Neuropsychiatric Evaluation Make Diagnoses for Psychological Symptoms? • Among the core goals of medicine are treating illnesses successfully, predicting their outcome, and finding their causes. • The process of diagnosis has become fundamental to meeting all three of these goals. • From early times, physicians have observed that afflictions tend to fall into syndromes, or patterns of signs and symptoms that are fairly stable across patients. Make Diagnoses for Psychological Symptoms? • Those with similar signs and symptoms often have a similar prognosis. • Additionally, the cause of an illness can often be found by comparing similarities in the backgrounds of different patients with the same syndrome. • Treatments that help one patient with a given syndrome often help others with the same syndrome. • The process of carefully listening to the patient, examining the patient, and classifying his/her symptoms and signs into recognized syndromes is called diagnosis. Diagnosis Began With Clinical Diagnosis Alone. • However, the advent of modern pathology in the nineteenth century had two significant effects on diagnosis. • First, many existing diagnoses made by purely clinical criteria (such as pneumonia) were validated by laboratory findings and autopsy. • Second, new diagnostic subcategories arose when different laboratory findings in the same clinical syndrome tended to help predict outcome (for example, streptococcal pneumonia). Diagnosis Began With Clinical Diagnosis Alone. • These new diagnoses based on pathology enjoyed great popularity for a simple reason. • They were generally superior to purely clinical diagnoses in the three previously mentioned functions of diagnosis: explaining illness, suggesting treatment, and predicting outcome. • Unfortunately, this change in paradigm helped change the concept of disease from a clinical syndrome to an illness marked by a specific pathological or laboratory abnormality. • The effects of this change were felt most in psychiatry, because psychiatrists of the early and mid-1900's largely abandoned illnesses with pathological or laboratory findings (such as neurosyphilus). Diagnosis Began With Clinical Diagnosis Alone. • These psychiatrists also lost interest in diagnosis because they emphasized factors unique to an individual rather than syndromal commonalities among patients and because they assumed that mental processes were similar in health and illness. • As a result of these changes in psychiatric and general medical thinking, two widespread misconceptions have arisen. • One is that meaningful diagnoses are always associated with laboratory or postmortem abnormalities. Diagnosis Began With Clinical Diagnosis Alone. • The other is that diagnosis for physical illness is meaningful, whereas diagnosis for mental illness is nothing but an arbitrary label. • These fallacies are common even among physicians. • For instance, the problem list for patients seen in other specialties may include the entry "psych problem," even though this label is nearly useless given the wide variety of causes, outcomes, and appropriate treatments for different psychiatric illnesses. • The truth is that diagnosis has invaluable benefits in psychiatry. PRACTICAL BENEFITS OF THE MEDICAL MODEL OF PSYCHIATRY • Reliable diagnosis allows better patient care. • Patients are more likely to receive treatments based on scientific evidence of efficacy. • The medical model allows a unified approach to all patients, without unreasonable illness boundaries. • It encourages early recognition of psychiatric illness by nonpsychiatric physicians. PRACTICAL BENEFITS OF THE MEDICAL MODEL OF PSYCHIATRY • The medical model of psychiatry promotes careful differential diagnosis of psychological symptoms. • Diagnosis is a common, accessible language for education and collaboration. • The medical model of psychiatry provides tools and motivation for discovery of etiology and treatment. • This model has a proven track record in psychiatric science. • This model has important implications for public policy. Myths About Psychiatry • Myth: Psychiatric Illnesses Aren't Real • Myth: Psychiatry is an Inexact Science • Myth: Even Psychiatrists Can't Agree on Diagnosis • Myth: Psychiatric Illnesses Are Diagnoses of Exclusion Only • Myth: People with Mental illnesses Don't Need a Physician Examination of Patients First, Make the Diagnosis • When a patient comes to a primary care physician complaining of symptoms, it is probable that this same physician will be the one who begins to treat him, even if he has a psychiatric illness. • The first task in any case is diagnosis. • Since a sizable minority of people who come to a physician are suffering from some psychiatric disorder, the physician must give the process of making a psychiatric diagnosis the same systematic attention as the process of diagnosing a medical or surgical disorder. • This is to serves as a guide to methods of interviewing that can make the processes of diagnosis and ongoing treatment of any disorder more effective and as a guide to the means of detecting psychiatric disorders specifically. The Initial Interview • In the first contact with a patient (or with another informant when the patient is unable or unwilling to communicate) the physician's inquiry is driven by the chief complaint. • Exploration of the chronology and details of that complaint, as well as of the immediate circumstances that brought the patient to the physician, is the beginning of the diagnostic process. • An initial interview does not start as psychiatric, medical, or surgical, regardless of the specialty of the physician doing the questioning. • An interview acquires a specialized character only as the types of symptoms are revealed, leading the physician to focus attention in particular areas. The Initial Interview • Ideally, an initial interview screens for all types of disorders and includes a review of systems wherein key questions are asked that extend beyond the boundaries of the chief complaint and present illness. • In a nonemergency circumstance, such as the initial visit to a physician's office or a clinic, enough time should be scheduled for an extended interview with its screening questions. • Even in situations where one clearly identified problem dominates the picture and requires urgent attention - for example, massive bleeding or a potentially lethal overdose - a comprehensive history should be obtained as soon as possible. • Important problems are often overlooked simply because the physician did not ask about them. Exploration of the Chief Complaint • The interview should usually begin with an exploration of the symptoms that led the patient to seek help and the specific circumstances that brought the patient to the physician at this particular time. • The latter subject may provide vital clues to the most important aspects of the problem. • For example, the main symptom of abdominal pain may have been present for months, but a patient only seeks help after a week of being too weak to perform his job. • It may turn out that the weakness is a result of occult bleeding that finally put the patient's red cell volume below a critical level. • Another patient may have been hearing hallucinated voices for many years but was not motivated to seek help until the day they frightened her with commands to kill her family. Exploration of the Chief Complaint • The physician must not only ask what is wrong but also (if it is not obvious) how and why the patient chose that time to seek help. • When the patient or other informant is capable, the physician should encourage him to give a spontaneous account of the chief complaint and the circumstances surrounding it. • To encourage spontaneity, from time to time the physician may need interject, "And then what?" or a similar phrase. • When specific clarification is needed on some point, it is best for the physician to ask for information in a way that discourages brief answers. • For example, "Tell me something about your marriage," elicits more information than, "Do you get along well with your wife?" Exploration of the Chief Complaint • While the patient is giving his account, the physician should not interrupt him with a premature checklist of her own questions. • If he/she does, important information may be missed and the diagnostic process may actually be prolonged. Exploration of the Chief Complaint • For instance, 5 or 10 minutes of patient's spontaneous and relevant discourse may contain enough positive and negative information to make many review-of-system and mental-status questions unnecessary. • After the patient's spontaneous account of the chief complaint has been completed, the physician asks questions to complete a detailed chronological picture of the present illness. • Further information is then elicited about the patient's medical and psychiatric history, review of systems, personal and social history, and family history of medical and psychiatric illnesses, especially in first degree relatives. Exploration of the Chief Complaint • Here the checklist method is essential; there are some things that should always be asked if the patient has not already mentioned them. • In almost all cases, collateral sources of history are nelpful; in some cases they are indispensable. • Whenever possible the physician should seek information from sources in addition to the patient. • These sources may include relatives, other physicians, and hospitals, and the patient's permission should be obtained unless the absence of information poses a threat to the patient's life. • It is usually best to talk with the patient first, but in some urgent situations that might not be practical. Rapport • Much is said about the desirability for physicians and patients to have relationships of mutual trust and respect. • In such circumstances patients are more comfortable, more likely to tell physicians what they need to know, and more likely to be compliant with treatment. • Behavior by physicians that promotes good rapport is not only the kindest way to deal with patients; it is also the most medically effective way. Rapport • This rapport is best established not by small talk about irrelevant pleasantries but by listening attentively to the patient talk about the things that trouble him most and by taking the patient's complaints seriously. • The patient has come to the doctor because of a problem; nothing is more reassuring to him at the outset than the knowledge that it is this problem and nothing else in which the doctor is most interested. • That is what it takes to get the physician and patient off to the right start. Diagnosis of Psychiatric Disorders • The foregoing discussion is applicable to the assessment of patients with any type of illness. • This section focuses on psychiatric disorders, including the clues that such disorders may be present, questions that should always be asked in such cases, and the mental status examination. Clues to Psychiatric Disorders Clue 1 • Direct complaints of persistent emotional distress, such as depressed mood, fearfulness and excessive worrying, or behavior suggesting such distress, are indications that a psychiatric disorder may be present, even when there is an obvious medical disorder. • Such symptoms do not automatically accompany even the most serious medical illnesses and demand further investigation. • For example, it is a common mistake for physicians to think that depression is normal in people who are very sick with a medical illness. • In fact it is not normal, and depression in such cases requires the same active treatment as major depressive illness occurring by itself. Clue 2 • Certain physical symptoms often accompany psychiatric disorders and may be the principal complaints. • Prominent among these symptoms are chronic fatigue, chronic headache, chronic musculoskeletal pain without objective findings, panic attacks with feelings of breathlessness and chest discomfort, changes in eating behavior, changes in sleep pattern, any gastrointestinal complaint, and unexplained neurological complaints of weakness or altered sensation. • Any of those symptoms can be part of the clinical picture of major depression, generalized anxiety disorder (GAD), and somatization disorder. Clue 3 • A change in the ability to think clearly, concentrate, or remember things occurs in a number of psychiatric disorders, most prominently major depression, schizophrenia, dementia, and delirium. • Depression is the most common of these disorders, and the intellectual impairment in severe cases is unfortunately often mistaken for dementia. Clue 4 • Changes in behavior, even in the absence of complaints by the patient, often indicate that a psychiatric disorder is present. • Irritability and temper outbursts occur in depression, delusional disorder, schizophrenia, dementia, and drug or alcohol dependence. • This behavior may appear before any other symptoms. • Lethargy, slovenliness, irresponsibility, or neglect of care for self may also be an early symptom of one of these disorders. • In contrast, increased energy, excessive talkativeness, multiple projects hastily launched, impatience with restraint, and intense spiritual zeal in a person who was previously casual about religion may herald the onset of mania. Clue 5 • Whenever a prominent aspect of the history is peculiar or just does not make sense, the physician should be alert to the possibility that a psychiatric disorder is present, even if other symptoms are denied. • In such cases further observation and information from reliable informants often reveal that the patient is suffering from delusions, is abusing drugs or alcohol, or is consciously making up stories for some gain of his own. • The physician should always follow up histories that seem conspicuously weird. • Something is going on that, for one reason or another, the patient does not want the physician to know about. Questions That Should Always Be Asked • The physician should always ask about increases or decreases in energy, interest in things, sexual function, sleep, appetite, and weight; headaches, chest pain, dyspnea, and gastrointestinal dysfunction; a detailed history of drug and alcohol use and the effects of those substances; problems with motivation, attention, concentration, or memory; problems with co-workers or job performance; problems in marriage and family; and the presence of upsetting events and circumstances in the patient's life. • At the end of the initial interview it is also well to ask if there is anything important that the patient has not mentioned. • At this time patients often disclose material that they were reluctant to talk about. Questions That Should Always Be Asked • Hopelessness leading to death wishes. Questions That Should Always Be Asked • Obsessions and Compulsions Questions That Should Always Be Asked • Eating Disorders Questions That Should Always Be Asked • Delusions Questions That Should Always Be Asked • Hallucinations PSYCHIATRIC DIAGNOSIS • Psychiatric diagnosis is based on clinical syndromes. • Most psychiatric syndromes have a medical differential diagnosis. • Psychiatric diagnosis is imperfect just like diagnosis in any other medical specialty. • Some psychiatric diagnoses are more valid (hence more useful) than others. PSYCHIATRIC DIAGNOSIS • Many psychiatric illnesses are both serious and treatable. • The physician should do the following: – Consider psychiatric illnesses early in the differential diagnosis of both psychiatric and medical patients – Gather a longitudinal history from more than one source – Conduct a careful mental status examination, including appropriate items from the physical examination – Refer to the exact diagnostic criteria, especially where accurate diagnosis is crucial – Exercise diagnostic humility often in the form of undiagnosed, NOS, or provisional diagnoses PSYCHIATRIC DIAGNOSIS • The physician should not do the following: – Think of psychiatric illnesses only as diagnoses of exclusion – Lump all psychiatric patients together, denying them the benefits of careful diagnosis – Make a firm diagnosis based on symptoms alone – Make a firm diagnosis based on a cross-sectional presentation PSYCHIATRIC DIAGNOSIS • STEPS TO ESTABLISHING DIAGNOSTIC VALIDITY – Clinical description – Laboratory studies – Delimitation from other disorders – Follow-up study (induding response to treatment) – Family study Neuropsychiatric Evaluation • Psychiatric setting: Mental health clinic, inpatient units, private offices • Medical Setting: Primary care offices, emergency rooms Emphasis on Details • Psychiatric setting: Primary goal is getting all the details to make a psychiatric diagnosis. • Medical setting: Screening patients for psychiatric illness which may relate to the primary medical illness. Indirect Assessment of Psychiatric Status • How does the patient relate to you or your staff? • Is the patient groomed/or dressed appropriately? • Does the patient appear alert? • What is the patient’s mood? • What is the patient’s affect? What “diagnoses”can we observe? • Depression • Mania • Psychosis • Dementia Clues to further screening • Physical symptoms related to stress, anxiety or depression • Personal or family history of psychiatric illness • Sudden changes in behaviors leading to problems at work or relationships • Alcohol or drug abuse More clues to further screening • Degree of disability or lifestyle changes disproportionate to medical symptoms • Chaotic life style – Erratic job performance – Unstable relationships – Frequent legal problems NO! NO! NO! • Do not label a patient “mental” or refer him to a psychiatrist just because the symptoms do not lead to a specific medical diagnosis – You may not know the diagnosis – Believing your patient It May Not All Be Just In Your Head – **Caution in patients over 45 years of age and no history of psychiatric problems. • Several medical and neurologic illnesses may initially present with symptoms that are difficult to localize – Multiple Sclerosis – Autoimmune disease Why is the neuropsychiatric evaluation so tough? • Physicians feel uncomfortable asking psychiatric questions because they do not want to embarrass patients • Patients may not be cooperative. Patients who come to non-psychiatric physicians for physical problems may view the questioning as invasion of privacy or become irritable Hmmmmm…….. • Patients may think that the physician is trivializing the medical condition if psychiatric questions are raised! Psychiatric Screening In The Medical Setting Depression • Sometimes low moods or feelings of sadness can affect an otherwise healthy immune system. Have you been bothered by low moods? – Energy loss – Loss of interest in things that you enjoyed in the past – Sleeping , eating patterns Mania • Doing too many things can sometimes affect health. Have you felt unusually energetic or on top of the world? • Have you been doing too many projects or things that you can’t sleep? Anxiety Disorder • Nervousness sometimes affects the way we see things? Have you been nervous lately. Have you been drinking too much coffee? If not, have you felt as if you were jittery, choking or going to die? Alcoholism • Sometimes people drink to relax or deal with stress. Do you think that you are drinking more than before? Has anyone in your family complained about your drinking? Psychosis • Have you ever had experiences that were unusual or unique to you and nobody other than you around you has had them? By that I mean hearing voices when nobody is there or having unusual beliefs? Basic Format Similar to Regular History Taking Format • Demographic Information • Chief Complaint • History of Present Illness • Past Medical History – Medical history – Drug and Alcohol history – Basic Personality – Past Psychiatric History Format continued • Family History • Preventive Health History • Social History • Review of systems • Behavioral examination • Cognitive examination • Physical/ neurologic exam • Diagnosis • Treatment plan Chief Complaint • In patient’s own words. Reason for seeking medical attention History Of Present Illness HPI • Similar to regular HPI • Generally refers to the time period between the onset of symptoms and time of evaluation. • HPI should relate to the chief complaint and include the onset and progression of symptoms. Psychiatric HPI The five must haves 1. Features related to the specific DSM diagnostic criteria for each specific diagnosis. Example: Depression: quality of mood, sleep, appetite disturbances, suicidal ideation. 2. Important symptoms affecting the treatment prognosis-overlapping psychosis etc Psychiatric HPI The five must haves 3. Dangerous behaviors: To self and others. If positive get specifics, plan, time, methods. 4. General medical or environmental features that precipitated of affected current mood. Loss of job, drinking, divorce. Homelessness, injury-head, other illness** Psychiatric HPI The five must haves 5. Negative symptoms, no psychosis, no mania, no delusions. Also record the treatments received during this illness including dose, duration, effectiveness and side effects. Past Medical History (five parts) 1. Medical/Surgical history: Current and past conditions, dates and treatments. Childhood illness, gestational/obstetric problems, seizures, head trauma, high fevers. 2. Drug and alcohol history with detailed description of each drug used, how obtained and taken. Include prescription drugs that could be abused and toxins (glue, solvents) 3. Drug/ Medication allergies-document none if none. Past Medical History (five parts) 4. Basic or premorbid personality: Ask specific information on the patient’s characteristics, interpersonal experiences and work relationships. Inquire about recreational patterns of behavior. Past Medical History (five parts) 5. Past psychiatric history: 1. Summary to establish whether it is chronic, continuous (worsening, same lessening), episodic. 2. State if the person returns to pre-illness functioning after each episode or if the patient deteriorates from premorbid status. 3. Describe each episode with specific details regarding precipitating event, severity, medications received and improvement. 4. Previous laboratory tests and results Family History • Family history as usual • Whenever possible include the names, addresses and telephone numbers of all first-degree relative (parents, children, brothers and sisters) • For each relative listed need to inquire about a history of mental illness, alcoholism, drug abuse, epilepsy or other family neurologic disorders. • Details of above Social History • Need not repeat if obtained in previous sections. • Need job, educational, sexual and socioeconomic details Review of Systems • It is very important to do full medical review of symptoms since other medical conditions/ symptoms should not be missed. • Find other diseases. • Side effects of medicine. Behavioral Examination 1. Appearance: age, gender, ethnicity, blood type, hygiene, dress, level of consciousness, interpersonal manner. 2. Motor: activity, speed and rhythm, extra pyramidal, frontal, and cerebellar features. Catatonic features or minor neurologic signs. 3. Affect: range, intensity and quality of mood. Lability, emotional expression, volition. Behavioral Examination 4. Speech and language: rate, rhythm, pressure, language, speech process, formal thought, thought content. 5. Delusions: moods, ideas 6. Perceptual: other hallucinations, dysmegalopsia, or other psychosensory phenomena, and illusions 7. First rank symptoms: thought broadcasting, experiences of alienation and control, voices, delusional perceptions Cognitive-Behavioral Neurologic Examination • Level of consciousness, attention and concentration • Screening for diffuse impairment – Mini-mental examination • Specific functions: motor praxis, language, aphasias, thinking, memory, visual spatial and higher perceptual function, integrating function. Mini-mental Examination 1. Can you tell me the date? Ask for any parts omitted. (5) 2. Where are you? (5) 3. Repeat three objects (3) 4. Ask patient to count serial sevens backwards, world spelled backwards (5) 5. Ask for the three items in #3 Mini-mental Examination 6. Show patient and object and ask its name (2) 7.Ask patient to repeat “no ifs, ands or buts” (1) 8. Offer patient a piece of blank paper and ask him to “take the paper in your right hand, fold it in half and place it on the floor.” (3) 9. Show patient a piece of paper with the command. CLOSE YOUR EYES and have the patient do it. (1) 10. Have the patient write a sentence of their own (1) Mini-mental Examination 11. Have patient copy intersecting pentagons onto blank paper. (1) 12. 24-30 out of 30 normal Physical and Neurological Examination Details, details, details Diagnosis and Assessment • Diagnosis as listed in DSM-IV • Also note any personality or pertinent medical disorders. • Examiner’s assessment of problem and treatment Factors affecting the neurological evaluation • Patients may have illnesses such as delirium, dementia that prevent them from remembering the information. • Patients may have thought disorders making it difficult to follow their thought process. • Patients may wish to hide the salient information out of embarrassment. Factors affecting the neurological evaluation Patients with illnesses such as mania or depression often have state dependent memory and therefore may not remember past episodes. A patient’s illness may affect their accurate appraisal of situation. It is therefore necessary that the patient’s history be confirmed by a collateral source such as a family member or medical record. Written Evaluation • The written evaluation is meant to be a communication to the reader about patient’s status. • Often the order of questioning must be modified to to make the history taking more conversational. • When you write an evaluation it should follow the thought process in such a way that the reader comes to a logical conclusion and can follow the history easily.