Chapter 3: Medical Evaluation of Psychiatric Symptoms

Richard J. Goldberg, M.D., M.S.

3.1 Medical Causes of Symptoms

recent pelvic surgery who has a panic attack is

more likely to have a pulmonary embolism than
the onset of a panic disorder.

How medical disorders produce psychiatric symptoms

1.

2.

3.

4.

5.

Medical problems can produce psychiatric symptoms

through nonspecific psychological stress. For example, the
stress of entering chemotherapy can trigger major
depression, especially if the patient is vulnerable to
affective illness because of previous psychiatric, persona,
or family history.
Medical problems can produce physical symptoms that
mimic a psychiatric disorder. For example, asthma can
manifest itself as panic attacks; multiple sclerosis might
initially be regarded as a conversion disorder.
Structural involvement of the central nervous system
(CNS) can cause psychiatric symptoms. The specific
psychiatric symptoms are determined by the region and
extent of CNS involvement. For example, lung cancer can
metastasize to the temporal love and cause a mood
disorder; frontal lobe involvement can produce impaired
executive function or loss of motivation.
Pharmacologic effects on the CNS can produce psychiatric
symptoms. For example, dextromethorphan can produce
hallucinations; benzodiazepines can produce depressive
symptoms.
Virtually any psychiatric symptoms may be caused by an
underlying medical problem.

Table 3.1 Examples of Medical Causes of Psychiatric Symptoms

Psychiatric Symptoms
Example of Medical Cause
Delusions
Amphetamine or cocaine
Hallucinations
Delirium tremens, dextromethorphan
Incoherence
Delirium
Catatonia
Neuroleptic malignant syndrome
Flat or inappropriate affect
Frontal lobe CVA
Strange speech
Language cortex CVA
Odd beliefs
Interictal temporal lobe epilepsy
Anxiety
Hyperthyroidism
Depression
Pancreatic cancer
Irritability
Substance abuse

4.

History
a.

b.

c.

i.

ii.

d.

ii.

e.

2.

3.

Symptoms of disordered mood, thought, or behavior must

be considered nonspecific symptoms that require
differential diagnosis.
It is a mistake to assume that some particular psychosocial
situation accounts for psychiatric symptoms without
performing a complete evaluation.
It is an equally serious mistake to launch into a
comprehensive medical diagnostic evaluation not
supported by adequate findings from the history or review
of systems.
a. In general, more medically ill patients are more
likely to have secondary psychiatric problems.
For example, a bedridden cancer patient with

f.

The elderly are especially vulnerable to

subdural hematomas, which can manifest
acutely or as gradual change in behavior
over months.
Schizophrenics, homeless patients, and
substance abusers are at risk for trauma,
assault, and head injury.

Migraine headache history should raise

consideration of an underlying cerebrovascular
etiology for psychiatric symptoms such as acute
psychotic symptoms.
i.

Principles of psychiatric evaluation

1.

Temporal onset. In general, sudden onset of

symptoms is more typical of a medical disorder.
Schizophrenia and affective disorders usually
have a prodromal period. Because the panic
attacks of panic disorder have sudden onset,
they often suggest some underlying problem.
Visual hallucinations are more suggestive of
delirium than schizophrenia or depression.
Ocular disorder, especially in the elderly, can be
reported as unusual experiences and mistaken
for hallucinations.
History of head injury should raise suspicion of
an intracranial pathologic condition.

New onset headache symptoms not typical

of tension headache pattern should suggest
the need for a more complete medical
evaluation.
Frontal headache with temporal tenderness
should raise the consideration for temporal
arteritis, which can produce other
psychiatric and constitutional symptoms.

History of seizure disorder is always relevant for

the psychiatric evaluation. Inadequate or
excessive plasma levels of anticonvulsant can
result in uncontrolled seizure activity, as well as
symptoms of medication toxicity such as
depression, lethargy, or confusion. In addition,
patients with one type of diagnosed seizure (e.g.
grand mal seizures) might also have a second
type of unrecognized disorder (such as complex
partial seizures) resulting in psychiatric
symptoms.
Use of medications and substances (Box 3-1).
i.
ii.

iii.

Obtain a list of every substance taken or

recently discontinued.
When in doubt, obtain a toxicology screen.
Urine screening is often more useful than
plasma screening because drugs and
metabolites may be detectable for a longer
time.
If you are unsure whether some medication
can cause psychiatric symptom, look it up!

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Chapter 3: Medical Evaluation of Psychiatric Symptoms

Richard J. Goldberg, M.D., M.S.
Box 3-1 Medications and Substances Causing Psychiatric Symptoms
Analgesics
Narcotic mixed agonists-antagonists: euphoria, dysphoria, derealization
Anti-AIDS and Antiviral Agents
Acyclovir: hallucinations, confusion, insomnia, hyperacusis
Efavirenz: hallucinations, confusion, anxiety, depression
Ganciclovir: psychosis, confusion
Nevirapine: hallucinations, delirium
Antiarrhythmics
All can cause delirium, excitement, agitation. Procainamide also can cause
delusions, depression or panic.
Disopyramide
Lidocaine
Mexiletine
Procaineamide
Quinidine
Tocainide
Antibiotics
Aminoglycosides: toxic psychosis
Cephalothin: delirium, paranoia
Nalidixic acid: delirium
Penicillin (procaine form): psychosis
Sulfonamides: delirium, anorexia
Trimethoprim: psychosis, mutism, depression, anorexia, insomnia,
headache
Anticholinergics
Can cause peripheral syndrome consisting of tachycardia; increased
temperature; hot, dry, flushed skin; urinary retention; constipation;
blurred vision; and dry mouth. These drugs also cause central
syndrome consisting of confusion, memory impairment, restlessness,
agitation, delirium, hallucinations, and severe anxiety.
Benzotropine
Diphenhydramine
Meperidine
Oxybutynin chloride (Ditropan)
Propantheline (Pro-Banthine)
Tricyclic antidepressants
Trihexyphenidyl
Anticonvulsants
Anticonvulsants can cause drowsiness, mood change, confusion,
psychosis, and agitation
Ethosuximide: confusion, paranoia, nightmares
Phenobarbital: depression, confusion, disinhibition
Phenytoin: irritability, depression, visual hallucinations, agitation
Antifungals
Amphotericin-B: delirium, anorexia
5-Flucytosine: confusion, hallucinations
Ketoconazole: headache, dizziness
Antihypertensives
ACE-inhibitors: mania, anxiety, psychosis, hallucinations, depression
-blockers: depression, insomnia, nightmares, psychosis
Calcium channel blockers (Nifedipine, Verapamil): irritability, agitation,
depression, hallucinations, panic
Clonidine: depression, hallucinations
Hydralazine: depression, euphoria, psychosis
Methyldopa: depression, lethargy, sedation
Reserpine: depression

Anti-inflammatory agents
Indomethacin: delirium, depression, hallucinations
NSAIDs: depression, anxiety, confusion
Phenylbutazone: anxiety, agitation
Antitubercular agents
Cycloserine: insomnia, delirium, paranoia, depression
Isoniazid: agitation, hallucinations, depression, euphoria, transient
memory impairment
Ethambutol: headache, confusion, hallucinations
Rifampin: drowsiness, fatigue, anorexia
Chemotherapy agents
AZT: headache, restlessness, insomnia, nightmares, agitation
Bleomycin: anorexia
Interferon-: depression, weakness
Methotrexate: fatigue
Procarbazine: mania, anorexia, confusion
Vinblastine: depression, anorexia, psychosis
Vincristine: hallucinations, weakness
Diuretics
Weakness, apathy, confusion, delirium
Dopaminergics
Dopamine antagonists cause motor symptoms including dyskinesias,
dystonias, akinesia, akathisia, and neuroleptic malignant syndrome
(see Chapter 12). Dopamine agonists can cause confusion, paranoia,
hallucinations, depression, and anxiety.
Dopamine agonists including amantadine, carbidopa-levodopa (Sinemet)
and L-dopa
Dopamine antagonists
Metoclopramide
Neuroleptics
Sedatives and Narcotics
Withdrawal can produce delirium, agitation, or confusion, accompanied
by tachycardia, fever, mydriasis, sweating, and tremors. Sedatives
also cause disinhibition.
Alcohol
Barbiturates
Benzodiazepines
Narcotics
Serotonergic Agents
These drugs (SSRIs, tricyclic antidepressants, venlafaxine, nefazodone,
trazodone, buspirone, lithium, defenfluramine, MAOIs) alone or in
combination can result in serotonin syndrome (see Chapter 7).
Steroids
Anabolic steroids: aggression, paranoia, mood disorders
Corticosteroids: mood change, mania, agitation
Oral contraceptives: depression, anxiety, somnolence

Stimulants
Stimulants can cause anxiety, agitation, paranoid psychosis, insomnia,
confusion. Withdrawal can cause severe depression.
Amphetamine
Caffeine
Cocaine
Methylphenidate
Theophylline

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Chapter 3: Medical Evaluation of Psychiatric Symptoms

Richard J. Goldberg, M.D., M.S.
Sympathomimetics
Sympathomimetics can cause anxiety, restlessness, agitation, psychosis,
and delirium
Albuterol
Phentermine
Phenylpropanolamine
Pseudoephrine
Miscellaneous Drugs
Chloroquine: delirium
Cyclobenzaprine (Flexeril): mania, psychosis
Digitalis: confusion, psychosis, depression
Griseofulvin: depression, delirium
Histamine H2 receptor blockers: hallucinations, confusion, delirium,
depression, paranoia
Hypoglycemic agents: anxiety
Metronidazole: depression, agitation, confusion
Phentermine: restlessness, headache, dizziness
Quinacrine: delirium

5.

Medical problems that cause psychiatric symptoms (Box 32).

a. Principles
i.
ii.

Construct a complete medical problem list.

If any problem could affect the CNS,
consider further evaluation.
iii. The psychiatric symptoms related to
medical problems depend on the type of
CNS involvement (see Table 3-1).
1.
Generalized brain impairment
results in delirium. Delirium can
manifest as agitation,
withdrawal, confusion, anxiety,
psychosis, or depressive
symptoms.
2.
Focal brain involvement results
in specific symptoms determined
by location.
3.
Neurochemical changes (e.g.
catecholamine depletion with
reserpine) result in specific
syndromes.
Box 3-2 Medical Causes of Psychiatric Symptoms
Metabolic and Endocrine causes
Addisons disease
Calcium imbalance
Carcinoid syndrome
Cushings syndrome
Electrolyte abnormalities
Hepatic failure
Hyperparathyroidism
Hyperthyroidism
Hypoglycemia
Hypothyroidism
Hypoxia
Magnesium imbalance
Pheochromocytoma
Porphyria
Renal failure
Serotonin syndrome
Wilsons disease

Electrical causes
Complex partial seizures
Peri-ictal states (depression, hallucinations)
Post-ictal states (depression, dissociation, or disinhibition)
Temporal lobe status epilepticus
Neoplastic causes
Carcinoid syndrome
Carcinoma of the pancreas
Metastatic brain tumors
Primary brain tumors
Remotes effects of carcinoma
Drug and Medication causes
See Box 3-1
Arterial causes
Arteriovenous malformations
Hypertensive lacunar state
Inflammation (cranial arteritis, lupus)
Migraine
Multi-infarct states
Subarachnoid bleeds
Subclavian steal syndrome
Thromboembolic phenomena
Transient ischemic attacks
Mechanical causes
Concussion
Normal pressure hydrocephalus
Subdural or epidural hematoma
Trauma
Infectious causes
Abscesses
AIDS
Hepatitis
Meningoencephalitis (including tuberculosis, fungal, herpes)
Multifocal leukoencephalopathy
Subacute sclerosing panencephalitis
Syphilis
Nutritional causes
Folate deficiency
Niacin (vitamin B3 deficiency)
Pyridoxine (vitamin B6 deficiency)
Thiamine (vitamin B1 deficiency)
Vitamin B12 deficiency
Degenerative and Neurologic causes
Aging
Alzheimers disease
Creutzfeldt-Jakob disease
Heavy metal toxicity
Huntingtons disease
Multiple sclerosis
Parkinsons disease
Picks disease

b.

Systematic evaluation
i.

A systematic evaluation decreases errors of

omission.

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Chapter 3: Medical Evaluation of Psychiatric Symptoms

Richard J. Goldberg, M.D., M.S.
ii.

MEND A MIND, a useful mnemonic for the

medical evaluation of psychiatric symptoms
is given in Box 3-3.

Electroencephalogram
1.

Box 3-3 MEND A MIND

A useful mnemonic for the medical evaluation of psychiatric symptoms
is MEND A MIND:

Metabolic (including endocrine)

Electrical

Neoplastic

Drug

Arterial

Mechanical

Infectious

Nutritional

Degenerative

c.

i.

ii.

ii.
iii.

iv.
v.
vi.
vii.

viii.
ix.

Metabolic: hyponatremia, hypothyroidism,

hypoxia
Electrical: complex partial seizures
Neoplastic: metastatic CNS involvement of
lung cancer, breast cancer, multiple
myeloma, or AIDS
Drug: see Box 3-1
Arterial: stroke
Mechanical: head trauma with concussion,
subdural hematoma
Infectious: CNS involvement with impaired
immunocompetence, human
immunodeficiency virus (HIV) infection,
or fever secondary to any common
infection
Nutritional: vitamin B12, thiamine, or folate
deficiencies
Degenerative: Alzheimers disease (AD)

The background EEG should be normal in

depression but is usually slowed in delirium
and dementia.
The EEG may be normal in mild metabolic
disorders.

c.

Common examples of medical causes of

psychiatric symptoms in each category.
i.

A waking electroencephalogram (EEG) is useful for

documenting the brains background rhythm. This may be
useful in:
a. Detecting and documenting mild delirium.
b. Distinguishing dementia and delirium from
depression.

2.

The waking background rhythm decreases with

age but usually does not go below 8 Hz without
disease.
d. Slowing more than 1 Hz per year in an elderly
patient suggests a progressive disease process.
e. Alzheimers disease usually shows a background
slowing of less than 8 Hz along with increased
theta (5 to 7 Hz) and delta (1 to 3 Hz) activity and
poor organization.
A sleep EEG is useful to evaluate possible seizure
disorders.
a. EEGs record only surface electrical activity for a
limited time. Therefore, a high rate of falsenegative results (approximately 40%) occurs
even in patients with documented complex and
simple partial seizures.
b. Complex partial seizures may be more accurately
diagnosed by EEG (with identification rates
approaching 90%) by use of:

Physical examination

i.
ii.
iii.

Repeated EEG recordings

Sleep deprivation
Nasopharyngeal leads *higher

iv.
v.

Ambulatory monitoring
Closed circuit TV monitoring

c.

1.

2.

3.

Physical examination findings provide important clues to

medical causes that underlie psychiatric symptoms. A
discussion of these issues is found in Chapter 3.
Follow-up and reevaluation of physical examination are
especially important when the clinical course is unusual or
unresponsive.
Underlying medical disorders may be obscured by
behavioral symptoms.

3.

3.2 Diagnostic Testing

The use of diagnostic testing must be guided by the history, review
of systems, and physical and neurologic examination. There is no set
regimen to follow for the routine laboratory evaluation of any
psychiatric patient. However, a routine evaluation has been
recommended for the evaluation of dementia (see Chapter 4).

4.

The EEG may be useful in distinguishing

generalized seizures from non-epileptic seizures,
because generalized tonic-clonic seizures are
always associated with an abnormal EEG, along
with post-ictal slowing. EEG can also distinguish
between many partial seizure types from nonepileptic seizures
Ambulatory EEG monitoring can be useful for:
a. Determining whether some periodic behavioral
problems (e.g. atypical panic attacks, episodic
psychotic and autonomic symptoms) are caused
by seizure activity.
b. Increasing the yield of routine EEG.
Effects of drugs on the EEG. Virtually any psychotropic
drug can produce EEG slowing.
a. The slowing effect of neuroleptics is mild.
b. Antidepressant slowing is also usually
accompanied by some increased fast activity.

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Richard J. Goldberg, M.D., M.S.
c.

d.

e.

At therapeutic doses, benzodiazepines,

barbiturates, and stimulants produce increased
fast activity.
Lithium (even at therapeutic levels, but more
commonly at high levels) can produce high
voltage runs of diffuse slow activity.
Tricyclic and neuroleptic agents lower the
seizure threshold and can induce paroxysmal
activity, with spike or sharp waves. When
significant abnormalities occur, the patient
should be evaluated for an underlying seizure
disorder.

vii.

4.

Neuroimaging
1.

2.

3.

Potential indications. Neuroimaging should not be

regarded as a screening test for every psychiatric patient,
but it should be considered in the following cases:
a. Confusion or dementia of unknown cause.
b. First episode of psychotic disorder of unknown
cause.
c. Movement disorder of uncertain cause.
d. Anorexia nervosa.
e. Prolonged catatonia.
f. First episode of major depression in the elderly.
g. Personality change after 50 years.
Advantages of magnetic resonance imaging (MRI) over
computed tomography (CT) scans.
a. Better soft tissue contrast.
b. Multiplanar imaging capability.
c. Fewer artifacts when imaging the posterior
fossa.
d. Lack of ionizing radiation
e. Generally no need for contrast materials,
although contrast agents maximize detection of
brain metastatic disease. With MRI, a
gadolinium-based agent is generally used, which
does not have the disadvantages (allergic
reactions and nephrotoxicity) of radiographic
contrast agents used in CT scanning.
Disadvantages of MRI.
a. Artifacts from excessive patient motion
b. Longer scan times
c. Claustrophobia. Generally can be managed with
anxiolytic agents.
d. Electromagnetically driven devices and
ferromagnetic or metallic objects lead to the
following contraindications:
i.
ii.
iii.
iv.
v.
vi.

Cardiac pacemakers in pacer-dependent

patients.
Implanted neurostimulators.
Cochlear implants.
Metal in the eye.
Ferromagnetic aneurysm clips.
Poor bone visualization.

5.

6.

7.

Pregnancy is a relative contraindication,

especially in the first trimester. However,
the unspecified risks are probably less than
the risks of ionizing radiation.

Diagnostic indications for MRI. For certain disorders, an

MRI is clearly preferable to a CT scan and the cost
differential is warranted. These situations in psychiatry
include:
a. Demyelinating disease.
b. Temporal lobe abnormalities (because artifacts
often obscure findings from that region).
c. Subcortical multiple lacunae or infarcts (often
too small to show up on CT scans).
d. Abnormal endocrine function (better resolution
and lack of bone artifact in visualizing the
pituitary gland).
e. Primary and metastatic neoplasms, along with
associated features such as edema, vascularity,
hemorrhage, and necrosis.
f. Abscess, encephalitis, meningitis. Early detection
of herpes simplex encephalitis is best achieved
with MRI. Other infections (often AIDS related)
can also be visualized, including toxoplasmosis,
lymphoma, cryptococcosis, and neurosyphilis.
g. Posterior fossa lesions.
h. Acute stroke, especially ischemic infarcts of the
brainstem or cerebellum.
i. Subacute and chronic brain hemorrhage or
hematoma.
j. Progressive multifocal leukoencephalopathy.
Non-contrast CT is the preferred neuroimaging technique
in emergency situations and in acute traumatic brain
injury.
Role of single positron emission computed tomography
(SPECT) scans.
a. SPECT allows imaging of blood flow patterns.
Potential uses in psychiatry include evaluation of
dementia. The SPECT scan shows a characteristic
bilateral hypoperfusion pattern in Alzheimers
that can be distinguished from multi-infarct
dementia.
b. Site of seizure focus.
c. Cerebral infarct in a patient with recent onset of
neurologic findings and no abnormalities on CT
or MRI.
d. Areas of poor perfusion after a stroke or head
trauma.
e. CNS Lyme disease.
f. Future uses might involve identification of
neuroreceptor sites using receptor-binding
radiotracers.
Role of positron emission tomography (PET) scans.
a. Inter-ictal seizure focus localization.
b. Differentiating AD from other dementias.

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Richard J. Goldberg, M.D., M.S.
c.
d.

Differentiating residual tumor from radiation

necrosis.
Receptor imaging is being evaluated in research
studies.

Lumbar Puncture
1.

2.

Lumbar puncture is indicated to evaluate the following:

a. Unexplained elevated temperature in a patient
with altered mental status, which should be
considered CNS infection until proved otherwise.
This is especially true for patients with altered
immunocompetence from chronic diabetes,
cancer, acquired immunodeficiency syndrome
(AIDS) immunosuppressive drugs, or steroids.
b. Possible CNS fungal infection (which has a high
false-negative rate).
c. CNS herpes (associated with increased ferritin
levels in cerebrospinal fluid).
d. Multiple sclerosis (with findings of elevated
immunoglobulin G [IgG] levels or oligoclonal
bands.
e. Neurosarcoidosis (patient might have lymphatic
pleocytosis and elevated angiotensin-converting
enzyme [ACE] level).
f. In AD, lumbar puncture (LP) is not a routine test
but should be considered if the patient has
atypical features such as rapid progression,
fever, meningeal signs, or a positive serologic
test for syphilis.
LP is contraindicated in:
a. Infection over the entry site.
b. Bleeding disorder.
c. Posterior fossa mass.
d. Midline shift.

Toxicology Screens

Thyroid Tests
Because hypothyroidism can be manifested as depression and
hyperthyroidism as anxiety, screening is often indicated.
1.

2.

Glucose and Glucose Tolerance Tests

Glucose screening (glucose tolerance test, GTT) should be
considered for patients with psychiatric symptoms along with
diabetes mellitus, alcoholism, or cirrhosis.
1.
2.

3.

4.

Toxicology screens are useful in the following situations:

1.
2.
3.

4.
5.

6.

Assessment of psychiatric symptoms that do not have a

clear diagnosis.
When doubt exists about possible drug or medication use.
If the patient is receiving medications for which levels are
available, obtain levels to see if the patients drug level is
toxic or subtherapeutic.
Alcohol levels. For interpretation of blood alcohol levels,
see Chapter 15.
Cocaine levels. Although cocaine has a brief plasma halflife, its metabolite benzoyl ecgonine can be detected in
urine for several days.
False-positive and false-negative results are possible,
depending on technique. When in doubt, talk to the
laboratory about suspicion of particular drugs.

A high sensitivity thyroid-stimulating hormone (TSH) is

sufficient as a screen for both hyperthyroidism and
hypothyroidism.
a. If the TSH level is elevated (indicating possible
hypothyroidism), a total or free thyroxine (T4)
level should be obtained.
b. If the TSH is suboptimal (indicating possible
hyperthyroidism), follow up with a total or free
T4 and triiodothyronine (T3).
Thyroid testing should be undertaken on a periodic basis
every 6-12 months for patients receiving lithium (see
Chapter 8).

Hyperglycemia can cause delirium by creating osmotic

imbalances in the brain.
Postprandial hypoglycemia is rarely a cause of psychiatric
symptoms.
a. A 5 hour GTT is rarely helpful in evaluating
symptoms of anxiety, fatigue, or depression.
b. A GTT may be relevant in patients after gastric
and small intestine surgery with dumping
syndrome.
Patients recovering from excessive insulin have
hypoglycemic episodes manifested as anxiety, confusion,
agitation, belligerence, or fatigue, which are responsive to
glucose infusion.
Initial fasting blood glucose (FBG) and periodic follow-up
of glucose levels are now indicated for patients treated
with the atypical antipsychotic agents.

Liver Function Tests

1.

2.

Patients with extensive liver disease caused by

malignancy, cirrhosis, or hepatitis are at risk for hepatic
encephalopathy if liver function deteriorates further. This
disorder is usually marked by generalized slow waves
(triphasic waves) on the EEG.
Liver function tests (LFTs) are important for patients
receiving medications that can cause allergic hepatic
responses, such as carbamazepine, chlorpromazine, or
valproic acid, if clinical symptoms such as nausea,
abdominal discomfort, or jaundice develop.

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Richard J. Goldberg, M.D., M.S.
Arterial Blood Gases
1.

2.

3.

Hypoxia. Any cause of brain hypoxia will make a patient

feel anxious: congestive heart failure, chronic obstructive
pulmonary disease (COPD), pneumonia, cardiac
arrhythmia, pulmonary embolism, asthmatic episode, and
so on. Therefore, assessment of PO2 may be an important
part of evaluating acute anxiety symptoms in such patients
Carbon dioxide retention (elevated PCO2) can result in
somnolence, confusion, and impaired attention.
a. Avoid using benzodiazepines in patients with
elevated PCO2, because they can suppress
hypoxic respiratory drive and lead to respiratory
depression or arrest.
Sleep apnea
a. Patients at risk often have short, thick necks or
snore loudly. However, sleep apnea can occur in
patients without these features.
b. Observing the patient for apneic episodes is a
first step toward a referral for sleep evaluation.

3.
4.

Creatine Kinase
Creatine Kinase (CK), an enzyme whose levels are elevated because
of muscle damage, is relevant to psychiatry in the following
situations:
1.

2.

Complete Blood Count

The complete blood count (CBC) is essential in psychiatry in a
number of situations:
1.
2.
3.
4.

Monitoring for patients taking clozapine.

When sore throat or fever develops in patients taking such
drugs as carbamazepine, phenothiazine, or mirtazapine.
In evaluation of postsurgical patient with altered mental
status who may have had significant operative blood loss.
To assess anemia in patients with altered mental status
(anemia resulting in fatigue, confusion, anxiety, and
depressive symptoms).

3.

Porphyria is a rare cause of episodic psychiatric symptoms.

1.

2.

3.

Blood urea nitrogen (BUN) and creatinine are relevant to psychiatry

in the following situations:

4.

2.
3.

To assess renal function in patients taking drugs that are

cleared by the kidneys (e.g. lithium, amantadine, or
risperidone).
Chronic renal failure. As uremia worsens, psychiatric
symptoms become more prominent.
As a clue to dehydration and associated orthostasis risk,
especially in patients with poor oral intake.

Electrolytes
Electrolytes are relevant in psychiatry in the following situations:
1.

2.

Syndrome of inappropriate antidiuretic hormone (SIADH)

can be caused by drugs such as lithium, carbamazepine, or
the selective serotonin reuptake inhibitors (SSRIs).
Hyponatremia from any cause (usually diuretics) can cause
delirium.

Neuroleptic malignant syndrome (NMS) (see Chapter 12)

in which CK elevations (MM fraction) are usually greater
than 800 IU/L. Elevations up to (but not above) 800 IU/L
can occur after intramuscular injections of struggling in
restraints.
Fractionation of the CK isoenzymes ensures that the
elevation is not caused by the cardiac fraction after a
myocardial infarction. Behavioral changes in the elderly
may be caused by silent myocardial infarction.
High elevations of CK may be found after muscle crush
injuries, such as those caused by car accidents.

Porphyrins

Blood Urea Nitrogen and Creatinine

1.

Hypokalemia leads to muscle fatigue and weakness, which

many patients identify as symptoms of depression.
For patients taking lithium, anything that significantly
alters sodium balance (diuretics, vomiting, diarrhea) will
alter lithium levels and can lead to lithium toxicity (see
chapter 8). *Monitor levels every 6-12 months.

Abdominal pain is the usual presenting complaint. Thirty

percent to 70% of cases are accompanied by episodic
psychiatric symptoms, usually delirium or psychosis.
During attacks, qualitative abnormalities of uroporphyrins
and coproporphyrins may be observed in the urine. These
tests are not useful between attacks.
Quantitative urine measurements of aminolevulinic acid
(ALA) and porphobilinogen (PBG) may be abnormal
between attacks.
A more definitive test involves measurement of
uroporphyrinogen I synthetase, in which decreased
activity can confirm a diagnosis.

Copper
Wilsons disease is an autosomal recessive genetic disorder that
results in abnormal accumulation of copper, leading to hepatic
cirrhosis, degeneration of the basal ganglia, neuropsychiatric
symptoms, and hemolytic anemia.
1.

2.

Screening tests include serum ceruloplasmin and 24-hour

urinary copper levels. Ninety percent of patients with
Wilsons disease have very low serum ceruloplasmin
levels. Twenty-four-hour urinary copper levels are high.
Screening for Wilsons disease should be considered in
patients with psychiatric symptoms and:
a. Family history of Wilsons disease.
b. Unexplained liver disease.

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Practical Guide to the Care of the Psychiatric Patient, 3rd Edition (2007)
Transcribed by PKST 2016-17

Chapter 3: Medical Evaluation of Psychiatric Symptoms

Richard J. Goldberg, M.D., M.S.
c.

Signs of basal ganglia or frontal lobe disease not

otherwise explained.

Pregnancy Test
1.

2.

Because psychotropic drugs have a number of fetal effects,

pregnancy status should be established before medication
is prescribed.
At times, a mysterious behavioral change in a young
woman is caused by an unannounced pregnancy.

Vitamin B12
1.

2.

3.
4.

5.

Psychiatric symptoms (anxiety, psychosis, delirium, or

dementia) occur in 35% to 85% of patients with vitamin B 12
deficiency.
a. The mental manifestation of vitamin B12
deficiency can precede the hematologic
abnormalities.
b. The standard lower limit of normal value for
vitamin B12 is 200pg/mL, but this may be too low
for psychiatric purposes, because psychiatric
symptoms may occur with values up to
300pg/mL.
Accompanying physical symptoms are paresthesias and
sensory loss (particularly vibration and proprioception
leading to ataxia).
Vitamin B12 deficiency may be present in the absence of
classic hypochromic macrocytic anemia.
If vitamin B12 is deficient, Schillings test may be performed
to differentiate dietary deficiency from impaired
absorption resulting from absent intrinsic factor.
Methylmalonic acid assay may be helpful in identifying
vitamin B12 deficiency when the B12 level is borderline low.

Folate
1.
2.

Folate deficiency often accompanies vitamin B12

deficiency.
Folate levels may also be low in alcoholic patients, patients
taking anticonvulsants, pregnant patients, and patients on
dialysis.

Polysomnography and Sleep Apnea

1.
2.

Sleep apnea can lead to symptoms of depression, anxiety,

panic disorder, and dementia (see Chapter 11).
Diagnostic polysomnography (PSG) is performed in a sleep
evaluation center and usually includes recordings of EEG,
electrocardiogram (ECG), electrooculography (EOG; eye
movements), and electromyography (EMG; muscle
movement), as well as respiratory effort, air flow, snoring,
and blood oxygen saturation.

8
Practical Guide to the Care of the Psychiatric Patient, 3rd Edition (2007)
Transcribed by PKST 2016-17