TCPR: Dr. Price, for most of your career, you’ve worked closely with psychiatrists in treating patients with neuropsychiatric disease. I thought we might start by discussing how psychiatrists might bring more neurological thinking into their evaluations. When should psychiatrists start thinking neurologically? Which patients should raise the red flag that something “organic” is going on?
Dr. Price: When a patient has an atypical history that doesn’t quite fit the usual DSM definitions or that doesn’t fit your clinical experience. For example, when there is an unusual age of onset of a psychiatric symptom, like a late onset of mania or major depression, especially when it is out of the blue, with no psychosocial explanation. Also, if there is an unusually acute onset of a sudden change in behavior, or the absence of a family history of a disorder that is usually familial, such as bipolar disorder.
TCPR: So, basically, any patient whose history and symptom pattern don’t quite jibe with what we normally see.
Dr. Price: Right. I also look at treatment history. If a patient has not responded to multiple psychiatric medications or therapies that are normally effective, you should wonder about an underlying neuropsychiatric problem. And then, of course, there are certain symptoms that are red flags. Patients who, in addition to typical psychiatric symptoms, also report things like new or worsening headache, somnolence, incontinence, focal weakness, sudden incoordination or gait difficulties, may have neurological illness.
TCPR: Are there any other things that we should be focusing on in the history?
Dr. Price: Yes, it is crucial to ask about a history of head injury. Traumatic brain injury can lead to syndromes that can appear “psychiatric,” like impulsivity, poor memory, anger, and the like. And when you ask about head injury, try to get the full story of what actually happened. Was there a loss of consciousness, and if so, how long did it last? And after the patient regained consciousness, how many hours or days did it take for him or her to regain normal memory functioning? Answers to these questions will give you a sense of how severe the head injury was, and how likely it is that current symptoms might be due to the event. On the other hand, getting a detailed history might reveal that the head injury was less severe than you originally thought. Sometimes families will exaggerate the extent of the injury because of an understandable desire to find some explanation for the patient’s psychiatric symptoms.
TCPR: What are some of the typical psychiatric symptoms that can be caused by traumatic brain injury (TBI)?
Dr. Price: There are many. The most common are cognitive impairment which gradually improves over the course of time, and a disinhibited personality, which might present as being atypically quick to anger, or, conversely, as being unusually or inappropriately jovial. Two syndromes that many psychiatrists are not aware of as possibly being worsened by TBI are borderline personality disorder and perpetration of domestic vio- lence. TBI can contribute to both of these by causing impulsivity and disinhibition.
TCPR: We’ve heard a lot recently about post-concussive syndrome in athletes leading to depression. What is a concussion, exactly?
Dr. Price: In the old days we used to think that it had to include loss of consciousness, but we now consider it to be any sudden impact of the head that even temporarily and briefly alters your mental state.
TCPR: Aside from a careful neuropsychiatric history, should psychiatrists be doing more of the actual neurological exam?
Dr. Price: In my dream world, yes, psychiatrists would conduct an elementary neurologic exam on intake, especially for patients whose history hints at a neuropsychiatric problem.
TCPR: Before going into exactly what that exam ought to be, how should we introduce this to our patients? After all, a neurologic exam involves touching the patient, which is something that most patients are not expecting from a psychiatrist.
Dr. Price: I would say something like, “The brain is so complex and we need to understand different angles to understand it. The neurologic exam offers one angle and we want to be sure we get the correct diagnosis.”
TCPR: That sounds reasonable. So what should we include in our neurological exam?
Dr. Price: Start by examining the visual field to make sure there is not a field cut. You have them look at your nose and you bring your hand out into the four quadrants of their visual field and wiggle your fingers, asking if they can see it. Then examine their gait for stability and for a focal weakness on one side or the other.
TCPR: My office is pretty small—how do we evaluate gait in a small space?
Dr.Price:Ihavesomesmallofficestoo,andIwatchthemwalkforfivestepstowardsthedoorandthencomebackfivestepstothechair. AndI would ask them to do a tandem gait, the heel-to-toe kind of test that cops use to check sobriety. You should tap the basic reflexes, including the biceps, the patellar (just below the knees), and the ankle. And I would stroke the bottom of the foot to make sure the toe goes down. Finally, test strength of the arms and legs, focusing on symmetry of strength.
Dr. Price: This is a five-minute neurologic exam. If it’s normal, docu- ment that so you have that as a baseline, and any abnormalities would prompt a referral to a neurologist.
TCPR: I know that lately you have been interested in the comorbid- ity of depression and major neurological diseases. Is there any- thing in particular psychiatrists should know about?
Dr. Price: Yes, depression is highly comorbid in some very common neurological diseases, such as Alzheimer’s disease, traumatic brain injury, multiple sclerosis, Parkinson’s disease, stroke, and epilepsy. Between 30%-50% of patients with these diseases will develop depression at some point, and there is increasing evidence that the pathogenesis of neuro- logic diseases and depression may have common mechanisms.
TCPR: How might this information be particularly relevant in a psychiatric practice?
Dr. Price: For example, patients who present with late-onset depression (defined as 65 years old or after) have a 2 to 4 times higher incidence of Alzheimer’s disease and Parkinson’s disease than people with no depres- sion. Thus, late-onset depression may be an independent risk factor for the development of Parkinson’s and Alzheimer’s.
TCPR: If I have a late-onset depression patient, should I automati- cally refer them to a neurologist saying, “Look Ms. Smith, there is data that you are 2 to 4 times more likely to develop a neurologic condition because of what is going on with you; I would like you to see Dr. Price.”
Dr. Price: Let’s put it this way. It would certainly heighten my aware- ness as a psychiatrist that there may be an accompanying neurodegenera- tive disease, and it would lower my threshold for neurologic referral.
TCPR: Thank you very much Dr. Price
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