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![Page 1: Slide 1 Volunteer Associate Professor of Psychiatry University of Cincinnati Medical Center July, 1987 to 2014 Senior Attending Good Samaritan Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062423/5697bf931a28abf838c8fc08/html5/thumbnails/1.jpg)
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
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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
![Page 3: Slide 1 Volunteer Associate Professor of Psychiatry University of Cincinnati Medical Center July, 1987 to 2014 Senior Attending Good Samaritan Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062423/5697bf931a28abf838c8fc08/html5/thumbnails/3.jpg)
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
![Page 4: Slide 1 Volunteer Associate Professor of Psychiatry University of Cincinnati Medical Center July, 1987 to 2014 Senior Attending Good Samaritan Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062423/5697bf931a28abf838c8fc08/html5/thumbnails/4.jpg)
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
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Slide 5
Entering the Room, You Hear Prolonged Screaming with Gasping Inhalations
Your Next Step ? ? ? ??
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Slide 6
You See: Violent Movement of Extremities with Clench Fists
Your Next Step ? ? ? ??
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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 ? ? ? ??
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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 ? ? ? ??
![Page 9: Slide 1 Volunteer Associate Professor of Psychiatry University of Cincinnati Medical Center July, 1987 to 2014 Senior Attending Good Samaritan Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062423/5697bf931a28abf838c8fc08/html5/thumbnails/9.jpg)
Slide 9
Findings and Course
Hypopituitarism Insulin Producing Lesions in
Abdomen Surgical Treatment
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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]
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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]
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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]
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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]
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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]
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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]
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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 ? ? ? ??
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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
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Slide 18
What Is Hunger ? ? ? ??
1 2 3 4
0% 0%0%0%
1. A Physical Symptom2. A Psychological
Symptom3. Both4. Neither
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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
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Slide 20
Strange Behavior Mood Changes Abnormal Thinking
- These Are Symptoms of Psychoses -
Whether Physical Psychoses Or
Functional – Psychiatric - Psychoses
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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%
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Slide 22
58% of Psychiatric Patients Have Physical Illnesses
Undiagnosed[23] - - - -21 Studies
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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%
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Slide 24
27% of the Physical Disorders of Psychiatric Patients
Produced Symptoms Related Directly to the “Psychiatric Symptoms”[23]
- - - -
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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%
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Slide 26
Non Psychiatric Physicians Miss Physical DiagnosesIn about 30% of Patients They Refer for Psychiatric Treatment[23]
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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%
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Slide 28
Psychiatrists and Psychiatric Institutions
Missed the Physical Disorders In about 50% of Patients[23]
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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%
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Slide 30
Non-Physicians Psychologists Social Workers Therapists Patients Relatives
Miss about 86% of Physical Disorders[23]
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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]
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Slide 32
Among Patients w/ “Psychiatric Symptoms”, Why Are Physical
Disorders Missed ? ? ? ??
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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]
![Page 34: Slide 1 Volunteer Associate Professor of Psychiatry University of Cincinnati Medical Center July, 1987 to 2014 Senior Attending Good Samaritan Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062423/5697bf931a28abf838c8fc08/html5/thumbnails/34.jpg)
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]
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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]
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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
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Slide 37
What Symptoms of Physical Disorders Are Also Psychiatric Signs
& Symptoms – Behavior, Mood, Thinking ? ? ? ??
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Slide 38
Caveat! ! ! !!
No Psychiatric Symptoms Exist That Cannot Be
Caused byor
Aggravated by Medical Illnesses[23]
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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
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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
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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
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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
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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
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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
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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
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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
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Slide 47
Screen Broadly[31]
CBC Comprehensive Metabolic Panel Erythrocyte Sedimentation Rate
Infection Suspected Antinuclear Antibodies Urine Analysis Comprehensive Drug Screen
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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
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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
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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
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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
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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
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Slide 53
Diagnoses:
Do Not Classify People Merely Classify Disorders and
Diseases
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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
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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
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Slide 56
The Basics of Doctoring
Be Curious Be Thorough Enjoy Caring for the Patient
![Page 57: Slide 1 Volunteer Associate Professor of Psychiatry University of Cincinnati Medical Center July, 1987 to 2014 Senior Attending Good Samaritan Hospital.](https://reader035.fdocuments.us/reader035/viewer/2022062423/5697bf931a28abf838c8fc08/html5/thumbnails/57.jpg)
Slide 57
Can’t See Well Flushed
Dry Mucus Membranes Can’t pee
Confused Can’t Evacuate Bowels
What Is Your Assessment ? ? ? ??
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Slide 60
-- Goodies –http://tinyurl.com/EnzerGrand
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Both with and without Notes Citations and Sources Consulted
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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