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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.

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.

Disability

Posted by Margaret Donohue on April 19, 2016 at 9:20 AM Comments comments (0)

Disability is a complex system of insurance companies, state regulations, federal regulations and governmental bodies with competing and differing codes for determination. It’s confusing to a lot of people. Our office can help with all forms of evaluation.

DEFINITIONS

A disabling condition is a physical or emotional illness or collection of symptoms that impairs the ability to function in one or more areas of life. Accommodations are methods to assist someone in performing tasks so they can function better.

Accommodations may include a device such as a computer that recognizes speech, or converts speech to text, or reads text aloud. It may be a wheelchair or a cane. It may be a device that helps to put on socks, or grab items, or button. It may be a device that helps someone hold a spoon, or fork, or pencil. It may be a cell phone or tape recorder. It may be a system of applications that says what color something is, what denomination of money someone has, or a prompting system to help with memory. It may be a medical device to test blood sugar, blood pressure, temperature, pulse. It may be extended time on exams, a private room, natural lighting, a test given on computer or a paper based test. It may be a service animal or emotional support animal. It may be voice activated door bells, light switches, smoke detectors. It’s not an advantage, but it may be an equalizer.

An off work notice. This is a letter to an employer indicating a disabled person is not able to function in their usual and customary job as a result of a temporary disabling condition. This usually needs to come from a physician (psychologists count as physicians in this regard). The person is expected to undergo some form of treatment to return them back to their usual and customary job.

Evaluation of disability by a treating provider. This is a letter or report of the symptoms and a description of functional impairments. This may be requested by an employer or by an insurance company handling a disability claim. This letter does not have to be written by a physician.

Evaluation of disability for the Social Security Administration. This is an evaluation of how an individual is able to function in their ability to perform simple work in the general labor market. The is not an evaluation of their ability to perform their usual and customary job. This is simple work. Examples would be the person who bags groceries at a grocery store and retrieves shopping carts, or the helper that waters plants at the local nursery. It involves some degree of judgment such as not putting the gallon of milk on top of the carton of eggs.

Evaluation of disability for accommodations. This is a complex evaluation involving multiple layers of documenting what is required and what is available. For conditions such as ADHD, or for tests such as licensing board tests these evaluations are lengthy and extensive.

We perform all tyes of evaluaitons on all age groups and write letters as part of those evaluations.  Feel free to contact our office.

Complex Trauma

Posted by Margaret Donohue on April 14, 2016 at 8:00 PM Comments comments (0)

I explain complex trauma to my students by telling the story of my cat Tatum.  I met Tatum through a cat rescue organization.  Tatum was described as a fragile medically ill cat.  I picked her up in my arms and she jumped out of my grasp.  The rescue group had me sign several forms and gave me her medical history.  Three foster homes in her six months of life.  Countless medical visits.  Found in a cardboard box in a McDonald's parking lot in Lancaster, California.  She was prescribed multiple medications, creams, pills, a special diet, and she couldn't get along with other animals.  She was "slow to warm up."  "She's not to go outside.  She gets terrified.  She responds quickly to being sprayed in the face with water if she's doing something you don't want her to do."


The first time she ripped open her face I assumed what everyone had, that she had mites, or an infection, or some sort of parasite.  The first vet didn't find anything but prescribed medication anyway.  The second vet didn't prescribe because she was already on medication and nothing was changing.  So I asked if it was possible it was just self-injurious behavior.  "Oh, we call it delusional parasites"  the vet said.  So I did research.


Post Traumatic Stress Disorder occurs commonly in animals. 

PTSD symptoms in pets can include:

  • Uncharacteristic aggressiveness
  • Fearfulness, trembling
  • Increased agitation
  • Decreased appetite and weight loss
  • Reduced interest in playing, going for walks, or interacting with other pets and/or people
  • Hypervigilance (an intense, “on guard” awareness of surroundings)
  • Tendency to be easily startled
  • Urinating or defecating inside (when previously housebroken)
  • Increased neediness or attachment
  • Unprovoked whining or crying
  • Excessive barking or meowing
  • Destructive behavior
  • Extreme escape behavior to avoid a stressor (such as chewing through drywall to attempt to flee during a thunderstorm)
  • Sudden changes in temperament
  • Hiding for no reason
  • Excessive panting
  • Pacing
  • Fear of being alone
  • Sleep disturbances
  • Avoidance of people, places, or things associated with a traumatic event

Once I decided Tatum was suffering from PTSD, I changed everything I was doing.  The first thing I did was set up cardboard boxes all over the house.  She investigated all of them.  She would jump in a tall one and scratch frantically at the bottom.  Eventually I realized she was digging to try to get to her lost litter mates.  She made friends with a neighborhood cat that the neighbors could no longer keep and now lives with us.  The older cat helped Tatum go outside, calm down when there was a noise, and learn to tollerate being around another animal.  

I started taking her outside in the backyard.  It took months to get her comfortable to go outside.  Initially she could tolerate 30 seconds.  Now she can stay out for an hour or more.  

I stopped all the medication.  It was doing nothing.  I stopped the special diet.  It was doing nothing.  The face ripping lessened.  If she gets stressed she rips her face or ears open and it heals in a day or so.  She'll use the cardboard boxes if she's stressed, or hide on top of the kitchen cabinets.  When not stressed she purrs, and cuddles.  I have a predictable schedule.  She has a predictable routine.  Anything out of the ordinary and she starts ripping her ears or her face.  Those events are infrequent now.

The students will ask what made her get crazy.   And I explain that her world was a very scary place when she was a kitten.  She was with her litter mates then suddenly put in a cardboard box in a noisy parking lot and separated from them and her mother.  She was moved from one house to another.  She had lots of painful and annoying medical treatments.  Things changed constantly.  She went to a noisy rescue with lots of other cats and was terrified.  The only thing that seemed to stay the same was her food because she was put on a special diet.  So the rescue thought that was what helped.

The same thing happens in people.  They get in situations that are frightening, unpredictable and out of their control. They can't self-soothe. They revisit the trauma over and over trying to master it.  We have good treatment for people with trauma.  But trauma is exceptionally common in rescued pets.  The story helps the students understand a bit better.





The Zika Virus Probable Complications

Posted by Margaret Donohue on February 2, 2016 at 10:35 PM Comments comments (0)

The new information on the Zika virus is that there is a confirmed case of sexual transmission of the virus in Texas.  This means that anyone, male or female, traveling to an area where the virus is epidemic, or anyone who has flu like symptoms following being bitten by a mosquito should:

  1. Not donate blood.
  2. Not engage in sexual activity without using a condom.
  3. Be closely monitored if you or your partner become pregnant following symptom development.  An ultrasound at 20 weeks to check head size for microcephaly may be indicated.

It would be appropriate to ask the CDC to do something to protect the blood supply.

It would also be important to identify anyone that has tested positive for the Zika virus and develop a data base to evaluate long term sequela.  Zika is a virus that can be expected to produce long term complications following infection.  For many people this may simply be arthritis and may be quite mild.  However, given the affinity of this virus for nerve cells in fetuses causing microcephaly, it would not be a stretch to expect that it may produce complications in nerve cells in adults.  

Possible complications:

  1. Arthritis.  This has already been found in people with the virus.
  2. Neuropathy, that sensation of pins and needles people experience when their arm or leg falls asleep.  
  3. Multiple sclerosis like symptoms from changes in nerve cells.
  4. Guillain-Barre syndrome, an ascending slow paralysis or weakness already associated with the virus.
  5. Muscle pain and weakness, already associated with the virus.
  6. Since the virus and vector are similar to Dengue fever, hemorrhage, thrombocytopenia, or other blood disorders may also be complications. 

The Zika Virus

Posted by Margaret Donohue on January 27, 2016 at 9:25 AM Comments comments (0)

For most people the Zika virus is a mild case of flu like symptoms if they notice anything at all.  For others, like pregnant women it can result in their children having abnormally small heads and brains, known as microcephally.  For others it may produce joint pain, or progressive symptoms of paralysis known as guillain barre syndrome.  Fever, rash and runny eyes are common. 


Zika virus is a viral infection of the blood carried by mosquitos.  Aedes aegypti, the mosquito that carries the virus, lives in tropical and subtropical areas throughout the world.  The mosquito strain is in the United States but their aren't enough infected people living in the United States to serve as hosts.   It originated in Uganda Africa and was found in a rhesus monkey in 1947. In 2013 it caused significant human outbreaks in French Polynesia.   It is likely also able to be sexually transmitted.  I say likely because blood borne viruses are usually also sexually transmitted and the virus has been isolated in semen.  The disease is most prevalent in South America, but it's also present in other countries.  If it's not already in the United States, it will likely be here soon.  There is no cure.  Prevention measures are to avoid pregnancy in countries where the infection is in epidemic proportions and to avoid mosquitos.  Treatment with antiviral medications have limited impact.  Several pharmaceutical companies are working on a treatment or preventative medication.


In the meantime, if you can avoid traveling to tropical areas, especially if you are pregnant, then do that.  Preventative treatment will likely be available within the next 2 to 5 years.  


If you ever have any questions about illness, disability or clinical trials, feel free to contact me.  818-389-8384.