Decoding Overlapping Medical and Psychiatric Symptoms

When physical and psychiatric ailments may present with overlapping symptoms, how can clinicians ensure they are identifying and targeting the right issue?

In this expert Q&A, Mercedes Dodge, MPAS, PA-C, CAQ-Psychiatry, Psych Congress PA Institute Co-Chair, explores key topics from her session, “When Physical and Psychiatric Symptoms Collide: A Clinical Approach to Diagnosis and Treatment,” at the inaugural PA Institute. Dodge offers practical insights for differentiating psychiatric symptoms from medical mimics, auditing cognitive biases that may lead to diagnostic error, and leveraging a collaborative approach to ensure patients receive timely, accurate, and effective diagnosis and treatment.

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Psych Congress Network: From your experience, what are the most commonly missed medical issues that initially appear as mood or anxiety symptoms, and why do they so easily slip under the radar?

Mercedes Dodge, MPAS, PA-C, CAQ-Psychiatry: In psychiatry, you begin to notice how often the body has been giving out clues long before the diagnosis becomes clear. Patients come in saying, “I think my anxiety is acting up,” and the more you listen, the more the story shifts. I’ve seen thyroid disease present as irritability and insomnia; anemia show up as “depression”; arrhythmias like supraventricular tachycardia (SVT) or postural orthostatic tachycardia syndrome (POTS) labeled as panic; autoimmune flares dismissed as stress; and neurological conditions mistaken for emotional volatility. One memorable case involved vivid visual hallucinations that ultimately turned out to be intracranial hypertension.

These patterns appear again and again—especially in women, neurodivergent patients, individuals with trauma histories, and anyone who already carries a psychiatric diagnosis. Once a psychiatric label is in the chart, everything afterward tends to get filtered through it. That’s diagnostic overshadowing, and it’s incredibly powerful.

What helps me stay grounded is something the psychiatrist Irvin Yalom, MD, writes in The Gift of Therapy: symptoms are never just symptoms—they’re stories. Stories layered with physiology, psychology, history, and context. When we stay curious, we hear the story the body is trying to tell. When we rush, the medical mimics slip right past us.

As psychiatric PAs, we meet patients at the intersection of mind and body. Many arrive with a well-constructed narrative of their symptoms. Our job is to meet them there, hold that story with compassion, and also turn our medical lens back on—because that integrated posture is what helps us notice when something doesn’t quite fit. 

PCN: In cases where patients present with overlapping psychiatric and medical symptoms, what early signs should clinicians look for that may indicate a non-psychiatric etiology?

Dodge: When psychiatric and medical symptoms collide, the earliest clues are usually subtle—small breaks in the expected pattern that quietly say, “Something here doesn’t quite fit.” In telepsychiatry especially, the history becomes my physical exam, and those pattern mismatches are often what guide me.

Over time, I’ve learned that medical mimics reveal themselves less by what the symptom is and more by how it behaves. I widen my differentials when I encounter:  

• Episodic or fluctuating symptoms that don’t follow a psychiatric arc.
  • Most mood and anxiety disorders follow recognizable clinical patterns, even when they involve fluctuation. So when symptoms come in unpredictable waves—such as orthostatic dizziness, palpitations, or visual changes observed in one patient—I start thinking autonomic, cardiac, neurologic, endocrine, or autoimmune contributors.
• Lack of expected response or worsening with appropriate treatment.
  • When a patient doesn’t improve after a reasonable trial of guideline-based therapy or medication, I don’t view it as “resistance.” I view it as diagnostic data. Non-response often tells us we may be treating the wrong mechanism.
• Symptoms involving multiple body systems or life-stage transitions.
  • Fatigue, chronic pain, GI issues, menstrual changes, heat intolerance, or presyncope clustering with mood symptoms—especially in contexts like postpartum, perimenopause, post-infection, or post-surgery—prompt me to ask, “Is there also an underlying medical explanation?”

As psychiatric PAs, our medical-model training helps us hear both the emotional narrative and the physiological clues woven into it.

PCN: Your session emphasizes collaborating early and ‘thinking across systems.’ What practical criteria or decision points do you recommend clinicians use to determine when it’s time to refer a patient to another specialty?

Dodge: One of the greatest strengths of psychiatric PAs is our medical training of the whole body systems (i.e. the medical model). So when I decide to “refer,” I don’t see it as passing the patient off; I see it as expanding the care team so no one is working inside a silo.

I tend to collaborate early when:

• The pattern doesn’t behave as expected.
• Treatment isn’t doing what it should. Non-response or partial response often signals the need for medical co-evaluation.
• The story is clearly bigger than one discipline. A patient with GI symptoms, tachycardia, chronic pain, fatigue, and anxiety doesn’t need one more medication adjustment—they need coordinated care to ensure each system gets proper attention.

In the real-world constraints of practice, I also use AI-generated medical summaries to outline treatment history, diagnostic concerns, and clear next steps for primary care and specialty colleagues. It saves time, improves clarity, and ensures no thread is lost.

Ultimately, collaboration isn’t about handing off the patient—it’s about ensuring that no symptom is dismissed, no pattern overlooked, and no patient lost between specialties.

PCN: What are some effective ways clinicians can audit their own cognitive biases to reduce the risk of diagnostic overshadowing?

Dodge: Cognitive bias is one of the biggest contributors to diagnostic error, especially when medical and psychiatric symptoms overlap. And it often happens unchecked. Once a psychiatric label is in the chart, every new complaint risks being interpreted through that lens. I’ve learned that the most reliable way to prevent diagnostic overshadowing is to build small moments of reflection into my work—moments that pull me out of autopilot and back into clinical curiosity.

To reduce these risks, I rely on:

• A brief diagnostic pause.
  • Before finalizing an impression, I take a few seconds to ask myself, “What doesn’t fit? What else could this be medically?” That brief pause helps me shift from fast, intuitive System 1 thinking into slower, more analytic System 2 when it matters most.
• Targeted cognitive-forcing questions.
  • I intentionally ask:
    • Am I anchoring to the first diagnosis I heard?
    • Am I giving too much weight to the psychiatric history?
    • What are 3 reasonable medical differentials for this presentation?
  • These questions keep me from prematurely closing that diagnostic door.
• Revisiting objective data.
  • Vitals, labs (even “borderline” ones), menstrual/OB history, trauma history, sleep patterns, and prior medication trials often contain the clues we miss when we rush.
• Staying grounded in metacognition.
  • Continuously asking, “How is my thinking shaping my decisions?” Collaborative case reviews with colleagues also help—shared reflection sharpens our diagnostic instincts. 

Reducing diagnostic overshadowing isn’t about eliminating bias entirely; it’s about creating enough space in our process to see when bias is trying to lead. Naming it—and recognizing it—is what allows us to correct the course.

PCN: Which takeaway from your session would you most like to emphasize for our audience of practicing clinicians?

Dodge: If there’s one lesson that continues to shape my practice, it’s that psychiatry is never just about symptoms—it’s about making sense of a person’s whole experience. When medical and psychiatric symptoms blur, the work becomes less about choosing the “right medication” and more about creating enough space to understand what the body and mind are trying to express together.

What I hope clinicians take away from this session is a paradigm shift of sorts in their practice—a willingness to slow down, stay curious, and let the story breathe.

For psychiatric PAs, our medical-model training is a real advantage. It allows us to step back and ask questions that honor both physiology and psychology. Instead of asking, “What diagnosis fits this?” we learn to ask, “What’s the full story here, and what might I be missing?”

In summary, these takeaways are: 

• Trust the mismatch.
  • When a symptom behaves strangely or the narrative feels slightly off, that’s the moment worth leaning into. Uncertainty is not a threat—it’s often the doorway toward a diagnosis.
• Prioritizing transparency with the patient.
  • When we name the uncertainty, patients feel seen rather than dismissed. The therapeutic alliance strengthens long before the diagnosis becomes clear.
• Holding compassion at the center.
  • Many patients with missed medical diagnoses have a long history of feeling unheard. Simply saying, “I believe you, and let’s figure it out together,” can be corrective and healing.

What ultimately improves outcomes isn’t just a lab test or a consult. It’s our willingness to validate and acknowledge the patient’s experience as something lived, layered, and intertwined. That’s the invitation I hope clinicians carry forward—to stay open, stay collaborative, and continue making patients’ lives better.

Mercedes Dodge, MPAS, PA-C, CAQ-Psychiatry, is a Board-Certified PA with a Certificate of Added Qualifications in Psychiatry and past experience in Family Medicine, Pediatric Medicine, Urgent Care, and Women’s Health. PA Dodge completed her undergraduate education in Psychology and Biology at Rice University, worked as an Emergency Medical Technician and then a researcher in both laboratory and clinical work at Baylor College of Medicine and University of California, Davis, respectively. She trained as a PA at the University of California - Davis Medical School and holds an MS in Physician Assistant Studies from the University of Texas, Rio Grande Valley. PA Dodge has served in many leadership positions including Director at Large for the California Academy of Physician Assistants (CAPA) and President of the San Diego Physician Assistant Society (SDSPA). She has been an active member of the AAPA, Central Texas Physician Assistant Society, Alaska Academy of Physician Assistants, PAs in Virtual Medicine and Telemedicine, and the Association of PAs in Psychiatry. She serves as President for PAs in Virtual Medicine and Telemedicine (2022-2023), and Secretary for the Association of PAs in Psychiatry. She is an advocate for children and families as she works also as a parent educator and parent advocate for Diversity, Equity, and Inclusion (DEI) in her own children's schools.

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