Biological Assessment of patients with Behavioral/Psychiatric Symptoms Overview o Biological alterations, abnormalities and unidentified medical illness can

influence the occurrence of psychiatric symptoms. o A variety of clinical studies are used to identify these problems. Physical Exam o A physical exam includes neurological assessment, including the sensory systems (e.g., hearing, vision). o Unidentified loss of sensory function can lead to depression and withdrawal. This is particularly important in elderly patients. o Skin lesions may indicate illicit drug use and/or domestic, or child abuse. o Blood studies to be conducted include a complete blood count (CBC), erythrocyte sedimentation rate (ESR), and the metabolic screening battery (glucose, hepatic and renal function tests, serum electrolyte levels). o Blood vitamin B12 and folate level analyses, and a toxicology screen should be conducted for patients with neuropsychiatric symptoms. Biogenic Amines and Psychotropic drugs o The levels of biogenic amines and their metabolites alter in conjunction with psychiatric symptoms and disorders. o The plasma levels of antidepressants or antipsychotic drugs may be used to evaluate patient compliance with treatment. They are also used to determine whether therapeutic levels have been reached. o Laboratory tests are used to monitor complications that may arise in the course of pharmacologic therapy: o Patients on the atypical antipsychotic agent clozapine [Clozaril] , or the antimanic/mood stablizer carbamazepine [Tegretol] , must be monitored for blood abnormalities, such as agranulocytosis (indicated by very low, e.g., <2,000, white blood count). Agranulocytosis typically presents in the ER as a severe throat infection. o Note: A low white blood cell count (leukopenia) is usually caused by a decrease in granulocytes. When severe it is known as agranulocytosis .The major complication resulting from agranulocytosis is bacterial or fungal infection, either of which may ultimately be fatal. o Liver function tests are performed on patients being treated with carbamazepine and valproic acid (antimanics/mood stabilizers). o Thyroid and kidney function tests should be performed on patients being treated with the antimanic/mood stabilizer lithium. Patients using lithium can develop hypothyroidism and, occasionally, hyperthyroidism, as well as nephrotoxicity. o Lithium levels should also be monitored on a regular basis. This drug has a very narrow therapeutic range. Test endocrine function o Psychiatric symptoms are associated with endocrine conditions, such as positive dexamethasone suppression testing (DST), hyper- and hypothyroidism, Addison disease (hypocortisolism), and Cushing disease (hypercortisolism).

Endocrine Function Testing: Dexamethasone Suppresion Test (DST) Dexamethasone is a synthetic glucocorticoid that suppresses pituitary ACTH production, resulting in suppression of adrenal cortisol, in patients in which the hypothalamic-adrenal-pituitary axis is normal. About one half of patients with major depressive disorder have a positive DST. That is, the usual suppression of cortisol is limited or absent. This finding can be of importance in depressive patients because there is evidence that patients with a positive DST (and subsequently, reduced suppression of cortisol) respond favorably to treatment with antidepressant agents or to electroconvulsive therapy (ECT). Note, however, that the DST is limited in terms of its clinical usefulness. Positive findings are not specific to major depressive disorder, and nonsuppression is seen in a wide range of other conditions. These other conditions include Cushing disease (to follow!) and other endocrine disorders, schizophrenia, dementia, pregnancy, and anorexia nervosa or severe weight loss. A positive DST (once again indicating cortisol non-suppression) is likewise seen in conjunction with the use of, and withdrawal from, alcohol and anxiolytic medications. Thyroid Function tests Thyroid function tests are used to screen for hypothyroidism and hyperthyroidism. These conditions can mimic depression and anxiety, respectively. The thyroid gland regulates body metabolism through the secretion of hormones (thyroxine [T4], triiodothyronine [T3]), that influence the rate that physiologic processes occur. Hyperthyroidism Hyperthyroidism is the condition which occurs when an excessive amount of thyroid hormone increases the metabolic rate (McConnell, 2007, p. 459). Increased thyroid hormone yields faster rate of metabolism wherein more O2 and calories are burned and more heat generated. Graves disease accounts for 80-90% of all hyperthyroidism cases. It is characterized by hyperthyroidism, goiter (an enlarged thyroid), bulging eyes (exophthalmos), pretibial myxedema (in less than of patients, and refers to skin disease over tibia, with brown, scaly plaques, with no relation to the systemic metabolic myxedema associated with hypothyroidism). Testing o The overactive metabolism results in weight loss, sweating, heat intolerance, increased appetite and bowel hypermotility, which can cause diarrhea and poor absorption of nutrients.

The autonomic nervous system is overactive and causes nervousness, irritability, tremor, tachycardia, palpitations, overactive reflexes, and anxiety. Symptoms o Tachycardia and palpitations o Nervousness and diaphoresis o Heat intolerance o Weakness, tremors o Diarrhea o Weight loss, despite having a good appetite o Elevated free T4 (and either decreased TSH [primary h.], or increased TSH [secondary or tertiary h.]) Hypothyroidism Hypothyroidism (thyroid failure): a state in which absence of thyroid hormone causes the metabolic rate to slow (McConnell, 2007). Everything slows down, and patients are weak and walk with a shuffle, reflexes are slow, intolerant of cold, slowed heart rate and constipation. Sympathetic activation is reduced. Symptoms o Fatigue, lethargy o Cold intolerance (increased sensitivity to cold); hypothermia o Constipation o Weight gain o Water retention o Bradycardia/decreased cardiac output o Fatigue o Decreased sweating o Muscle cramps, joint pain o *Dry, itchy skin; course, brittle, straw-like hair; pallor, jaundice; hair loss (scalp, axillary and pubic) o *Thin, brittle fingernails o *Goiter o Poor muscle tone o Female infertility, disturbed/anovulatory menstrual cycles o Hyperprolactinemia o Galactorrhea o Elevated serum cholesterol o Decreased T4 (and elevated TSH [primary h.], and decreased TSH [secondary and tertiary h.] o Anemia, dilutional hyponatremia, reversible creatinine increase o Myxedema (a specific form of cutaneous edema secondary to increased deposition of connective tissues components in hypothyroidism and other conditions) o accumulation of proteoglycans /glycosaminoglycans and water

facial/periorbital edema (puffiness) peripheral edema (hands and feet) deepened voice macroglossia Addison Disease o (aka chronic adrenocortical insufficiency) o Caused by: adrenal cortex damaged results indefic of glucocorticoids, mineralocorticoids, and androgens o Physical signs and symptoms: hyperpigmentation of the skin, particularly in skin creases, low blood pressure, pain, fainting, hypoglycemia, diarrhea, vomiting. o Psychiatric symptoms: fatigue, depression, psycosis, & confusion. Cushing Disease o Cushing disease is characterized by increased levels of glucocorticoids. o Physical signs and symptoms include round, moon face, bruising, purple striae on the skin, sweating, facial hair, hypertension, fat on the back of the neck (buffalo hump), and positive DST. o Psychiatric symptoms include elevated mood, psychosis, anxiety and depression. Depression o Patients with depression may have other endocrine irregularities (other than a positive DST), including reduced response to a challenge with thyrotropin-releasing hormone, and abnormalities in growth hormone, melatonin, and gonadotropin. Acute intermitten porphyria *** o Psychiatric symptoms are also associated with metabolic/enzyme disorders, such as acute intermittent porphyria (AIP). o Physical signs and symptoms: porphobilinogen, ++pain, abdo cramps, diarrhea, vomit, seizures, cardiac arrhythmias, flushing, and port wine or purplish discoloration of urine. o Psychiatric symptoms: paranoid delusions and hallucinations, depression, and anxiety. Neuroimaging and Electroencephalography (EEG) Structural and physiological brain abnormalities and EEG changes may be associated with specific psychiatric problems and conditions. Computed tomography (CT) Identifies anatomically based brain changes (i.e., enlarged brain ventricles) in cognitive disorders (e.g., such as Dementia of the Alzheimers Type, and schizophrenia).

CT Scan and Alzheimer Disease

Nuclear magnetic resonance imaging (NMRI, MRI) Identifies demyelinating disease (e.g., multiple sclerosis). Shows physical appearance , water content , etc. (but not function), of neural tissues without exposing the patient to ionizing radiation (is a form of structural imaging). How it works: Radio waves in a magnetic field Func: Provides best anatomical view of brain o Identifies demyelinating disease multiple sclerosis

Pros: Non-invasive Positron Emission Tomography (PET) Localizes areas of the brain that are physiologically active during specific tasks. PET works through measuring metabolism of ligands such as glucose in neural tissue. Measures specific neurotransmitter receptors, and requires a cyclotron Is a functional imagining technique. Functional MRI (fMRI) Also localizes areas of the brain that are physiologically active during specific tasks. fMRI has largely superceded PET for study of brain activation patterns. Can reveal structures and processes associated with perception, thought and action. Is a functional imaging technique. Activity in Brocas area, one of the brains language centres, while subjects thought of a single word beginning with a letter which was flashed on a screen (pic on S37, not really an important pic) Single photon emission tomography (SPECT) Obtains similar data to PET or fMRI. It is more practical for clinical use because it uses a standard gamma camera rather than a cyclotron. EEG (Electroencephalogram) Measures electrical activity in the cortex.

Is useful in diagnosing epilepsy and differentiating delirium (abnormal EEG) from dementia (typically normal EEG). Schizophrenics: in schizo pts, an EEG shows: alpha and theta, delta waves and epileptiform activity. o Evoked EEG (evoked potentials) Measures electrical activity in the cortex in response to tactile, auditory, sound or visual stimulation. Is used to evaluate vision and hearing loss in infants and brain response in comatose and suspected brain-dead patients. Other Tests: Drug-assisted interview o Interviews conducted with amobarbital sodium (the Amytal interview), are used both diagnostically and therapeutically. o Diagnostically, the interviews may help differentiate between organic and nonorganic conditions, particularly in certain patients (e.g., catatonia, stupor, muteness). o This is because organic conditions tend to worsen with amytal infusions, but psychogenic or otherwise nonroganic condiotions tend to get better with disinhibition, decreased anxiety, and/or increased relaxation. o Sedatives can relax patients with conditions such as dissociative disorder, conversion disorder and other disorders involving high levels of anxiety and mute psychotic states. o This will allow patients to express themselves coherently during the interview . o Benzodiazepines may be substituted for amobarbital in the interview. o Sodium Lactate Admin Intravenous (IV) administration of sodium lactate can provoke a panic attack in susceptible patients and can thus help to identify individuals with panic disorder. Inhalation of carbon dioxide can produce similar results. o Galvanic Skin response A component of the famous lie detector test. The electric resistance to skin (galvanic skin response) varies with the patients psychological state. Higher sweat gland activity, seen with sympathetic nervous system arousal (e.g., when lying) results in decreased skin resistance and a positive test However, innocent but anxious people may also have positive tests (false positive) There are biofeedback devices that allow users to gain some voluntary control of their GSRs.