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This blog covers current events, brain injury, general psychology, health psychology, medical psychology, testing, and general issues.

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Mental Status Examination

Posted by Margaret Donohue on July 28, 2017 at 10:00 PM Comments comments (0)

The Mental Status Examination

The mental status examination is a screening test for a wide variety of mental disorders and conditions. In it’s most common form it is abbreviated to a mini state exam with fewer categories and often used to evaluate cognitive difficulties.

The full exam consists of evaluation in multiple categories:

  • Appearance and behavior
  • Orientation, concentration and attention
  • Language and memory
  • General information and intellect
  • Thought process
  • Thought content
  • Mood and affect
  • Delusions, illusions and hallucinations
  • Insight and judgment
  • Abstract reasoning and synthesis of thought
  • Reading, writing and math
  • Drawing and copying
  • Repetition, Registration
  • Risk assessment
  • Validity of assessment results and effort of person being evaluated


The mini exam has fewer categories and is generally used to assess significant cognitive impairment:

  • Orientation
  • Immediate Recall
  • Counting backwards
  • Spelling backwards
  • Delayed Recall
  • Language Naming
  • Repetition of a complex phrase
  • Following a three step-command
  • Reading
  • Writing
  • Copying


A standard verbally based IQ test combined with behavioral observations will provide as much or more information than a full mental status examination if performed by a skilled examiner. If the examiner is familiar with a wide variety of psychological and neuropsychological test instruments the screening test can be scaled up to reflect a higher general education or premorbid level of intellect or scaled down to reflect someone from a more culturally improverished environment. Items can be substituted to document more subtle degrees of impairment and to clarify areas of strengths as well as areas of weakness or concern.

A skilled examiner performing the examination in it’s complete form can be as much art as science. Some parts of the test are developmental in nature, so some items are easier to complete than others for average people with no impairment. Most people with no difficulties will pass a mental status examination with very few minor errors. Significant cognitive impairment is readily apparent to a trained observer on presentation and a mental status examination is simply for the purpose of documenting global difficulties. Likewise, individuals attempting to fabricate results often perform so poorly as to be obvious.

If you know of someone needing an assessment, feel free to contact our office. We offer a wide variety of assessment and treatment services.

1985 to the future

Posted by Margaret Donohue on May 3, 2017 at 7:45 AM Comments comments (0)

It was 1985.  I was newly licensed with specialty training in this weird not-yet-ready-for-prime-time area of psychology no one really knew anything about-Medical Psychology.  And I was working in a medical practice with a physician I knew.  I had training in both medicine and pharmacy.  So I went through paper charts of any patient that had been seen for four visits with no clear diagnosis.  While all of the patients I saw had psychiatric symptoms, 80% would be found to have a primary medical conditions that would account for those symptoms.  The patients were then scheduled.  I took vitals of height, weight, blood pressure, temperature, and reviewed all their medications and how they were taking them.  The history took from 1-3 visits to ensure I had everything correct.  I documented in the patient's chart.  I had patients document symtpoms and keep records. I made house calls.  I made recommendations for lab studies, changes in medications, and referrals for specialty care.  I explained diagnosis, lab studies, medications, and how to take them.  I set up systems for taking medications.  I explained diets.  I would even help patients shop for food.  I did psychological testing to differentiate psychological conditions.  The internet was not a standard household item.  I had AOL dialup service at home, but I had access to multiple medical libraries in Los Angeles.  When the field of medical psychology was initially conceptualized this was how it looked.  A cross between psychological history taking and testing services and physician assistant and health educator.  Ideally, in the future, we would have prescribing abilities.  The future never came.  


There are about 5 medical psychologists in the greater Los Angeles area.  We know each other.  The field merged with Health Psychology back in the late 1990's and the concept of psychologist as physician assistant was lost in the process.  It's a field that needs to return.  In force.  


It's 2017.  A patient sees their physician or physician assistant or nurse practitioner.  They download all their initial information from a patient portal and upload it back to an electronic health record (EHR).  The physician's scheding team books the first appointment and ensures the physician has access to the patient data.  In the 15 to 30 minute initial office consultation, the patient is expected to report their symptoms and get any needed testing or treatment planning for future visits.  Five minutes of that visit are spent taking vitals.  The patient may have completed a health screening questionnaire or a psychological symptoms checklist.  If they check positive on those questionnaires they may be sent to a psychologist for further treatment.  80% of them will have a primary medical condition that accounts for their psychological symptoms.  It's likely to be missed.  


There's another issue now that wasn't present back in 1985.  A patient contacted me because the labs in her patient access portal had come back positive.  Her physician will see her in two weeks.  Because the scope of practice in medical psychology is weird, (I can make suggestions to physicians that they can accept or reject) but I can't actually order things directly, I had made recommendations for the labs that had now come back abnormal.  So I now have more information than her physician does.  I can see her urgently and provide her with information (based on research) about her illness, give her information about support groups, provide her online information about clinical trials, and suggest all the next steps she'll need to discuss with a specialist she needs to have her physician refer her to.  The patient portal is new.  Physicians don't yet know how to manage that.


in the past, this process could have taken months. The diagnosis part alone could have taken that long.  Her psychological complaints don't match the medical illness, unless you listen for 40 minutes and really hear what she's saying.  You also have to look at her.  Medical things are often visible.  That part of looking at people to see medical illness is known as clinical medicine and it's a lost art and getting more lost as it's replaced by laboratory medicine.  That means that if the lab reports are all normal, some physicians will say the person is normal too.  And they are wrong.  80% of the time and more likely with women than with men patients.  Women start with psychiatric complaints and then go to physical complaints.  This gets physicians off on the wrong decision tree.  So a heart attack will present as depression, fatigue, feeling tired and not able to do housework, almost like the flu in women.  Men will complain of nausea, chest, neck, back or jaw pain with a heart attack.  So women get a prescription for Prozac and men get an ER visit.  So my patient's medical symptoms got lost in the psychiatric complaints that are part of the medical condition.  The patient portal allowed her to send me labs in seconds.  I had her diagnosis as soon as the positive labs were read.  I have her full history and I saw her and actually looked at her.  Now there is nothing psychiatric.  She'll get some specialty care to rule out complications, but she can now spend her time investigating treatment options.


In the future there should be more people like me.  We will likely have virtual practices.  I can see the patient through a video.  I can get their labs through their patient portal.  I can still take a history.  In rare cases I may need to see the person face to face.  But may cases like this can be done through telehealth.  There still needs to be the psychologist/physician that says it's not a psychological condition untill all the medical conditions are ruled out.  we still need the field of medical psychology.  Maybe it can be brought back.

Sepsis

Posted by Margaret Donohue on April 17, 2017 at 9:10 AM Comments comments (0)

A female patient of mine with chronic pain had a new symptom.  Severe abdominal pain.  "It's like I'm being stabbed with a hot knife."  That's a very specific description.  One that will prompt an emergency room doctor to start poking around in the abdomen or taking an x-ray of the abdomen or doing an ultrasound of the abdomen.  But the symptom has nothing to do with the abdomen.  The gastrointestinal tract is where the immune system is going into overdrive.  On a scale of 1 to 10 the pain ranges from an 8 to a 10.  Although the person may have a fever, they tend to complain of feeling cold.  The temperature drops in the morning and rises in the afternoon or evening.  There are night sweats.  These are the beginning signs of the development of a septic infection.  


It's important to find out the actual location of the infection.  In the case of my patient she had a vaginal discharge.  So the infection wasn't in her GI tract, it was in her vagina.  When caught this early, these infections can be treated with antibiotics.  If she had waited for the next symptoms of sepsis to develop, the one's that may still get missed by an emergency room physician, the prognosis becomes grim.  25% of early sepsis patients die after an initial misdiagnosis.


I've had patients with the abdominal pain have a simple infected pimple or cut, or even a sinus or lung infection progress to sepsis.  All present with the strange severe abdominal pain.  If it's a lung infection, the cough may prompt a physician to prescribe a steroid.  That will help the cough, and slightly stop the pain, but the infection will get a huge boost.  The rate of infection spread can be alarmingly fast.  The next two stages can progress in as little as 6 to 12 hours.


The next stage of sepsis is a strange confusional state where thinking becomes difficult.  Blood pressure rises or drops, heart rate elevates, blood sugar elevates.  The body is going into massive overdrive as it tries to fight off the infection and is loosing.  This is where many physicians may make the diagnosis of sepsis or at least an infection.  The abdominal pain will have returned.  This pain seems to confuse physicians.  If they missed the infection initially, they may not realize how severe it is.  At this point the infection must be treated aggressively because the next stage has a mortality rate nearing 85%.


The last stage of sepis is recognizable to emergency room physicians.  The person is in severe pain, the blood counts are severely depressed or severely elevated.  The blood itself is infected and can be cultured.  The temperature is very high or very low.  The blood pressure is very high or very low and the blood volume is depleted.  The heart rate is elevated and the lungs are starting to gain fluid.  The kidneys are shutting down and no longer producing urine.  The person may be vomiting from the pain or pacing from the pain.  This stage is treated with intravenous antibiotics and may require surgery to remove the infected tissue.


If you have unusually severe abdominal pain, keep going back to see your physician and report all signs of infection, no matter how small or how far away from the abdomen the apparant infection may be located.  If your temperature is over 101 degrees or below 96.8 degrees and your heart is beating too fast go see your doctor or go to a hospital emergency room.  It may save your life.



Diagnosis of medical versus psychiatric anxiety or depression

Posted by Margaret Donohue on April 10, 2017 at 11:35 PM Comments comments (0)

Medical causes of depression and anxiety account for about 58-79 % of all diagnosed cases of depression and anxiety.  So it's helpful to differentiate them.  

  • Psychological cases respond generally well to evidence based treatments for depression and anxiety.  So if a person has been through an evidence based treatment, and followed the protocol, and was adherent, they should have some degree of improvement in about 4 to 6 weeks. 
  • In addition there should be something that triggered the depression or anxiety to start.  So if that's missing, it's more likely to have a medical cause.  
  • The most common causes of missed diagnosed medical conditions are infection, endocrine, medication side effects, neurological conditions, vitamin or mineral deficiencies, allergic reactions, and malignancy. 
  • There should also be thoughts related to emotions in psychological conditions but there may not be thoughts related to mood issues in medical conditions.

One thing I try with people is to see if they respond to what I call the straw test.  See if the person can access the anxious or depressed feeling.  Have them then place a straw lengthwise between their teeth forcing their mouths into a wide smile.  See if they can still access the feeling of depression or anxiety.  If they can it's more likely medical than psychiatric.  Psychiatric conditions will respond to changing behaviors or thoughts.  This was first found in 1988 in a study by Strack, et.al.  where he had people hold a pencil between their teeth or between their lips.  Between the teech creates a forced smile and between the lips a forced frown.  He said it was a facial feedback hypothesis.  Neurolinguistic programming would hypothesize that it's a physical anchor.  It's a simple trick that can help with differential diagnosis.

Sexual Assault

Posted by Margaret Donohue on October 9, 2016 at 9:50 AM Comments comments (1)

I don't believe I know any woman over the age of 15 that hasn't been sexually assaulted, inappropriately gropped, fondled or touched without her consent by someone.  So I'm not surprised that when @kellyoxford asks women on twitter to share their first sexual assault stories that there are more than 1 million responses with most of the events starting in childhood.


While the tipping point in the conversation about the prevalence of assault against women may be the latest video clip about Trump, it started earlier with the story of the rapes on campuses across the country, the victim letter from the Stanford rape case, the film The Hunting Ground, and the dozens of women talking about Bill Cosby assaulting them.   It started with Anita Hill talking about sexual harassment at work before congress and that conversation about how a reasonable person and a reasonable woman might have different perspectives.  


On Friday President Obama signed into law the Sexual Assault Survivor's Rights Act that allows rape kits to be preserved for up to 20 years or the State's maximum statue of limitations.  It also lets survivors be advised in writing 60 days before their rape kit is destroyed and lets them request preservation beyond the scheduled destruction date.


Sexual assault is one of the most unreported crimes.  Reading through the responses to Kelly Oxford's post on twitter, men apologize, point out that Bill Clinton did bad things too, or talk about how people are innocent until proven guilty.  They blame the media and point out that men are sexually assaulted as well.  


To men out there, you don't need to apologize or deflect.  What you need to do is to speak out.  The conversation Trump had in 2005 is common.  It's not okay and it normalizes inappropriate behavior.  It's your turn to speak out against the men that talk like this.  Get offended.  The men that talk this way prey upon your mothers, sisters wives and daughters.  Talk to the women that have been assaulted.  Find out for yourself that it's almost every woman you know and often most girls you know.  You have to get horrified before you support tremendous change.

Herxheimer Reactions

Posted by Margaret Donohue on September 24, 2016 at 12:35 AM Comments comments (0)

Jarisch-Herxheimer Reaction also known more simply as Herxheimer or Herx reaction sometimes occurs after antibiotic treatment causes a large die off of bacteria, fungus, yeast, or other systemic infections. initially described by Adolf Jarisch in 1895 and later by Karl Herxheimer in 1902, the reactions have been found in syphillis, sarcoidosis, rheumatoid arthritis, chronic lyme disease, leptospirosis, relapsing fever and candidiasis starting within an hour or so of taking the antibiotic to several weeks later and can last for a few hours to weeks.  


Symptoms of a herxheimer reaction include:

  • Flu like illness
  • Muscle or joint pain
  • Low grade fever
  • Bone pain
  • Nausea
  • Diarrhea
  • Vomiting
  • Mental Confusion
  • Anxiety
  • Depression
  • Neurological Symptoms
  • High or low blood pressure
  • Changes in heart rate or rhythm
  • Heart palpitations
  • Rashes

It's important to recognize that the reaction is the result of the toxins being released by the bacteria, fungus or yeast dying off and not the result of a side effect of the antibiotic.  The reaction is generally mild, but may be severe and may require medical treatment to lessen the severity.  Treatment may consist of corticosteroids, IV fluids, blood pressure medication, and even dialysis.

If you think you may be having a Herxheimer reaction check with your physician.  In most cases the reaction subsides without incident in a day or so.

If you have quyestions about any medical condition we can assist with information, research and support.  Feel free to contact us at 818-223-4116.

Ehlers-Danlos Syndrome

Posted by Margaret Donohue on September 6, 2016 at 9:45 AM Comments comments (0)

Jessica Jacobs died in August. She had Ehlers-Danlos Syndrome. She is also described as having Postural Orthostatic Tachycardia Syndrome. I say described because I’m not sure I believe that. I think she had Ehlers-Danlos Syndrome with Autonomic Dysregulation and postural orthostatic tachycardia syndrome is just a part of that. She lived most of her adult life in Washington, DC but moved back to Twain Harte, California when she became too disabled to continue working. She wanted to be closer to her family.


Ehlers-Danlos Syndrome has several variants. The symptoms can consist of a variety of any of the following: hypermobility of the joints, thoracic outlet syndrome, early onset of osteoarthritis, degenerative joint disease, long slender fingers with swan-neck deformity, boutonniere deformity of the fingers, tearing of tendons or muscles, scoliosis, kyphosis, a tethered spinal cord, muscle pain, joint pain, trendelenberg’s sign (balance instability), Osgood-Schlatter disease, fragile skin, atrophic scarring, easy bruising, multiple skin folds, subcutaneous spheroids, molluscoid pseudo tumors, valvular heart disease, postural orthostatic tachycardia syndrome, arterial rupture, aneurysm of the ascending aorta, Raynaud’s phenomena, heart murmur, heart conduction abnormalities, hiatal hernia, gastrointestinal dysmotility, dysautonomia, the ability to hyperextend the tongue to touch the nose, anal prolapse, collapsed lung, Arnold-Chiari malformation, platelet aggregation, pregnancy complications, sleep apnea, chronic pain and insensitivity to local anesthetics., drooping eyelids.


Jessica Jacobs was an advocate for the disabled and a blogger that wrote about her poor medical care and lack of coordination of her medical treatment. The types with dysregulation of the autonomic nervous system, and bleeding disorders are at risk for sudden death. Jessica noted all the places that were not accessible to her in a wheelchair, including her hospital room bathroom. She attempted to ensure that all her doctors could share medical records but carried around a binder of them because they couldn’t. She found her primary care physician dumping her onto uncoordinated specialist care abhorrent. Unfortunately, this is a common practice with any rare medical condition. It’s a bit more common with Ehlers-Danlos Syndrome.


She’ll be missed.

Pulse Nightclub and the Stanford Rape Case

Posted by Margaret Donohue on June 18, 2016 at 7:10 AM Comments comments (0)

I am as appalled by the media coverage of the Pulse Nightclub massacre and the Stanford Rape case as I am of the events themselves.  I'm chairing a dissertation on rape and I have a clinical practice that is LGBTQIA friendly.  The media turns these events into single incidents rather than common place occurrences.  The rape case stands out only because of the articulate first person account of the victim.  Rarely do we hear the words of the victims.  And 7000+ words not only captured the nation but put focus on the judge for handing down the light sentence to Brock Turner.  And there is a discussion about rape culture and the misrepresentation of men like Brock as boys and just drinking too much, and not as the face of the rapists they are.  So that discussion is well needed.  But the sentence itself is common.  The rapist I saw a week or so ago was given 3 years for breaking a woman's jaw twice during her rape.  He was out in less than two years.   He's already violating his parole.  I'll see 2 or 3 more just like him over the next few months.  It's common.  So women don't get to feel safe because we know.  We know that reporting gets nothing more than a slap on the wrist.  That going to court gets a laughably light sentence.  That we will be blamed for the rape instead of the rapist.  We know that.  I was told my rapist couldn't be convicted so no charges were brought.  He raped acquaintances.  I know three other women he raped.  There were no charges brought by the State.


The massacre at the Pulse Nightclub is marked by the lack of media coverage of it being a place of safety for people within the transgender drag Latinx community.  It was a continuation of the violence that has been historical from the time of colonization on.  It was the continuation of violence against the community that occurs within a daily basis.  This is a community that wakes up knowing people want to kill them every day. It's not about guns or Muslims.  It's about a massacre that normally happens piecemeal.  The media usurps the community by not naming them. By not calling this what it was, part of the ongoing massacre of people of color, of the homosexual and transgender communities, of the marginalized.


My cisgender white male friends of privilege do not understand.   They think nothing of walking outside, alone, at night.  They think nothing of going to a nightclub and maybe having a drink.  They do not understand why I own a gun, why I'm afraid, or what it means to be a survivor of crime.  A survivor of rape.  They think the police the police will help if something bad happens.  They think the police will come.  But what the media gets so wrong is that as members of these communities, we know the police will not come, if they do come they will come late and ineffectively, they will blame the community, and if we defend ourselves we will be vilified.  The script the media endorses is that these are gun crimes or terrorist activites or the problems of mental illness.  No.  They are the problems of marginalization and dehumanization.  There are countless murders and countless rapes.  It's not about guns, or terrorists or the mentally ill.  It's about a lack of safety and a lack of awareness of how often these crimes are occuring.

Medical Psychology

Posted by Margaret Donohue on May 3, 2016 at 8:30 AM Comments comments (0)

Depending on the study, somewhere between 58 and 79 percent of all psychological diagnoses have a substantial medical component.  That's a very alarming statistic.  In the 1970's the field of medical psychology was created to address this need.  By the late 1980's it had all but dissappeared, replaced by the less medically intense health psychology field or the broader behavioral medicine field.  


When I first went into practice I worked with a family practice physician.  My office was located in his office.  The referral question was simple: "This person has been seeing me (the MD) for 4 or more visits and the diagnosis is unclear" or "This person is not responding to treatment."  Of the hundred or so people I saw over the first year, I diagnosed about 30 cases of cancer, 20 cases of heart disease, and 35 cases of endocrine disorders.  The rest were a mixture of psychological conditions and non-compliance with complicated medical treatment.  My private practice geared to work with heart disease and cancer was starting to be filled by men with what would eventually be diagnosed as HIV/AIDS.  I drove to San Francisco on the weekends to be with a client who was being treated at San Francisco General.  I stopped counting the deaths at 175 and closed my practice to start working for one of the insurance companies.  


At a risk management seminar I was sitting at a table of physicians.  They presented a case of a woman with persistent neck pain.  The cardiologist at the table and I were arguing over the diagnosis. The case was presented in pieces, just like it is in a medical office.  She had been cleaning the shower and her neck started hurting.  It felt better after some rest but still didn't go away.  She thought maybe she had the flu.   I was telling the cardiologist the woman had a heart attack.  He was telling me I wasn't a doctor.  After the third visit for neck adjustment the woman collapsed at home.  She'd had three heart attacks.  I explained to the cardiologist that women experience heart attacks differently than men and they have different symptoms mainly neck and jaw pain, fatigue and muscle aches.  Almost all my heart patients were women.  Almost all were misdiagnosed in medical offices or even at emergency rooms.


The endocrine diagnoses were worse.  Almost all my endocrine patients were misdiagnosed with depression, anxiety, or personality disorders.  Some had endocrine tumors.  Some of those tumors were malignant.  Just trying to get the correct tests done or imaging studies done was challenging.  Eventually I had physicians I worked with because we knew each other, and they understood what I did.  For physicians not trained in clinical medicine, they decided I was psychic.  For physicians trained in clinical medicine, they honed their skills and trusted them more than the lab studies they treated like oracles.  


Now I tend to work with more neurological symptoms, recent head injury or abnormal test results that don't seem to correlate with any illness.  When the Dr. House series was on television it was easier to explain what I did.  That was a show about clinical medicine.  I like the puzzle.  I like figuring out what's going on.


If you don't have a diagnosis and have seen your physician for more than 4 visists, or if you aren't responding to treatment, contact me.  I'm likely to be able to help with diagnosis and treatment.

Patient Shaming

Posted by Margaret Donohue on April 24, 2016 at 12:40 PM Comments comments (0)

Patient shaming. This time it happened to/about my cat. This happens by physicians (or vets) when they don’t know what is going on and all the treatment options they know of have been exhausted. It usually happens to people on the fourth visit either when there isn’t a diagnosis or the treatment is ineffective.

I ‘ve had Tatum since she was just under 2 years old. She was a hot mess. She was in several foster homes. The rescue organization referred to her as medically fragile. She had a couple of common cat conditions, namely cat acne, and bilateral herpes of the eyes. But she was ripping her face and ears open and the go-to diagnosis was some sort of unseen parasite. She was subjected to scrapings, dips, multiple medications and a food diet so extreme that she was only eating one brand of cat food and only turkey pate at that. She still had all the conditions. The rescue person dropped her off, did a cursory look at the house and ran out yelling “Start the car. They took the cat.”

I kept up with all the craziness for a year. Then I stopped the pills. I stopped the drops. I kept her eating out of ceramic or glass dishes. I started varying her food. No change. She ripped her face open and I took her to two vets. No parasites. It’s stress. Cat self-harm. Cat trauma. New people trigger it. Sometimes the other cat triggers it. Sometimes it’s a thunderstorm. She eventually gets over it. She’s been fine for the last several days.

She just turned five and I took her to the vet. New vet. “She should be on L-Lysine twice a day” she said.

“I did that,” I said. “It does nothing.”

“She’s ripping her face open because of the cat acne. It’s painful” she said.

“No,” I said. “She rips her face open when she’s psychotic.”

“We can treat that. There’s medication for it” she said.

“I’ve given her creams and drops for a year. It does nothing. No thank you.”

“So you want your cat to be in pain. I guess you know everything.”

“She’s here for vaccinations. Can you do those?”

“Yes,” she said.

Stalemate.

It’s annoying. It happens because doctors are taught in medical school that they have to know everything. For many it hinders later collaborative practice. They blame patients with chronic medical conditions that don’t respond to typical treatment. They blame parents for children not improving. They blame people when they can’t diagnose. They refer to therapy as a last resort rather than as a first line of options. Switching doctors happens with disgruntled patients or being referred out to specialists is the common practice for physicians. It fragments treatment, limits history, and results in poorer medical care. As more physicians integrate psychologists into their practices hopefully this will lessen.


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