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Use of Medication

Posted by Margaret Donohue on December 24, 2012 at 10:40 AM Comments comments (0)

A friend of mine went to a psychiatrist recently to look into getting medication for his depression and was surprised when the psychiatrist referred him to therapy instead.  "Medication for mild to moderate depression, just isn't that helpful, but therapy is far more effective."  


That's true, for the most part.  It depends on the type of therapy being offered.  It also depends on making sure the actual diagnosis is depression.  Supportive psychotherapy, where a therapist is listening but doing virtually nothing besides that isn't very helpful.  So if you are having therapy and the treatment doesn't seem much different from what you would be doing if you were seeing a barber or hairstylist and they casually talked with you about your life, then it's not really therapy.  It's support.  There are several types of therapy that are effective and have good evidence to support the fact that they are effective.  This includes some short term dynamic psychotherapies, cognitive behavioral therapy, acceptance and commitment therapy, mindfulness therapy, and brief behavioral therapy. Medication may help with severe depression, and may be needed with moderate depression in addition to therapy.


I often see people who report depressive symptoms but also report other symptoms which suggest a medical illness.  The most common medical illness that causes depressive symptoms is long term untreated infection.  This often presents as very severe chronic abdominal pain in addition to depressed mood.  Endocrine disorders can also cause symptoms associated with depression such as difficulty sleeping, weight problems and fatigue.  Darkening of the skin around the neck, also known as Acanthosis nigricans, is a symptom of endocrine disorders and needs to be evaluated by an appropriate medical specialist.  Swelling of the fingers and ankles, or erectile dysfunction in men needs to be referred to a cardiologist because those types of symptoms may be associated with cadiac problems and those can cause symptoms of depression as well.


I routinely refer clients for medication with any conditions that have a genetic, neurological or a medical basis to them.  These are conditions where medication is often not only useful but required for symptom relief.  These include conditions like attention deficit disorder, bipolar disorder, and psychotic disorders.  In some cases, behavior problems are so severe that a short term course of medication to get symptoms under control may be needed.  This includes some personality disorders.  In some of the cases of personality disorders medication may be required for long term stability.  Differential diagnosis by psychological testing can help to determine a diagnosis when multiple conditions may be present.  Screening questionnaires are relatively inexpensive, and can refine and clarify diagnostic symptoms.  


In some cases a history is all that is required.  I met a man indicating he had panic attacks.  His symptoms of panic attacks were that he had temper tantrums where he yelled and threw things.  This isn't a panic attack.  This is a behavior problem and can easily be treated with behavior therapy.  I met another man who thought he had schizophrenia because following being shot at gunpoint he kept reliving the incident as if it was occuring again.  This isn't schizophrenia. This is a description of post-traumatic stress disorder and can be treated with psychotherapy.  Simple rating scales and checklists can differentiate these kinds of conditions.  More formal psychological testing may be needed to assess types of psychotic disorders, types of attention disorders or executive dysfunctions, and differentiate conditions like bipolar disorder from behavior disorders or personality disorders.  Some people confuse sleep disturbances with hallucinations.  One is a dream state, which can occur even if the person is awake, the other is a sensory disturbance.


If you have a question about your diagnosis please feel free to call our office for an assessment.



Misdiagnosis of ADD

Posted by Margaret Donohue on June 24, 2012 at 11:40 PM Comments comments (0)

In the past week a colleague of mine and I have seen about 6 children that appear to have been misdiagnosed with attention deficit disorder or attention deficit hyperactivity disorder.  The children had a few things in common.  They were all reportedly diagnosed by their elementary or preschool teachers and referred to their primary care physicians for medication.  They all live in an underserved community and were all boys.


The hallmark of Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder (also known as ADD or ADHD) is difficulty with sustained attention and concentration.  It may include impulsivity or hyperactivity.  It isd a diagnosis of exclusion of other conditions.  The gold standard for diagnosis is a continuous performance test.  This is a computer based test that measures response time in miliseconds.  The test is either auditory or visual or both and is long and boring making it easy to lose focus.  The test is administered by a psychologist or neuropsychologist that has training in diagnosis and testing.  Cognitive testing can show difficulties in working memory and will allow for some other difficulties to be ruled out like depression, anxity and learning disorders.  Teacher and parent questionnaires can also assist in the diagnosis but only after a careful history to exclude other conditions is done.


So let me talk about the children that were misdiagnosed.  The first was a young boy that was hit by a car a couple of years ago.  He had blank staring episodes, bed wetting and repetitive movements in addition to inattention.  It's likely he's having absence seizures.  He was given a referral to neurology.


The second is a child with a chronic medical condition.  The medication causes difficulty paying attention, and unusual changes in mood and behavior.  He was referred back to his physician for a medication reevaluation.


The third child had a relative die recently.  He is clinically depressed.  The whole family is having difficulty coping.  He isn't sleeping and has lost weight and has crying spells.  Yes he can't pay attention, but his problem is due to grief and depression.


The fourth child is highly anxious.  Hyperactivity and inattention help to manage the constant worries and nerousness the child has about catastrophic thoughts.  Therapy to lessen anxiety is likely to help.


The fifth child has been removed from his family home due to child abuse.  He is in foster care.  He has nightmares and flashbacks of very violent events to himself and others in his family.  He is threatening to hurt other children periodiclly.  His inattention is due to physical and psychological trauma.


The sixth child is hyperactive and inattentive when he's at school doing reading out loud.  He has a significant learning disability that hasn't been assessed.  When he gets out of his seat he gets sent to a different classroom and doesn't have to read out loud.  Once he gets into a specialized educational program and his reading disorder is addressed, he will likely improve.


Psychologists and neuropsychologists can perform specific tests that allow for other conditions to be ruled out and can assess the impact of medication on symptoms and test performance.  Elementary and preschool teachers are not able to provide a definitive diagnosis of an attentional problem, nor are primary care physicians.  A diagnosis by medication trial can incorrectly classify a child and fail to deal with an underlying condition that may need treatment.

Neuroplasticity

Posted by Margaret Donohue on June 17, 2011 at 9:40 AM Comments comments (0)

The new box came in the mail.  It's a treatment program for dyslexia based on neuroplasticity theories.  The day I got it, a client called telling me they wanted an assessment because they are "hopelessly dyslexic." It was the second person to use that term this month.  I don't think of anyone as "hopelessly" anything.


I didn't get the program for a specific client, although I think many of my clients would benefit from it. I got it for me, because one of the things it does is to target spelling as well as reading and I suck at spelling.  Maybe for my brother-Chuck who has problems reading.  Maybe for my niece who has multiple strategies to avoid reading. I know a lot of people that struggle with learning disorders.


Most people that have dyslexia give up or struggle with reading.  Most people that can't spell give up, and rely on spell checkers, dictionaries, or hire assistants to edit and proof read.  Most people that have dyscalculia give up or rely on calculators. 


When my spelling problems, speech difficulties  as well as coordination problems surfaced in elementary school, I got assigned to special classes.  Only the speech problems were effectively treated.  The spelling problems remained.  I know I have difficulty with spelling (and had problems speaking) due to hearing loss as a result of ear infections in infancy.  The coordination problems are due to a genetic disorder that didn't get diagnosed until I was in my 40's.


So I opened the box and put one of the first CD's in my computer and set up the two earpieces so my right and left ears would have different inputs and started on one of the exercises.  Not the first one.  About part way into the series.  Just to see what it was like.  In less than 5 minutes I could tell the difference between when to use the letter c or the letter k to spell words with the K sound in them...like cat.


Let me explain the significance.  I gave the commencement address when I graduated from the California School of Professional Psychology in Los Angeles in 1983.  I explained to the audience that I had expected when I graduated to become smart and to know how to spell because I spelled so badly that cat could just as easily have been written by me as katt.  So in a matter of 5 minutes after opening a new box and reading literally two pages of material I now know that if the letter after that k sound is an e, i, or y, I use a k and for everything else I use a c. 


Almost 30 years later. I suspect that within a few weeks I'll be smart.



"Why can't they find anything?"

Posted by Margaret Donohue on April 1, 2011 at 12:14 AM Comments comments (0)

This question was raised at the Health Psychology group I belong to.  The situations were a bit different but the questions remained. 

  • "I referred a patient out for a dementia work up and they said he was normal." 
  • "I referred a head trauma patient out for an evaluation and the test came back anxious, not head injured."
  • "I referred a patient out for a medical evaluation.  They said the symptoms were all in her head, not real."

Several of us.  We're in our 50's and 60's.  In clinical practice for 30 to 40 years.  So we see things differently.  What we see is clinical medicine.  It's based on experience and nuance.  So when we send someone out for an evaluation we expect the same kind of evaluation we have already done.  We're expecting confirmation of our clinical experience.

  • The dementia case was diagnosed as dementia.  It took 3 years.
  • The head trauma case was diagnosed with a brain injury.  It took 4 months.
  • The patient had end stage cancer by the time she was diagnosed.  She died a year later.

And we feel guilty, because we knew.  We knew.  We knew.

So what do we do to improve things?  We teach.  We mentor.  We supervise. 

Some of the problems are the tests.  We were trained on old tests designed to help localize problems to the cortex.  The Halsted-Reitan Neuropsychological Test Battery, The Luria Nebraska Neuropsychological Test Battery, The Boston Neuropsychological Test Battery.  Younger neuropsychologists are less likely to use the old measures calling them "out of date," "old fashioned," or "archaic."  The Luria Nebraska isn't even being sold any more.  Neither are parts of the Boston Neuropsychological Battery.  They aren't profitable.  Too few people are trained on their use.  They are expensive.

Pathognomic findings.  The signs and symptoms of disease that lends to diagnosis.  We know these. 

  • Lower than expected speech, language and memory given occupation and educational history.
  • Signs of bilateral injury to the brain with sensorimotor impairment, executive dysfunction and occipital impairment suggestive of impact to the skull with blunt force.
  • Chronic pain, fatigue, abdominal bloating, weight loss.  Excess caffiene use not stopping the fatigue.

So we refer.  The patient gets a brief consultation.  A minimal review.  A standard evaluation.  And the pathognomic symptoms get missed. 

So I write consultations and talk to the patients and I'll go to their appointments with them if I have to and they want me to.  And after all that if things still get missed then at least I know I've done what I could. 

In talking with my colleagues yesterday I found out we're all doing this.  And we're all doing it for the same reason.  Because just missing one case, one diagnosis, is one case too many.



Testing in Neuropsychology

Posted by Margaret Donohue on February 23, 2011 at 9:54 AM Comments comments (0)

What's the difference between testing in neuropsychology and psychology?

I met a psychologist who does psychological testing that includes some neuropsychological instruments.  I've also met neuropsychologists who are primarily using psychological tests as neuropsychological instruments.  So here's the difference.  A neuropsychologist can relate brain functioning to testing. 

A standard psychological test is the Wechsler Adult Intelligence Scale (WAIS).  It's part of the Wechsler series of testing, which includes memory (Wechsler Memory Scales) and achievement (Wechsler Individual Achievement Test) in addition to intellectual processes.  When administered, scored and interpreted by a psychologist, this test provides raw and scaled scores and index scores.  A variety of information is collected on Verbal Comprehension, Perceptual Reasoning, Working Memory, and Processing Speed.  Computerized reports can be generated that will provide between 10 to 20 pages of scientifically valid, empirically based data on all aspects of intellectual functioning.

When the same test is administered by a neuropsychologist in addition to all of the above data is information on how that all translates to brain functioning.  Using the exact same test I look at estimated functioning of cognition prior to how the individual is testing now.  I look for things that suggest brain damage specifically (pathognomic indicators).  I look to see if there are psychological factors that are noted in off-hand comments being made by the person I'm examining.  ("Oh I was never good at this kind of thing."  Or "I think this is hard, can anyone do this?" Or "I don't understand how to do this.")

I also notice things that tell me how someone thinks about the test and how their brain works.  Do they consistently ignore materials I place on their right or left side?  Do they have a systematic trial and error method of responding to the materials or are they making guesses?  If they miss items and recognize their limitations, do they get overwhelmed or shrug it off?  Do they notice errors at all or do they think what they did was correct?

Little things become important.  When using both hands are the movements symetrical or is one slower?  Is there a tremor when writing or even just holding a pencil?  Are they sitting upright or leaning to one side?  Do they tilt their head when working? Squint their eyes?  Does their coloring change?  Their respiration? Do they stop responding and seem to get lost then seem to return? 

Hundreds of little observations, perhaps thousands, in the course of an hour or so.  Even if I use a computer to score the data, I have to add all the observations that go into doing the testing.  Then I have to tie all those observations into brain function.

A graduate student of mine commented that she holds her pencil between her thumb and third finger "because it's more comfortable."  She's taken a WAIS as part of her training.  But now she's learning neuropsychology.  So the class talked about cortical functioning of fine motor skills and the distinction between pencil grip, hand coordination, fingering of small items, handedness, and gross motor skills of arm movement, fluidity of hand motion, the distinction between nerves coming from the spinal cord along the hands and arms and the movements generated in the brain down those same brain pathways.  As we talked and evaluated the student and class came to realize how much brain was involved in that single comment. That little "just feels more comfortable" grip of a pencil.  There was some gross motor involvement, memory involvement, directional sense, and sensory experiences. 

Tying all those together and testing the theories of brain functioning to show how they all relate, differentiates a neuropsychologist from a psychologist.  Even when neuropsychologists and psychologists do the exact same tests in the exact same way we get different data.

Brain Injury Due to High Speed Impact

Posted by Margaret Donohue on February 14, 2011 at 10:36 AM Comments comments (0)

Today I get to do one of my favorite exercises with my class.  I downloaded actual accident reports from the internet on train, airplane crashes with diagrams or photos and car accident simulation diagrams for the class.  Then we get to talk about the physics of brain injury, the use of restraints to mitigate injury, and the complexity of orthopaedic injuries and soft tissue injuries compounding brain injuries.


So here's what the class gets to find out:

  • The faster a person is traveling at the moment of impact the more likely the brain injury will be greater than the same type of injury at a slower speed
  • Fatal injuries often have to do with orthopaedic injuries such as broken necks, or hemmorhage and blood loss
  • Oxygen loss to the brain produces adverse consequences such as heart attack and stroke
  • Damage to the brain can occur hours after impact due to swelling and other complications
  • Endocrine complications can produce significant impact on the progress and outcome of TBI rehabilitation
  • Endocrine complications are more common with facial fractures
  • The risk of post-concussive seiures following traumatic brain injury persists for about 1.5 to 2 years following the injury

Things are much more complicated in children than in adults. 


In a recent study in Sweden at the Neurointensive Care Unit at Lund University Hospital between 2002 and 2007. One hundred children were evaluated following traumatic head injury Results: During 6 years, 100 children with head injury needed neurointensive care or neurosurgery for their injury in southern Sweden.


Traffic accidents (50%) were the main cause of head trauma, followed by falls (36%). Thirty-two percent of all children were injured in bicycle and motorcycle accidents. Both loss of consciousness and amnesia were absent in 23% of the children with intracranial injury.


Seven children with intracranial injury, 6 of them requiring neurosurgery, were classed as having minimal head injury according to the Head Injury Severity Scale (HISS). Interesting differences in intracranial injuries between helmet users and nonusers were observed.


Conclusion: Children with minimal head injuries according to the Head Injury Severity Scale--HISS, may develop intracranial complications and may even require neurosurgical intervention. Hence, the HISS classification, as well as other risk classifications based upon unconsciousness and amnesia, are unreliable in children.

Complications of brain injury

Posted by Margaret Donohue on January 23, 2011 at 10:32 AM Comments comments (0)

Minor brain injury can result in long term complications.  The average healthy adult can anticipate recovery from a minor brain injury in 3 to 6 months.  Some people with minor brain injuries are not healthy premorbidly and some people have had more than one brain injury.  This leads to more complications that can occur over a longer period of time.


Head trauma sets in motion a complex neurochemical and physiological reaction.  The range of physiological processes can be more damaging than the initial injury itself.  There's a window of time in which the brain can have bleeding and swelling following a head injury.  There can be a massive release of neurotransmitters designed to help the brain manage to start to repair itself.  Glucose and blood pressure can elevate, resulting in problems with increased potential for heart attack, stroke, or the development of hormone difficulties with diabetes, thyroid and other endocrine problems noted.  Personality, mood, sleep and appetite can all be disregulated.  Patients can note problems with anxiety, depression, and transient paranoia, and manic states all have been reported.  Post traumatic stress disorder can occur even in individuals with post-traumatic amnesia.


Of more recent concern are longer term sequelae of injury.  There appears to be increased risk of death from all causes in the first several years post injury.  As people age, people with prior minor head injuries may have increased risk of developing alzeheimer's disease or other forms of dementia, autoimmune disorders also appear to increase in this population.


It's important that all treating physicians know that a patient has had a head injury because adjustments to medications may be required.


The best thing to do following even a minor head injury is to have an assessment by a neuropsychologist to evaluate the person's functioning and to establish a baseline so progress and course of recovery can be assessed.

Neuropsychological Assessment

Posted by Margaret Donohue on January 21, 2011 at 9:38 AM Comments comments (0)

Neuropsychological assessment involves an evaluation of the cortex of the brain through psychological and neuropsychologial tests and measures to gain an understanding of how a person is functioning in a variety of areas.  These areas include evaluation of:

  • Executive functioning, including planning and organization
  • Language and speech functioning
  • Visual functioning
  • Sensory awareness
  • Motor functioning
  • Concept formation
  • Academic Skills
  • Attention and concentration
  • Personality and Mood
  • Memory functioning
  • Speed of processing
  • Behavior and habits

Evaluation is especially important to determine:

  • a correct diagnosis
  • a treatment plan
  • location of specific deficits
  • needs for special accommodations at school or work or for exams
  • a prognosis
  • a rehabilitation plan

Individuals that may benefit from a neuropsychological evaluation include individuals with suspected:

  • Attention Deficit Disorder
  • Learning Disorders
  • Exposure to toxic substances
  • Brain injury
  • Closed head trauma
  • Brain tumors
  • Strokes
  • Degenerative disorders (Huntington's Disease, Dementia with Lewy Bodies, Parkinson's Disease, etc.)
  • Psychiatric disorders
  • Medical conditions with neurological symptoms (Migraines, kidney, endocrine and liver disease)
  • Seizures
  • Genetic disorders (Turner Syndrome, Williams Syndrome)

All evaluations are conducted by a licensed psychologist specializing in neuropsychology at our offices.

30 Neuropsychology applications for the iPad

Posted by Margaret Donohue on January 5, 2011 at 11:52 AM Comments comments (1)

I love my iPad.  I use the medical applications in my work frequently and other professionals often ask what I've recently downloaded.  So here are my most frequently used medical applications:


1.  MedPage

2. NEJM

3. Medical News

4. HD brain

5. ICD 9 Consult

6. Universal DrSpeaker

7. TinnitusTrainer

8. 3D Brain

9. NeuroSuite

10. EMSG (Medical Spanish)

11. HDSystemEndocrine

12. WebMD

13. Epocrates

14. HealthCalc XL

15. BloodPressure

16. Lose It!

17. Psych Drugs

18. DSM-IV Codes

19. Psych Notes

20. NeuroMind

21. Radiopaedia

22. MicroMedex

23. Epicurious

24. GoMeals

25. Remote Desktop

26. ReachMD Medical Radio

27. Mind Grid (Memory games)

28. Matches (Memory games)

29. Skyscape

30. Intelecare


Disclaimer:  Most of these applications are free, some are paid.  Some will not apply to neuropsychologists without a medicine background.  Many of these will not apply to physicians without a psychology background.  All have good descriptions in the iTunes apps store.  Read the description before you download the application to see if it will apply to your practice.

Brain Injuries

Posted by Margaret Donohue on October 1, 2010 at 10:50 AM Comments comments (0)

There's a very inspiring article in Lemondrop about Jenna Phillips, a personal trainer in Los Angeles.  She had a head injury in 2000.  The field of head injury evaluation and rehabilitation has improved substantially in understanding what happens in a head injury and what anticipated recovery should be. 


In the 1980's the vast majority of individual were told that concussion was "mild," that recovery would occur in weeks or months, and that any residual symptoms were more psychological than physical. 


In the 1990's begining research on neuroplasticity in the brain was changing the expected outcomes for stroke and spinal cord patients.  The concept that a concussion was a "brain injury" was starting to take hold.  The idea that recovery was completed in a few months was starting to be challenged.  Ideas about mid-brain injury and hormonal cascade from injury resulting in neuroendocrine difficulties such as late onset diabetes, thyroid, or other hormonal problems, and the impact of stress hormones leading to heart attack or stroke following head injury were showing up in research.


By 2005 ideas about neuroplasticity were incorporated into some mainstream treatment programs for head injury with focus on managing headaches, tinnitus, dystonias, and nerve injuries with neural feedback.  Head injury was considered brain injury and concussions were not discussed as "minor" except to document level of brain injury.  Monitoring for seizures for 18 months post injury, monitoring for neuroendocrine and neuro-opthamalogical disorders was occuring in some areas with trauma centers, and rehabilitation was focusing on long term recovery with estimates of brain improvement occuring for decades.


Today, technological advances in evaluation and rehabilitation allow for many more people to significantly improve their functioning following head injury.  While Jenna Phillips' story is inspiring, it is no longer unique and represents what is expected for the type of injury she had.  Evaluation and treatment is essential in helping people to recover.