Introduction to the Medical History
This is Part 1 in our series on Medical History
When Psychiatric Symptoms Signal Medical Illness: Key Red Flags
Not all psychiatric symptoms arise from primary psychiatric disorders. Recognizing when symptoms may have a medical or neurological cause is a critical clinical skill that can prevent misdiagnosis and ensure patients receive appropriate treatment. The distinction between primary psychiatric illness and psychiatric symptoms arising from medical conditions directly impacts diagnosis, treatment selection, patient safety, and long-term outcomes.
As a clinician conducting a psychiatric evaluation, your role extends beyond characterizing psychiatric symptoms, you must actively screen for medical and neurological contributors that could account for or exacerbate the presentation. This requires integrating information from multiple sources: the medical chart, patient interview, family history, review of systems, physical examination, and targeted diagnostic testing. The patterns and red flags described in this guide help you identify when a seemingly psychiatric presentation warrants medical investigation.
This assessment complements your standard psychiatric history and mental status examination. While you gather information about mood, thought processes, and functional impairment, you simultaneously evaluate whether features such as age of onset, temporal course, associated physical symptoms, or specific risk factors suggest an underlying medical etiology. Early recognition of these patterns ensures appropriate workup, prevents delays in treatment of potentially reversible conditions, and protects patients from ineffective or potentially harmful psychiatric interventions when medical treatment is indicated.
Learning Objectives
After reading this section, you should be able to:
- Identify key red flags that suggest psychiatric symptoms may have a medical or neurological etiology, including atypical age of onset, fluctuating course, and treatment resistance
- Integrate patient age, chronic medical conditions, physical signs, and temporal associations into your differential diagnosis for new-onset or worsening psychiatric symptoms
- Conduct a systematic chart review to identify medical risk factors and temporal associations before interviewing the patient
- Formulate targeted interview questions that explore medical context, medication changes, and temporal patterns of psychiatric symptoms
- Document medical screening appropriately and formulate an initial diagnostic workup plan for patients with suspected medical contributors to psychiatric symptoms
Start With Chart Review
Before interviewing the patient, thoroughly review the medical record to identify existing information that may suggest medical or neurological contributors to psychiatric symptoms. This pre-interview chart review allows you to formulate targeted questions and recognize patterns that warrant immediate medical investigation.
Key elements to review:
- Problem list and active diagnoses: Look for chronic medical conditions (diabetes, thyroid disease, autoimmune disorders, neurological conditions, cardiovascular disease, renal or hepatic disease) that are associated with psychiatric symptoms. Note the timing of diagnosis relative to psychiatric symptom onset.
- Recent hospitalizations and emergency department visits: Identify acute medical events (stroke, head injury, infections, metabolic crises, surgical procedures) that may have precipitated or coincided with psychiatric symptoms.
- Medication list: Review all current medications, including recent additions, dose changes, or discontinuations. Pay special attention to corticosteroids, beta-blockers, interferons, isotretinoin, anticholinergics, opioids, antiparkinsonian agents, and any medications known to cause psychiatric side effects.
- Recent laboratory and imaging results: Check for abnormalities in metabolic panels, thyroid function, vitamin B12, complete blood count, liver and renal function, drug screens, and any neuroimaging. Note if basic medical screening has never been performed.
- Specialist notes: Review recent neurology, endocrinology, obstetrics/gynecology, or primary care notes for documentation of neurological symptoms, hormonal changes, reproductive health issues, or concerns about organic contributors to behavioral changes.
- Prior psychiatric records: Look for documentation of treatment resistance, atypical features, previous medical workups for psychiatric symptoms, or provider concerns about medical etiologies.
💡 Clinical Pearl: If the chart reveals recent corticosteroid initiation, new antihypertensive medications, or recent head trauma, consciously probe for temporal associations during your interview. Ask explicitly: “Did you notice any changes in your mood, thinking, or behavior after starting this medication?” or “How soon after the injury did these symptoms begin?” Chart findings should directly inform your interview strategy and hypothesis generation.
Why this matters: Chart review often reveals critical context that patients may not spontaneously report or may not recognize as relevant. A patient presenting with “depression” may not mention their recent diagnosis of hypothyroidism or their new prescription for a beta-blocker. Identifying these factors before the interview allows you to gather more precise history and avoid anchoring prematurely on a primary psychiatric diagnosis.
Interview the Patient
After reviewing the chart, conduct a targeted interview to assess for medical and neurological contributors to psychiatric symptoms. Your questions should explore the temporal pattern of symptoms, medical context, and specific risk factors identified in your chart review.
General Medical Context and Temporal Associations
Opening questions:
- “When did you first notice these symptoms?”
- “Have you had any recent changes in your physical health?”
- “Have you been diagnosed with any medical conditions recently, or has anything changed with your existing medical problems?”
- “Have you started any new medications, changed doses, or stopped taking anything in the weeks or months before these symptoms began?”
Follow-up and context questions:
- “Do your symptoms come and go, or are they constant? If they fluctuate, is there any pattern to when they’re better or worse?”
- “Have you noticed any physical symptoms along with the mood changes, anxiety, or other concerns? For example, headaches, weakness, numbness, tremor, changes in vision, dizziness, palpitations, pain, changes in energy or sleep beyond what you’d expect?”
- “Have you had any recent infections, fevers, or illnesses?”
- “Do you take any over-the-counter medications, supplements, or herbal remedies?”
- “Have you tried psychiatric medications before? If so, how did they work for you?”
Patterns Suggesting Medical Etiology
The Age 40 Rule
🚩 Red Flag: Abrupt onset of psychiatric symptoms after age 40 in a patient with a chronic medical condition should strongly prompt suspicion for a medical etiology. This presentation is atypical for primary psychiatric disorders and is frequently seen in medical or neurological illnesses. This is especially true when the patient has no prior psychiatric history or family history of psychiatric illness.
💡 Clinical Pearl: While many primary psychiatric disorders can have onset after age 40, first-episode psychosis, mania, or severe depression with no prior history or family history occurring after age 40 should trigger systematic medical investigation before attributing symptoms to primary psychiatric illness.
Atypical Clinical Features
Watch for presentations that don’t fit the typical pattern of primary psychiatric disorders:
- Unusual age of onset (especially first episode after 40)
- Paroxysmal or fluctuating course
- Resistance to standard psychiatric treatment
- Absence of family history of psychiatric illness
Physical and Neurological Signs
🚩 Red Flag: The presence of these findings should heighten suspicion for underlying medical causes:
- Cognitive impairment or confusion
- Focal neurological deficits
- Autonomic symptoms (abnormal vital signs, sweating, tremor)
- Unexplained pain
- Other systemic findings
💡 Clinical Pearl: Any new-onset psychiatric symptoms accompanied by focal neurological signs (weakness, sensory changes, visual field defects, aphasia, ataxia) should be treated as a neurological emergency until proven otherwise. Do not attribute these to “functional” symptoms without thorough medical evaluation.
Temporal Associations
Consider medical etiologies when psychiatric symptoms coincide with:
- New medical illness or worsening of chronic condition
- Medication changes (including prescribed, over-the-counter, and supplements)
- Substance use or withdrawal
Prodromal Presentations
Psychiatric symptoms may be early manifestations of developing medical illness:
- Mood or anxiety symptoms preceding diagnosis of endocrine disorders
- Behavioral changes before metabolic derangements become apparent
- Subtle personality shifts in early autoimmune or neurologic disease
- Anxiety or depression heralding infectious or neoplastic processes
Additional Specialized Assessments
While the general framework above applies to all psychiatric evaluations, certain patient populations and clinical scenarios require additional focused assessment:
- Female reproductive health: Menstrual history, pregnancy status, reproductive surgeries, and contraception use all significantly impact psychiatric symptoms and treatment safety. This topic is covered in detail in Part [X+1]: Female Reproductive History.
- Head injury history: Traumatic brain injury is a significant risk factor for psychiatric disorders and can directly cause or mimic psychiatric symptoms. Comprehensive assessment of head trauma is covered in Part [X+2]: Head Injury History.
- Seizure disorders: Seizures can mimic psychiatric presentations and are associated with high rates of psychiatric comorbidity. Evaluation of seizure history is covered in Part [X+3]: Seizure Disorders in Psychiatric Patients.
These specialized assessments should be integrated into your evaluation when clinically indicated based on patient demographics, presenting symptoms, and chart review findings.
What to Document
When documenting your assessment for medical contributors to psychiatric symptoms, your goal is to demonstrate not only that you considered medical causes, but how you systematically evaluated them. Your documentation should reflect the depth of your assessment and provide clear reasoning for your diagnostic formulation and treatment plan.
| Documentation Level | What to Include | Example | When to Use This Level |
|---|---|---|---|
| Minimal | Basic screening for medical red flags: age of onset, chronic medical conditions, temporal association with medications or medical changes, and explicit statement that medical contributors were screened for | “Patient is a 28-year-old with no chronic medical conditions who presents with first episode of depression. Onset was gradual over 6 months with no temporal association to medical illness or medication changes. No focal neurological symptoms. Denies significant medical history. Medical screening negative for obvious organic contributors.” | Typical presentations in younger patients without chronic medical conditions, no atypical features, gradual onset, no concerning physical symptoms |
| Standard | Above + detailed medical history with temporal relationships; relevant physical findings; medications reviewed; initial workup plan | “Patient is a 45-year-old woman with type 2 diabetes and hypothyroidism presenting with 3-month history of depressive symptoms. Symptoms began approximately 2 months after her levothyroxine dose was decreased by her PCP. She reports fatigue, weight gain, cold intolerance, and low mood. No prior psychiatric history. No head injury or seizure history. On exam, appears bradycardic (HR 54), delayed deep tendon reflexes. Given temporal association with thyroid medication change and physical signs of hypothyroidism, obtained TSH prior to initiating antidepressant. TSH elevated at 8.2.” | Atypical presentations, age >40, chronic medical conditions, temporal associations with medication changes, presence of physical signs |
| Detailed | Above + comprehensive assessment of all risk factors, pattern analysis over time, diagnostic reasoning, and explicit discussion of how medical factors influence treatment decisions | “Patient is a 52-year-old woman with no prior psychiatric history presenting with acute onset of paranoid delusions, visual hallucinations, and agitation over the past 2 weeks. Patient reports sudden onset with no prodrome. Medical history significant for recent hospitalization 3 weeks ago for pneumonia, treated with high-dose prednisone (60mg daily, now tapering). Denies head trauma or seizure history. On mental status exam, patient is disoriented to date, has waxing and waning attention, visual hallucinations of ‘shadow figures,’ and paranoid delusions that neighbors are ‘plotting against her.’ Vital signs notable for tachycardia (HR 110), BP 156/94. Given acute onset after age 50, temporal association with corticosteroid use, presence of cognitive impairment and autonomic symptoms.” | First-episode psychosis after age 40, acute onset with delirium features, multiple medical risk factors, focal neurological signs, treatment resistance, complex medication regimens |
Why This Information Matters
The systematic identification of medical and neurological contributors to psychiatric symptoms fundamentally shapes every aspect of clinical decision-making, from diagnostic formulation to treatment selection and risk management. Understanding how to recognize and evaluate these contributors is not simply about completing a checklist, it requires integrating multiple streams of clinical data to distinguish primary psychiatric illness from psychiatric manifestations of medical disease.
Diagnostic reasoning and differential diagnosis: When psychiatric symptoms emerge in the context of medical red flags, particularly abrupt onset after age 40, chronic medical illness, atypical features, or accompanying physical signs, the probability of an underlying medical etiology increases substantially. A 25-year-old with gradual-onset depression, strong family history, and typical symptom presentation has a markedly different pre-test probability for medical causes compared to a 55-year-old with first-episode psychosis, no family history, and focal neurological signs. Your assessment of these patterns directly informs whether psychiatric treatment should be the primary intervention or whether urgent medical workup should take precedence. Failure to recognize these distinctions can lead to diagnostic anchoring, where the presence of psychiatric symptoms prematurely closes the differential diagnosis and delays identification of treatable medical conditions.
The temporal relationship between medical events and psychiatric symptom onset provides crucial diagnostic information. When a patient develops depression two weeks after starting a beta-blocker, anxiety during a corticosteroid taper, or personality changes following a head injury, these temporal associations shift the likelihood away from coincidental primary psychiatric illness and toward medication effects or organic sequelae.
Risk assessment and patient safety: Missing a medical etiology for psychiatric symptoms carries significant morbidity and mortality risk. A patient with new-onset depression due to hypothyroidism will not respond adequately to antidepressants alone and may experience progressive cognitive decline and cardiovascular complications if the thyroid disorder remains untreated. A patient with first-episode psychosis at age 60 due to a brain tumor or paraneoplastic syndrome requires immediate neurological intervention, and delays while pursuing psychiatric treatment could prove catastrophic.
Recognizing that psychiatric symptoms may be prodromal manifestations of medical illness, mood changes preceding a diagnosis of pancreatic cancer, anxiety heralding hyperthyroidism, or personality changes signaling early dementia, allows for earlier detection and treatment of potentially life-threatening conditions.
Treatment planning and medication selection: The presence of medical contributors fundamentally alters treatment strategy. When psychiatric symptoms are secondary to medical illness, the primary treatment target is the underlying medical condition, with psychiatric interventions serving as adjunctive or temporizing measures. A patient with depression due to untreated hypothyroidism requires thyroid replacement as the primary intervention; antidepressants may be considered if symptoms persist after euthyroidism is achieved, but starting antidepressants without addressing thyroid function is suboptimal care.
Level of care and disposition planning: The recognition of medical red flags often necessitates higher levels of care or changes in disposition. A patient with acute-onset psychiatric symptoms accompanied by vital sign abnormalities, altered consciousness, or focal neurological signs requires medical hospitalization for diagnostic workup rather than psychiatric admission. Even when psychiatric admission is appropriate, the identification of medical contributors influences the treatment setting, patients requiring close medical monitoring may need admission to a psychiatric unit with enhanced medical capabilities or a medical floor with psychiatric consultation rather than a freestanding psychiatric facility.
The comprehensive assessment of medical contributors protects both the patient and the clinician. For the patient, it ensures that treatable medical conditions are not missed, that medications are selected with attention to safety in the context of medical comorbidities, and that the treatment plan addresses the true etiology of symptoms rather than suppressing symptoms of an undiagnosed medical illness. For the clinician, systematic documentation of medical screening demonstrates due diligence, supports diagnostic reasoning, and provides a clear rationale for treatment decisions that can withstand later scrutiny if outcomes are unfavorable or if diagnoses change as more information becomes available.
Next in this series: Part 2 – Female Reproductive History: How It Shapes Psychiatric Diagnosis and Treatment Safety
