Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 5: Examination and Diagnosis of the Psychiatric Patient

neuropsychologist might refer the child to an occupational or physical therapist for further, more specific, evaluation. Neuropsychological testing is commonly undertaken according to several discrete domains that reflect areas of brain functioning. Typically, these include attention and executive functioning, memory, and language as well as visuoperceptual and sensory/motor functioning. In consider- ing neuropsychological issues, the following factors should be kept in mind:  After early brain injury, language and motor functioning are the most likely to benefit from “plasticity.” Some research suggests that, with this process of reorganization, other functions (most notably, visuoperceptual abilities) may be “crowded out,” yielding scores that are lower than expected.  Interventions for neurologically driven developmental delays have their most profound effect on younger children. Recent studies have shown that, in children with reading disabilities, bilateral representa- tion of language identified with fMRI before intervention shifted to the left hemisphere by several orders of magnitude in every subject after only 80 hours of reading intervention. These changes in the brain were accompanied by improved reading skills. Thus, the philosophy of delaying intervention until a deficit is fully expressed may keep chil- dren from receiving the full benefit that early intervention provides.  Risk factors for reading disabilities include family history, early language delays, poor articulation, chronic ear infections, poor early rhyming abilities, inability to recite (not sing) the alphabet by the end of kindergarten, and early brain injury.  Ambidexterity (consistently using the right hand for some specific tasks and the left hand for other specific tasks) often runs in families in which several members are left handed. In contrast, ambiguous handedness (or the use of either hand for the same task; sometimes writing with the right hand, sometimes writing with the left hand) can be a pathognomonic sign suggesting poor cerebral organization for specific behaviors.  Attention-deficit/hyperactivity disorder (ADHD) more adversely affects abilities typically associated with right hemisphere func- tioning (such as fine motor skills and visuoperceptual abilities) and affects attention and executive functioning. Psychostimulant medication has been shown to improve functioning in all of these domains in children with ADHD. R eferences Cleary MJ, Scott AJ. Developments in clinical neuropsychology: Implications for school psychological services. J School Health. 2011;81:1. Dawson P, Guare R. Executive Skills in Children and Adolescents: A Practical Guide to Assessment and Intervention. 2 nd ed. NewYork: Gilford; 2010. Fletcher JM, Lyon RG, Fuchs LS, Barnes MA. Learning Disabilities: From Iden- tification to Intervention. NewYork: Guilford; 2007. Jura MB, Humphrey LA. Neuropsychological and cognitive assessment of children. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Text- book of Psychiatry. 9 th ed. Philadelphia: Lippincott Williams &Wilkins; 2009:973. Korja M,Ylijoki M, Japinleimu H, Pohjola P, Matomäki J, Kusmierek H, Mahlman M, Rikalainen H, Parkkola R, Kaukola T, Lehtonen L, Hallman M, Haataja L. Apolipoprotein E, brain injury and neurodevelopmental outcome of children. Genes Brain Beh. 2013;28(4):435–445. Mattis S, Papolos D, Luck D, CockerhamM,Thode HC Jr. Neuropsychological factors differentiating treated children with pediatric bipolar disorder from those with atten- tion-deficit/hyperactivity disorder. J Clin Experi Neuropsychology. 2010;33:74. Pennington B. Diagnosing Learning Disorders: A Neuropsychological Frame- work. 2 nd ed. NewYork: Guilford; 2008. Scholle SH, Vuong O, Ding L, Fry S, Gallagher P, Brown JA, Hays RD, Cleary PD. Development of and field test results for the CAHPS PCMH survey. Med Care. 2012;50:S2. Stark D, Thomas S, Dawson D, Talbot E, Bennett E, Starza-Smith A. Paediatric neuropsychological assessment: an analysis of parents’ perspectives. Soc Care Neurodisabil . 2014;5:41–50. Williams L, Hermens D, Thein T, Clark C, Cooper N, Clarke S, Lamb C, Gordon E, Kohn M. Using brain-based cognitive measures to support clinical decisions in ADHD. Pediatr Neurol. 2010;42(2):118.

▲▲ 5.7 Medical Assessment and Laboratory Testing in Psychiatry

Two recent issues have pushed medical assessment and labora- tory testing in psychiatric patients to the forefront of attention for most clinicians: the widespread recognition of the pervasive problem of metabolic syndrome in clinical psychiatry and the shorter life expectancy of psychiatric patients compared with that of the general population. Factors that may contribute to medical comorbidity include abuse of tobacco, alcohol and drugs, poor dietary habits, and obesity. Further, many psycho- tropic medications are associated with health risks that include obesity, metabolic syndrome, and hyperprolactinemia. Conse- quently, monitoring the physical health of psychiatric patients has become a more prominent issue. A logical and systematic approach to the use of medical assessment and laboratory testing by the psychiatrist is vital to achieving the goals of arriving at accurate diagnoses, identify- ing medical comorbidities, implementing appropriate treatment, and delivering cost-effective care. With respect to the diagnosis or management of medical disease, consultation with colleagues in other specialties is important. Good clinicians recognize the limits of their expertise and the need for consultation with their nonpsychiatric colleagues. Physical Health Monitoring Monitoring the physical health of psychiatric patients has two goals: to provide appropriate care for existing illnesses and to protect the patient’s current health from possible future impair- ment. Disease prevention should begin with a clear concept of the condition to be avoided. Ideally, in psychiatry this would be a focus on commonly found conditions that could be a signifi- cant source of morbidity or mortality. It is clear that in psychia- try a small number of clinical problems underlie a significant number of impairments and premature deaths. A thorough history, including a review of systems, is the basis for a comprehensive patient assessment. The history guides the clinician in the selection of laboratory studies that are rel- evant for a specific patient. Many psychiatric patients, owing to their illnesses, are not capable of providing sufficiently detailed information. Collateral sources of information, including fam- ily members and prior clinicians and their medical records, may be particularly helpful in the assessment of such patients. The patient’s medical history is an important component of the history. It should include notation of prior injuries and, in particular, head injuries that resulted in loss of conscious- ness and other causes of unconsciousness. The patient’s medi- cal history also should note pain conditions, ongoing medical problems, prior hospitalizations, prior surgeries, and a list of the patient’s current medications. Toxic exposures are another important component of the medical history. Such exposures are often workplace related. Role of History and Physical Examination