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 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.

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.

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.

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.

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.

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. 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.