LABORATORY TESTS AND

IMAGING IN
PSYCHIATRY

PRESENTED BY
DR. WAI YAN MOE MYINT

INTRODUCTION

Biological evolution of Psychiatry became popular since 1960s

Biological treatments (medications, stimulations, surgery) become mainstay

of Psychiatry

Usage of functional neuroimaging methods (SPECT, PET, fMRI, etc.) for

both clinical and research purposes become more common

Even, more and more evidences are found that Psychotherapies change the
brain and neurotransmitter regulations (visualized by neuroimaging)

INTRODUCTION
But, still diagnoses in Psychiatry are based entirely on behavioral , not
biological, criteria.

Director of NIMH: 'The weakness (of DSM-5) is its lack of validity. Unlike our definitions of ischemic heart
disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical
symptoms, not any objective laboratory measure'.

The chair of DSM-5 issued this agreement: 'In the future, we hope to be able to identify disorders using
biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability
and validity'.
But they also stated: It would be great to have them, but much good diagnostic work can be done without
tests and their lack is not unique to psychiatry.
(According to Psychiatric Times)

INTRODUCTION
Laboratory tests and neuroimaging methods are currently used for;

To support the diagnosis

To rule out potential physical causes
To identify co morbid physical illness (4-18%)

To monitor medication level in our body system

To monitor physiological changes secondary to medications

BASIC SCREENING TESTS

Complete blood count (CBC),
Renal function tests,
Liver function tests, and
thyroid function tests, and
blood sugar

Are ALL these routine testing enough to evaluate for medical illness in
ALL psychiatric patients??

The answer is NO !!

Do not forget medical history and physical examination.

NEUROENDOCRINE TESTS
1. Thyroid function test
Total thyroxine (T4), Free thyroxine (T4), Triiodothyronine (T3) uptake, Total
serum triiodothyronine (T3), Thyroid-stimulating hormone (TSH), The thyrotropinreleasing hormone (TRH) stimulation test (For suspected subclinical Hypothyroidism &
lithium-induced hypothyroidism)

Up to 10 percent of patients complaining of depression and associated fatigue had

incipient hypothyroid disease.

Other symptoms of hypothyroid; weakness, stiffness, poor appetite, constipation,

menstrual irregularities, slowed speech, apathy, impaired memory, and even
hallucinations and delusions

Hyperthyroid might be mistaken for mania, psychosis or anxiety.

Interpretation of thyroid function tests may be complex and is often best done

NEUROENDOCRINE TESTS
2. Dexamethasone-Suppression Test
1 mg of dexamethasone by mouth at 11 pm, and the plasma cortisol level is

measured at 8 am, 4 pm and 11 pm. Plasma cortisol concentrations above 5 mg/dL

(known as non-suppression) are considered abnormal (i.e., a positive result).

help confirm a diagnostic impression of major depressive disorder

False-positive and false-negative results are common, and many
medical conditions and pharmacological agents can interfere with
results

NEUROENDOCRINE TESTS
Other Endocrine Tests
Prolactin

Antipsychotics induced hyperprolactinemia

growth hormone, somatostatin, gonadotropin-releasing hormone (GnRH), the

sex steroids, luteinizing hormone (LH), follicle-stimulating hormone (FSH),
testosterone, and oestrogen.

Anorexia nervosa

Melatonin

Seasonal affective disorder

Arginine vasopressin (AVP)

Lithium induced Diabetes Insipidus

NEUROENDOCRINE TESTS
Anorexia
nervosa

Low Caloric
intake

Low TSH

Low Thyroid
hormone

Disturbed
GnRH
pulsitility
Increased
FSH:LH

Low
oestrogen

Secondary
amenorrhoea

Stress

Increased
Cortisol

Increased GH

COMPLETE BLOOD COUNT

Low RBC and Hb%
Low Hb with high MCV

Carbamazepine
Alcoholic and Folate and vitamin B12
deficiencies

Folate and vitamin B12 deficiencies are associated with dementia; delirium; psychosis, including
paranoia; fatigue; and personality change

High WBC

Lithium toxicity, Neuroleptic malignant

Low WBC

Clozapine, Carbamazepine

WBC of less than 3,000 per mm3 or neutrophil count of less than 1,500 per mm3 is indication to stop
both clozapine and carbamazepine.

Low Platelets

Clozapine, Carbamazepine

INFECTION SCREENING
HIV
High risk: Mania and IVDU
Presentation: dementia, personality changes, affective symptoms of either
mania or depression, and psychosis

Syphilis
High risk: Mania patient
Presentation: Neurosyphilis (Delusions, Hallucinations, Irritability, memory
deterioration)
VDRL (+), TP-PA (-) Possibly false positive due to other infection and rheumatic
diseases

VDRL (-), TP-PA (+) Possibly previous infection

VDRL (+), TP-PA (+) Active infection (Candidate for treatments)

Viral hepatitis (A,B,C)

TESTS RELATED TO PSYCHOTROPIC DRUGS

Benzodiazepine
Antipsychotics

- Baseline LFT

- CBC, LFT, RFT, Lipids, blood sugar

and ECG

Tri/tetracyclic antidepressants - ECG (quinidine-like effect)

MAOI
- LFT, blood pressure
Lithium
- Thyroid function tests,
Electrolyte monitoring,
CBC (WBC),
Renal function tests and

Baseline ECG

TESTS RELATED TO PSYCHIATRIC TREATMENTS

Carbamazepine
Valproate

- CBC, U&E, LFT, ECG

- CBC, LFT

Screening urine pregnancy test in women of childbearing age

before administration of above mood stabilizers ( also Lamotrigine)

Neuroleptic Malignant Syndrome

BUN, Cr, and
myoglobin

Electroconvulsive Therapy
urinalysis, and
ECG, fundoscopy

- CBC, serum electrolytes,

creatine kinase, urine
- CBC, serum electrolytes,
liver function tests,

MONITORING BLOOD CONCENTRATION OF

PSYCHOTROPIC MEDICATION
Lithium

- 0.6-1.2 mEq/L (Normal range)

?? 1.5-1.8 mEq/L (For acutely maniac patient)

<0.4 mEq/L ( Placebos effect)

>2.0 mEq/L (Toxic concentration)

Carbamazepine

- 8 to 12 ng/mL (Normal range)

>15 ng/mL (Toxic concentration)

Valproate

- 45 to 50 ng/mL (Normal range)

>125 ng/mL (Toxic concentration)

Clozapine
Nortriptyline

- 350-500 g/L (Normal range)

- 50-150 g/L (Normal range)

The blood specimen should be drawn 10 to 14 hours after the last dose,
usually in the morning after a bedtime dose.

URINE TESTS FOR DRUGS OF ABUSE

Drug
Alcohol
Amphetamine

Length of Time Detected in Urine

712 hrs
48 hrs

Barbiturate
Benzodiazepine

24 hrs (short acting); 3 wks (long acting)

3 days

Cocaine
Codeine
Heroin
Marijuana
Methadone (Dolophine)

68 hrs (metabolites, 24 days)

48 hrs
3672 hrs
3672 hrs
3 days

Methaqualone

7 days

Morphine (Duramorph)

4872 hrs

Phencyclidine

8 days

Propoxyphene (Darvon)

648 hrs

IMAGING STUDIES IN PSYCHIATRY

Magnetic Resonance Imaging (MRI)

Can detect a large variety of structural abnormalities

Provide the clinician with images of anatomical structures viewed from
cross-sectional, coronal, or oblique perspectives

Unique in its ability to identify periventricular white matter

hyperintensities

Useful in examining the patient for particular diseases, such as

nonmeningeal neoplasms, vascular malformations, seizure foci,
demyelinating disorders, neurodegenerative disorders, and infarctions

IMAGING STUDIES IN PSYCHIATRY

Scan parameters; T1 and T2.
T1-weighted scans provide detailed visualizations of brain anatomy.
Extracellular fluid, such as edema, looks dark. In contrast, T2-weighted scans
reveal a white pattern for edema. These scans are useful in examining the patient
for white matter disease.

The advantages of MRI include the absence of ionizing radiation and

the absence of iodine-based contrast agents. Contrast agents are
based on gadolinium, a rare earth metal, and usually do not provoke
an allergic response

IMAGING STUDIES IN PSYCHIATRY

Computed Tomography

Cross-sectional X-ray images of the brain

Can detect structural abnormalities in the cortical and subcortical
regions of the brain

Looking for evidence of a stroke, subdural hematoma, tumor, or

abscess, skull fractures

May be performed with or without contrast. The purpose of contrast is

to enhance the visualization of diseases that alter the bloodbrain
barrier, such as tumors, strokes, abscesses, and other infections

Allergic reactions to contrast may occur

IMAGING STUDIES IN PSYCHIATRY

Indications commonly include focal findings on the neurological
examination or abnormalities on an EEG

Slightly more controversial indications include impaired cognition on

the mental status examination, the first episode of psychosis
(especially if the presentation is atypical), delirium, late-onset (after 50
years of age) personality disorders, psychosis, or affective illness,
prolonged catatonia

IMAGING STUDIES IN PSYCHIATRY

Positron Emission Tomography

require a PET tomograph (the scanner) and a cyclotron to create the

relevant isotopes

involves the detection and measurement of emitted positron radiation

after the injection of a compound that has been tagged with an
positron emitting isotope

Typically, PET scans use fluorodeoxyglucose (FDG) to measure

regional brain glucose metabolism

regional glucose metabolism is directly proportionate to neuronal

activity

Brain FDG scans are useful in the differential diagnosis of dementing

IMAGING STUDIES IN PSYCHIATRY

Single Photon Emission Computed Tomography

performed using a dedicated tomographic camera to detect radiation

emitted from a patient after the injection of radiolabeled compounds

SPECT scanners to measure blood flow in dementia patients in whom

a pattern of reduced temporal-parietal blood flow is found

IMAGING STUDIES IN PSYCHIATRY

Functional Magnetic Resonance Imaging

fMRI data are superimposed on conventional MRI images, resulting in

detailed brain maps of brain structure and function.

The measurement of blood flow involves the clever use of the haem
molecule as an endogenous contrast agent

IMAGING STUDIES IN PSYCHIATRY

Magnetic Resonance Spectroscopy
Specific upgrades to the hardware and software

Signal from protons is suppressed, other conpounds to be

measured
MRS is able to measure compounds tagged with nonradioactive
isotopes of hydrogen, phosphorus, lithium, sodium, and fluorine

Magnetic Resonance Angiography

Method for creating three-dimensional maps of cerebral blood
flow
The effect of the iron atom in the haemoglobin molecule is used

OTHER STUDIES IN PSYCHIATRY

ELECTROENCEPHALOGRAM

Can be used in different ways to study specific brain states or

activities

Displayed on paper tracings in the manner of conventional EEG

recordings

Can be digitized, and the digitized data can be transformed, to yield

color-coded topographic brain maps of regional activity

Are used to localize seizure foci and to evaluate delirium

Important to remember that seizures are a clinical diagnosis; a
normal EEG does not rule out the possibility of a seizure disorder

OTHER STUDIES IN PSYCHIATRY

Evoked Potential

Measurement of the EEG response to specific sensory stimulation

Stimulation may be visual, auditory, or somatosensory (flashing lights,
a specific tone, an electrical stimulation to an extremity)

Assist in the assessment of demyelinating disorders such as multiple

sclerosis (MS). In psychiatry.

In Psychiatry, EP testing may help in the differentiation of organic

from functional impairments. (evaluate possible hysterical blindness)

OTHER STUDIES IN PSYCHIATRY

Polysomnography

is used to assess disorders of sleep

concurrently assessing the EEG, ECG, blood oxygen saturation,
respirations, body temperature, the electromyogram, and the electrooculogram, during sleep

REFERENCES
1. Kaplan and Sadocks Comprehensive Textbook of Psychiatry 8th edition; Chapter
7.8, Medical Assessment and Laboratory Testing in Psychiatry

2. kaplan and Sadocks Concise Textbook of Clinical Psychiatry 3rd edition; Chapter
3, Laboratory Tests in Psychiatry

3. Thyroid Disease and Mental Disorders;

(http://www.medscape.com/viewarticle/723663_6)

4. British Journal of Clinical Pharmacology; Therapeutic drug monitoring of

psychotropic medications
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2014933/)

5. American Medical Association Journal of Ethics, Diagnostic Brain Imaging in

Psychiatry: Current Uses and Future Prospects (http://virtualmentor.amaassn.org/2012/06/stas1-1206.html)

6. Psychiatric Times; The Role of Biological Tests in Psychiatric Diagnosis

(http://www.psychiatrictimes.com/blogs/dsm-5/role-biological-tests-psychiatricdiagnosis)