Health and Psychology

Psychological Assessments

The first question I ask people when they call for a psychological or neuropsychological assessment is “Who is the report going to go to?” The reason I ask this is that there are a variety of types of assessment and the purpose of the report will determine what the requirements of the assessment are.

For example:

A report will go to the patient because they want to know if they have a specific condition or not. This may not even entail an assessment. It may just need a good history.

A physician may want an evaluation to ensure the person meets criteria for a diagnosis in order to prescribe. There may be an issue about medical necessity for testing in this case. In most cases a physician can prescribe without a psychological evaluation being required.

A person may want accommodations for a test or for school. This is a substantial evaluation that must meet the criteria set forth by the laws regulating school accommodations, or test accommodations under ADA law.

A person may have seen several mental health providers and there is a question about diagnosis for treatment purposes. This may require a psychological evaluation.

Knowing who will receive the report will help me determine what types of testing are required.

The Omicron Variant of Covid-19 was reported November 11, 2021 in South Africa. It has spread across the globe to multiple countries. It was labeled a variant of concern by the World Health Organization a couple of days ago due to changes in the spike protein that is targeted by the vaccines.

This variant is likely transmitted by droplet, so distance measures and mask wearing are likely to be effective. Because of the mutations in the virus thus far (there are millions of mutations, most are insignificant) there are likely to have mutations that are more or less transmissable and more or less lethal. This appears to be more transmissable. There are questions about illness severity that have not been answered yet.

The governments of several countries are closing their borders to countries with reported cases. This has been described in scientific circles as putting up a picket fence to stop mosquitoes. It's unlikely to work, and because the US doesn't do much genetic sequencing, the virus mutatioon is likely already here. Wear a mask. Stay away from other people as much as possible. I've turned down meeting with friends and relatives over the holidays. We can always meet by zoom or facetime.

If you haven't been vaccinated go get vaccinated. The technology has been around for decades and isn't new. You will likely need additional shots as the virus mutates and the vaccines lose potency over time. It will take 3-4 months for companies to gear up for a new vaccine to hit a different spike protein, but with mRNA, that's very quick.

The coronavirus COVID-19 is showing a propensity towards neurological symptoms.  This is similar to other coronaviruses that infect people.  There are 7 corona viruses that infect people. 

• 229E
• NL63
• OC43
• HKU1
• MERS-CoV
• SARS-CoV
• SARS-CoV-2

The novel Coronavirus now known as COVID-19 started in Wuhan in the provence of Hubei, China.  This is a slow onset, significantly contageous illness, believed to originate from bats and perhaps pangolins and morphed to infect humans.  It is fatal about 10% of the time.  at this time there are more than 100000 cases in the United States and 1,000,000 worldwide.

Contagious illnesses are referred to by the letter R and a subscript.  COVID-19 has between an R 2.5 and an R 4.2.  influenza A or B has an R 1.4 to 2.8.  The common seasonal flu kills 70,000 unvaccinated, older or infirm people annually.  Each infected person infects two others on average.  COVID-19 has no determined treatment or vaccine and each infected person can infect 3 people on average.  The main difference is the latency of onset of COVID-19 and the fact that it can kill otherwise healthy people.

In the United States the rate of infection has been limited to an R of just 1.  That is due to the quarantine and screening and isolation procedures.

It is unlikely COVID-19 will stop and disappear with seasonal changes.  The possible transmission routes of airborne, droplet, fomite (surfaces), and bodily waste combined with a long viral life of up to 14 days, make it likely to be around seasonally, or transmitted through other vectors besides humans.  It is far more likely that the infection will mutate and eventually become less fatal over time. 

The best defense against the virus is to be as healthy as you can be.  Get a seasonal flu shot for some antiviral protection. Stay home from work when you are sick.  Wash your hands and avoid touching your face.  in the United States, unless you've had direct contact with an infected person, you are unlikely to contract the illness and more likely to get the flu.

The vast majority of neuropsychologists publishing research on brain injury in the United States appear to have some connection to insurance companies.  So the research they tend to publish minimizes the impact of repetitive brain injury, the apparent delay in symptom onset from time of injury, the impact of whiplash without loss of consciousness and correlation to brain injury.  What they focus on is estimates of effort and use a population of individuals simulating brain injury in college students as a "deceptive group."  This creates incorrect data about brain injuries that are then believed by physicians, neurologists, neuropsychologists, and psychologists in general.

MYTHS:

1. Brain injuries completely recover in a few days to a few months.  All brain injuries such as concussion completely resolve in 6 months.

2. Low impact crashes with whiplash only do not result in concussion or brain injury.

3. People complaining of ongoing symptoms are either faking, exaggerating, have a mental illness, or something else is wrong besides their brain injury.

4. Neuropsychological testing for brain injury requires multiple measures of malingering, effort and attempts to fabricate their presentation.

FACTS:

1. A lot of brain injuries with mild concussion completely recover with no residual symptoms, but about 20% have ongoing symptoms.

2. Following an injury or accident symptoms can occur as long as 96 hours post accident or injury.

3. Neuropsychological testing is expensive.  The use of testing time to document exaggeration or effort is better spent looking at functional ability and limitations.  The testing should match the symptoms, and be consistent with the history and medical records.  If the testing doesn't match the history THEN do testig for malingering and effort.

4. Brain injuries cause psychological difficulties.  In addition if someone has pre-existing depression, anxiety, or other symptoms of mental illness the brain injury will complicate coping and response to treatment.

5. A very small percentage of people that have sustained a brain injury will go on to develop a malignant leision in that area of the brain or an autoimmune disorder.  We are currently researching that population.  If you or a family member has developed an autoimmune disorder or any form of brain cancer after a traumatic brain disorder or concussion, I'm interested in hearing from you.  Please drop me an email Donohuema1@me.com.

There are two types of doctoral degrees in psychology.  A Doctor of Philosophy (PhD) and a Doctor of Psychology (PsyD). The first degree is heavily involved in training in the scientist practitioner model and focuses on research, statistics, and evaluation.  The second is applied psychology with a focus on training, experience, and applications of psychological theory.

I have a PhD.  I am a researcher.  I value research. And I like good research.  Good research enlightens and moves the field into newer areas. It can be replicated.  It actually seeks to know new information.  The best research is published in peer reviewed journals.  It looks at research scientifically.  Poor research sets the field back.  It pushes future research into attempts to replicate the research multiple times and not being able to do so.  Poor research has an agenda.  It's not designed for scientific inquiry but to prove a point.  Poor research can also be research that can't get published in scientific journals but gets published as articles in pop magazines. 

Individuals with a PsyD also do research but they tend to look at the experiences people are having.  Not just data but what people think about their experience.

We've discovered men and women are different yet again.  This is true for cardiac presentation, learning issues, and most recently autism spectrum disorders.The ccommonly perceived presentation of boys that may also be intellectually disabled, that are non-verbal, socially inept, don't make eye contact, spinning in circles and flapping their hands is a misleading stereotype.  It has been popularized in books, television and movies, is wrong for most autistic females.

More and more women are realizing they have intensely focused passions, repetitive behaviors and perhaps some issues with language that also fall within the spectrum.  But they are also social, verbal, make eye contact, and seek out people to have as friends.  The small percentage that are intellectually challanged, is outweighted by those that aren't. 

Further, autistic people are speaking out about the therapies that diminish them and force them to interact in ways that run counter to their own mental health needs.  And they don't use politically correct "people first" language. 

I'm reluctant to diagnose autism in individuals with other known genetic disorders.  But some psychologists aren't as reluctant.  So if someone is positive on a major test for autism such as an Autism Diagnostic Observational Schedule, or an Autism Diagnostic Interview, or a self-report such as the Ritvo Autism Asperger Diagnostic Scale or other similar screening instruments they may have autism, but if they are female they are less likely to be diagnosed with the condition.

It's also important to point out that individuals with autism may cope just fine when not in neurotypical environments.  They are normal autistic people not abnormal neurotypical people.

There's a wonderful meme circulating from Autistic not weird.com:

"I'm autistic, which means everyone around me has a disorder that makes them say things they don't mean, not care about structure, fail to hyperfocus on singular important topics,have unreliable memories, drop weird hints and creepily stare into my eyeballs."

"So why do people say that YOU'RE the weird one?"

"Because there's more of them than me."

If you need help with a diagnosis feel free to contact our office 818-389-8384. Or email at DonohueMA1@me.com.

I want to let you know about the Sleep Help institute.  They have a lot of information on sleep, resources, medical conditions and sleep.

www.Sleephelp.org/sleep-deprivation  has articles about sleep deprivation.

www.Sleephelp.org/autism-asd Sleep and autism Spectrum Disorders. 

Here's a link to their full collection of resources:

www.sleephelp.org

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.

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.