Psychiatry in Neurology

Psychiatry in Neurology

• 1. Psychiatric diagnoses, as described in the Diagnostic and Statistical Manual , 5th Edition (DSM-5), are generally idiopathic diagnoses of exclusion based on sign and symptom clusters (i.e., phenomenology-based syndromes) that cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning.”
• 2. Rather than categorically exclusive, mental illnesses, including personality disorders, exist on a spectrum and are multidimensional.
• 3. Many psychiatric disorders may be described as “functional” disorders as they generally involve dysfunction cortical–subcortical circuits and distributed neuronal networks.
• 4. Psychiatric disorders and neurologic disorders are interrelated and often comorbid, and many neurologic disorders may present first with psychiatric symptoms.
• 5. All patients should be screened for psychiatric disorders and suicidality.
• 6. An elevated suicide risk is associated with depressive disorders, anxiety disorders, schizophrenia, and some neurologic disorders (e.g., Huntington’s disease).
• 7. Clozapine and lithium are associated with a reduction in suicide in certain populations.
• 8. Psychiatric problems generally respond very well to treatment; the best approach is generally combinations of psychotherapy, pharmacotherapy, lifestyle modification, and strengthening social supports.
• 9. Supportive therapy and psychoeducation are appropriate for most patients and can be empowering and bolster healthy coping and resilience.
• 10. Clinicians can foster alliance by first listening and empathically and nonjudgmentally reflecting the patient’s understanding and concerns and validating the patient’s experience of symptoms.
• 11. The mental status exam is performed by observation throughout the patient encounter.
• 12. The cardinal feature of delirium is impaired attention and awareness, which may wax and wane. No other psychiatric disorder can be diagnosed in the context of delirium.
• 13. A patient’s capacity for medical decision making is assessed by the treating physician as part of the informed consent process to some degree for every medical decision.
• 14. Catatonia, neuroleptic malignant syndrome, and serotonin syndrome are emergencies that overlap considerably in their pathophysiology, phenomenology, and treatment.
• 15. Psychiatric disorders typically manifest before the fourth decade, and new onset outside of this range should raise diagnostic suspicion and consideration of additional workup.
• 16. Routine evaluation of psychiatric signs and symptoms includes a physical exam and basic laboratory workup. Additional tests may be necessary depending on the clinical presentation.
• 17. Mood is the persistent “emotional climate” and affect is the transient “emotional weather,” and both have subjective and objective components.
• 18. Bipolar disorder is defined by persistent (lasting many days to weeks) and extreme shifts in mood, not transient affective lability.
• 19. SSRIs are first-line therapies for a broad range of disorders due to their efficacy and tolerability.
• 20. Second-generation “atypical” antipsychotics are associated with lower rates of extrapyramidal symptoms but higher rates of metabolic adverse effects than “typical” antipsychotics.
• 21. Psychosis describes a deficit in reality testing but psychotic disorders typically also involve impairments in thought, beliefs, motor function, and emotional regulation.
• 22. Electroconvulsive therapy is by far the most effective treatment of major depressive disorder.
• 23. Exposure and response prevention is a mainstay of treatment for anxiety disorders.
• 24. Eating disorders are among the most debilitating and potentially lethal mental health disorders.
• 25. The ABC approach is an effective intervention for managing problematic behavior.
• 26. Alcohol and sedative hypnotic withdrawal can be lethal.

Sources

Flashman LA, McAllister TW: Environmental and behavioral interventions. In Arciniegas DB, Anderson CA, Filley CM (eds): Behavioral neurology & neuropsychiatry. New York: Cambridge University Press, 2013, pp 604-626.