IT is a common, faulty public perception that any “strange behaviour” on a person’s part is linked to a mental illness. This notion, unfortunately, spills over into the minds of health practitioners with, at times, long-term devastating consequences.

Patients are often labelled as having a psychiatric illness when the true cause of their symptoms is an undiagnosed serious medical disorder. The worst case scenario is death of a patient who could have been saved, given timely diagnosis and treatment of the underlying medical condition.

It is important to remember to treat “strange behaviour” as a symptom rather than a diagnosis. Psychosis, mania and depressed mood are often manifestations of and provide early clues to a grave condition, which can be lethal. The list of medical conditions which can result in development of psychiatric symptoms is inexhaustible. However, I have attempted to highlight some of the main ones based on biological systems and secondary causes.

NEUROLOGICAL

It should be no surprise that many neurological conditions can present with psychiatric manifestations, as both entities affect the brain.

Brain tumours, infections such as meningitis and encephalitis, stroke, Parkinson’s disease, Huntington’s disease, and multiple sclerosis are some of the conditions which commonly present with change in personality, psychosis, mania, or depressive symptoms in patients.

ENDOCRINE

Thyroid disorders, including both hypo and hyper functioning of the thyroid glands, are notorious in causing development of psychiatric symptoms in a previously healthy and well patient.

Disorders affecting the adrenal gland, especially a disorder known as Pheochromocytoma, have resulted in psychotic and manic symptoms.

METABOLIC

Dysregulation and lack of homeostasis in the body’s internal environment can have negative consequences on mental health. This includes changes in blood and fluid volume and increase or decrease in essential minerals such as sodium and potassium.

This usually results in an acute change in a patient’s mental status, resulting in confusion associated with a fluctuating level of consciousness.

GASTROINTESTINAL/RENAL

The liver plays an important role in detoxification and elimination of harmful waste products. Thus, it is no surprise that liver failure can result in build-up of nitrogenous toxic wastes which can cross the blood-brain barrier and cause psychopathology.

The kidneys play a similar role, and often patients with kidney failure awaiting dialysis will develop changes in mental status that mimic a primary psychiatric disorder such as schizophrenia.

MEDICATIONS

Many over-the-counter and prescription medications result in psychiatric symptoms. A common culprit is prednisone, which is taken for various medical conditions including asthma, chronic obstructive pulmonary disease and many inflammatory conditions such as rheumatoid arthritis.

Steroid-induced psychopathology often causes a challenge for clinicians who have to seek the perfect balance between adequate steroid dose, which may be a necessary life-saving treatment, and controlling the patient’s psychiatric symptoms.

Many herbal supplements are also on the list of risk factors and these include Jimson weed (Datura) and ginseng.

DRUGS

Ingestion of illicit drugs not limited to cocaine, heroin and legal drugs, such as alcohol can lead to a compromised mental state. The effects of the drug often result in an acute onset of psychiatric symptoms and, at times, rapid resolution once the drug is metabolised and excreted from the body.

IMMUNE SYSTEM

Infections such as acquired immunodeficiency syndrome (AIDS) and syphilis, which is known as the great imitator, can cause psychotic, manic and depressive symptoms and need to be considered. It is important to consider the patient’s risk factor for sexually transmitted disease by conducting a thorough sexual history.

Any person who presents with a change in their baseline mental state needs a full and proper diagnostic evaluation not limited to a complete blood count, electrolyte panel, liver and renal function tests, brain imaging, with a computed tomography scan or magnetic resonance imaging and human immunodeficiency virus and venereal disease research laboratory testing to rule out syphilis.

A complete medical and psychiatric history and examination must be carried out and further diagnostic tests may be recommended depending on physical exam findings. A urine toxicology screen is a must to rule out secondary effects from a substance or drug.

It is vital for both medical and non-medical personnel to remember that “strange behaviour” does not necessarily equate to schizophrenia or bipolar disorder or another primary psychiatric conditions.

Significant clues to a possible psychiatric condition include a premorbid history of deteriorating mental state and a family history of mental conditions. It is also our imperative to remember that even patients with primary psychiatric conditions do have medical conditions and are at increased risk compared to the general population, which often result in shorter life expectancy and these need to be addressed.

At the end of the day, it is our duty to attempt to stem the stigma associated with being diagnosed with a mental disorder and prevent commitment to lifelong psychotropic medications by managing treatable underlying conditions.

Dr Ashish Sarangi MBBS is a resident psychiatrist at the University Hospital of the West Indies. He may be contacted via email at aks_sarangi@hotmail.com