Neuropsychiatric Evaluation

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					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.

				
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