Assessment and Diagnosis · 4 min read
Physiological Causes of Psychiatric Symptoms
Many medical conditions, substances, and medications produce psychiatric symptoms. New-onset symptoms, atypical presentations, and symptoms in a middle-aged or older adult with no psychiatric history call for a search for an underlying physiological cause before a primary psychiatric diagnosis is made.
Neurological Conditions
Traumatic brain injury
Produces psychiatric symptoms in a substantial proportion of cases. Frontal injury: personality change, disinhibition, apathy, executive dysfunction. Temporal injury: memory impairment, emotional dysregulation, psychosis. Ask about head injury in anyone with new psychiatric symptoms
Seizure disorders
Ictal phenomena include altered consciousness, automatisms, and emotional experiences; interictal symptoms include depression, anxiety, and psychosis. Temporal lobe epilepsy carries especially high psychiatric comorbidity, and anticonvulsants can cause psychiatric side effects
Cerebrovascular disease
Post-stroke depression affects about one-third of stroke survivors and impairs rehabilitation. Vascular dementia causes cognitive decline with psychiatric symptoms; strategic infarcts produce characteristic syndromes
Multiple sclerosis
Psychiatric symptoms may precede the neurological diagnosis. Depression affects about 50% of patients; euphoria, emotional lability, and cognitive impairment also occur because white matter disease disrupts connections between regions governing mood and cognition
Parkinson disease
Depression affects up to 50% of patients and may precede motor symptoms; anxiety is common. Dopaminergic medications can cause impulse control disorders and psychosis
Brain tumors
May present first with psychiatric symptoms. Frontal tumors cause personality change and executive dysfunction; temporal tumors may cause psychosis. New symptoms in a middle-aged or older adult without psychiatric history warrant neurological evaluation
Endocrine Disorders
| Condition | PsychiatricManifestationsandNursingPoints |
|---|---|
| Hyperthyroidism | Anxiety irritability emotionallability andoccasionallypsychosis;patientsmaybereferredfor , , , |
| psychiatricratherthanmedicalevaluation | |
| Hypothyroidism | Depression cognitiveslowing fatigue andpsychomotorretardation Thyroidfunctionscreeningis , , , . |
| recommendedforallpsychiatricpatients | |
| Cushingsyndrome | Excesscortisolcausesdepression anxiety cognitiveimpairment andoccasionallypsychosis , , , |
| Addisondisease | Adrenalinsufficiencycausesfatigue apathy anddepression;recognizephysicalfindingsthatsuggest , , |
| adrenalpathology | |
| Diabetesmellitus | Bidirectionallink:depressionistwotothreetimesmorecommoninpeoplewithdiabetes poorglycemic , |
| control worsens psychiatric symptoms and psychiatric symptoms impair self -management , . | |
| Hypoglycemiacausesanxiety confusion andbehavioraldisturbancethatmustbedistinguishedfrom , , | |
| primarypsychiatricillness | |
| Parathyroiddisorders | Hyperparathyroidismcausesdepression anxiety cognitiveimpairment andpsychosis;hypocalcemia , , , |
| fromhypoparathyroidismcausesanxiety emotionallability andconfusion Checkcalciumwhen , , . | |
| psychiatricsymptomsareunexplained | |
| Pheochromocytoma | Catecholaminesurgesmimicpanicdisorderwithepisodicanxiety tachycardia diaphoresis and , , , |
| hypertension sometimes with hypertensive crises Consider it in treatment-resistant panic especially , . , | |
| withhypertension |
Infectious Diseases
| Condition | PsychiatricManifestationsandNursingPoints |
|---|---|
| HIV | Affects the central nervous system directly and through opportunistic infections HIV -associated . |
| neurocognitivedisorderrangesfromasymptomaticimpairmenttodementia;depressionismore | |
| prevalent;antiretroviralsmaycausepsychiatricsideeffects | |
| Syphilis | Tertiarysyphilis(generalparesis)causespersonalitychange cognitivedecline grandiosity and , , , |
| psychosis Consider screening in new-onset psychosis especially with risk factors . , | |
| Lymedisease | Maycausedepression anxiety irritability andcognitiveimpairment "ChronicLymedisease"asan , , , . |
| explanationforpersistentsymptomsiscontroversial;geographyandtickexposureinformassessment | |
| Viralencephalitis | Causesacuteconfusion behavioralchange andpsychosis Herpessimplexencephalitistargetsthe , , . |
| temporal lobes; post-encephalitic syndromes may persist | |
| COVID-19 | Delirium in severely ill patients; post-acute depression anxiety cognitive impairment and fatigue The , , , . |
| pandemicalsocausedsecondarymentalhealtheffectsthroughisolation grief economicstress and , , , | |
| disruptedcare |
Metabolic and Nutritional Disorders
| Condition | PsychiatricManifestationsandNursingPoints | |
|---|---|---|
| Hepaticencephalopathy Uremia | Ammoniaaccumulationdisruptsneurotransmitterfunction producinganythingfromsubtleperson1ality , changetocoma;earlysignsaresleepdisturbance irritability andcognitiveslowing , , Kidneyfailurecausescognitiveimpairment depression anxiety anddelirium Dialysispartlyreverses , , , . symptoms but has its own complications so uremic medication-related and primary psychiatric causes , , , mustbeseparated |
| Condition | PsychiatricManifestationsandNursingPoints |
|---|---|
| Electrolyteabnormalities | Hyponatremia:confusion lethargy andseizureswhensevere Hypercalcemia:depression cognitive , , . , |
| impairment psychosis Hypomagnesemia:anxietyandirritability , . | |
| VitaminB12deficiency | Depression cognitiveimpairment psychosis andmoodlabilitythatcanprecedeanemia Olderadults , , , . |
| andpeoplewithmalabsorptionareatrisk;checkB12inelderlypatientswithpsychiatricsymptoms | |
| Thiaminedeficiency | Wernicke-Korsakoff syndrome: confusion ataxia ophthalmoplegia and profound memory impairment , , , . |
| Chronicalcoholuseisthemainriskfactor;givethiaminepromptlytopreventpermanentdamage | |
| Folatedeficiency | Depressionandcognitivesymptoms;folateisneededformonoaminesynthesis Especiallyimportantin . |
| pregnancybecausedeficiencycausesneuraltubedefects |
Autoimmune and Inflammatory Conditions
| Condition | PsychiatricManifestationsandNursingPoints |
|---|---|
| Systemiclupus | Cognitive dysfunction mood disorders psychosis anxiety and seizures possibly through anti -neuronal , , , , , |
| erythematosus | antibodies Corticosteroidtreatmentcanalsocausepsychiatricsymptoms . |
| Anti -NMDA receptor | Psychiatricsymptoms movementdisorders seizures andautonomicinstability Earlypsychiatric , , , . |
| encephalitis | presentationsmayleadtopsychiatricadmissionbeforethecauseisfound;youngwomenwithovarian |
| teratomasareatparticularrisk | |
| Hashimoto | Psychiatric symptoms cognitive impairment and seizures with elevated anti -thyroid antibodies even , , , |
| encephalopathy | whenthyroidfunctionisnormal;respondstosteroids Consideritinunexplainedencephalopathy . |
| Multiplesclerosis | Inflammationofwhitematterpathwaysproducesdepression anxiety andcognitiveimpairment , , |
| Inflammatorybowel | Higher rates of depression and anxiety The gut-brain axis links intestine and brain through neural . , |
| disease | hormonal andimmunepathways , |
Substance-Induced Psychiatric Symptoms
| Substance | Intoxication | ChronicUseandWithdrawal | |
|---|---|---|---|
| Alcohol | Disinhibition moodlability cognitiveimpairment , , | Tolerance;withdrawalcausesanxiety tremor and , , | |
| autonomichyperactivity andinseverecasesseizures , | |||
| anddeliriumtremens Withdrawalrequiresmedical . | |||
| monitoringandpharmacologicalmanagement | |||
| Stimulants | Euphoria grandiosity paranoia;psychosiswhen , , | Withdrawalbringsdepression anhedonia andcognitive , , | |
| (cocaine , | severe | impairment; stimulant-induced psychosis may outlast | |
| amphetamines) | intoxication | ||
| Opioids | Euphoria sedation respiratorydepression , , | Withdrawalcausesdysphoria anxiety pain diarrhea , , , , | |
| andautonomicchanges Opioidusedisorderistreated . | |||
| withmethadone buprenorphine ornaltrexone , , | |||
| Cannabis | May precipitate psychosis especially with high , - | Regularadolescentuseraisesschizophreniarisk; | |
| Hallucinogens | potencyproductsorvulnerability Perceptualdisturbance alteredconsciousness , | withdrawalcausesirritability sleepdisturbance and , , decreased appetite 1 Serotonergichallucinogensrarelycausedependence butmaytriggerpsychosisorpersistingperception disorder;dissociatives(phencyclidine ketamine)cause , moreseriousbehavioraldisturbance |
Corticosteroids can cause mania, depression, or psychosis; beta-blockers may cause depression; anticholinergic drugs cause confusion, especially in older adults; and opioid analgesics cause sedation and may cause dysphoria. Review the medication list carefully whenever psychiatric symptoms are new.
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