CFB PSY03 Psychiatric Conditions In Medical Settings
Psychiatric conditions in medical settings refer to mental health disorders—such as delirium, depression, anxiety, and somatoform disorders—that arise in, coexist with, or complicate the presentation and management of general medical illnesses.
Psychiatric Conditions in Medical Settings
This lecture, delivered by Dr. CW Law (Department of Psychiatry, QMH) for the Clinical Foundation Block, addresses the complex interface between physical medicine and psychiatry — a topic that every doctor will encounter regardless of specialty. The central thesis is that physical and psychiatric illness do not exist in silos; they interact bidirectionally, and failing to recognize this leads to missed diagnoses, iatrogenic harm, and poor patient outcomes.
The big idea: When a patient presents with both physical and psychiatric symptoms, there are seven distinct categories of interaction to consider (adapted from Lipowski 1967). This framework is the lecture's backbone and the most testable concept. [1]
Learning Objectives
- Systematically approach patients with co-existing physical and psychiatric symptoms using the Lipowski framework.
- Recognize psychiatric presentations of medical conditions (especially delirium and focal organic syndromes).
- Understand medical presentations of psychiatric conditions (somatization, somatic symptom disorder, illness anxiety disorder).
- Identify psychiatric side effects of common non-psychotropic medications.
- Differentiate somatic symptom disorder, factitious disorder, and malingering.
- Apply a compassionate, structured approach to persistent or functional somatic presentations.
- Diagnose depression in patients with chronic medical illness (five key points).
The approach to patients with co-existing physical and psychiatric symptoms uses seven categories (adapted from Lipowski 1967). This is the lecture's core framework and the most exam-relevant concept. [1]
| # | Category | Direction | Example from Lecture |
|---|---|---|---|
| 1 | Co-morbid medical & psychiatric conditions | Conditions overlap; causality may be independent or shared | Interictal psychosis with epilepsy; a common disorder may contribute to both |
| 2 | Psychiatric presentations of medical conditions | Medical → Psychiatric | Delirium, thyroid disease → mood symptoms, Wilson disease → psychosis |
| 3 | Psychological/psychiatric symptoms as reactions to medical conditions | Medical → Psychological | Learned helplessness in epilepsy, adjustment disorder after cancer diagnosis |
| 4 | Psychiatric side effects of medical treatment | Treatment → Psychiatric | Corticosteroids → mania/depression; L-dopa → psychosis |
| 5 | Medical presentations of psychiatric conditions | Psychiatric → Somatic | Somatic symptom disorder; functional/dissociative seizures (older slide term: “pseudo-seizure”) |
| 6 | Medical side effects of psychiatric treatment | Psychiatric Rx → Medical | Epileptogenic propensity of some psychiatric medications; metabolic syndrome from antipsychotics |
| 7 | Medical complications of psychiatric conditions | Psychiatric → Medical | Self-harm, malnutrition in anorexia, dehydration in psychosis |
Why This Framework Matters
This is not just an academic exercise. In clinical practice, the same patient can fall into multiple categories simultaneously. For example, a patient with epilepsy may have (1) interictal psychosis [Category 1], (2) ictal psychiatric symptoms [Category 2], (3) learned helplessness from repeated seizures [Category 3], (4) depression related to antiseizure medication [Category 4], (5) functional/dissociative seizures [Category 5], and (6) seizures promoted by a psychiatric medication that lowers seizure threshold [Category 6]. The lecture uses epilepsy as a running illustration precisely because it touches almost every category.
How to Read the Lecture's Venn Diagram
The slide places co-morbid medical and psychiatric conditions in the overlap. The other six categories sit on the side from which the problem originates:
| Predominantly psychiatric side | Predominantly medical side |
|---|---|
| Medical presentations of psychiatric conditions | Psychiatric presentations of medical conditions |
| Medical side effects of psychiatric treatment | Psychiatric side effects of medical treatment |
| Medical complications of psychiatric conditions | Psychological/psychiatric reactions to medical conditions |
This layout is a visual reminder to reason in both directions. A psychiatric-looking symptom may have a medical cause, while a physical-looking symptom may be a psychiatric presentation; neither direction removes the need to assess genuine co-existing disease.
Category-by-Category Detailed Notes
Inter-ictal psychotic disorders and the possibility of a common organic condition leading to both epilepsy and psychiatric symptoms illustrate this category. [1]
Why this matters: Two conditions co-exist, but the relationship is not established merely by their co-occurrence. They may be independent, share risk factors or biology, or interact through treatment. For example, some antipsychotics lower seizure threshold, so management of one condition can affect the other.
Clinical relevance:
- Patients with epilepsy have a higher prevalence of depression and psychosis than the general population, even inter-ictally.
- Always screen for psychiatric co-morbidity in chronic medical conditions and vice versa.
Category 2: Psychiatric Presentations of Medical Conditions
Organic causes of psychiatric symptoms can be classified by whether they cause global cognitive impairment vs. focal/specific symptoms, and whether they are acute/transient vs. chronic/persistent. [1]
| Acute/Transient | Chronic/Persistent | |
|---|---|---|
| Global cognitive impairment | Delirium | Dementia |
| Focal/specific symptoms | e.g., focal impaired-consciousness seizure (slide term: complex partial seizure) | e.g., thyroid disease, Wilson disease |
- Global vs. Focal tells you the extent of brain involvement.
- Acute vs. Chronic tells you about reversibility and urgency.
- Delirium is an acute medical syndrome requiring prompt assessment for one or more causes. A major neurocognitive disorder (often called dementia in general clinical use) usually has a longer course, but delirium can be superimposed on it.
- Focal or systemic presentations can resemble a primary psychiatric illness, but the matrix is a triage scaffold, not a diagnosis. Time course, fluctuation, attention/consciousness, neurological examination, medications/substances and systemic findings determine the work-up.
Ictal and post-ictal psychiatric disorders are direct psychiatric presentations of epilepsy. [1]
- Ictal phenomena: During a focal seizure, people may experience fear, déjà vu, depersonalisation, hallucinations (for example olfactory or visual), automatisms or altered consciousness that can resemble a psychiatric episode.
- Post-ictal phenomena: After a seizure, people may have confusion or behavioural, mood or psychotic symptoms lasting from hours to days. A lucid interval after a seizure cluster is a recognised clue to post-ictal psychosis, but other acute causes still require assessment.
The slide uses “complex partial seizure.” ILAE replaced this with focal impaired-awareness seizure in 2017 and updated the classifier again in 2025 to focal impaired-consciousness seizure, defined using awareness and responsiveness. [20]
High Yield Clinical Pearl
Always ask "Could this psychiatric symptom be ictal or post-ictal?" in a patient with known epilepsy presenting with acute psychiatric change. Correlate witness history, timing and recovery with neurological assessment; video-EEG may be required when the diagnosis remains uncertain.
| Medical Condition | Psychiatric Presentation | Mechanism |
|---|---|---|
| Hypothyroidism | Low mood, cognitive slowing, psychomotor slowing | Assess symptoms and thyroid function in context; avoid attributing a full depressive syndrome to one laboratory result. [7] |
| Hyperthyroidism | Anxiety, irritability and, less commonly, mood or psychotic symptoms | Look for autonomic and systemic features and confirm biochemically. [7] |
| Cushing syndrome | Mood, sleep, cognitive or psychotic symptoms | Consider endogenous disease and exogenous glucocorticoid exposure. |
| Wilson disease | Personality/behavioural change, mood or psychotic symptoms, cognitive and movement abnormalities | Particularly important in a younger person with hepatic or neurological signs. |
| SLE/neuroinflammatory disease | Delirium, cognitive, mood, behavioural or psychotic symptoms | Integrate systemic activity, neurological findings, medications and targeted investigations. |
| Delirium (multifactorial) | Acute/fluctuating inattention, altered awareness and cognition, sometimes perceptual or behavioural change | Search promptly for interacting precipitants rather than relying on a single-neurotransmitter explanation. [21] |
The lecture's image-heavy differential table is broader than the selected examples above. Use it as a prompt when psychiatric symptoms are new, atypical, late-onset, fluctuating, or accompanied by neurological/systemic signs:
| Group | Examples shown on the slide |
|---|---|
| Infectious | HIV/AIDS and opportunistic disease, syphilis, Lyme disease, prion disease |
| Rheumatological/autoimmune | SLE, sarcoidosis, vasculitides, multiple sclerosis |
| Endocrine | Thyroid or parathyroid disease, Cushing syndrome, adrenal insufficiency |
| Metabolic/nutritional | Thiamine or B12 deficiency, calcium disturbance, acute hepatic porphyria, Wilson disease, hepatic encephalopathy, uraemia |
| Neoplastic | Primary/metastatic CNS tumour, paraneoplastic syndrome, carcinomatous meningitis |
| Haematological/genetic | Sickle-cell cerebrovascular disease, Huntington disease, lysosomal storage disease |
This is a differential scaffold, not a universal test panel: investigations should follow the presentation, examination and red flags.
Learned helplessness as a consequence of repeatedly experiencing unpredictable and unavoidable seizures (Weigartz et al. 1999). This includes fear of seizure, parental overprotection, stigma & discrimination, and deteriorated socioeconomic status & quality of life. [1]
How to read this image: The callout links seizure unpredictability to fear, reduced perceived control, family overprotection, stigma, socioeconomic harm and poorer quality of life. “Learned helplessness” is a historical psychological model, not an inevitable response or a diagnosis. Individual experience, resources, seizure control and social context vary greatly.
Clinical implications:
- A reaction to illness may be proportionate distress, an adjustment disorder, or another mood/anxiety disorder; do not label every understandable reaction as an adjustment disorder.
- In epilepsy, fear of another event can lead to avoidance, reduced independence and isolation, which may in turn worsen mood and quality of life. Explore safety restrictions that are genuinely required separately from fear-driven restriction.
- Family protection can be helpful, but over-restriction may limit autonomy and self-efficacy. Frame this collaboratively rather than blaming parents or carers.
Category 4: Psychiatric Side Effects of Medical Treatment
Psychiatric side effects of antiepileptic medication and psychiatric complications after epileptic surgery illustrate this category. [1]
Possible psychiatric side effects of non-psychotropic drugs include: agitation/aggression, anxiety, delirium, cognitive impairment, depression, lethargy, suicidal ideation, mania, psychosis, and hallucination. [1]
This is a very high-yield topic for exams because medication lists are directly testable. The slide lists reported associations, but a temporal association is not automatically causal: consider dose, timing, drug interactions, withdrawal, the underlying illness, delirium and alternative diagnoses.
| Drug | Interpretation / caveat |
|---|---|
| L-dopa | Mood can fluctuate with motor “on/off” states; dopaminergic therapy is also more classically associated with hallucinations, psychosis and impulse-control problems |
| Corticosteroids | Systemic corticosteroids can cause a broad range of affective, behavioural, psychotic, sleep and cognitive effects; reactions can also occur during withdrawal. [22] |
| Antihypertensives (e.g., calcium channel blocker, reserpine) | Reserpine has a historical monoamine-depletion association; evidence for calcium-channel blockers causing depression is inconsistent |
| Propranolol | Fatigue, sleep disturbance and CNS effects can resemble depression; a strong causal link with depressive disorder is not established |
| Phenobarbital | CNS depressant (GABAergic), also used as AED |
| Interferons | Inflammatory and neurochemical effects are associated with depressive syndromes |
| Oral contraceptives | Mood effects vary between individuals and formulations; do not assume causation from exposure alone |
| Drug | Interpretation / caveat |
|---|---|
| Corticosteroids | Higher systemic doses increase overall risk, but the type, severity and duration of reaction are not reliably predicted by dose. [22] |
| Anticholinergic agents | More often cause an anticholinergic delirium with agitation than a clean primary manic syndrome |
| Isoniazid | Rare neuropsychiatric toxicity; consider pyridoxine-related mechanisms and drug interactions |
This is a signal list from the 2024 slide, not a blacklist or proof of causation:
| Drug class | Examples | Practical interpretation |
|---|---|---|
| Anticholinergics & sedating antihistamines | — | Often produce an anticholinergic delirium, not an isolated primary psychosis. |
| Dopaminergic drugs | Levodopa, amantadine | Can contribute to hallucinations, delusions, behavioural change or impulse-control problems, especially with vulnerability and polypharmacy. |
| Interferon | — | Historical treatment association; consider mood, cognitive and psychotic symptoms. |
| Stimulants / sympathomimetics | Includes some OTC preparations | Dose, sleep deprivation, intoxication and withdrawal matter. |
| Corticosteroids | — | Can cause mood, psychotic, behavioural and cognitive syndromes. [22] |
| Antiseizure medicines | Drug-specific | Behavioural or psychiatric adverse effects are drug- and patient-specific; “high-dose anticonvulsants” is too broad as a class statement. |
| Pain medicines | Opioids | Sedation, intoxication, withdrawal and delirium may include perceptual disturbance. |
| Antimicrobials | Ciprofloxacin; selected antivirals, antimalarials and anti-TB drugs | Consider renal/hepatic function, interactions and toxic encephalopathy; not every altered mental state is primary psychosis. |
| Cardiac drugs | Digoxin and selected antiarrhythmics | Check toxicity, electrolytes, renal function and interactions. |
| Antineoplastics | Ifosfamide | May cause toxic encephalopathy, which can include behavioural or perceptual symptoms. |
For a new syndrome, establish the medication timeline (start, dose change, missed doses or withdrawal), review interactions and organ function, assess attention/fluctuation for delirium, and balance any change against the medicine’s indication. Do not stop corticosteroids or other essential therapy abruptly without an appropriate plan.
Exam Trap
Corticosteroids can cause mood, psychotic, behavioural, sleep or cognitive symptoms, often within days to weeks, and reactions are also reported during withdrawal. Assess the actual syndrome and timing; do not assume “steroids = depression only.” [22]
High Yield
The lecture specifically lists reserpine under antihypertensives associated with depression. Its monoamine-depleting action contributed historically to the monoamine hypothesis; treat this as lecture-era pharmacology, not proof that every exposed patient develops depression.
Category 5: Medical Presentations of Psychiatric Conditions
This is the largest section of the lecture and covers somatization, somatic symptom disorder, illness anxiety disorder, factitious disorder, and malingering.
Medical presentations of psychiatric conditions can occur via: (A) Somatic symptoms as part of secondary symptoms of other psychiatric disorders (e.g., mood disorders, anxiety disorders, psychotic disorders, substance-related disorders, eating disorders), or (B) Psychiatric disorders with somatoform symptoms as the main presentation. [1]
Path A: Somatic symptoms secondary to another psychiatric disorder
- Depression → fatigue, pain, anorexia, weight loss, insomnia
- Anxiety → palpitations, chest tightness, breathlessness, GI symptoms, tremor
- Psychosis → bizarre somatic delusions (e.g., "my organs are rotting")
- Substance use → withdrawal symptoms, autonomic dysfunction
- Eating disorders → amenorrhea, electrolyte disturbance, osteoporosis
Path B: Somatic or functional symptoms as the main presentation
- Somatic symptom disorder
- Illness anxiety disorder / Hypochondriasis
- Conversion disorder (Dissociative disorder)
Somatization: two historical explanatory diagrams [1]
The lecture presents two older models of how physical symptoms and psychiatric distress may relate. They are hypotheses for formulation, not diagnostic tests or established mechanisms in every patient.
The diagram shows a psychiatric disorder feeding into both psychiatric symptoms and “unexplained physical symptoms,” with an amplifying perceptual style increasing the physical-symptom pathway and subsequent healthcare use. [1]
Modern interpretation: attention, autonomic arousal and threat appraisal can change symptom intensity and disability without making symptoms voluntary or unreal. However, persistent symptoms may also reflect recognised or evolving physical disease, functional disorders, medication effects, or several processes at once. “Unexplained” should never mean “not assessed.”
The second diagram routes a psychiatric disorder toward physical symptoms and healthcare use while “psychological defences” block overt psychiatric symptoms. [1]
Modern interpretation: this is a historical psychodynamic account of a “masked” presentation. Do not infer unconscious conflict merely because a patient reports physical rather than emotional symptoms, and do not require psychological distress to diagnose a functional disorder. Ask openly about mood, anxiety, trauma and stress while continuing proportionate physical assessment.
What the diagrams do—and do not—show
The diagrams explain how attention, beliefs, arousal, avoidance and help-seeking can maintain distress. They do not prove that symptoms are psychogenic, exclude medical disease, establish intentionality, or justify telling a patient that symptoms are “all in the mind.”
| Population/condition | Prevalence estimate shown |
|---|---|
| General population | 3–4% |
| Cancer | 15–25% |
| Coronary heart disease | 15–23% |
| Diabetes | 12–18% |
| Chronic kidney disease | 20–50% |
| Chronic pain | 25–60% |
These are lecture-era ranges from selected studies, not current universal constants. They vary with case definition, disease stage, disability, setting and sampling. The slide also gives selected case-series figures (diabetes 11%, multiple sclerosis 26%, chronic pain 61%); do not mix those single-study estimates with the broader ranges.
Over 60% of depressed patients report chronic pain (Magni et al. 85, Ohayon & Schatzberg 10). One-third to one-half of patients presenting to pain clinics have a current major depression (Dersh et al. 06). The two conditions detrimentally affect each other in terms of recovery time and symptom duration, suggesting a synchronicity in symptom severity (IsHak et al. 18). [1]
How to interpret the association: pain and depression influence one another through biological, psychological and social pathways, including sleep, activity, threat appraisal, loss, disability and social isolation. Some treatments can benefit selected pain and mood syndromes, but co-occurrence does not prove a single neurotransmitter mechanism or mean that all chronic pain is “somatisation.”
The Venn diagram reports the following percentages of the whole primary-care sample (N=2091; Löwe et al., 2008):
| Venn region | % of total sample |
|---|---|
| Depression only | 1.7% |
| Anxiety only | 3.4% |
| Somatization only | 4.4% |
| Depression + anxiety only | 1.1% |
| Depression + somatization only | 1.6% |
| Anxiety + somatization only | 1.2% |
| All three | 2.3% |
The printed totals—depression 6.7%, anxiety 8.0%, somatization 9.5%—include every region within that circle. Do not mistake an “only” region (for example, anxiety only 3.4%) for a pairwise overlap.
Clinical implication: In this 2008 primary-care sample, severe depressive, anxiety and somatisation symptoms overlapped. The diagram shows co-occurrence, not causal direction, and its screening thresholds should not be treated as current population prevalence estimates.
Somatic-symptom terminology across classification systems [1]
The lecture provides a three-column comparison of DSM-5, ICD-10, and ICD-11 terminology. [1]
| DSM-5-TR | ICD-10 | ICD-11 |
|---|---|---|
| Somatic Symptoms & Related Disorders | Somatoform Disorders | Disorders of Bodily Distress and Bodily Experience |
| Somatic Symptom Disorder (300.82) — Specify: with predominant pain, persistent; Severity: mild/moderate/severe | Somatization disorder (F45.0, F45.1); Persistent somatoform pain disorder (F45.4) | Bodily Distress Disorder (6C20) — Mild/Moderate/Severe |
| Illness Anxiety Disorder (300.7) | Hypochondriacal disorder (F45.2) | Hypochondriasis (6B23) — now classified under Obsessive-compulsive or related disorder |
Key classification point
In ICD-11, hypochondriasis is located under obsessive-compulsive or related disorders, while bodily distress disorder sits under disorders of bodily distress or bodily experience. Preserve the classification fact without assuming that every health concern is obsessional or that reassurance-seeking alone establishes the diagnosis. [16]
DSM-5 diagnostic core shown on the slide (retained in DSM-5-TR):
- One or more somatic symptoms cause distress or significant disruption.
- At least one of the following is excessive: persistent thoughts about seriousness, health/symptom anxiety, or time and energy devoted to the concern.
- The symptomatic state persists, typically for more than 6 months, even if the individual symptom changes.
The diagnosis is based on the distress/disruption and excessive thoughts, feelings or behaviours—not on proving that symptoms are medically unexplained. A diagnosed medical condition can coexist. [15]
The next slides describe a female predominance, a chronic fluctuating course, repeated consultations across clinicians, iatrogenic risk from repeated procedures/polypharmacy, possible opioid or benzodiazepine misuse, and common psychiatric comorbidity. [1] Interpret these as risk patterns, not defining criteria or character judgements:
- Replace the stigmatising phrase “doctor shopping” with fragmented or repeated multi-provider care and ask what unmet need, poor continuity or new symptom is driving it.
- Do not assume chronicity means recovery is rare; treatment aims to reduce distress, improve function and coordinate safe care.
- The slide's “Axis I/Axis II” terminology was retired after DSM-IV. Describe coexisting depressive, anxiety, substance-use or personality disorders directly.
- Avoid both indiscriminate repeat testing and premature diagnostic closure. A new objective sign, changed pattern or red flag requires reassessment.
Important DSM-5/DSM-5-TR shift: unlike older somatoform concepts, SSD does not require the symptom to be “medically unexplained.” APA explicitly cautions against diagnosing SSD solely because no medical cause has been demonstrated. [15]
DSM-5 diagnostic core shown on the slide (retained in DSM-5-TR):
- Preoccupation with having or acquiring a serious illness; somatic symptoms are absent or mild, or the concern is clearly excessive relative to genuine risk/illness.
- High health anxiety with either excessive health behaviours (such as repeated checking) or maladaptive avoidance.
- The illness preoccupation persists for at least 6 months, although the feared diagnosis may change.
- It is not better explained by SSD, panic disorder, GAD, body dysmorphic disorder, OCD or a somatic delusion.
Illness Anxiety Disorder is:
- Equally common in men and women
- Patients are easily alarmed about personal health status
- Normal or commonplace sensations and appearances are often interpreted as abnormal and distressing
- Distorted belief that good health is a relatively symptom-free state, and that symptoms mean disease (Barsky et al. 1993)
- The belief is NOT of delusional intensity [1]
Why "not delusional intensity" matters: If the health belief is held with delusional conviction despite contrary evidence, consider a somatic delusion and other psychotic disorders. The differential and management then change; “bizarre” content is not required for a belief to be delusional.
This is a directly testable table from the lecture. [1]
| Feature | Somatic Symptom Disorder | Factitious Disorder imposed on self | Malingering |
|---|---|---|---|
| Symptoms intentionally produced/falsified? | No | Yes—deception or induction is intentional | Yes—fabrication or exaggeration is intentional |
| Patient's illness concern | Symptoms and distress are genuinely experienced | Presents self as ill/impaired/injured; need not believe the fabricated illness is real | Presentation is used instrumentally; genuine illness may still coexist |
| Incentive | No external incentive defines the disorder | No obvious external reward; classically associated with adopting the patient role, though the exact psychological motive need not be known | External incentive, e.g. money, drugs, shelter, avoiding work/duty/legal consequences |
| Diagnostic status | Psychiatric diagnosis | Psychiatric diagnosis | A behaviour/context, not a mental disorder diagnosis |
How to Remember This
SSD: The patient genuinely suffers; the symptoms are not intentionally produced. They are not faking.
Factitious disorder: The patient deliberately falsifies or induces symptoms and presents themself as ill, without an obvious external reward. “Munchausen syndrome” is an older label for a severe, chronic pattern; it is not a synonym required for every case.
Malingering: The person consciously fabricates symptoms for a clear external incentive (money, avoiding jail, getting drugs). This is NOT a psychiatric diagnosis — it is a behaviour.
Key discriminator for exams: Ask “Is symptom production intentional?” and “Is there an obvious external incentive?”
- Intentional falsification + No obvious external gain = Factitious
- Intentional fabrication/exaggeration + External gain = Malingering
- Not intentionally produced = SSD
Potential maintaining mechanisms for somatic distress [1]
The lecture outlines four levels of potential maintaining factors: [1]
| Level | Mechanisms |
|---|---|
| Physiological | Autonomic arousal, muscle tension/pain, hyperventilation, sleep disturbances |
| Psychological | Beliefs about causes behind physiological symptoms, mood, personality factors (coping strategies, stress tolerance, emotion control) |
| Behavioural | Inactivity, frequent checking/increase in focus |
| Interpersonal | Reinforcing actions of relatives and friends, health care system, disability system |
These factors form a biopsychosocial formulation, not proof that a symptom has no physical basis. Select interventions from the patient's actual formulation: optimise physical treatment, address arousal/sleep and mood, reduce unhelpful checking or avoidance, rebuild activity safely, and improve continuity of care. Avoid describing relatives, disability support or healthcare use as “reinforcement” without understanding their protective and practical functions.
The slide shows two reinforcing loops, both beginning with pain-related fear and returning to pain:
The first loop is behavioural/physical; the second is attentional/cognitive. The arrows represent potential maintaining pathways, not a claim that pain is imagined. Structural disease and sensitisation can coexist with fear, avoidance and deconditioning.
Treatment implication: after appropriate assessment, agree paced or graded rehabilitation that is safe for the underlying condition, address threat interpretation and sleep, and treat any coexisting anxiety or depressive disorder. Avoid forcing activity through an unassessed red flag or post-exertional symptom pattern.
Checking and reassurance can reduce anxiety briefly but keep attention fixed on the body and prevent uncertainty from being tolerated, thereby maintaining the cycle. The clinical response is not abandonment: arrange proportionate medical follow-up while reducing repetitive, low-value testing and treating health anxiety.
This is the most clinically practical and examable section of the lecture.
Grief/Adjustment versus Depressive Disorder in Terminal Illness
The slide's comparison is a pattern-recognition aid, not a rule that grief and depression cannot coexist. In advanced illness, cognitive-affective features such as pervasive anhedonia, worthlessness/excessive guilt and despair may discriminate better than fatigue, appetite or sleep symptoms that illness and treatment can also cause. [18]
| Feature | Grief/adjustment pattern | Depressive pattern |
|---|---|---|
| Focus | Linked to a particular loss | Pervasive across life |
| Course | Comes in waves; may ease over time | More constant/protracted |
| Pleasure | Capacity for pleasure and connection remains, despite reduced activity | Pervasive anhedonia |
| Hope | Hope may shift toward comfort, family or achievable goals | Persistent, pervasive hopelessness |
| Self-worth | Usually maintained | Worthlessness or life felt to have no value |
| Guilt | Regret about specific events | Excessive or global guilt |
| Thoughts of death | May be passive/fleeting | Recurrent preoccupation, intent or planning is more concerning |
Point 1: Some symptoms of medical illness could resemble those of depression — fatigue, anorexia, weight loss, insomnia, weakness, diminished concentration. Also consider hypoactive delirium and medication/treatment adverse effects. [1]
Why this is tricky: In a patient with cancer receiving chemotherapy, fatigue and anorexia may arise from illness, treatment, depression or several causes together. Do not automatically discard somatic symptoms, but do not diagnose depression from them alone either. NICE recommends a comprehensive assessment that considers duration, functional impairment, past mood elevation, comorbidity, relationships, living conditions, medications and the physical illness—not a symptom count alone. [17]
Point 2: Physical suffering and disability may diminish the capacity to experience pleasures in formerly enjoyable activities. Depressed mood or withdrawal DISPROPORTIONATE to disability could be a hint. [1]
Clinical interpretation: Loss of access to an activity is not the same as loss of the capacity for pleasure. Explore whether interest, connection or enjoyment remains in activities still possible for the person. The slide's word “disproportionate” is a clue for further assessment, not a formal threshold and never a judgement about how distressed someone should be.
Point 3: Desire for death vs. adaptive death acceptance in terminally ill patients. Active suicidal ideation is ALWAYS an alarming sign. [1]
Why this is nuanced: Acceptance of approaching death can coexist with hope for comfort, connection or unfinished goals. A wish for death may also signal uncontrolled pain or other symptoms, delirium, depression, fear, demoralisation or social distress. Ask directly and respond to the formulation; intent, planning or immediate danger requires urgent intervention. [18]
Point 4: Difficulty in determination of "hopelessness," "worthlessness," and "guilty feeling" as depressive symptoms. Look for distorted thinking (e.g., maximization & catastrophic thoughts, over-generalization). "Hopelessness" is not absolute — e.g., still hope for being with family, hope for symptom alleviation. [1]
Clinical application: “There is no hope for cure” may be a realistic appraisal rather than depressive hopelessness. Explore whether hope has shifted toward achievable goals, and ask about pervasive loss of meaning, worthlessness or excessive guilt. Avoid debating a person's beliefs as “distorted” before understanding prognosis, culture, values and lived circumstances.
Point 5: Depressive symptoms may manifest in atypical or masked forms, e.g., amplification of somatic symptoms, non-compliance with or refusal of medical treatment. [1]
Why this matters: A change in treatment engagement may signal depression, cognitive impairment, delirium, adverse effects, cost, access, health literacy, cultural beliefs, loss of capacity, or an informed preference. Use treatment engagement/adherence rather than “compliance,” screen for depression, and assess capacity and barriers without assuming refusal is psychopathology.
Pseudodementia — The Classic Exam Trap
Depression in older adults can cause substantial cognitive impairment (historically called “depressive pseudodementia”). Past paper Q24 (2020) tests the label; the answer is depressive disorder. [11] A more abrupt, mood-linked course and improvement when depression is treated support the diagnosis, but bedside mannerisms such as “don't know” answers do not reliably exclude neurocognitive disease. Depression and dementia can coexist, and persistent impairment needs follow-up.
The slide uses the older term “pseudo-seizure” as an example of a psychiatric condition presenting medically. Prefer functional seizures or functional/dissociative seizures; “pseudo-seizure” can imply that the event is fake. The ILAE uses functional/dissociative terminology, while DSM-5-TR classifies the presentation within functional neurological symptom disorder and ICD-11 within dissociative neurological symptom disorder. [19] [23]
Functional seizures are genuine, involuntary episodes that resemble epileptic seizures. Diagnose them from a coherent history and positive clinical/semiological evidence, supported by video-EEG of a typical event when feasible—not merely because tests are normal. No single bedside sign proves the diagnosis:
| Finding during a typical event | Interpretation |
|---|---|
| Long, fluctuating event; asynchronous movements; eye closure; retained responsiveness | May support functional seizure in context, but none is diagnostic alone |
| Stereotyped brief event, lateral tongue injury, clear postictal confusion | May support epilepsy, but absence does not exclude it |
| Incontinence or injury | Can occur in either condition |
| Serum prolactin | Limited, time-sensitive adjunct after selected generalised tonic-clonic or focal impaired-consciousness seizures; a normal result does not diagnose functional seizures |
| Video-EEG capturing the patient's typical event | Diagnostic reference standard when available; some epileptic seizures may lack a clear scalp-EEG correlate |
Some patients have both epilepsy and functional seizures. Communicate the diagnosis positively and respectfully, explain that symptoms are real and potentially treatable, and assess coexisting psychiatric, neurological and medical conditions. The AAN published an evidence-based functional-seizure management guideline in December 2025. [19]
Consideration of the epileptogenic propensity of some psychiatric medications. [1]
| Psychiatric Drug | Seizure Risk | Notes |
|---|---|---|
| Clozapine | Higher, dose-related | The clearest antipsychotic example; risk also depends on titration, level and patient factors |
| Chlorpromazine | Moderate | Low-potency typical antipsychotic |
| Bupropion | Dose/formulation-related | Avoid exceeding the product dose limit; risk rises with overdose and predisposition |
| TCAs (e.g., clomipramine) | Moderate | More than SSRIs |
| Lithium | Mainly with toxicity | Check level, renal function, interacting drugs and electrolytes |
| SSRIs | Relatively low at therapeutic doses | Usually preferred over higher-risk antidepressants when treatment is indicated |
| Haloperidol | Relatively low | Risk is not zero, particularly with overdose or other predisposing factors |
Other medical side effects of psychiatric treatment (from supporting context [8]):
- Antipsychotics: Weight gain (olanzapine, clozapine > risperidone > quetiapine), metabolic syndrome, QTc prolongation, hyperprolactinemia, extrapyramidal symptoms, NMS
- Lithium: Nephrogenic diabetes insipidus, hypothyroidism, hypercalcemia, tremor, renal impairment [9]
- Antidepressants (TCAs): Anticholinergic effects, cardiac conduction abnormalities, weight gain
- Antidepressants (SSRIs): Serotonin syndrome, hyponatraemia (SIADH), GI bleeding (esp. with NSAIDs)
- Valproate: Weight gain, teratogenicity, hepatotoxicity, pancreatitis, thrombocytopenia [8]
While the lecture mentions this category in the framework, it does not elaborate extensively. Key examples include:
- Eating disorders: Electrolyte disturbances (hypokalaemia → arrhythmia), osteoporosis, amenorrhoea, dental erosion, Mallory-Weiss tear, cardiac failure
- Substance use disorders: Liver disease, pancreatitis, cardiomyopathy, Wernicke-Korsakoff syndrome
- Severe depression/psychosis: Self-neglect → malnutrition, dehydration
- Self-harm/suicide: Physical injuries, overdose toxicity
- Catatonia: DVT, rhabdomyolysis, aspiration pneumonia
Approach to Persistent Somatic or Functional Presentations [1]
The lecture provides a comprehensive management framework that is highly testable:
1. Appreciate that the symptoms are REAL to the patient [1]
2. Provide a positive explanation, including how behavioural, psychological, and emotional factors may exacerbate physiologically based somatic symptoms [1]
3. Offer opportunity for discussion of their worries [1]
4. Identify and treat mood or anxiety disorder [1]
5. Protect patients from iatrogenic problems [1]
6. Minimize polypharmacy [1]
7. Provide specific treatment when indicated [1]
8. Discuss and agree a treatment plan [1]
9. Slide wording: “reduce your expectation of cure” and aim for “containment and damage limitation” [1]
10. Change social dynamics [1]
11. Encourage return to normal activity and work (coping and not curing) [1]
12. Recognize and control negative reactions, beware of counter-transference [1]
Counter-Transference Warning
"Recognize and control negative reactions, beware of counter-transference." Persistent or complex symptoms can evoke frustration, dismissiveness or helplessness in clinicians. These reactions can lead to:
- Dismissing real medical pathology (patients with somatization DO get real diseases)
- Over-investigating to "prove there's nothing wrong" (iatrogenic harm)
- Abandoning the patient (therapeutic rupture)
The warning is about clinician responsibility: notice the reaction, seek supervision or team discussion when needed, and preserve curiosity and continuity rather than labelling the person “difficult.”
| Principle | Practical Application |
|---|---|
| Symptoms are REAL | Never say "it's all in your head." Validate the experience. |
| Positive explanation | Share a formulation based on the person's findings; explain what is known, what has been ruled out, and how body, attention, arousal, behaviour and context can interact. |
| Treat coexisting disorders | Assess and treat depression, anxiety, substance use, sleep and relevant physical disease according to their own indications. |
| Protect from iatrogenesis | Coordinate records and prescribers; avoid low-value repeat tests/procedures while keeping an explicit red-flag and re-evaluation plan. |
| Minimize polypharmacy | Review all medications at each visit |
| Recovery-oriented goals | Replace the slide's pessimistic “containment/damage limitation” language with jointly agreed goals for symptoms, function, participation, quality of life and safe care. APA describes improved symptom control and function as treatment aims. [15] |
| Continuity | Offer planned review with one coordinating clinician/team, plus clear safety-netting for changed symptoms or new objective signs. |
| Activity and rehabilitation | Agree a paced return to valued activity where medically safe; tailor it to the underlying condition and the person's goals. |
| Social context | Explore family needs, work, finances, housing and disability support without presuming “secondary gain.” |
Avoid two opposite errors
Do not repeatedly investigate without a clinical question, but do not make “no more tests” an inflexible rule. Somatic symptom disorder and physical disease can coexist; new red flags, objective change or a changed pattern deserves proportionate reassessment. Regular, trusted follow-up and psychotherapy can improve coping and function. [15]
Delirium is the most important Category 2 example and is tested heavily in past papers.
DELIRIUM mnemonic from senior notes [5]:
- D = Drugs
- E = Electrolytes, Ears and Eyes
- L = Low oxygen
- I = Infection
- R = Retention (urine or faeces)
- I = Ictogenic (seizures)
- U = Underhydration or Undernutrition
- M = Metabolic (especially glucose)
DSM-style diagnostic core for delirium [5]:
- A: Disturbance in attention AND awareness
- B: Develops over short period (hours to days), fluctuates
- C: Additional cognitive disturbance (memory, orientation, language, visuospatial, perception)
- D: Not explained by another neurocognitive disorder, not in coma
- E: Evidence of medical cause, substance intoxication/withdrawal, or toxin exposure
Current bedside pathway
When acute or fluctuating change raises concern for delirium, NICE recommends assessment with the 4AT in most hospital or long-term-care settings, or CAM-ICU/ICDSC in critical care or recovery. A competent clinician makes the final diagnosis, searches for one or more underlying causes, and if delirium versus dementia remains uncertain, manages delirium first. [21]
Exam Intelligence
| Question Type | Example Stem | What They're Testing |
|---|---|---|
| MCQ | "A patient on corticosteroids develops euphoria and grandiosity. Most likely diagnosis?" | Category 4: Drug-induced mania |
| MCQ | "Which condition mimics dementia in the elderly?" | Pseudodementia (depression) [11] |
| SAQ | "List 4 differential diagnoses for fatigue in primary care" | Including psychiatric causes [10] |
| SAQ | "Name 2 screening questions for depression" | PHQ-2 type questions [10] |
| SAQ | "Differentiate SSD from factitious disorder from malingering" | The three-way table |
| Minicase | "Patient with chronic pain, normal investigations, multiple doctor visits" | SSD approach |
| Minicase | "Patient with epilepsy develops psychiatric symptoms" | Categories 1-6 of Lipowski framework |
| OSCE | "Explain to patient why their symptoms are real but not from a serious disease" | Positive explanation, empathy |
- Forgetting that SSD patients can have real medical conditions — DSM-5-TR does not require symptoms to be “medically unexplained”
- Confusing factitious disorder with malingering — both involve intentional falsification, but malingering has an external incentive whereas factitious disorder has no obvious external reward
- Attributing all somatic symptoms to depression without considering that the medical illness itself causes similar symptoms
- Treating all discussion of death as equivalent—or dismissing it as “normal” — distinguish acceptance, passive death wishes, intent and planning, but assess safety whenever a wish for death is expressed
- Forgetting Category 7 (medical complications of psychiatric conditions) when asked about the Lipowski framework
- Assuming changed treatment engagement is “non-compliance” — screen for depression, but also assess cognition, delirium, adverse effects, access, capacity and informed preference
- 2018 SAQ Q10: Fatigue in primary care — requires listing psychiatric differential diagnoses and depression screening questions [10]
- 2020 MCQ Q24: Pseudodementia — depression mimicking dementia [11]
- 2021 Minicase Case 3: Panic disorder after physical trauma — psychiatric symptoms in reaction to medical event [12]
- 2021 SAQ Q3: Psychiatric classification systems and differential diagnosis for low mood + anxiety [13]
- 2024 MCQ Q14: Postpartum mood disturbance — differentiating postpartum depression from baby blues from puerperal psychosis [14]
High Yield Summary
-
The Lipowski 7-category framework
- is the backbone of this lecture: (1) Co-morbid conditions, (2) Psychiatric presentations of medical conditions, (3) Reactions to medical conditions, (4) Psychiatric SE of medical Rx, (5) Medical presentations of psychiatric conditions, (6) Medical SE of psychiatric Rx, (7) Medical complications of psychiatric conditions.
-
Diagnosing depression in chronic medical illness
- Use a whole-syndrome assessment: medical illness/treatment can mimic somatic symptoms; explore pervasive anhedonia and cognitive-affective symptoms; distinguish acceptance from depression without dismissing any death wish; ask directly about suicide; and assess all causes of changed treatment engagement.
-
SSD vs. Factitious vs. Malingering
- SSD = symptoms/distress are not intentionally produced. Factitious disorder = intentional falsification/induction without obvious external reward. Malingering = intentional fabrication/exaggeration for external incentive.
-
Drug-induced psychiatric symptoms
- Start with syndrome and timeline. Systemic steroids can cause affective, psychotic, behavioural and cognitive reactions; anticholinergics more often cause delirium than isolated mania; dopaminergic drugs can cause hallucinations or behavioural change. The slide's other associations vary greatly in evidence and frequency.
-
Approach to persistent somatic symptoms
- Validate symptoms, give a positive formulation, treat coexisting disease, coordinate proportionate assessment, reduce iatrogenic harm, agree recovery-oriented functional goals, safety-net new changes and monitor clinician reactions.
Active Recall - Psychiatric Conditions in Medical Settings
[1] Lecture slides: CFB (PSY03) Psychiatric conditions in medical settings.pdf (all pages) [2] Senior notes: Ryan Ho Psychiatry.pdf (p.28, p.124, p.150, p.163) [3] Senior notes: Ryan Ho Fundamentals.pdf (p.325 — Delirium) [4] Senior notes: Ryan Ho Neurology.pdf (p.94-95 — Delirium, consciousness disorders) [5] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p.1131-1135 — Delirium) [6] Senior notes: Ryan Ho GI.pdf (p.118 — IBS and somatization comorbidity) [7] Lecture slides: General Clerkship-Psychiatric Assessment Skills Training-Learning Materials 2024_3 Sep.pdf (p.13 — thyroid and psychiatric DDx) [8] Senior notes: Block A - I am overweight, doctor_ obesity; Hyperlipidaemia.pdf (p.8 — psychiatric drugs causing weight gain) [9] Senior notes: Block A - Two cases of polyuria and polydipsia.pdf (p.5 — lithium side effects) [10] Past papers: 2018 Fourth Summative SAQ.pdf (p.5 — Q10 fatigue and depression screening) [11] Past papers: 2020 Fourth Summative Assessment MCQ paper.pdf (p.9 — Q24 pseudodementia) [12] Past papers: 2021 Fourth Summative Minicase.pdf (p.22 — Case 3 panic disorder) [13] Past papers: 2021 Fourth Summative SAQ.pdf (p.4 — Q3 psychiatric classification) [14] Past papers: 2024 Fourth Summative MCQ.pdf (p.6 — Q14 postpartum depression) [15] American Psychiatric Association. What is somatic symptom disorder? Reviewed July 2024; based on DSM-5-TR. [16] World Health Organization. Clinical descriptions and diagnostic requirements for ICD-11 mental, behavioural and neurodevelopmental disorders. 2024. [17] National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: recognition and management. CG91. [18] National Cancer Institute. Depression (PDQ®) – Health Professional Version. Updated 25 July 2024. [19] American Academy of Neurology. Management of Functional Seizures. Practice guideline, December 2025. [20] Beniczky S, et al. Updated classification of epileptic seizures: Position paper of the International League Against Epilepsy. Epilepsia. 2025;66:1804–1823. [21] National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. CG103; updated January 2023. [22] Medicines and Healthcare products Regulatory Agency. Corticosteroids: early psychiatric side-effects. Drug Safety Update. [23] International League Against Epilepsy. Functional / Dissociative Seizures.
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Family Medicine is a medical specialty that provides comprehensive, continuous, and patient-centered primary care to individuals of all ages within the context of their families and communities.
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