precipitate manic episodes in undiagnosed bipolar patients 4, 5
• Do not rely solely on screening questionnaire scores—positive screens require full diagnostic interviews using DSM criteria 9
• Avoid diagnosing psychiatric disorders without ruling out medical causes—obtain thorough history, physical examination with vital signs, and indicated laboratory testing 7
• Do not overlook substance use—directly ask about all substances and obtain toxicology screening when indicated 7, 8
• Assess suicidality in all patients screening positive for mood disorders—bipolar disorder and depression have high suicide attempt rates 4, 2
• Obtain collateral information from family members—patients often lack insight during acute psychiatric episodes 4
• Use longitudinal perspective—create a life chart mapping symptom patterns, episode duration, and treatment responses over time 4

Follow-Up and Monitoring

• Patients screening positive require clinical diagnostic assessment, not just screening scores, to confirm diagnosis 9
• Reassess diagnosis periodically as the clinical picture may evolve over time 4
• Monitor treatment response every 2-4 weeks until symptom remission 2
• Untreated patients who screen positive are likely to have enduring symptoms and increased emergency service utilization at long-term follow-up 9