NEUROPSYCHIATRY (September 2008) Indications for CT Scan or MRI

UST Faculty of Medicine and Surgery • Confusion and/or dementia of unknown cause
LABORATORY TESTS IN PSYCHIATRY • First episode of a psychotic disorder of unknown etiology
Lecturer: Dr. Ramon S. Javier • First episode of a major mood disorder after age 50 years
• Marked personality change after age 50 years
• History of recent head trauma
Objectives • Anorexia nervosa with marked weight loss
1. To complete a general medical workup of the sort done routinely for • Alcoholism or other substance abuse disorder with signs and
any hospital admission symptoms of cognitive deterioration
2. To rule out non-psychiatric causes of the presenting symptoms
3. To conduct a specific work-up appropriate for a specific treatment that Some clues suggestive of organic mental disorder
has been planned 1. Psychiatric symptoms after age 40
4. To obtain information that will assist in making a differential diagnosis 2. Psychiatric symptoms
among several different mental illnesses a. during a major medical illness
5. To assist in determining pathophysiology, estimating prognosis, and b. while taking drugs that can cause mental symptoms
formulating a treatment plan. 3. History of
a. alcohol or drug abuse
I. GENERAL MEDICAL WORKUP b. physical illness impairing organ function
• standards vary in different hospital settings c. taking multiple prescribed or over-the-counter drugs
• CBC, FBS, BUN, Creatinine, liver enzymes, serum 4. Family history of
electrolytes a. degenerative or inheritable brain disease
• Chest X-ray, ECG b. inherited metabolic disease (eg, diabetes, pernicious
anemia, porphyria)
II. TO RULE OUT . . . . . 5. Mental signs including
• ‘organic’ vs ‘functional’ a. altered level of consciousness
b. fluctuating mental status
Conditions Considered in the c. cognitive impairment
Differential Diagnosis of Major Mental Illnesses d. episodic, recurrent, or cyclic course
• Multi-infarct Dementia e. visual, tactile, or olfactory hallucinations
• Subdural Hematoma 6. Physical signs including
• Normal-Pressure Hydrocephalus a. signs of organ malfunction that can affect the brain
• Tumors b. focal neurologic deficits
• HIV-related Dementia c. diffuse subcortical dysfunction ( slowed speech / mentation
• Temporal Lobe Epilepsy /movement, ataxia, incoordination, tremor, chorea,
• Endocrine/Metabolic Disorders asterixis, dysarthria)
• Exposure to Toxins 7. Cortical dysfunction ( dysphasia, apraxias, agnosias, visuospatial
• Vitamin Deficiency Syndromes (eg pernicious anemia) deficits, or defective cortical sensation)
• Other CNS infections (TBM, syphilis)
• Substance-induced Symptoms Provocative tests for Panic Disorder
• Neuropsychiatric effects of medical treatment (eg K depletion Intravenous lactate infusions – reported to induce panic attacks
from diuretics, fatigue from propranolol, digitalis toxicity, (+) in 70 % – 90 % of pts with panic disorder
Phenytoin toxicity) (+) in 0 – 30 % of control subjects
Other substances: CO2, isoproterenol, beta-carboline, yohimbine, &
III. PERTAINING TO A SPECIFIC TYPE OF TREATMENT Caffeine
• to determine & document the pt’s physical condition before
the tx The Future
• to rule out conditions that might be adversely affected by the 1. Genetic markers
treatment 2. Biochemical markers – examination of potentially relevant
• to establish baseline values for the pt before instituting compounds found in blood, urine, CSF, skin
treatment
Body fluid markers - molecular compounds,
ECT - eg., DA, 5HT, NE & their metabolites ( HVA,
• routine chemistries, urinalysis 5-HIAA, MHPG), various neuropeptides
• ECG – baseline cardiac status (endorphins, enkephalins) & biological
• if with questionable signs of dementia -> further workup compounds (IgM, plasma melatonin)
LITHIUM Therapy Peripheral tissue markers:
• BUN, serum creatinine, serum electrolytes, urinalysis blood – NT receptors, enzymes
• T3, T4 levels platelets – MAO, alpha1-adrenergic receptors, serotonin
• ? ECG (age) reuptake sites, H-labeled-imipramine binding sites
• serum lithium levels RBC – lithium transport mechanism, COMT
skin – fibroblasts – NT receptors, important transport systems
ANTIPSYCHOTIC Therapy
• no special work-up prior to therapy
• if poor response -> blood levels (haloperidol, clozapine, CBZ,
VPA)
• clozapine & blood dyscrasias
• clozapine, olanzapine & weight gain
• genetic subtyping for cytochrome P450 allele
• SPECT, PET – visualize & measure density of D2 receptors

ANTIDEPRESSANT Therapy
• no special work-up prior to therapy
• tricyclics – ECG
• poor response
– blood levels
– no imaging techniques available yet

IV/ V. TO ASSIST IN PSYCHIATRIC DIFFERENTIAL DIAGNOSIS and

TREATMENT PLANNING
• Various neuroimaging and psychological tests
• Determines the overall integrity of brain function, the presence
of structural abnormalities, or the presence of generalized
intellectual deficits or specific learning disabilities

Abnormalities Commonly Seen in Schizophrenia

• Ventricular enlargement
• Prominent cortical sulci
• Decreased cerebral size
• Decreased frontal / temporal /thalamic / etc size
• Increased caudate/putamen size
• Midline developmental abnormalities

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