James A. Bourgeois, OD, MD

FROM THE ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY

“Ms Zorn” was a 45-year-old woman with no previous psychiatric history who presented with a 2-month period of “feeling like I am losing myself” and seeing “visually distorted faces.” Faces of people she was looking at would appear to be hideously elongated, with the facial components distorted, as if it was melting. Cars would also appear to be more round than usual.

She was admitted to an inpatient psychiatry unit for unspecified psychosis, but after 2 days she was transferred to a general medical unit for additional medical evaluation. She was started on 25-mg quetiapine bid, which was titrated to 200 mg bid. Lumbar puncture was completed to rule out central nervous system infection or autoimmune encephalopathy, with results pending at the time of transfer to an academic medical center for higher level of multispecialty care.

On interview, she said that she felt like she was “losing” herself and reported visual distortions of “faces melting.” Ms Zorn was able to recognize faces and colors. She reported photophobia. She had headaches, which were relieved with ketorolac. Her husband reported that she had new onset of episodes of shaking her arms in a circular motion. She would also walk around the room in circular patterns while saying to herself that she was “lost.”

Ms Zorn had decreased appetite, weight loss, and decreased sleep. She denied depressed mood, decreased energy, mania, trauma, or previous problems with memory. She denied auditory hallucinations and suicidal/homicidal ideation. She denied a family history of suicide and psychiatric illness. Developmental history was unremarkable. She had no history of substance abuse.

On mental status examination, she was awake, alert, oriented to person, time, place, and situation. She continued to experience visual distortions of “faces melting.” Ms Zorn’s thought process was linear and coherent. Affect was mildly anxiously perplexed, non-labile, and non-tearful. Speech was normal. Insight and judgment were marginal. Her Montreal Cognitive Assessment (MoCA) score was 10/30. Her decisional capacity was impaired, and the screening neurological examination was non-focal.

Due to the atypical presentation of psychotic disorder, the full workup included a neurology consultation; brain MRI and lumbar puncture results were normal, except for autoimmune encephalitis results that were pending. Serum HIV, syphilis, vitamin B12, lead, rapid plasma regain (RPR), anti-nuclear antibody ammonia, and thyroid stimulating hormone (TSH) levels were normal; EEG was unremarkable. Pelvic ultrasound and CT were ordered to rule out ovarian teratoma. Quetiapine regimen was changed to 100 mg in the morning and 300 mg in the evening.

Ms Zorn was seen in follow-up on hospital day 2. Neurology had started her on 1-g methylprednisolone daily for a 5-day course for presumed 

. She was placed on a continuous EEG. On exam, she reported feeling better compared with the previous day. She no longer reported any distortions of faces or objects in the room, although she did report some “blue dots” in her field of view. She had 3 hours of sleep the previous night. Her husband noted that the she had decreased episodes of her aimless pattern of waving her arms in a circular motion. Her MoCA score was 14/30. Due to the significant improvement in her hallucinations following the first dose of methylprednisolone, the scheduled quetiapine was held.

When seen on hospital day 3, Ms Zorn said that she could fall asleep, but had trouble staying asleep. She had an episode where she got up and walked around the room purposelessly. Her MoCA score was 13/30 and decisional capacity was impaired. Quetiapine 50 mg post merdien (PM) was started to address poor sleep. On hospital day 4, she reported that her visual phenomena had returned, with her seeing “pixels” (flashing punctate lights) and “faces melting.” She had had difficulty sleeping. MoCA was 12/30 with continued limited insight, judgment, and 

. Quetiapine was increased to 100 mg pm and mirtazapine 7.5 mg pm was started to improve sleep.

On hospital day 5, her husband reported that she had had continued visual phenomena of pixels and faces melting. Ms Zorn was only able to sleep for 1.5 hours after receiving quetiapine and mirtazapine. On exam, she reported the visual hallucinations and had a MoCA score of 12/30. Continuous EEG was reported as normal and abdomen CT was negative for ovarian teratoma. To address continued 

and poor sleep, quetiapine was increased to 100 mg am and 300 mg pm. Mirtazapine was increased to 15 mg pm.

Ms Zorn was seen again on hospital day 6. She reported that she had been able to sleep for 8 hours. She denied any visual “melting” of faces but stated that the “world looked pixelated at times.” MoCA score was 14/30. Subsequently, when seen on hospital day 8, she stated that she was still seeing pixels in the periphery of her visual field. MoCA score improved to 17/30. Quetiapine was consolidated to 400 mg pm.

She was next seen on hospital day 10. The cerebrospinal (CSF) encephalopathy panel came back positive for anti-NMDA receptor antibody R1, confirming a diagnosis of anti-NMDA (N-methyl-D-aspartate)-receptor encephalopathy (ANMDARE). Neurology started plasmapheresis for 7 treatments, every other day. She had no hallucinations. She reported that she was getting “deep sleep.” MoCA score was 16/30. A quetiapine 50 mg am dose was added.

Plasmapheresis started on hospital day 11. The patient denied any visual distortions. She said that she felt significantly better than the previous week; MoCA score was 16/30. When next seen on hospital day 15, Ms Zorn reported sleeping from 11:00 pm to 5:30 am. She denied visual distortions. MoCA score had improved to 21/30; however, 

continued to be impaired. On hospital day 18, she was doing well. She had declined her scheduled quetiapine the previous day “to give it a try.” She no longer saw distorted faces. She had no gait disturbance. MoCA score improved further to 25/30. Given her improved mental status, the psychiatry team decided that she had recovered her decision-making capacity. Mirtaza-pine was decreased to 7.5 mg pm and quetiapine held.

Ms Zorn was seen for the last time on day 22 of hospital admission. After her final 

treatment, she continued to be free of psychotic symptoms. She stated that she was “doing better than last week,” and that she was “80% back to normal.” She was sleeping well and was increasingly physically active during the day. She was excited to return home; MoCA score was 22/30. Decisional capacity continued to be intact. Mirtazapine 7.5 mg bedtime was continued.

As she was medically stable for discharge, she was referred for psychiatric follow-up near her home. She was advised that any future recurrence of psychosis should first be addressed as if it was a recurrence of delirium and/or ANMDARE.

ANMDARE is a relatively recently described illness that may present with psychiatric symptoms, neurologic symptoms, or both (either simultaneously or sequentially).

 While the exact mechanism remains obscure, antibodies to the NMDA receptor (on CSF and/or serum assay) is 

 Management includes empiric treatment of manifest symptoms and immunomodulation systemic therapies.

ANMDARE is important to the consultation-liaison psychiatrist for a number of reasons. First, its presentation lies in the “neuropsychiatric borderland” involving collaboration between psychiatry and neurology (as in other neuropsychiatric illnesses like Parkinson disease, Huntington disease, and multiple sclerosis). Second is its importance in the often hard-to-define syndrome of “atypical psychotic disorder.” In comparison to the classic presentation of schizophrenia, ANMDARE features a later age of onset, female predominance, visual hallucinations, relative lack of cognitive disorganization, and a lack of an extended prodromal period.

This case illustrates the atypical presentation of psychotic illness rather well. Ms Zorn was in her mid-40s, of high academic and professional achievement, adaptive social function; without a clear prodrome, she relatively promptly developed a psychotic picture with striking and disturbing visual hallucinatory phenomena. Clinical suspicion for ANMDARE was confirmed with reference laboratory (Mayo Clinic) results of + R1 antibody to NMDA receptor on CSF analysis. This was accomplished in the context of a thorough laboratory evaluation for other esoteric causes of atypical psychotic illness.

Empiric treatment of the psychiatric symptoms with mirtazapine and quetiapine, concurrent with 2 rounds of immunomodulation therapy, led to amelioration of symptoms and near complete cognitive recovery in a period of 2.5 weeks. Her cognitive status based on objective measure with the 

(MoCA) was initially in the moderate to severely impaired range.

 With comprehensive treatment, Ms Zorn’s cognitive status improved to a level of only mild impairment. Correspondingly, her decisional capacity improved from significantly impaired to largely intact over the same period.

Psychiatrists assessing and treating patients with atypical presentation of psychotic illness should actively consider a diagnosis of ANMDARE as explanatory.

 In female patients with suspicion of ANMDARE, pelvic ultrasonography and/or CT scan should be ordered to rule out commonly co-occurring ovarian teratoma.

 Patients with ANMDARE who are treated with high-dose intravenous corticosteroids should be monitored (and treated for) any corticosteroid-associated psychiatric adverse effects, which can overlap with the atypical psychotic symptoms at illness onset. Empiric treatment with psychopharmacology for psychotic and/or depressive symptoms should be pursued, although such medications may not be necessary indefinitely once definitive immunomodulation therapy is completed.

ANMDARE should be on the differential for atypical psychosis, with an expectation of a thorough search for laboratory and systemic clinical (especially neurologic) findings, empiric treatment of psychiatric symptoms, and reassessment of the patient as immunomodulation therapy is completed. Prospective study of ANMDARE illness cohorts are needed to quantify recurrence risk, need for ongoing intervention, and ultimate prognosis.

Consultation-liaison psychiatrists working in academic medical centers may be in a position to assist multispecialty teams in the identification, diagnosis, management, and ongoing follow-up of these patients. As with any illness that affects cognitive function, attention to and serial assessment of decisional capacity is a critical part of C-L psychiatry care, especially as pertains to patient consent for major immunomodulation therapies.

 is chair, Department of Psychiatry, Baylor Scott & White Health, Central Texas Division, and clinical professor for medical education, Texas A&M University Health Science Center, Temple, TX. 

is a medical student, Texas A&M University Health Science Center, Temple, TX. The authors report no conflicts of interest concerning the subject matter of this article.

1. Tuzun E, Zhou L, Baehring JM, et al. Evidence for antibody-mediated pathogenesis in anti-NMDAR encephalitis associated with ovarian teratoma. 

2. Gresa-Arribas N, Titulaer MJ, Torrents A, et al. 

Antibody titres at diagnosis and during follow-up of anti-NMDA receptor encephalitis: a retrospective study

3. Kayser MS, Titulaer MJ, Gresa-Arribas N, Dalmau J. Frequency and characteristics of isolated psychiatric episodes in anti-N-methyl-d-aspartate receptor encephalitis. 

4. Warren N, O’Gorman C, McKeon G, et al. Psychiatric management of anti-NMDAR encephalitis: a cohort analysis. 

5. Titulaer MJ, McCracken L, Gabilondo I, et al. Treatment and prognostic factors for long-term outcome in patients with anti-NMDA receptor encephalitis: an observational cohort study. 

6. Nasreddine Z. Montreal Cognitive Assessment (MoCA) Administration and Scoring Instructions. Montreal Cognitive Assessment. Accessed July 9, 2020. 

http://www.mocatest.org/wp-content/uploads/2015/tests-instructions/MoCA-Instructions-English_2010.pdf

Articles

In comparison to the classic presentation of schizophrenia, ANMDARE features a later age of onset, female predominance, visual hallucinations, relative lack of cognitive disorganization, and a lack of an extended prodromal period.

Anti-NMDA Receptor Encephalitis With Visual Hallucinations and Cognitive Impairment

Consultation-liaison (C-L) psychiatry is a major psychiatric subspecialty that, within general medical/surgical and academic medical and increasingly in primary care settings, serves as the “tip of the spear” for psychiatry. This metaphor reflects consultation-liaison’s place as the most forward clinical psychiatry service in the wider medical world and the opportunity to lead improvements in patient care in all medical services.

Consultation-liaison psychiatrists specialize in the diagnosis and management of psychiatric disorders that are comorbid with general medical/surgical illness. Examples include the psychiatric comorbidity of neurological illnesses (eg, Parkinson disease, multiple sclerosis, cerebrovascular disease), endocrinological illness (eg, diabetes mellitus, hyper- or hypothyroidism), rheumatic illness (eg, systemic lupus erythematosus, giant cell arteritis), and cardiovascular illness (eg, heart disease, vascular disease). In addition to psychiatric comorbidity, there is a broad area of psychiatric adverse effects of systemically administered medications (eg, corticosteroids, other immunomodulators, CNS-active agents) and the often complicated systemic medical and 

 of medications used for primary psychiatric illness (eg, anticonvulsants, lithium, antipsychotics, antidepressants).

The general medical context of consultation-liaison psychiatry practice means that the psychiatric illness profile differs from that of general psychiatry practice. The most common disorders in the general medical setting include dementia, delirium, other neurocognitive disorders (eg, the sequelae of traumatic brain injury), catatonia, substance use disorders, intoxication and withdrawal states, and medical complications of psychiatric interventions (eg, neuroleptic malignant syndrome, serotonin syndrome, medication toxicity states. adverse effects) as well as depressive, anxiety, and substance use disorders. The psychiatric illnesses that constitute much of general psychiatric practice are also seen by consultation-liaison psychiatrists when they are associated with a general medical illness (eg, melancholic/psychotic depressive disorders, acute manic states, acute psychotic states) and when they result from medical illness and the trauma of treatment (eg, acute stress disorder, PTSD following major surgery or intensive care).

Consultation-liaison psychiatrists are expert at the complex task of managing psychiatric illness in the context of the general hospital and the emergency department. The responsibility of the C-L psychiatrist is first to assure that the proper medical evaluation and management are accomplished for the medical stabilization of patients before providing the necessary psychiatric treatment in collaboration with the patient’s clinical team. The C-L psychiatrist then arranges for psychiatric disposition, if and when that is clinically indicated.

Current training models for C-L psychiatry include 2 or more months of core rotation in the standard psychiatry residency program. Following residency there is an additional full academic fellowship year for psychiatrists who wish to qualify for subspecialty board eligibility and certification in consultation-liaison psychiatry.

Modern C-L psychiatry has developed as a distinct model of psychiatric practice. Unlike the care of patients with serious mental illness in long-term inpatient psychiatric facilities or the care for high functioning psychiatric outpatients with psychotherapy, the C-L model 

from placing psychiatric services in general medical hospitals, which began in the mid-20th century. This innovation led to the development of the dual partnered concepts of “consultation” and “liaison” functions in hospital-based psychiatric practice. The consultation role refers to the direct care of the medical inpatient on request from the admitting physician, with recommendations for direct care and brief, in-hospital follow-up. In contradistinction, the liaison function refers to the psychiatrist sharing their understanding and interpretation of behavioral manifestations of psychiatric illness in medical/surgical patients and direct advice to medical and nursing services to improve the care of medical/surgical patients with comorbid psychiatric conditions.

Until recently, with its inpatient medical/surgical hospital heritage, C-L psychiatry was primarily hospital-based subspecialty, with the development of one-year fellowships in C-L psychiatry that were primarily inpatient-based. However, in the past 20 years, there has been an accelerating development of outpatient C-L models. This movement involves placing psychiatrists in outpatient specialty medical settings and in primary care, where specialty physicians and primary care physicians work together with psychiatrists to care for patients.

The development of psychiatry in the general hospital led to a movement to establish C-L psychiatry as a specific and differentiated subspecialty of psychiatry. In the US, this happened in 2003 with the establishment of the subspecialty board in psychosomatic medicine (a synonym of consultation-liaison psychiatry) and with the first 

 examinations offered in 2005. The subspecialty has thrived ever since.

We are now in a period of the rapid and robust development of C-L psychiatry, driven by an increasing awareness of the need to treat the whole patient as well as by increasing amounts of evidence that indicates the clinical and financial importance of better management of psychiatric illnesses in patients under general medical care. Two major medical journals, 

, are devoted specifically to C-L psychiatry scholarship.

There are a rapidly increasing number of C-L psychiatry fellowships. The leading national and international organization, the Academy of Consultation-Liaison Psychiatry (ACLP; 

) has almost 2000 members; the most recent annual meeting in San Diego, CA, attracted more than 1200 attendees-an all-time record. The next annual meeting is in Phoenix, AZ, in November 2020 (

) and promises to be even larger. This spectacular growth largely reflects the expansion of C-L psychiatry beyond academic medical centers into community and other non-academic hospitals.

Within the broader subspecialty of C-L psychiatry, there has been further differentiation to better serve the needs of specific types of patients. Examples include HIV psychiatry, transplant psychiatry, neuro-psychiatry, psycho-oncology, and cardiovascular psychiatry. While these areas are all within the scope of practice of C-L psychiatry, there are C-L psychiatrists whose primary identification is with these sub-subspecialty areas.

Building on the pioneering work of a cadre of C-L psychiatrists such as Wayne Katon, it is increasingly common for mental health services to be embedded within primary care in innovative ways. An example of such is collaborative care, which uses standardized clinical pathways and the extension of psychiatrists’ time by care managers. Care managers deliver care and monitor outcomes under psychiatric supervision. Collaborative care allows primary care services to provide high quality evidence-based care for large number of patients who may have mild to moderate psychiatric illness.

Consultation-liaison psychiatrists have also been early adopters of innovative communication and other technology for advancing patient care. These technologies include the provision of psychiatric care by video communication (telemedicine or telepsychiatry) and the creative use of the electronic health record to enhance psychiatric care for medical patients (eg, standardized clinical pathways, incorporation of outcome and rating measures).

There are many exciting opportunities for C-L psychiatry to improve patient care. It is now clear that all sizeable hospitals must have real-time access to psychiatric consultation (whether in-person or by telemedicine). New proactive and integrated models of inpatient C-L psychiatry are increasing the field’s reach and effectiveness. The incorporation of standard clinical approaches to psychiatric illnesses (eg, dementia, delirium, catatonia, traumatic brain injury) commonly encountered in C-L practice into electronic health records is ensuring better and safer care for patients with these high-acuity psychiatric illnesses. Greater availability of psychiatric consultation for medical outpatients, with standardized pathways for patients with the common psychiatric comorbid illnesses in primary care, is extending consultation-liaison care outside the hospital setting.

Consultation-liaison psychiatrists will also continue to lead in many areas. These include emerging areas of medical genomics in psychiatry, the monitoring of drug-drug interactions, and the management of behavioral and cognitive syndromes with complicated attributable systemic illness causes. Consequently, C-L psychiatry has an important place at the forefront of clinical, academic, and administrative leadership for psychiatry.

As clinical science and technology advances at an extraordinary pace, the value of C-L psychiatry within academic departments of psychiatry, and, indeed, in medical centers and medical schools, is being reflected in increased leadership and academic opportunities acting as the tip of the spear in psychiatry’s reintegration into the house of medicine.

is Chair, Department of Psychiatry, Baylor Scott & White Health, Central Texas Division, and Clinical Professor (Affiliated), College of Medicine, Texas A&M University Health Science Center, Temple, TX; 

is President, Academy of Consultation-Liaison Psychiatry and Professor of Psychological Medicine, University of Oxford, UK. They report no conflicts of interest concerning the subject matter of this article.

The “tip of the spear" metaphor reflects consultation-liaison’s place as the most forward clinical psychiatry service in the wider medical world that can lead improvements in patient care.

Consultation-Liaison Psychiatry: The Interface of Psychiatry and Other Medical Specialties

is Attending Psychiatrist, Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, New York;

is Clinical Professor, Department of Psychiatry, Texas A & M University Health Science Center, College of Medicine, Bryan, TX;

is a Senior Undergraduate, Fordham University, New York;

is Clinical Assistant Professor, Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, 

is Acting Assistant Professor, University of Washington, Seattle, WA;

is Assistant Professor of Psychiatry, Harvard Medical School, Boston, MA; and

is Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York.

Psychiatrists are often consulted to determine whether a patient has the capacity to make medical decisions during an inpatient medical hospitalization. Some of the most challenging decisional capacity consultations are requests to determine if a patient has the capacity to participate in discharge planning. For a patient to demonstrate capacity to participate in discharge planning, the patient should have the capacity for self-care, the ability to cope with illness, and be capable of accessing medical care and treatment once he or she has left the hospital. Frequently such psychiatric consultations are requested when a patient is refusing what the medical team defines as a safe discharge.

In this article, we present some of the complexities of what we propose to call “dispositional capacity,” or the capacity to participate in discharge planning. Inherent in a dispositional capacity determination is an assessment of whether the patient will be able to survive safely and independently in the community following a hospital stay and whether he or she can refuse placement in a chronic care or rehabilitation facility. Basically, the primary medical team is asking the psychiatrist to answer the question: “Can this patient go home?”

Dispositional capacity is a subset of decisional capacity determinations that is distinct from the capacity to give informed consent for or to refuse medical procedures. Although all determinations of decisional capacity are complex and require consideration of the medical, ethical, legal, and psychosocial dimensions of care, most decisional capacity determinations pertain to a single decision as a threshold inquiry of whether the patient can give or withhold informed consent.

While the ability of a patient to participate in his or her own discharge plan is inclusive of elements of a procedure-specific decisional capacity assessment, discharge planning requires other unique dimensions for the clinician to consider. Dispositional capacity determination, in contrast to most other decisional capacity determinations, requires some assessment of a patient’s current functional capacity, prediction of a patient’s future behavior, and ability to self-manage after hospitalization. After discharge from the hospital, the patient must have the ability to make decisions conducive to recovery. Dispositional capacity is therefore a unique subset of decisional capacity that requires an element of prediction.

Decisional capacity assessments that clinicians perform every day help protect vulnerable individuals from neglect and exploitation, preserve autonomy and self-determination, and help other clinicians and administrators communicate with each other to address complex bioethical and biomedical questions and dilemmas. Decisional capacity has been extensively described elsewhere. These standard capacity evaluations provide a forum for the multidisciplinary hospital team to engage in thoughtful deliberation about how we care for patients in a manner that upholds the highest ethical values of our profession. Myths and facts about decisional capacity are summarized in 

Capacity questions and their assessments lie on a gradient depending on what is being asked of the patient and the potential risks of their decision. Medical decision-making falls on a spectrum: some choices require more complex thought processes and thus a more sophisticated demonstration of the domains of capacity, including understanding, reasoning, appreciation, and communication of a choice (

Decisional capacity determinations have medical, psychiatric, functional, and socio-economic components, all of which are involved in the complexity of the patient’s decision-making process. While neurocognitive disorders are the primary drivers of impaired decisional capacity, other psychiatric disorders may also have an adverse impact on decision making. The psychiatrist needs to make a biopsychosocial assessment that includes all elements that may adversely affect decisional capacity. (See 

 for examples of how psychiatric disorders can impair decisional capacity).

Understanding dispositional capacity as a distinct concept

On the spectrum of decisional capacity, dispositional capacity appears to be a particularly special circumstance. In the case of decisional capacity, a patient is required to demonstrate adequate cognition as evidenced by an understanding and appreciation of the facts and circumstances and an ability to rationally manipulate information, be capable of intact reality testing relative to the medically relevant information, and sufficient emotional stability to make a consistent choice over time.

Dispositional capacity, on the other hand, is more complicated in that it requires the patient to make multiple present and future decisions that are conducive to good health, and it requires that patients demonstrate adequate functional abilities in the physical and occupational performance areas to survive in the community. Thus, dispositional capacity hinges on many more factors than a focal, discrete choice to accept or reject a medical intervention or diagnostic procedure while in the hospital.

Seen in this light, dispositional capacity to refuse a safe discharge requires a higher bar of understanding and self-awareness by the patient. A patient may have the decisional capacity to give informed consent for an extremity amputation, but may not have dispositional capacity or the capacity to care for himself or herself at home after recovering from the surgery. Conversely, a patient may lack decisional capacity to refuse a risky CNS tumor resection but nonetheless have dispositional capacity to return home with family supports. Each type of decision requires a full psychiatric assessment, and “one size does not fit all.”

Special elements of dispositional capacity

Dispositional capacity determination requires a multidimensional biopsychosocial approach to the patient. This approach, while important in all capacity determinations, is even more critically salient in determination of dispositional capacity, and includes an appreciation of the biological, psychological, and social obstacles that must be overcome to maintain health, safety, and access to care in the community. A dispositional capacity assessment requires an evaluation of:

• Obstacles to understanding (eg, language, socio-cultural barriers, neurocognitive disorders, substance use disorders, other psychiatric disorders)

• Ability to perform activities of daily living (ADLs) and instrumental activities of daily living (iADLs) or to accept assistance with these needs

• Social factors (family dynamics, housing, economics, and broader social supports)

• Access to and navigation through the health care system

To begin, a clinician must first assess a patient’s understanding of his or her ongoing medical problems and what specific interventions are needed upon discharge (eg, physical or occupational therapy, follow-up medical appointments). Subsequently, the clinician must assess cognitive difficulties that are interfering with the patient’s understanding of the illness and medical care needs.

Mr. A is an 85-year-old with a past medical history of hypertension, diabetes, and coronary artery disease who presents after a fall in his apartment. It was hours before his daughter found him on the bathroom floor. Upon admission to the hospital, Mr. A was dehydrated with associated rhabdomyolysis, acute kidney injury, and hypernatremia; he was treated with IV hydration. He sustained a hip fracture but refused the recommended hip replacement. The consulting psychiatrist diagnosed delirium, possibly superimposed on a major neurocognitive disorder (dementia), and prescribed PRN haloperidol for agitation. His daughter provided informed consent for the surgery.

After surgery, the orthopedic team recommended discharge to a subacute rehabilitation facility (SAR) to assist with his post-operative recovery. Mr. A was adamant that he be discharged home. The psychiatrist was called in to assess dispositional capacity. Mr. A believed he would be fine at home because he’s a “strong man” and “I can take care of myself.” He seemed unaware of any risks to returning home and couldn’t explain how he would prepare his food or attend to his grooming. He scored poorly on the Montreal Cognitive Assessment with a score of 16. An occupational therapy evaluation demonstrated a failing score on the KELS. The psychiatrist found that Mr. A lacked dispositional capacity; after much encouragement from his daughter, Mr. A agreed to a temporary SAR stay to regain his mobility.

Functional assessments to clarify a patient’s limitations with daily activities, including iADLs and ADLs, can further elucidate areas of concern. Collaboration with a team of experts is most relevant in dispositional capacity determinations. Specifically, an occupational therapist can provide a Kohlman Evaluation of Living Skills (KELS) or other similar assessment of self-management abilities that can be selected based on patient-specific characteristics. KELS or similar instruments can provide comprehensive evidence of cognitive skills involved in self-management. Input from physical, occupational, and speech and language therapists can assist the psychiatrist in better understanding the patient’s current level of functioning.

Social workers can arrange access to community programs such as home health aides, visiting nurses, physical and occupational therapy, companions for persons who are visually impaired, transportation to medical appointments, prepared food delivery for meals, and panic buttons, all of which can make home a safer place for elderly patients with cognitive impairment. A patient who is unable to adequately perform iADLs and ADLs may still be safely discharged if a family member, friend, or a home health aide is available to assist with shopping, cleaning, food preparation, and transportation to medical appointments. Social workers can also help identify untapped resources such as family, friends, or members of the patient’s religious faith to help the patient after discharge.

There are many types of medical decisions, and each of these may require greater or lesser levels of understanding, cognition, and emotional function. For example, there are simple versus complex surgical and other procedures for which a patient might need to consent. To appoint a surrogate decision-maker, the necessary decisional capacity level is an understanding of the role of the surrogate and an ability to consistently name that person with little focus on the patient’s awareness of the strengths or weaknesses of each proposed surrogate. This applies as long as there are no concerns about the appropriateness of the surrogate and it is not a risky decision.

To accept a recommended medical procedure, the necessary capacity level is a consideration of the risks of failure and benefits of success from the procedure that is being recommended by the treating physician. To reject a recommended procedure, the necessary decisional capacity level involves knowledge of the risks of recovery without the procedure.

As with the varieties of risk among the different kinds of medical decisions, there is a spectrum of different levels of dispositional capacity that a patient might need. Overall, we can speculate that because dispositional capacity requires a greater degree of cognition for consistent and ongoing self-management, patients who “just barely” satisfy the functional criteria of valid decisional capacity for a routine medical procedure may nonetheless lack dispositional capacity.

Patients with poor cognitive function who lack capacity to refuse a medical or surgical procedure, are also likely to lack dispositional capacity. Conversely, a patient with a stable home, caring family members, good access to clinical follow-up, and adequate financial resources may be better able to manage post-hospital care at a lower level of cognitive and psychiatric function than a patient without ready access to these resources. Patients who are paranoid, either from a neurocognitive disorder or a psychotic disorder, may not fare as well in the community because they will not allow family or homecare agencies access to their home to provide needed assistance.

Ms B is a 90-year-old widow with hypothyroidism, schizophrenia, and mild neurocognitive disorder. She lives in her own home with the support of a home health aide and assistance from 2 sons. She has chronic paranoia and life-long beliefs that the FBI is spying on her and targeting her children. Ms B’s pharmacy packages risperidone in blister packs and her aid reminds her to take the medication.

She presents to the hospital with her son for abdominal pain and is found to have a perforated duodenal ulcer. Although she believes the FBI has caused the ulcer, she agrees to all recommended treatments and her decisional capacity is not questioned. Her hospital course is complicated by sepsis and delirium. She requires PRN risperidone, in addition to her standing risperidone, which is recommended by the consulting psychiatrist.

When it is time for discharge, the medical team recommends SAR. However, Ms B wants to go home because she believes that the FBI will have better access to her at SAR. The psychiatrist is called in for an assessment of dispositional capacity. Ms B explains her reasoning to the psychiatrist and acknowledges that others might choose differently. She agrees to resume her homecare services, and her sons agree to check on her daily.

Ms B scores in the mildly impaired range on the Montreal Cognitive Assessment with a score of 18. She has prominent delusions but her family and psychiatrist confirm that she is at her baseline; she has no homicidal or suicidal thinking. She is found to have dispositional capacity and is safely discharged home with resumption of her community supports.

Dispositional capacity is a specific subset of decisional capacity that addresses a patient’s ability to accept or reject a safe discharge plan. Psychiatrists are often called upon to assess dispositional capacity when a patient is refusing the recommended discharge plan, sometimes in concert with decisional capacity for informed consent for a medical procedure, and sometimes solely in the discharge context.

Assessment of dispositional capacity, framed as a distinct subtype of decisional capacity, includes a comprehensive diagnostic psychiatric evaluation as well as targeted evaluations by occupational and physical therapy staff and social workers to provide the optimal interdisciplinary assessment of the patient. This complete appraisal, tailored to the patient’s specific circumstances, addresses the patient’s safety and honors the 4 principles of biomedical ethics, specifically balancing patient autonomy against physician beneficence, nonmaleficence, and justice. Mastery of the dispositional capacity assessment is an essential core skill for consultation-liaison psychiatrists who are crucial members of the health care team.

Acknowledgement-The authors acknowledge the Academy of Consultation-Liaison Psychiatry for helping to bring this article to fruition. The Academy is the professional home for psychiatrists providing collaborative care bridging physical and mental health. Over 1200 members offer psychiatric treatment in general medical hospitals, primary care, and outpatient medical settings for patients with comorbid medical conditions.

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Some of the most challenging decisional capacity consultations are requests to determine if a patient has the capacity to participate in discharge planning.

What Psychiatrists Need to Know About the Determination of Dispositional Capacity

Evaluations of decisional capacity are among the most common-and the most complex-psychiatric consultations. Determination of decisional capacity is fraught with myths that may mislead all physicians. These misunderstandings present clinical pitfalls that can result in serious medical, ethical, legal, and psychosocial challenges. Conversely, the ability to conduct a decision-making capacity assessment with knowledge, skill, empathy, and wisdom is a duty and service of high ethical value and significance. Decisional capacity assessments that psychosomatic medicine psychiatrists perform every day help protect vulnerable individuals from neglect and exploitation, preserve autonomy and self-determination, and help other clinicians and administrators solve complex bioethical and biomedical dilemmas.

These evaluations provide a forum for the entire health care community and its stakeholders to engage in thoughtful deliberations that inform policy development that upholds the highest ethical values of our profession and society regarding medical care and research.

This article will focus on capacity to participate in medical decisions rather than research, but there is considerable overlap in the principles and procedures presented.

Facts and myths about decision-making capacity

One of the most important reasons to tease apart the facts from the myths is that so many of the individuals for whom capacity assessments are requested have psychiatric disorders, such as schizophrenia and dementia (

 with schizophrenia and most patients with mild to moderate dementia are-with psychiatric care, assistance, patience, kindness, and time-able to make many basic medical and dispositional decisions.

Many clinicians, including psychiatrists, may confuse and conflate commitment and capacity, not recognizing that many patients who are committed retain the ability to participate in treatment decisions.

 of over 2500 patients indicate that, contrary to the hypothesis of the research, it was not psychosis that led to incapacity but rather cognitive impairment and substance use.

 The exception is when the psychopathology directly interferes with the patient’s decision-making process as in the frequently encountered case examples in 

The presumption that patients with psychopathology do not have decisional capacity is often grounded in an even more profound misunderstanding of decision-making capacity as monolithic: that decisional incapacity in one area, such as finances, precludes capacity in all areas. Most of us are able to make better decisions in some areas of our lives than in others. Similarly, it is often assumed that capacity is static, when it is really a dynamic, granular ability that is better at some times and worse at others.

 is among the most frequently encountered, yet often unrecognized, conditions that impair the capacity of patients to make decisions in the settings of emergency departments as well as medical, surgical, and intensive care units.

 Because of the intrinsically fluctuating nature of delirium, which typically worsens toward evening, and our obligation to offer the patient an optimal opportunity to perform well on the assessment, it is often best to conduct capacity evaluations in the morning-especially for patients with or at 

Yet this variability is also a positive: it means that we can enhance a patient’s ability through basic interventions we know well as psychiatrists, such as normalizing the sleep-wake cycle; treating anxiety, depression, and psychosis; and providing supportive psychotherapy. Both pharmacological and psychological treatments as well as a variety of cultural adjustments, such as having a trained interpreter and educational modalities (eg, audiovisuals, social supports involving family members), have been shown to improve the ability of patients with physical and psychiatric illnesses to optimize their decisional capacity. Ethically, it is our obligation to try these interventions so that we give the patient the “best chance” to do as well as possible and to assess the patient at the point of his or her highest capacity.

An essential aspect of this “best chance” is that the psychiatrist must define the object of the capacity request. The first thing we teach psychiatric residents who respond to a consultation request for capacity determination is to discuss with the requesting clinician, “Just exactly what is the question?” This helps to begin a dialogue and to elicit the latent as well as the manifest content of the consultation question. A study examined 100 consecutive consultations for capacity evaluations submitted to a 

 service at an academic medical center. The results of this study showed that approximately the same number of consultations were received for the capacity to consent to a treatment or procedure, the capacity to refuse a treatment or procedure, the capacity to leave the hospital against medical advice, and the 

The importance of patient self-determination requires that, at the outset, we recognize the legal limits of medical capacity assessments. Only a judge or other officer of the court can make the legal determination of competence. Although our capacity assessments often inform the court’s decision, medical assessments of incapacity are not formal legal adjudications that patients are incompetent with all the attendant limitations on their rights and responsibilities as citizens. Although some experts believe this distinction is purely semantic, the 2 terms functionally refer to quite distinct but related processes.

This is an especially salient distinction when applied to patients with psychiatric disorders who have been involuntarily committed. Many clinicians, including psychiatrists, may confuse and conflate commitment and capacity, not recognizing that many patients who are committed retain the ability to participate in treatment decisions and provide informed consent (

). Conversely, there is an inherent assumption that when a patient refuses a recommended hospitalization, test, or procedure or suggested medical treatment, he or she “must be mentally ill.” Similar to innocence in our system of criminal justice, in Anglo-American bioethics, the patient should be presumed capacitated unless it is clear that the refusal is based on a psychiatric disorder that is interfering directly with the decision-making process. Persons with neuropsychiatric illness have the same rights as all patients and can refuse or consent to medical care.

Determination of decisional capacity: who and how?

While law and policy endow any physician with the requisite training and scope of practice to perform a capacity evaluation, in reality, when non-psychiatric physicians are struggling with the evaluation or are confronted with a particularly complicated patient, they often turn to psychosomatic physicians to conduct the assessment. A 

 that compared the capacity of medical inpatients to make major decisions using the Mini-Mental State Examination (MMSE), clinical impression, and expert evaluation showed that the MMSE and clinical impression were often inaccurate predictors of decision-making.

 However, this does not mean that there is no structured or standardized approach for performing capacity assessments. A widely accepted and utilized method for analysis of decisional capacity is 

Communication and understanding can be conceptualized as the lower order of abilities necessary to make the most basic decisions, such as choosing a surrogate, while rationality and appreciation are higher-order abilities needed for complex decisions, such as selecting surgery, chemotherapy, or radiation for cancer. Using the MacArthur Assessment Tool, 

 found that patients who scored low on the understanding component were not likely to be capacitated. Appreciation was a better test of capacity in psychiatric patients, while reasoning was superior in those with systemic medical disorders. The correlation of brain imaging with specific capacity impairments is in its infancy but is a promising future direction for capacity research.

In assisting patients and clinicians to determine whether a patient has the capacity to make 

, psychosomatic medicine physicians are fortunate to have access to several useful decision aids. The MacArthur Competence Assessment Tools for Clinical Research and Treatment is the most evidence-based tool, and the Aid to Capacity Evaluation (ACE) is among the most clinically useful.

 These instruments can provide results that can also support psychosomatic medicine psychiatrists in the presentation of their findings to other clinicians and family members and document the results of an evaluation in a formal report suitable for submission to social service agencies or courts.

One of the most significant pitfalls to avoid when using any structured instrument is to realize that it cannot supplant-only supplement-the clinical evaluation. Research suggests that medical patients who score on the low end of the range on cognitive instruments are more likely to lack decision-making capacity; similarly, those with near-normal scores are probably able to make decisions. In the middle range, however, there is no exact or predictable correlation.

It is precisely in the most complex of capacity evaluations where relevant clinical context is crucial and where a clinical “gradient” decisional capacity model can be highly beneficial in formulating the evaluation. On this gradient, capacity is conceived as “dimensional,” in that different decisions require different levels of sophistication (

). It is important to recall that many otherwise cognitively impaired patients may at least name a surrogate decision maker.

As such, assessment for the capacity to name a surrogate (can the patient understand the role of a surrogate, when the surrogate would be used, and that the surrogate may not make the decision the patient “would have wanted”) is often a practical matter, even if the patient cannot demonstrate decisional capacity for the medical or surgical intervention at hand. While some have criticized sliding-scale types of models, 

The gradient of capacity should remind the capacity evaluator that even patients who perform poorly on cognitive screens may have intact functional capacity and are able to care for themselves in the community through routine and a network of friends and family; or a patient with progressive cognitive impairment may have “good old-fashioned common sense” and recognize, for example, that he is unsafe at home and agree to assisted living. In these decisions, balancing respect for patient autonomy and the duty to keep the patient safe are the paramount ethical values in conflict.

Evaluators must be cautious to avoid too quickly substituting their preferences as a substituted judgment. Refusal of care, including psychiatric treatment, accentuates this challenge.

In consultations to determine the patient’s future decisional capacity for independent living and self-care (ie, “dispositional capacity”), as opposed to a decision about a specific medical intervention-where the Appelbaum and Grisso framework is most clearly applicable-additional consultation with an occupational therapist for a Kohlman Evaluation of Living Skills and similar in vivo dynamic assessment of self-care skills may greatly add to the psychiatrist’s assessment.

Ethical challenges are intensified in marginalized and underserved populations, such as individuals who are undomiciled or marginally housed, undocumented immigrants, the elderly, and persons with addiction or other psychiatric disorders-all of whom are vulnerable to exploitation and victimization. Ironically, although we recognize the fragile position of the economically disadvantaged and incapacitated, the wealthy can also be vulnerable and victimized. Take, for example, the widely publicized case of Brooke Astor whose son stole and sold artwork and other valuables worth millions from his mother, including works of art that she personally treasured.

Emerging research on the challenges of determining capacity in persons who are undomiciled is illustrative of the difficulties in evaluating decision-making in marginalized groups. When caring for undomiciled individuals, 

 with feelings of anger-directed at “the system” or the undomiciled individual-lack of empathy, disgust, and even futility.

 These emotional responses can impair objective assessment of patient needs, decisional capacity, and reaction to behaviors. There may be an excessive reluctance to discharge undomiciled patients, even with resolution of acute medical needs. Alternatively, there may be a risk of refusing care or of faster than indicated discharge as a consequence of negative countertransference to the undomiciled individual.

Evaluators must be cautious to avoid too quickly substituting their preferences as a substituted judgment. Refusal of care, including psychiatric treatment, accentuates this challenge. Legal precedents have supported the right of homeless psychotic individuals to refuse care. When considering capacity in a homeless individual, the same general standards need to be applied, while keeping in mind some of the potential complicating factors:

• Distrust of medical profession based on prior encounters

• Higher potential for medical consequences of refusing care

• Risk of alienation from future care with forced treatment

There is no one-size-fits-all in decisional capacity. Every assessment is determined on a case-by-case basis. Understanding the myths and facts about decisional capacity allows patients to preserve dignity and autonomy and helps clinicians mediate conflicts, meet the bioethical challenges of determination of decisional capacity, and provide compassionate resolutions for both patients and their caregivers.

The authors acknowledge Christina Wichman, DO, FAPM, and Catherine C. Crone, MD, of the Academy of Psychosomatic Medicine (APM) for helping bring this article to fruition. The APM is the professional home for psychiatrists providing collaborative care bridging physical and mental health. Over 1200 members offer psychiatric treatment in general medical hospitals, primary care, and outpatient medical settings for patients with comorbid medical conditions.

Dr. Geppert is Professor of Psychiatry and Director of Ethics Education, University of New Mexico School of Medicine; and Chief, Consultation Psychiatry and Ethics, New Mexico VA Health Care System, Albuquerque, NM. Dr. Cohen is Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York. Dr. Bourgeois is Clinical Professor and Vice Chair of Clinical Affairs, department of psychiatry, Langley Porter Psychiatric Institute, University of California, San Francisco. Dr. Peterson is Associate Professor in Psychiatry, University of Wisconsin School of Medicine and Public Health and Director of Hospital Psychiatric Services, University Hospital, Madison, WI. The authors report no conflicts of interest concerning the subject matter of this article.

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The authors parse myths and facts about decisional capacity, with the goal of preserving patients' dignity and autonomy and helping you mediate conflicts, meet bioethical challenges, and provide compassionate resolutions.

Bioethical Challenges for Psychiatrists: Determination of Decisional Capacity

FROM THE ACADEMY OF PSYCHOSOMATIC MEDICINE

Psychiatrists are uniquely positioned to provide both preventive and therapeutic interventions for children, adolescents, adults, and elderly persons who are vulnerable to, infected with, or affected by HIV. Psychiatrists routinely take patient histories that include substance use; sexual activities; relationships; and trauma, including childhood neglect and emotional, physical, and sexual abuse-as well as comprehensive medical, psychiatric, and social histories. Progress in preventing HIV infection has lagged far behind progress in the disease’s diagnosis and treatment. Stigma, discrimination, and fear may prevent persons with risk behaviors such as unprotected sex and injection drug use from getting tested, learning that they have HIV infection, or obtaining much needed care.

While there are similarities, HIV/AIDS differs from many complex and severe medical illnesses because it is an infectious and stigmatized disease that can lead to and is associated with other multimorbid medical illnesses. It is also associated with psychiatric illnesses because of the affinity of HIV for brain and neural tissue as well as its profound impact on persons who are infected.

Increasing awareness of stigma, discrimination, and psychiatric factors associated with the HIV pandemic can lead to decreased transmission as well as early diagnosis and treatment. Compassionate medical and psychiatric care can mitigate suffering in persons at risk for, infected with, and affected by HIV.

Strategies have been developed for communicating, preventing HIV transmission, improving adherence to risk reduction and medical care, addressing health care disparities, and ameliorating stigma. These include the National AIDS Strategy Updated to 2020, the 2015 Blueprint to Eliminate AIDS in New York State, and the World Health Association Guidelines. Key prevention strategies for all patients are presented in 

Persons who are thought to be the most substantially vulnerable to HIV infection include HIV-negative members of serodiscordant couples and HIV-negative injection drug users. An HIV-negative member of a serodiscordant couple may take pre-exposure prophylaxis (PrEP) to prevent infection. PrEP and postexposure prophylaxis (PEP) with antiretroviral medications such as tenofovir together with emtricitabine-in combination with safe sex, barrier contraception, and safe injection drug practices-can prevent HIV transmission in serodiscordant couples. The evidence for the use of PrEP and PEP in serodiscordant couples is strong.

Psychiatrists can prevent transmission of HIV, ameliorate HIV stigma and suffering, decrease morbidity and mortality, and provide care for persons infected and affected by HIV.

PrEP may also be an effective measure in persons with HIV infection who are injection drug users. In 2014 and 2015, both the Centers for Disease Control and the World Health Organization included injection drug users in their endorsement of PrEP as an HIV prevention method. Much of the evidence for the efficacy of PrEP in injection drug users was derived from the Bangkok Tenofovir Study, which showed a 48.9% reduction in HIV infections.

 Ongoing PrEP demonstration projects have included injection drug users in their participant pool, but data concerning overall awareness, uptake, and engagement in injection drug users are limited. A summary of recommendations for prevention and pre- and postexposure prophylaxis is provided in 

The comprehensive, compassionate, and nonjudgmental approach to the care of persons at risk for or infected with HIV begins with a thorough psychiatric evaluation. This evaluation is designed to provide an ego-supportive assessment.

Shaking hands, while important with all initial patient encounters, takes on special relevance in the context of  AIDSism, or HIV stigma and discrimination against gay persons, drug users, and those with infectious disease.

 Assessing the impact of HIV infection is best done by asking about the individual’s understanding of his or her illness. Special attention is needed to address sensitive issues related to sexual history, gender, and sexuality. See 

Because over half of persons with HIV infection have a lifetime history of depression or bipolar disorder, psychiatrists are uniquely positioned to provide both preventive and therapeutic interventions to vulnerable patients.

Author | James A. Bourgeois, OD, MD

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