Psychoses : Behaving Like a Psychiatrist vs Behaving Like an Internist

1. Volunteer Associate Professor of PsychiatryUniversity of Cincinnati Medical CenterJuly, 1987 to 2014 Senior AttendingGood Samaritan HospitalDepartment of Psychiatry2002 to Present Psychoses: Behaving Like a Psychiatrist vs Behaving Like an Internist Slides and Sources Available at http://tinyurl.com/EnzerGrand

2. Disclosures • No Potential Conflicts of Interest to Report • Senior Attending • Good Samaritan Hosital • Practiced Psychiatry for 90,000+ Hours • Board Certified General Psychiatrist • Board Certified Child and Adolescent Psychiatrist • Past Board Examiner • Volunteer Associate Professor of Psychiatry • University of Cincinnati Medical Center

3. Interruptions vsContributions • Questions Are Contributions • Criticisms Are Contributions • Comments Are Contributions Who Is Wise: Who Learns from Every Person Sayings of the Fathers, Chapter 4, Verse 1 איזה הוא חכם -- הלמד מכל אדם

4. We Can Educate One AnotherWe Can Help Those in NeedWe Can Make a Difference - - - - - • Divide Up into Teams of 5 to 7 • Each Team to Have: • At Least One Attending • At Least One Resident

5. Entering the Room, You Hear Prolonged Screaming with Gasping InhalationsYour Next Step ? ? ? ??

6. You See: Violent Movement of Extremities with Clench FistsYour Next Step ? ? ? ??

9. Findings and Course • Hypopituitarism • Insulin Producing Lesions in Abdomen • Surgical Treatment

15. Course • Admitted to Prestigious Los Angeles Hospital • Opening Spinal Pressure of 400 mm • One Cell • Colorless • Protein 30 mg • Pressure Lowered 400  220 mm • Doctor Harvey Cushing in Baltimore Called • 24 Hours Later, Neurosurgery Begun • 3.5 Hours Later Tumor Located • 3.5 Days after Admission, Dies of Pleocytic Astrocytoma[38]

17. Strange Behavior, Mood Changes, Abnormal Thinking Are Symptoms of [23] • Medical Disorders • Toxic Disorders • Psychiatric Disorders • Medical & Toxic • Toxic and Psych. • All of the Above

18. What Is Hunger ? ? ? ?? • A Physical Symptom • A Psychological Symptom • Both • Neither

19. What Type of Symptom Is Pain ? ? ? ?? • A Physical Symptom • A Psychological Symptom • Both • Neither

20. Strange Behavior • Mood Changes • Abnormal Thinking - These Are Symptoms of Psychoses - • Whether Physical Psychoses • Or • Functional – Psychiatric - Psychoses

21. Percent of Psychiatric Patients Having Undiagnosed Physical Illnesses? • 0 – 20% • 21 – 40% • 41 – 60% • 61 – 80% • 81 – 100%

22. 58% of Psychiatric Patients Have Physical Illnesses Undiagnosed[23]- - - -21 Studies

23. Percent of Physical Disorders Producing Symptoms Related Directly to the “Psychiatric Symptoms” ? ? ? ?? • 0 – 20% • 21 – 40% • 41 – 60% • 61 – 80% • 81 – 100%

24. 27% of the Physical Disorders • of Psychiatric Patients • Produced Symptoms Related Directly to the “Psychiatric Symptoms”[23] - - - -

25. Non-Psychiatric Physicians Miss the Physical Disorders of Referred PatientsHow Often ? ? ? ?? • 0 – 20% • 21 – 40% • 41 – 60% • 61 – 80% • 81 – 100%

26. Non Psychiatric Physicians • Miss Physical Diagnoses • In about 30% of Patients • They Refer for Psychiatric Treatment[23]

27. How Often Do Psychiatrists Miss the Physical Disorders of Their Patients ? ? ?? • 0 – 20% • 21 – 40% • 41 – 60% • 61 – 80% • 81 – 100%

28. Psychiatrists • and Psychiatric Institutions • Missed the Physical Disorders • In about 50% of Patients[23]

29. How Often Do Non-PhysiciansMiss Physical Diagnoses in Patients They Refer ? ? ? ?? • 0 – 20% • 21 – 40% • 41 – 60% • 61 – 80% • 81 – 100%

30. Non-Physicians • Psychologists • Social Workers • Therapists • Patients • Relatives • Miss about 86% of Physical Disorders[23]

31. Physical Disorders Missed by Referral Source: • 18% of These Physical Disorders Caused Symptoms • 31% Coincided with the Psychiatric Morbidity • 51% of These Physical Disorders Aggravated Psychiatric Morbidity[23]

32. Among Patients w/ “Psychiatric Symptoms”, Why Are Physical Disorders Missed ? ? ? ??

33. Physical Disorders Are Missed by Medical Physicians: • We Do Incomplete Histories • We Do Incomplete Examinations • Overt Psychosis or Poor Hygiene Put Us Off • We and Patient Communicate Poorly • Using Language Level above 6th Grade • Patient Doesn’t Feel Safe • Patient Focuses on Consequences – Not Sx • Don’t Sort Sx: Medical from Mood or Behavior • See Consultation Merely to r/o Reasons against Meds[23]

34. Why Are Physical Disorders Missed so often by Psychiatrists: • Same as for Medical Physicians • Psychiatrist Sees the Physical Not of Concern • Fail to Ask “What Else May be Going on” • Dislike Doing Physical Examination • Fear Litigation Examining Women • Elderly May Take too Long to Undress Note: Women and Elderly Have Significantly Higher Rates of Undiagnosed Disorders.[23]

35. Making a Diagnosis • Years Ago, Diagnoses Were Made at Bedside • History and Physical Examination Were Key • Tests and Studies Were Confirmatory • Today, Technologies Have Blossomed • Physicians Choose What Tests to Run • Tests Are Viewed as Making the Diagnosis[42]

36. Nonetheless • Numerous Studies: • Psychiatric Patients Have • a Greater Susceptibility • to Medical Disorders • The Non-Psychiatric Portion • of the Charts of Psychiatric Patients • Weigh Significantly More than the Charts of Other Patients

37. What Symptoms of Physical Disorders Are Also Psychiatric Signs & Symptoms – Behavior, Mood, Thinking ? ? ? ??

38. Caveat! ! ! !! No Psychiatric Symptoms Exist That Cannot Be Caused by or Aggravated by Medical Illnesses[23]

39. Any of These Gross Impairments in Reality Testing:[39] • Delusions • Hallucinations • Incoherence • Marked Loosening of Associations, • Marked Illogical Thinking, • Behavior: Bizarre, Disorganized, Catatonic Yes Organic Delusional Syndrome, Organic Personality Disorder, Hallucinosis, Other Organic Syndromes Yes • Any Organic Factors: • History • Examination • Studies No Functional Psychiatric Disorders

40. Summary of This Diagnostic Decision Tree • All Psychiatric Diagnoses are Diagnoses of Exclusion • First, Physical Diagnoses Are to be Excluded • Avoid Missing a Treatable Physical Disorder • Avoid Needless Psychiatric Treatment • George Gershwin Had Years of Psychiatric Treatment • Dying of a Slow Growing Treatable Brain Tumor

41. Diagnosis of Medical Psychoses[31] • Use the Overall Clinical and EpidemiologIcal Situation • Narrowing the Broad Differential Diagnosis of Psychoses • Keeps the Work Up Manageable • Initially, Thorough Neurological Cognitive H & P • There is No Agreed upon Work up • Select Studies Based upon: • Sensitivity • Specificity • Prevalence

42. Issues Selecting Studies[31] • If Prevalence Is Low • Good Chance of a False Positive • Avoid Using Studies Indiscriminately • Use the Most Sensitive Study • Negative Result Removes from Differential • If Clinical Suspicion Is Strong • Repeat Study a Number of Times • A Positive Result Does Not Establish Causality

43. Rational Use of Evidenced Based Questions and Procedures • High Sensitivity • True Positive Rate High • False Negative Rate Low • High Specificity • True Negative Rate High • False Positive Rate Low

44. Karl Bonhoeffer, 1909[7], [30]A Father of Organic Psychiatry • Crude exogenous organic damage of the most varying kind can produce acute psychotic clinical pictures of a basically uniform kind. • The psychiatric clinical picture produced by a medical condition is rather uniform and unspecific, regardless of etiology

45. No Easy Way to Differentiate Medical from Functional Psychoses[31] • No Pathognomonic Signs or Symptoms • Some Acute, Primary Psychiatric Presentations Can Include Confusion and Perplexity • Look to: • Age At Onset • Symptoms • Treatment Response • Course • Temporality Probability • Biological Plausibility

46. Medical or Functional Psychoses:Diagnostic Mistakes[31] • Missing a Toxic Psychoses • Endogenous or Exogenous • Attributing Causality to Incidental Finding(s) • Indiscriminate Screening without Organizing Framework • Premature Diagnostic Closure • Not Getting a Family and Medical History • Not Appreciating Medical Abnormalities • Such as, Vital Signs • Not Revisiting the Initial Diagnostic Impression of a Medical Psychosis

47. Screen Broadly[31] • CBC • Comprehensive Metabolic Panel • Erythrocyte Sedimentation Rate • Infection Suspected • Antinuclear Antibodies • Urine Analysis • Comprehensive Drug Screen

48. Exclude Specifically[31] • Thyroid Stimulating Hormone • Random Urine for Ratio of Methymalonic Acid to Creatinine • If Elevated Vitamin B-12 • Folate • Ceruloplasmin • HIV • Fluorescent Treponemal Absorption Test • Less False Positives • Less False Negative

49. Consider Brain Imaging[31] • No Consensus about Role in Routine Screening • Low Yield for Functional Psychoses with Typical Findings and Course • Better Yield If: • Positive History – for Example, Head Injury • Abnormal Neurological Examination • Poor Response to Treatment

50. If Clinically Indicated[31] • EEG • Chest Imaging • Lumbar Puncture • Blood and Urine Cultures • Arterial Blood Gases • Serum Cortisol Levels • Toxin Search • Drug Levels • Genetic Testing