Slide 1 Volunteer Associate Professor of Psychiatry University of Cincinnati Medical Center July, 1987 to 2014 Senior Attending Good Samaritan Hospital.

Slide 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 InternistSlides and Sources Available athttp://tinyurl.com/EnzerGrand

Charles Hart Enzer, MD, FAACAP

5599 Kugler Mill RoadCincinnati, OH 45236-2035

513-281-0074Email:  [email protected]:  TinyURL.com/EnzerMD

Child - Adolescent - Adult - Family – Psychiatry

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 vsContributions

Who Is Wise: Who Learns from Every PersonSayings of the Fathers, Chapter 4, Verse 1

הלמד מכל אדם-- איזה הוא חכם

Questions Are Contributions Criticisms Are Contributions Comments Are Contributions

Slide 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

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

1- 31 Year Social Worker 4- Recent Anxiety Attacks

2- Long Standing Apathy 5- Recent Impotency

3- Authority Conflicts 6- Recent “Immaturity”

Your Next Step ? ? ? ??

Slide 8

FBS = 94 mg/dL 3 Hour = 15 mg/dL

1 Hour = 74 mg/dL 4 Hour = 64 mg/dL

2 Hour = 53 mg/dL 5 Hour = 51 mg/dL

What is Your Assessment ? ? ? ??

Slide 9

Findings and Course

Hypopituitarism Insulin Producing Lesions in

Abdomen Surgical Treatment

Slide 10

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

11 years Ago Became restless and nervous

2 Years AgoPersonality Change, Depressions, Anxieties and Stress Stomach

What Would Have Been Your Next Step ? ? ? ??[11]

Slide 11

After Many Medical Consultations, Started Psychoanalysis

One Year Later

Still Healthy Looking Irritable, Melancholy, Loneliness

What Would Have Been Your Next Step ? ? ? ??[11]

Slide 12

About a Half Year Later

Petite Mal Hours Later, Grand Mal Seizure

Complained of a Loathsome, Repulsive Smell

Severe Photophobia

What Would Have Been Your Next Step ? ? ? ??[11]

Slide 13

He Had Many Exams and then 3 Days in Hospital

Normal Physicals & Neurologicals

Severe Photophobia

Normal Skull Films Normal Labs

What Would Have Been Your Next Step ? ? ? ?? [11]

Slide 14

Working Assessment: Hysteria == Somatization Disorder

Petite Mal with Attempt to Push Chauffer out of Car

Petite Mal with Smearing Gift Chocolates as a Cream over Body

What Would Have Been Your Next Step ? ? ? ??[11]

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

1- 78 Yr Man: Hallucinations

4- Dizziness

2- Headache: Dull, Frontal, Continuous

5- Unsteady Gait

3- Malaise 6- Agitated

What Is Your Next Step ? ? ? ??

Slide 17

Strange Behavior, Mood Changes, Abnormal Thinking

Are Symptoms of [23]

1 2 3 4 5 6

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

1. Medical Disorders2. Toxic Disorders3. Psychiatric

Disorders4. Medical & Toxic5. Toxic and Psych.6. All of the Above

Slide 18

What Is Hunger ? ? ? ??

1 2 3 4

0% 0%0%0%

1. A Physical Symptom2. A Psychological

Symptom3. Both4. Neither

Slide 19

What Type of Symptom Is Pain ? ? ? ??

1 2 3 4

0% 0%0%0%

1. A Physical Symptom2. A Psychological

Symptom3. Both4. Neither

Slide 20

Strange Behavior Mood Changes Abnormal Thinking

- These Are Symptoms of Psychoses -

Whether Physical Psychoses Or

Functional – Psychiatric - Psychoses

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 of Psychiatric Patients

Produced Symptoms Related Directly to the “Psychiatric Symptoms”[23]

- - - -

Slide 25

Non-Psychiatric Physicians Miss the Physical Disorders of Referred

PatientsHow 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 DiagnosesIn 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]

Slide 29

How Often Do Non-PhysiciansMiss 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 ? ? ? ??

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 of the Charts of Psychiatric Patients Weigh Significantly More than the

Charts of Other Patients

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 byor

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

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

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 of 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

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

VolunteeringStudying

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

Slide 53

Diagnoses:

Do Not Classify People Merely Classify Disorders and

Diseases

Slide 54

SummaryKey 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

SummaryKey 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

Slide 57

Can’t See Well Flushed

Dry Mucus Membranes Can’t pee

Confused Can’t Evacuate Bowels

What Is Your Assessment ? ? ? ??

Slide 60

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Slide 61

"Prescribing Is So Easy,

Understanding People So Hard.“

Kafka, Franz. (1917)

A Country Doctor. The Penal Colony, Stories and Short Pieces