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Psychoses : Behaving Like a Psychiatrist vs Behaving Like an Internist

Volunteer Associate Professor of Psychiatry University of Cincinnati Medical Center July, 1987 to 2014 Senior Attending Good Samaritan Hospital Department of Psychiatry 2002 to Present. Psychoses : Behaving Like a Psychiatrist vs Behaving Like an Internist Slides and Sources Available at

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Psychoses : Behaving Like a Psychiatrist vs Behaving Like an Internist

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  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 ? ? ? ??

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

  8. 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]

  9. 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

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

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

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

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

  14. 58% of Psychiatric Patients Have Physical Illnesses Undiagnosed[23]- - - -21 Studies

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

  16. 27% of the Physical Disorders • of Psychiatric Patients • Produced Symptoms Related Directly to the “Psychiatric Symptoms”[23] - - - -

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

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

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

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

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

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

  23. 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]

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

  25. 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]

  26. 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]

  27. 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]

  28. 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

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

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

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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

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

  40. 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

  41. 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

  42. 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

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