Psychiatry for the ABIM: an in-depth look at how Mental Health & Internal Medicine co-exist

Editor’s Note: Anyone who thinks that psychiatry is a distinct field from medicine and thus not covered on the ABIM Internal Medicine Board exam is mistaken. In fact, the ABIM exam blueprint lists Psychiatry as comprising 4% of the exam, the same as Neurology and more than Dermatology. In a series of blog posts, Psychiatrist Esther Oh, MD breaks down the barriers between psychiatry and internal medicine.

Internal medicine and psychiatry are two distinct medical specialties, but there’s an overwhelming overlap of the patients and symptoms they treat. More than 100 medical conditions – such as neurologic, infectious, endocrine, cardiopulmonary and toxic disorders – can initially present with psychiatric symptoms. Plus, patients with psychiatric issues frequently report physical complaints and suffer from chronic medical conditions which are managed by their primary care providers.

Despite the wealth of knowledge physicians obtain during their medical training and while preparing for board exams, they may find it difficult to decipher medical versus psychiatric causes for various symptoms or fall into the trap of prematurely categorizing patients into one or the other. To optimize the quality of patient assessment and care, physicians must learn to differentiate between the two as the type of treatment will vary drastically depending on the origin of illness.

My goal over the next few blogs is to offer a systematic yet practical guide to comfortably working with psychiatric patients – tools for internists to confidently assess and diagnose medical disorders that may be mistaken as psychiatric in origin.

When you evaluate an acute physical or psychiatric complaint of a patient with a history of mental illness, keep in mind:

#1: Patients with mental health issues can present with real acute medical problems

Yes, they are notorious for being demanding, difficult to work with, unpredictably violent, poor historians, or acting strange, which can make the evaluation process frustratingly time-consuming and challenging. It’s easy for physicians to dismiss patients’ physical complaints or label them “crazy” or individuals who don’t have “real illnesses”. This leads to incomplete care and treatment of the patients.

#2: A psychiatric presentation can originate from a medical problem

Never assume that a certain symptom “must be” psychiatric. For example, psychosis does not automatically equate to schizophrenia; having a labile mood does not always mean bipolar disorder. Before finalizing the diagnosis of a mental illness for a patient’s psychiatric symptoms, it’s crucial to rule out any possible medical causes. Even if there is a definitive history of mental illness, physicians cannot forget a patient’s current complaints or recent change in behavior may stem from an acute medical condition, which must be treated.

#3: Ensure patients are fully medically cleared before considering psychiatric diagnoses

Studies have shown that disliked patients (such as some psychiatric patients) are more likely to receive poor evaluations and treatments compared to liked patients. They can be discharged prematurely or receive less comprehensive care since physicians may be quick to dismiss their complaints or blame the complaints on the fact that they are “psych patients.” Since inpatient and outpatient psychiatric facilities rarely are equipped to handle major acute medical issues if they were to arise, it’s vital to rule out these possible urgent matters that may need to be further evaluated, monitored, or treated in a medical setting.

#4: Top priority: if available, gather collateral information from people who know the patient well

In an acute setting, patients may lack the ability to provide a thorough history of their medical and psychiatric conditions. Whether patients are cognitively impaired, too disorganized in thought or psychotic, physicians cannot base a diagnosis or treatment solely on their responses. Obtaining information from other sources – family, friends, or caretakers – will allow physicians to make more informed decisions.

When should a physician seriously consider a medical illness rather than a psychiatric cause? With these red flags:

Any patient over the age of 40 with no previous psychiatric history
No previous history of similar symptoms
History of head trauma
History of chronic medical disease
Abnormal vital signs
Fluctuations in level of consciousness: disorientation/waxing and waning presentation
Speech deficits such as dysarthria or aphasia
Visual disturbances such as double vision or isolated visual hallucinations
Recent change in headache pattern
Patients who don’t improve on antipsychotics or anxiolytic medications

After evaluating a patient’s acute complaints and completing a full review of symptoms and physical exam, there are a few more questions that will help rule out common medical issues that may manifest with psychiatric symptoms:

Any family history of medical or psychiatric illnesses?
Any current medical problems such as asthma, thyroid disease, seizures, cancer, hypertension, diabetes, hypercholesterolemia?
History of high risk behavior, possible HIV exposure?
Current medication list
History or current use of substances including alcohol, illicit drugs, or tobacco?

If there is any suspicion that a medical issue may be the culprit, laboratory testing and imaging can be useful tools to screen them out. Such as:

Blood tests including a complete blood count (CBC), comprehensive metabolic panel (CMP), lipid panel, thyroid stimulating hormone (TSH), liver function test (LFT), fasting glucose, serum albumin, serum calcium, vitamin B12, rapid HIV
Urinalysis to test for diabetes, illicit drugs, urinary infections
Urine pregnancy test
Electroencephalogram (EEG) to rule any seizure activity
Head CT scan to rule out any acute bleed, mass, stroke

Empathy combined with comprehensive assessment and treatment are the key to effective patient care, especially for the patients who can be difficult.

_______________________________________________________________________________ Dr. Oh is currently a child and adolescent psychiatry fellow at the University of California in Los Angeles. She completed her adult psychiatry residency at Harbor-UCLA Medical Center in Torrance, CA. She obtained her medical degree from the David Geffen School of Medicine at UCLA. Dr. Oh is interested in reducing stigma against mental health and increasing the awareness and acceptance of treatment especially within the Asian community. _______________________________________________________________________________

As you approach the ABIM Internal Medicine Board exam, tune into Dr. Oh’s next blog post which will discuss various medical disorders that can present with psychosis.