Fred Ovsiew, MD

Neuropsychiatry is thriving, and the articles in this 

 demonstrate its breadth and depth while providing the opportunity to characterize and delimit its scope.

Neuropsychiatry-now with a credential it shares with behavioral neurology (

)-is the subspecialty of psychiatry devoted to understanding the mental and behavioral consequences of brain diseases and to providing care for persons with these diseases. That this care often critically depends on psychological and environmental management, rather than on altering the brain itself, testifies to the intractability of many brain diseases and to the need for neuropsychiatry to remember its psychiatric roots. Being a neuropsychiatrist does not mean a one-sided commitment to organic explanations or treatments of behavior disorders.

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, offers a perspective from neuroscience on a core problem of clinical general psychiatry. To what extent neuropsychiatry, as defined above, provides help in understanding the phenomena of general psychiatric illness is uncertain. On the one hand, the momentum of general psychiatry for many years has been toward a biological take on schizophrenia, affective disorders, and other psychiatric illnesses. The neuropsychiatric knowledge gained from analyzing the relation of known brain lesions to clinical symptoms naturally seems highly relevant to the neuroscientific understanding of psychiatric symptoms. On the other hand, similarity in clinical phenomena offers no guarantee of similarity in underlying mechanisms. Indeed, the mechanism of symptom production in acquired brain disease-the core of the neuropsychiatric enterprise-may be quite different from the mechanism operating in idiopathic disorders that develop over the life span and depend, presumably to a greater degree, on genetic factors.

Transcranial Magnetic Stimulation in Neuropsychiatry: An Update

,” by Jonathan Hsu and Dr Daniel M. Blumberger, addresses one of many fascinating aspects of this new technology. The capacity of transcranial magnetic stimulation (TMS) to produce temporary functional lesions means that it has potential as a tool to understand brain function. Its potential as a treatment for depression is being actively investigated. The potential of TMS as a treatment for cognitive disorders, fatigue, pain, and other manifestations of brain disease is discussed, as is the encouraging prospect for neuropsychiatric management of many patients.

Drs Jason Brandt and Antonio N. Puente address, so to speak, the inverse of neuropsychiatry in their article “

Update on Psychogenic Nonepileptic Seizures

.” There is precisely no organic basis to the spells, sometimes called pseudoseizures, that are the focus of treatment, even though these spells mimic a cardinal manifestation of brain disease. Why then is the problem of pseudoseizures so important to neuropsychiatrists? Because, we believe, the clinician trained to understand the manifestations of epilepsy and experienced in the variability and oddness of such manifestations is particularly well suited to provide psychiatric care to patients with nonepileptic seizures.

Management of Mild Traumatic Brain Injury

,” by Drs Adam M. Willis, Jon P. Williams, John H. Sladky, and Jeffrey C. McClean, the most centrally neuropsychiatric article in this Special Report, addresses the nature and consequences of traumatic brain injury (TBI). TBI, especially mild TBI, is common and is a risk factor for many psychiatric syndromes. Psychiatrists are often called on to treat the consequences of TBI, sometimes without fully realizing that they are doing so.

The articles in this Special Report show, each from a different angle, the excitement, way of thinking, and progress of the field of neuropsychiatry.

Articles

Neuropsychiatry is thriving, and the articles in this Special Report demonstrate its breadth and depth while providing the opportunity to characterize and delimit its scope.

Introduction: Neuropsychiatry Is Thriving

“Good psychiatry begins with a responsible Doctor undressing the patient and carrying out a proper physical examination.”
-Pediatrician and psychoanalyst Donald Winnicott (quoted by Issroff

In one of his inimitable essays, Richard Asher tells of a patient whose retinitis pigmentosa was diagnosed by an ophthalmologist. The ophthalmologist's report concluded that the findings suggested the Laurence-Moon-Biedl syndrome. Was there, the ophthalmologist asked, any evidence of polydactyly? Asher comments bitingly that surely this is specialization run amok--can an eye doctor not count the patient's fingers?

Asher-among whose accomplishments were the description and naming of Munchausen syndrome-was an internist who specialized in psychological medicine. Behind his complaint was the assumption that we are all physicians first, specialists only afterward: “A good doctor should be a jack-of-all-trades and master of one.”

 The evaluation of the mental patient, from his perspective, was first the job of a physician. Should a physical examination be part of that job description?

Psychiatrists specialize in mental phenomena, but this special expertise does not confer license to ignore the additional information that can be gathered from physical signs. For example, delirium is well characterized in its psychological dimensions by psychiatric diagnostic manuals

 Unmentioned in these references is the near-pathognomonic status of asterixis in identifying a toxicmetabolic encephalopathy. Why would one think that as a psychiatrist one has no need of the techniques that are useful, indeed necessary, for other specialists-or perhaps the question is, why would one attempt to make a diagnosis with one hand tied behind one's back?

Psychiatric patients commonly suffer from general medical conditions; often these conditions affect or even produce the mental disorder.

 In formulating the psychopathologic condition and identifying its cause, why would one want to forgo tools that generations of physicians have found useful in the diagnostic endeavor?

For several decades, commentators have pointed out that psychiatrists endorse physical examinations more often than they perform them.

 Those who omit performing a physical examination offer several reasons. Concern about the psychological impact of the physical contact or intrusion is prominent. Lack of appropriate facilities for physical examination and lack of sufficient skill are mentioned.

Of course, psychiatrists must be concerned about the meaning of the physical examination to the patient. Under certain circumstances, to refrain from performing a physical examination may be wise. For example, imagine a patient referred by a trusted oncologist colleague. The patient, with a recent diagnosis of cancer, has been through the mill of consultations, examinations, and invasive investigations. The referral letter from the oncologist indicates the lack of cerebral disease in the staging evaluation. The patient's mental state gives no hint of an organic mental disorder; rather, the patient seems to be worn out by the process of becoming a cancer patient and to want to talk with someone about it. Such a person might do best to talk with a psychotherapist, who is not doing any physical poking and prodding. At least this judgment is one a reasonable clinician might make.

It is hard to understand, however, why giving a prescription for psychiatric medicine is less intrusive than looking at the rash the medicine may have caused or measuring the blood pressure the medicine may have altered. Indeed, the psychological impact of the physical examination-especially when few encounters with a psychiatrist are for exploratory psychotherapy based on understanding of the transference-may help rather than interfere with treatment.

Establishing oneself as a physician in the eyes of the patient-with the skills, the prerogatives, and certainly the responsibilities and professional abstinence that being a physician entails-can facilitate rapport and move the treatment along. Looking at or touching the affected body parts in a physically ill patient can bring those aspects of the patient's experience into the conversation.

Obviously, lack of skill in performing the examination merits concern. Unfortunately, this reason for not performing the examination is a self-fulfilling prophecy; one's skills will not improve sitting on the shelf. No one can expect that the psychiatrist will be as expert a cardiac examiner as the cardiologist, as expert an examiner of peripheral nerves as the neurologist. However, the objection overstates the difficulty of the examination. To be sure, subtleties and rarities may escape the psychiatrist, but auscultation of the heart may disclose an irregular rhythm audible to any physician. Examination may discover that tendon jerks are absent in the lower extremities, a conspicuous clue.

Taking the process seriously and improving with practice may be part of the remedy for a self-perceived lack of skill. Further, the psychiatrist should have the advantage over other examiners of having hypotheses in mind as to the organic conditions needing consideration in the particular psychiatric setting. Nonetheless, competent psychiatrists will know the limits of their competence and continue, when indicated, to make referrals for general medical evaluation of their patients.

Unavailability of suitable facilities hamstrings many potential examiners; administrators of psychiatric clinics should be brought to task about this. However, a great deal can be done even with a fully dressed patient seated in a chair opposite an examiner equipped only with knowledge. For example, 

 suggests a few relevant steps to take if alcohol abuse is part of the clinical picture. Is this a comprehensive physical examination? No. Should one rest content after this screening assessment? No. But for what reason would one do nothing?

In my view, an undeclared reason for clinicians' discomfort is the failure of teachers of psychiatry to shape the key elements of the physical examination into a tool sharpened for psychiatric purposes. Statements in psychiatric textbooks such as “All patients presenting with 'psychiatric' symptoms require a careful and complete physical examination” do not go far enough.

No practical examination includes all possible elements; moreover, an examination should be undertaken with a set of hypotheses to be explored and confirmed or refuted. It goes without saying that any element of a comprehensive examination may, in a given patient, be informative or even crucial. However, just as other specialties home in on the elements of the comprehensive examination critical for diagnosis with their patients, so should psychiatrists be able to choose from among the tools in the toolbox those most relevant for psychiatric patients.

Psychiatrists may well use laboratory testing to screen for general medical illness, but ordering laboratory tests without guidance from the history and physical examination is widely and rightly deplored. Again, any element of the medical history is potentially pertinent in a given patient, but one cannot ask everyone about everything as a screening technique. In recent years, several clinicians have offered advice on focused history taking and psychiatric physical examinations. Sanders and Keshavan

 outlined an approach to the physical examination of the psychiatric patient, as did Garden.

 I also provided a review of physical diagnosis of the psychiatric patient.

The use of the physical examination as a diagnostic tool for the recognition of organic factors in mental disorders is not the only reason to concern oneself with physical diagnosis. As psychiatrists, we often see patients who lack the social skills and material resources to obtain adequate general medical care. Such patients have a substantial rate of significant general medical disorders.

 We need to ensure their access to proper care, not only by advocacy and social work measures but also by functioning as physicians, even if the disorders in question are incidental to the psychiatric illness (in the sense that they are not causing organic psychopathology).

Furthermore, we may make our patients sick with the medicines we prescribe. The current, justified concern over the metabolic effects of psychotropic drugs in itself should force reconsideration of the appropriate general medical role of the psychiatrist. The metabolic syndrome has had several definitions; its elements are listed in 

. Consensus guidelines for management of patients taking atypical antipsychotic agents now call for frequent measurement of weight, blood pressure, and waist circumference.

 How the implementation of such recommendations will affect the process of care in general psychiatry deserves thought.

 A practice set up to meet these needs might feature the psychiatrist in a rather different position from what is now customary.

Dr Ovsiew is professor of psychiatry at the University of Chicago, medical director of adult inpatient psychiatry and chief of clinical neuropsychiatry at the University of Chicago Hospitals; he is also president-elect of the American Neuropsychiatric Association. He has no conflicts to report regarding the subject matter of this article.

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Psychiatrists specialize in mental phenomena, but this special expertise does not confer license to ignore the additional information that can be gathered from physical signs.

Author | Fred Ovsiew, MD

Articles

Introduction: Neuropsychiatry Is Thriving

Should Psychiatrists Perform Physical Examinations?