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EMOTIONAL AND BEHAVIORAL SYMPTOMS ACCOMPANY and may exacerbate many chronic diseases, and thus, almost every practitioner will at some point encounter patients with psychiatric comorbidities. This chapter aims to provide a framework for approaching the psychiatric patient. Diagnosing and treatment calls for first viewing the patient as a human with psychiatric symptoms. Some extra precautions for protecting the patient and oneself may be needed, such as obtaining information on safety precautions or reliability as a historian, but many of these should already be part of good clinical practice for any patient.

Some keys to working successfully with psychiatric patients involve:

  • Having a fundamental knowledge of a patient's psychiatric condition to help assess treatment compliance, safety issues, and potential barriers to treatment.

  • Knowing the psychiatrist's treatment plan, and being able to anticipate a patient's mental progress over time.

  • Working in unison with the psychiatric team (and preventing patients from engaging in “team-splitting”).

  • Protecting oneself mentally to avoid burnout.

  • Remaining open-minded to increase chances of finding overlooked diagnoses.

  • Being aware of psychiatric medication side effects such as weight change, orthostatic hypotension, movement disorders, confusion, irritability, fatigue, anxiety, or increased fall risk.

  • Helping find organic causes for psychiatric symptoms by reviewing labs, screening for infections, and so on.

  • Helping diagnose movement disorders, which may represent primary medical conditions or medication side effects.

  • Using exercise and physical movement to help break a downward cycle.

  • Reducing unnecessary systemic medication usage, especially for pain management, and helping prevent substance abuse.

  • Recognizing physical maladies as clues to undiagnosed mental disorders.


Mental illness accounts for more disability in the developed world than any other health condition. In the United States, a fourth of adults annually report having mental illness meeting Diagnostic and Statistical Manual of Mental Disorders-IV criteria.

Psychiatric conditions often lead to a host of patient stressors: family, finance, and work are often adversely affected. Often, the patient suffering from psychiatric illness is afflicted with poor health habits, diet, lack of self-care, and inability to perform activities of daily living (ADL). In extreme cases, an individual may have also sustained musculoskeletal injury from dangerous behaviors. A paranoid patient might not even cooperate with therapists, a depressed individual may lack motivation to follow a home exercise program, an Alzheimer's patient may not comprehend instructions, or a schizophrenic may halt amidst gait training on account of hallucinations. It is no wonder that prior caregivers may have given up on attempts to mobilize a patient, leading to a downward spiral involving inactivity, deconditioning, frailty, and even obesity. In such cases, a progressive physical reconditioning program emphasizing functional training and self-care may help turn things around.

Adding to the toll of mental illness is its often-early onset: in the United States, three-fourths of all lifetime cases start by age 24 years.1 By age 75, about half the population has had some psychiatric condition....

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