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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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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
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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
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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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Entering the Room, You Hear Prolonged Screaming with Gasping Inhalations
Your Next Step ? ? ? ??
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You See: Violent Movement of Extremities with Clench Fists
Your Next Step ? ? ? ??
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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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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 ? ? ? ??
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Findings and Course
Hypopituitarism Insulin Producing Lesions in
Abdomen Surgical Treatment
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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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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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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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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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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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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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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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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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What Is Hunger ? ? ? ??
1 2 3 4
0% 0%0%0%
1. A Physical Symptom2. A Psychological
Symptom3. Both4. Neither
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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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Strange Behavior Mood Changes Abnormal Thinking
- These Are Symptoms of Psychoses -
Whether Physical Psychoses Or
Functional – Psychiatric - Psychoses
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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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58% of Psychiatric Patients Have Physical Illnesses
Undiagnosed[23] - - - -21 Studies
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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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27% of the Physical Disorders of Psychiatric Patients
Produced Symptoms Related Directly to the “Psychiatric Symptoms”[23]
- - - -
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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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Non Psychiatric Physicians Miss Physical DiagnosesIn about 30% of Patients They Refer for Psychiatric Treatment[23]
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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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Psychiatrists and Psychiatric Institutions
Missed the Physical Disorders In about 50% of Patients[23]
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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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Non-Physicians Psychologists Social Workers Therapists Patients Relatives
Miss about 86% of Physical Disorders[23]
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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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Among Patients w/ “Psychiatric Symptoms”, Why Are Physical
Disorders Missed ? ? ? ??
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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]
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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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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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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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What Symptoms of Physical Disorders Are Also Psychiatric Signs
& Symptoms – Behavior, Mood, Thinking ? ? ? ??
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Caveat! ! ! !!
No Psychiatric Symptoms Exist That Cannot Be
Caused byor
Aggravated by Medical Illnesses[23]
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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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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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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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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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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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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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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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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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Screen Broadly[31]
CBC Comprehensive Metabolic Panel Erythrocyte Sedimentation Rate
Infection Suspected Antinuclear Antibodies Urine Analysis Comprehensive Drug Screen
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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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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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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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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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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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Diagnoses:
Do Not Classify People Merely Classify Disorders and
Diseases
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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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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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The Basics of Doctoring
Be Curious Be Thorough Enjoy Caring for the Patient
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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 61
"Prescribing Is So Easy,
Understanding People So Hard.“
Kafka, Franz. (1917)
A Country Doctor. The Penal Colony, Stories and Short Pieces
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