Disclosures 513-281-0074 Email: Charles.Enzer@uc.edu WebSite: - - PowerPoint PPT Presentation

Evaluation of Psychosis: as an Internist vs as a Psychiatrist August 27, 2014 Hatton Grand Rounds Page 1

Slide 1 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

http://tinyurl.com/EnzerGrand

Child - Adolescent - Adult - Family – Psychiatry 5599 Kugler Mill Road Cincinnati, OH 45236-2035 513-281-0074 Email: Charles.Enzer@uc.edu WebSite: TinyURL.com/EnzerMD

Charles Hart Enzer, MD, FAACAP

Slide 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

Slide 3

Interruptions vs Contributions

Who Is Wise: Who Learns from Every Person Sayings of the Fathers, Chapter 4, Verse 1 םכח אוה הזיא-- םדא לכמ דמלה

Questions Are Contributions Criticisms Are Contributions Comments Are Contributions

Slide 4

We Can Educate One Another We Can Help Those in Need We Can Make a Difference

• - - - -

Divide Up into Teams of 5 to 7 Each Team to Have: At Least One Attending At Least One Resident

Evaluation of Psychosis: as an Internist vs as a Psychiatrist August 27, 2014 Hatton Grand Rounds Page 2

Slide 5

Entering the Room, You Hear Prolonged Screaming with Gasping Inhalations Your Next Step ? ? ? ??

Slide 6

You See: Violent Movement of Extremities with Clench Fists Your Next Step ? ? ? ??

Slide 7

6- Recent “Immaturity” 3- Authority Conflicts 5- Recent Impotency 2- Long Standing Apathy Your Next Step ? ? ? ?? 4- Recent Anxiety Attacks 1- 31 Year Social Worker

Slide 8

What is Your Assessment ? ? ? ?? 5 Hour = 51 mg/dL 2 Hour = 53 mg/dL 4 Hour = 64 mg/dL 1 Hour = 74 mg/dL 3 Hour = 15 mg/dL FBS = 94 mg/dL

Evaluation of Psychosis: as an Internist vs as a Psychiatrist August 27, 2014 Hatton Grand Rounds Page 3

Slide 9

Findings and Course

Hypopituitarism Insulin Producing Lesions in Abdomen Surgical Treatment

Slide 10

Personality Change, Depressions, Anxieties and Stress Stomach What Would Have Been Your Next Step ? ? ? ??[11]

2 Years Ago

Became restless and nervous

11 years Ago

Man 38: Athletic, Self-Confident, Disciplined, Creative Until

Slide 11

What Would Have Been Your Next Step ? ? ? ??[11] Irritable, Melancholy, Loneliness Still Healthy Looking One Year Later After Many Medical Consultations, Started Psychoanalysis

Slide 12

What Would Have Been Your Next Step ? ? ? ??[11] Severe Photophobia Complained of a Loathsome, Repulsive Smell Hours Later, Grand Mal Seizure Petite Mal About a Half Year Later

Evaluation of Psychosis: as an Internist vs as a Psychiatrist August 27, 2014 Hatton Grand Rounds Page 4

Slide 13

What Would Have Been Your Next Step ? ? ? ?? [11] Normal Labs Normal Skull Films Severe Photophobia Normal Physicals & Neurologicals He Had Many Exams and then 3 Days in Hospital

Slide 14

What Would Have Been Your Next Step ? ? ? ??[11] Petite Mal with Smearing Gift Chocolates as a Cream over Body Petite Mal with Attempt to Push Chauffer out of Car Working Assessment: Hysteria == Somatization Disorder

Slide 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]

Slide 16

What Is Your Next Step ? ? ? ?? 6- Agitated 3- Malaise 5- Unsteady Gait 2- Headache: Dull, Frontal, Continuous 4- Dizziness 1- 78 Yr Man: Hallucinations

Evaluation of Psychosis: as an Internist vs as a Psychiatrist August 27, 2014 Hatton Grand Rounds Page 5

Slide 17

Strange Behavior, Mood Changes, Abnormal Thinking Are Symptoms

• f [23]

1 2 3 4 5 6

0% 0% 0% 0% 0% 0%

• 1. Medical Disorders
• 2. Toxic Disorders
• 3. Psychiatric

Disorders

• 4. Medical & Toxic
• 5. Toxic and Psych.
• 6. All of the Above

Slide 18

What Is Hunger ? ? ? ??

1 2 3 4

0% 0% 0% 0%

1.

A Physical Symptom

2.

A Psychological Symptom

3.

Both

4.

Neither

Slide 19

What Type of Symptom Is Pain ? ? ? ??

1 2 3 4

0% 0% 0% 0%

1.

A Physical Symptom

2.

A Psychological Symptom

3.

Both

4.

Neither

Slide 20

Strange Behavior Mood Changes Abnormal Thinking

• These Are Symptoms of Psychoses -

Whether Physical Psychoses Or Functional – Psychiatric - Psychoses

Evaluation of Psychosis: as an Internist vs as a Psychiatrist August 27, 2014 Hatton Grand Rounds Page 6

Slide 21

Percent of Psychiatric Patients Having Undiagnosed Physical Illnesses?

1 2 3 4 5

0% 0% 0% 0% 0%

1.

0 – 20%

2.

21 – 40%

3.

41 – 60%

4.

61 – 80%

5.

81 – 100%

Slide 22

58% of Psychiatric Patients Have Physical Illnesses Undiagnosed[23]

• - - -

21 Studies

Slide 23

Percent of Physical Disorders Producing Symptoms Related Directly to the “Psychiatric Symptoms” ? ? ? ??

1 2 3 4 5

0% 0% 0% 0% 0% 1.

0 – 20%

2.

21 – 40%

3.

41 – 60%

4.

61 – 80%

5.

81 – 100%

Slide 24

27% of the Physical Disorders

• f Psychiatric Patients

Produced Symptoms Related

Directly to the “Psychiatric Symptoms”[23]

• - - -

Evaluation of Psychosis: as an Internist vs as a Psychiatrist August 27, 2014 Hatton Grand Rounds Page 7

Slide 25

Non-Psychiatric Physicians Miss the Physical Disorders of Referred Patients How Often ? ? ? ??

1 2 3 4 5

0% 0% 0% 0% 0% 1.

0 – 20%

2.

21 – 40%

3.

41 – 60%

4.

61 – 80%

5.

81 – 100%

Slide 26

Non Psychiatric Physicians Miss Physical Diagnoses In about 30% of Patients They Refer for Psychiatric

Treatment[23]

Slide 27

How Often Do Psychiatrists Miss the Physical Disorders of Their Patients ? ? ??

1 2 3 4 5

0% 0% 0% 0% 0% 1.

0 – 20%

2.

21 – 40%

3.

41 – 60%

4.

61 – 80%

5.

81 – 100%

Slide 28

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

Evaluation of Psychosis: as an Internist vs as a Psychiatrist August 27, 2014 Hatton Grand Rounds Page 8

Slide 29

How Often Do Non-Physicians Miss Physical Diagnoses in Patients They Refer ? ? ? ??

1 2 3 4 5

0% 0% 0% 0% 0%

1.

0 – 20%

2.

21 – 40%

3.

41 – 60%

4.

61 – 80%

5.

81 – 100%

Slide 30

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

Slide 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]

Slide 32

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

Evaluation of Psychosis: as an Internist vs as a Psychiatrist August 27, 2014 Hatton Grand Rounds Page 9

Slide 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]

Slide 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]

Slide 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]

Slide 36

Nonetheless

Numerous Studies: Psychiatric Patients Have a Greater Susceptibility to Medical Disorders The Non-Psychiatric Portion

• f the Charts of Psychiatric Patients

Weigh Significantly More than the Charts of

Other Patients

Evaluation of Psychosis: as an Internist vs as a Psychiatrist August 27, 2014 Hatton Grand Rounds Page 10

Slide 37

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

Slide 38

Caveat! ! ! !! No Psychiatric Symptoms Exist That Cannot Be Caused by

• r

Aggravated by Medical Illnesses[23]

Slide 39

Any of These Gross Impairments in Reality Testing:[39]

• Delusions
• Hallucinations
• Incoherence
• Marked Loosening of Associations,
• Marked Illogical Thinking,
• Behavior: Bizarre, Disorganized, Catatonic

Any Organic Factors:

• History
• Examination
• Studies

Yes Organic Delusional Syndrome, Organic Personality Disorder, Hallucinosis, Other Organic Syndromes Functional Psychiatric Disorders Yes No

Slide 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

Evaluation of Psychosis: as an Internist vs as a Psychiatrist August 27, 2014 Hatton Grand Rounds Page 11

Slide 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

Slide 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

Slide 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

Slide 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

Evaluation of Psychosis: as an Internist vs as a Psychiatrist August 27, 2014 Hatton Grand Rounds Page 12

Slide 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

Slide 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

• f a Medical Psychosis

Slide 47

Screen Broadly[31]

CBC Comprehensive Metabolic Panel Erythrocyte Sedimentation Rate Infection Suspected Antinuclear Antibodies Urine Analysis Comprehensive Drug Screen

Slide 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

Evaluation of Psychosis: as an Internist vs as a Psychiatrist August 27, 2014 Hatton Grand Rounds Page 13

Slide 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

Slide 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

Slide 51

The History Is Key

I Wonder: When Was the Last Time You Felt Normal When Did [Specify the Symptoms] Begin What Else Was Going on People Change from Time to Time How They

Take Their Medications

I Wonder about the Changes in Medications

During the Last [Time Since Felt Normal]

I Wonder What We Haven’t Discussed that

Needs Discussion

Slide 52

Normality[9]

• A Way to Rule Out Psychiatric Disorders -

Regularly Enjoys:

Working or Volunteering Studying Being with People of the Same Age Playing Being a Member of a Family Loving Someone Being Useful to Others

Evaluation of Psychosis: as an Internist vs as a Psychiatrist August 27, 2014 Hatton Grand Rounds Page 14

Slide 53

Diagnoses:

Do Not Classify People Merely Classify Disorders and

Diseases

Slide 54

Summary Key Point Evaluating New-Onset Psychoses [1 of 2]

No Pathognomonic Signs to Point to

Physical or Functional Psychoses

Critical to Diagnosing Toxic Psychoses Is

H & P Including

Vital Signs Serial Mental Status Examinations Epidemiology Counts - Extent of Workup: Prior Probabilities Treatable Conditions

Slide 55

Summary Key Point Evaluating New-Onset Psychoses [2 of 2]

More Studies Not Necessarily Better Positives Results May be Just Incidental

Findings

False Positives Best Guard against Misdiagnosing Treatable

Disorders

Long-Term Follow Up for New Findings Long-Term Follow Up for Atypical

Findings

Slide 56

The Basics of Doctoring

Be Curious Be Thorough Enjoy Caring for the Patient

Evaluation of Psychosis: as an Internist vs as a Psychiatrist August 27, 2014 Hatton Grand Rounds Page 15

Slide 57

What Is Your Assessment ? ? ? ?? Can’t Evacuate Bowels Confused Can’t pee Dry Mucus Membranes Flushed Can’t See Well

Slide 60

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Citations and Sources Consulted

Slide 61

"Prescribing Is So Easy, Understanding People So Hard.“

Kafka, Franz. (1917) A Country Doctor. The Penal Colony, Stories and Short Pieces