Psychiatric

Assessment and
Consultation

Felicia A. Smith, M.D.

John Querques, M.D.
James L. Levenson, M.D.
Theodore A. Stern, M.D.

(Reprinted with permission from The American Psychiatric Publishing Textbook of Psychosomatic Medicine. Edited by Levenson JL.
Washington, DC, American Psychiatric Publishing, 2005, pp 314)

PSYCHIATRIC

CONSULTATION IN THE
GENERAL HOSPITAL

Psychiatrists who work in medical settings are

charged with providing expert consultation to medical and surgical patients. In many respects, psychiatric care of such patients is no different from the
treatment of patients in a psychiatric clinic or in a

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private office. However, the constraints of the modern hospital environment demand a high degree of
adaptability. Comfort, quiet, and privacy are scarce
commodities in medical and surgical units.
Interruptions by medical or nursing staff, visitors,
and roommates erode the privacy that the psychiatrist usually expects. Patients who are sick, preoccupied with their physical condition, and in pain are
ill-disposed to engage in the exploratory interviews
that often typify psychiatric evaluations in other settings. Monitoring devices replace the plants, pictures, and other accoutrements of a typical office.
Nightstands and tray tables are littered with medical
paraphernalia commingled with personal effects.
The consultant must be adept at gathering the
requisite diagnostic information efficiently from the
data permitted by the patients clinical condition
and must be able to tolerate the sights, sounds, and
smells of the sickroom. Additional visits for more
history are often inevitable. In the end, the diagnosis will likely fall into one (or more) of the categories
outlined in Lipowskis (1967) classification, which is
still relevant today (Table 1).
Although the consultant is summoned by the
patients physician, in most cases the visit is unannounced and is not requested by the patient, from
whom cooperation is expected. Explicitly acknowledging this reality and apologizing if the patient was
not informed are often sufficient to gain the
patients cooperation. Cooperation is enhanced if
the psychiatrist sits down and operates at eye level
with the patient. By offering to help the patient get
comfortable (e.g., by adjusting the head of the bed,
bringing the patient a drink or a blanket, or adjusting the television) before and after the encounter,
the consultant can increase the chances of being welcomed then and for follow-up evaluations.
When psychiatrists are consulted for unexplained
physical symptoms or for pain management, it is
useful to empathize with the distress that the
patient is experiencing. This avoids conveying any
judgment on the etiology of the pain except that

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INFLUENTIAL
P U B L I C AT I O N S

Psychosomatic medicine is clinically rooted in

consultation-liaison psychiatry, expanding from its
beginnings on a few general medical wards of large
hospitals in the 1930s to specialized medical units
throughout various parts of the health care delivery
system. Practitioners in this discipline assist with the
care of a variety of patients, especially those with
complex illnesses such as cancer, organ transplantation, and HIV infection (Gitlin et al. 2004; Hackett
et al. 2004). In the medical setting, prompt recognition and evaluation of psychiatric problems are
essential because psychiatric comorbidity often exacerbates the course of medical illness, causes significant distress in the patient, prolongs hospital length
of stay, and increases costs of care. Psychiatrists in
medical settings may be asked to evaluate a wide
variety of conditions. These can include dementia,
delirium, agitation, psychosis, substance abuse or
withdrawal, somatoform disorders, personality disorders, and mood and anxiety disorders, as well as
suicidal ideation, noncompliance, and aggressive
and other behavioral problems. In addition, ethical
and legal considerations are often critical elements of
the psychiatric consultation.
In this introductory chapter, we present a detailed
approach to psychiatric assessment and consultation
in a medical setting. Flexibility is essential for psychiatric consultants to be successful in the evaluation of affective, behavioral, and cognitive
disturbances in medically ill patients. In the final
section of the chapter, we briefly outline the benefits of psychiatric consultation for patients as well as
for the greater hospital and medical communities.

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Categories of Psychiatric Differential

Diagnoses in the General Hospital
Table 1.

Psychiatric presentations of medical conditions

Psychiatric complications of medical conditions or treatments
Psychological reactions to medical conditions or treatments
Medical presentations of psychiatric conditions
Medical complications of psychiatric conditions or treatments
Comorbid medical and psychiatric conditions
Source: Adapted from Lipowski 1967

the suffering is real. After introductions, if the

patient is in pain, the consultants first questions
should address this issue. Failing to do so conveys
a lack of appreciation for the patients suffering
and may be taken by the patient as disbelief in his
or her symptoms. Starting with empathic questions about the patients suffering establishes rapport and also guides the psychiatrist in setting the
proper pace of the interview. Finally, because a
psychiatric consultation will cause many patients
to fear that their physician thinks they are crazy,
the psychiatrist may first need to address this fear.

THE

PROCESS OF THE CONSULTATION

Although it is rarely as straightforward as the following primer suggests, the process of psychiatric
consultation should, in the end, include all the components explained below and summarized in Table 2.

SPEAK

DIRECTLY WITH THE REFERRING CLINICIAN

Requests for psychiatric consultation are notorious for being vague and imprecise (e.g., rule out

Procedural Approach to Psychiatric

Consultation
Table 2.

Speak directly with the referring clinician.

Review the current records and pertinent past records.
Review the patients medications.
Gather collateral data.
Interview and examine the patient.
Formulate diagnostic and therapeutic strategies.
Write a note.
Speak directly with the referring clinician.
Provide periodic follow-up.

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depression or patient with schizophrenia). They

sometimes signify only that the team recognizes
that a problem exists; such problems may range
from an untreated psychiatric disorder to the experience of countertransferential feelings. In speaking
with a member of the team that has requested the
consultation, the consultant employs some of the
same techniques that will be used later in examining the patient; that is, he or she listens to the
implicit as well as the explicit messages from the
other physician (Murray 2004). Is the physician
angry with the patient? Is the patient not doing
what the team wants him or her to do? Is the fact
that the patient is young and dying leading to the
teams overidentification with him or her? Is the
team frustrated by an elusive diagnosis? All of these
situations generate emotions that are difficult to
reduce to a few words conveyed in a consultation
request; moreover, the feelings often remain out of
the teams conscious awareness. This brief interaction may give the consultant invaluable information about how the consultation may be useful to
the team and to the patient.

REVIEW

THE CURRENT RECORDS AND PERTINENT

PAST RECORDS

When it is done with the unfailing curiosity of a

detective hot on the trail of hidden clues, reading
a chart can be an exciting and self-affirming part
of the consultation process. Although it does not
supplant the consultants independent history taking or examination, the chart review provides a
general orientation to the case. Moreover, the consultant is in a unique position to focus on details
that may have been previously overlooked. For
example, nurses often document salient neurobehavioral data (e.g., the level of awareness and the
presence of confusion or agitation); physical and
occupational therapists estimate functional abilities crucial to the diagnosis of cognitive disorders
and to the choice of an appropriate level of care
(e.g., nursing home or assisted-living facility); and
speech pathologists note alterations in articulation, swallowing, and language, all of which may
indicate an organic brain disease. All of them may
have written progress notes about adherence to
treatment regimens, unusual behavior, interpersonal difficulties, or family issues encountered in
their care of the patient. These notes may also provide unique clues to the presence of problems such
as domestic violence, factitious illness, or personality disorders. In hospitals or clinics where nurses
notes are kept separate from the physicians
progress notes, it is essential for the consultant to
review those sections.

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REVIEW

THE PATIENTS MEDICATIONS

Construction of a medication list at various time

points (e.g., at home, on admission, on transfer
within the hospital, and at present) is always good,
if not essential, practice. Special attention should
be paid to medications with psychoactive effects
and to those associated with withdrawal syndromes
(both obvious ones like benzodiazepines and opiates, and less obvious ones like antidepressants,
anticonvulsants, and beta-blockers). Review of
order sheets or computerized order entries is not
always sufficient, becausefor a variety of reasonspatients may not always receive prescribed
medications; therefore, medication administration
records should also be reviewed. Such records are
particularly important for determining the frequency of administration of medicines ordered on
an as-needed basis. For example, an order for
lorazepam 12 mg every 46 hours as needed may
result in a patient receiving anywhere from 0 mg to
12 mg in a day, which can be critical in cases of
withdrawal or oversedation.

GATHER

COLLATERAL DATA

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AND EXAMINE THE PATIENT

Armed with information gleaned and elicited

from other sources, the psychiatric consultant now
makes independent observations of the patient and
collects information that may be the most reliable
of all because it comes from direct observations.
For non-English-speaking patients, a translator is
often needed. Although using family members may
be expedient, their presence often compromises the
questions asked and the translations offered
because of embarrassment or other factors. It is
therefore important to utilize hospital translators
or, for less common languages, services via telephone. This can be difficult, but it may be necessary in obtaining a full and accurate history.

Mental status examination

A thorough mental status examination is central to
the psychiatric evaluation of the medically ill patient.
Because the examination is hierarchical in nature,
care must be taken to complete it in a systematic
fashion (Hyman and Tesar 1994). The astute consultant will glean invaluable diagnostic clues from a
combination of observation and questioning.
Level of consciousness. Level of consciousness
depends on normal cerebral arousal by the reticular
activating system. A patient whose level of consciousness is impaired will inevitably perform
poorly on cognitive testing. The finding of disorientation implies cognitive failure in one or several
domains, and it is helpful to test orientation near
the start of the mental status examination.
Attention. The form of attention most relevant
to the clinical mental status examination is the sustained attention that allows one to concentrate on
cognitive tasks. Disruption of attentionoften by
factors that diffusely disturb brain function, such as
drugs, infection, or organ failureis a hallmark of
delirium. Sustained attention is best tested with
moderately demanding, nonautomatic tasks such
as reciting the months backward or, as in the MiniMental State Examination (MMSE; Folstein et al.
1975), spelling world backward or subtracting 7
serially from 100. Serial subtraction is intended to
be a test of attention, not arithmetic ability, so the
task should be adjusted to the patients native ability and educational level (serial 3s from 50, serial 1s
from 20). An inattentive patients performance on
other parts of the mental status examination may
be affected on any task requiring sustained focus.
Memory. Working memory is tested by asking the
patient to register some information (e.g., three
words) and to recall that information after an interval of at least 3 minutes during which other testing

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INFLUENTIAL
P U B L I C AT I O N S

Histories from hospitalized medically ill

patients may be especially spotty and unreliable, if
not nonexistent (e.g., with a patient who is somnolent, delirious, or comatose). Data from collateral sources (e.g., family members; friends;
current and outpatient health care providers; case
managers; and, in some cases, police and probation officers) may be of critical importance.
However, psychiatric consultants must guard
against prizing any single partys version of historical events over anothers; family members and
others may lack objectivity, be in denial, be overinvolved, or have a personal agenda to advance.
For example, family members tend to minimize
early signs of dementia and to overreport depression in patients with dementia. Confidentiality
must be valued when obtaining collateral information. Ideally, one obtains the patients consent
first; however, this may not be possible if the
patient lacks capacity or if a dire emergency is in
progress (see Chapter 3, Legal Issues, and
Chapter 4, Ethical Issues). Moreover, in certain
situations there may be contraindications to contacting some sources of information (e.g., an
employer of a patient with substance abuse or the
partner of a woman who is experiencing abuse).
Like any astute physician, the psychiatrist collates
and synthesizes all available data and weighs each
bit of information according to the reliability of
its source.

INTERVIEW

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prevents rehearsal. This task can also be considered a

test of recent memory. Semantic memory is tapped by
asking general-knowledge questions (e.g., Who is
the President?) and by naming and visual recognition tasks. The patients ability to remember aspects
of his or her history serves as an elegant test of episodic
memory (as well as of remote memory). Because
semantic and episodic memories can be articulated,
they constitute declarative memory. In contrast, procedural memory is implicit in learned action (e.g., riding a bicycle) and cannot be described in words.
Deficits in procedural memory can be observed in a
patients behavior during the clinical evaluation.
Executive function. Executive function refers to
the abilities that allow one to plan, initiate, organize,
and monitor thought and behavior. These abilities,
which localize broadly to the frontal lobes, are essential for normal social and professional performance
but are difficult to test. Frontal lobe disorders often
make themselves apparent in social interaction with
a patient and are suspected when one observes disinhibition, impulsivity, disorganization, abulia, or
amotivation. Tasks that can be used to gain some
insight into frontal lobe function include verbal fluency, such as listing as many animals as possible in 1
minute; motor sequencing, such as asking the
patient to replicate a sequence of three hand positions; the go/no-go task, which requires the patient
to tap the desk once if the examiner taps once, but
not to tap if the examiner taps twice; and tests of
abstraction, including questions like What do a tree
and a fly have in common?
Language. Language disorders result from lesions
of the dominant hemisphere. In assessing language,
one should first note characteristics of the patients
speech (e.g., nonfluency or paraphasic errors) and
then assess comprehension. Naming is impaired in
both major varieties of aphasia, and anomia can be a
clue to mild dysphasia. Reading and writing should
also be assessed. Expressive (Brocas or motor) aphasia is characterized by effortful, nonfluent speech
with use of phonemic paraphasias (incorrect words
that approximate the correct ones in sound),
reduced use of function words (e.g., prepositions
and articles), and well-preserved comprehension.
Receptive (Wernickes or sensory) aphasia is characterized by fluent speech with both phonemic and
semantic paraphasias (incorrect words that approximate the correct ones in meaning) and poor comprehension. The stream of incoherent speech and
the lack of insight in patients with Wernickes aphasia sometimes lead to misdiagnosis of a primary
thought disorder and psychiatric referral; the clue to
the diagnosis of a language disorder is the severity of
the comprehension deficit. Global dysphasia combines features of Brocas and Wernickes aphasias.

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Selective impairment of repetition characterizes conduction aphasia. The nondominant hemisphere

plays a part in the appreciation and production of
the emotional overtones of language.
Praxis. Apraxia refers to an inability to perform
skilled actions (e.g., using a screwdriver, brushing
ones teeth) despite intact basic motor and sensory
abilities. These abilities can be tested by asking a
patient to mime such actions or by asking the
patient to copy unfamiliar hand positions.
Constructional apraxia is usually tested with the
Clock Drawing Test. Gait apraxia involves difficulty
in initiating and maintaining gait despite intact basic
motor function in the legs. Dressing apraxia is difficulty in dressing caused by an inability to coordinate
the spatial arrangement of clothes with the body.
Mood and affect. Mood and affect both refer to
the patients emotional state, mood being the
patients perception and affect being the interviewers perception. The interviewer must interpret
both carefully, taking into account the patients
medical illness. Normal but intense expressions of
emotion (e.g., grief, fear, or irritation) are common
in patients with serious medical illness but may be
misperceived by nonpsychiatric physicians as evidence of psychiatric disturbance. Disturbances in
mood and affect may also be the result of brain dysfunction or injury. Irritability may be the first sign
of many illnesses, ranging from alcohol withdrawal
to rabies. Blunted affective expression may be a
sign of Parkinsons disease. Intense affective lability
(e.g., pathological crying or laughing) with relatively normal mood occurs with some diseases or
injuries of the frontal lobes.
Perception. Perception in the mental status
examination is primarily concerned with hallucinations and illusions. However, before beginning any
part of the clinical interview and the mental status
examination, the interviewer should establish
whether the patient has any impairment in vision
or hearing that could interfere with communication. Unrecognized impairments have led to erroneous impressions that patients were demented,
delirious, or psychotic. Although hallucinations in
any modality may occur in primary psychotic disorders (e.g., schizophrenia or affective psychosis),
prominent visual, olfactory, gustatory, or tactile
hallucinations suggest a secondary medical etiology. Olfactory and gustatory hallucinations may be
manifestations of seizures, and tactile hallucinations are often seen with substance abuse.
Judgment and insight. The traditional question
for the assessment of judgment (i.e., What would
you do if you found a letter on the sidewalk?) is
much less informative than questions tailored to
the problems faced by the patient being evaluated;

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for example, If you couldnt stop a nosebleed,

what would you do? If you run out of medicine
and you cant reach your doctor, what would you
do? Similarly, questions to assess insight should
focus on the patients understanding of his or her
illness, treatment, and life circumstances.
Further guidance on mental status examination.
An outline of the essential elements of a comprehensive mental status examination is presented in
Table 3. Particular cognitive mental status testing
maneuvers are described in more detail in Table 4.
More detailed consideration of the mental status
examination can be found elsewhere (Strub and
Black 2000; Trzepacz and Baker 1993).

Physical examination

The Mental Status Examination

Level of consciousness
Alert, drowsy, somnolent, stuporous, comatose; fluctuations suggest
delirium
Appearance and behavior
Overall appearance, grooming, hygiene
Cooperation, eye contact, psychomotor agitation or retardation
Abnormal movements: tics, tremors, chorea, posturing
Attention
Vigilance, concentration, ability to focus, sensory neglect
Orientation and memory
Orientation to person, place, time, situation
Recent, remote, and immediate recall
Language
Speech: rate, volume, fluency, prosody
Comprehension and naming ability
Abnormalities include aphasia, dysarthria, agraphia, alexia, clanging,
neologisms, echolalia
Constructional ability
Clock drawing to assess neglect, executive function, and planning
Drawing of a cube or intersecting pentagons to assess parietal function
Mood and affect
Mood: subjective sustained emotion
Affect: observed emotionquality, range, appropriateness
Form and content of thought
Form: linear, circumstantial, tangential, disorganized, blocked
Content: delusions, paranoia, ideas of reference, suicidal or homicidal
ideation

INFLUENTIAL
P U B L I C AT I O N S

Although the interview and mental status examination as outlined above are generally thought to be the
primary diagnostic tools of the psychiatrist, the
importance of the physical examination should not be
forgotten, especially in the medical setting. Most psychiatrists do not perform physical examinations on
their patients. The consultation psychiatrist, however,
should be familiar with and comfortable performing
neurological examinations and other selected features
of the physical examination that may uncover the
common comorbidities in psychiatric patients
(Granacher 1981; Summers et al. 1981a, 1981b). At
an absolute minimum, the consultant should review
the physical examinations performed by other physicians. However, the psychiatrists examination of the
patient, especially of central nervous system functions
relevant to the differential diagnosis, is often essential.
A fuller physical examination is appropriate on medical-psychiatric units or whenever the psychiatrist has
assumed responsibility for the care of a patients medical problems. Even with a sedated or comatose
patient, simple observation and a few maneuvers that
involve a laying on of hands may potentially yield a
bounty of findings. Although it is beyond the scope of
this chapter to discuss a comprehensive physical
examination, Table 5 provides a broad outline of
selected findings of the physical examination and
their relevance to the psychiatric consultation.

Table 3.

Perception
Auditory, visual, gustatory, tactile, olfactory hallucinations
Judgment and insight
Understanding of illness and consequences of specific treatments
offered
Reasoning
Illogical versus logical; ability to make consistent decisions
Source: Adapted from Hyman and Tesar 1994

FORMULATE

DIAGNOSTIC AND THERAPEUTIC

STRATEGIES

By the time the consultant arrives on the scene,

routine chemical and hematological tests and urinalyses are almost always available and should be
reviewed along with any other laboratory, imaging,
and electrophysiological tests. The consultant then
considers what additional tests are needed to arrive
at a diagnosis. Attempts have been made in the past

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to correlate biological tests, such as the dexamethasone suppression test, with psychiatric illness;
despite extensive research, however, no definitive
biological tests are available to identify psychiatric
disorders. Before ordering a test, the consultant
must consider the likelihood that the test will contribute to making a diagnosis.

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Table 4.

Detailed Assessment of Cognitive Domains

Cognitive domain

Assessment

Level of consciousness and arousal

Inspect the patient

Orientation to place and time

Ask direct questions about both of these

Registration (recent memory)

Have the patient repeat three words immediately

Recall (working memory)

Have the patient recall the same three words after performing another task for at least 3
minutes

Remote memory

Ask about the patients age, date of birth, milestones, or significant life or historical events
(e.g., names of presidents, dates of wars)

Attention and concentration

Subtract serial 7s (adapt to the patients level of education; subtract serial 3s if less educated). Spell world backward (this may be difficult for non-English speakers). Test digit span
forward and backward. Have the patient recite the months of the year (or the days of the
week) in reverse order.

Language

(Adapt the degree of difficulty to the patients educational level)

Comprehension

Inspect the patient while he or she answers questions

Ask the patient to point to different objects
Ask yes or no questions
Ask the patient to write a phrase (paragraph)

Naming

Show a watch, pen, or less familiar objects, if needed

Fluency

Assess the patients speech

Have the patient name as many animals as he or she can in 1 minute

Articulation

Listen to the patients speech

Have the patient repeat a phrase

Reading

Have the patient read a sentence (or a longer paragraph if needed)

Executive function

Determine if the patient requires constant cueing and prompting

Commands
Construction

Have the patient follow a three-step command

Have the patient draw interlocked pentagons
Have the patient draw a clock

Motor programming tasks

Have the patient perform serial hand sequences

Have the patient perform reciprocal programs of raising fingers

Judgment and reasoning

Listen to the patients account of his or her history and reason for hospitalization
Assess abstraction (similarities: dog/cat; red/green)
Ask about the patients judgment about simple events or problems: A construction worker
fell to the ground from the seventh floor of the building and broke his two legs; he then ran to
the nearby hospital to ask for medical help. Do you have any comment on this?

There is an extensive list of studies that could be

relevant to psychiatric presentations; the most
common screening tests in clinical practice are
listed in Table 6. It was once common practice for
the psychiatrist to order routine batteries of tests,
especially in cognitively impaired patients, in a
stereotypical diagnostic approach to the evaluation
of dementia or delirium. In modern practice, tests
should be ordered selectively, with consideration
paid to sensitivity, specificity, and cost-effectiveness. Perhaps most importantly, careful thought

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should be given to whether the results of each test

will affect the patients management. Finally, further studies may be beneficial in certain clinical situations as described throughout this book.

Routine tests
As far as screening is concerned, a complete
blood cell count may reveal anemia that contributes to depression or infection that causes psychosis. Leukocytosis is seen with infection and

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Table 5.

Selected Elements of the Physical Examination and Significance of Findings

Elements

Examples of Possible Diagnoses

General
General appearance healthier than expected
Fever
Blood pressure or pulse abnormalities
Body habitus

Somatoform disorder
Infection or NMS
Withdrawal, thyroid or cardiovascular disease
Eating disorders, polycystic ovaries, or Cushing syndrome

Skin
Diaphoresis
Dry, flushed
Pallor
Changes in hair, nails, skin
Jaundice
Characteristic stigmata
Bruises

Fever, withdrawal, NMS

Anticholinergic toxicity, heat stroke
Anemia
Malnutrition, thyroid or adrenal disease
Liver disease
Syphilis, cirrhosis, or self-mutilation
Physical abuse, ataxia, traumatic brain injury

Eyes
Mydriasis
Miosis
Kayser-Fleischer pupillary rings

Opiate withdrawal, anticholinergic toxicity

Opiate intoxication, cholinergic toxicity
Wilsons disease

Neurological
Tremors
Primitive reflexes present
(e.g., snout, glabellar, and grasp)
Hyperactive deep-tendon reflexes
Ophthalmoplegia
Papilledema
Hypertonia, rigidity, catatonia, parkinsonism
Abnormal movements
Abnormal gait

Delirium, withdrawal syndromes, parkinsonism

Dementia, frontal lobe dysfunction

Loss of position and vibratory sense

Note: EPS=extrapyramidal side effects; NMS=neuroleptic malignant syndrome

other acute inflammatory conditions, lithium therapy, and neuroleptic malignant syndrome, whereas
leukopenia and agranulocytosis may be caused by
certain psychotropic medications. A serum chemistry panel may point to diagnoses as varied as liver
disease, eating disorders, renal disease, malnutrition, and hypoglycemiaall of which may have
psychiatric manifestations (Alpay and Park 2004).
Serum and urine toxicological screens are helpful in
cases of altered sensorium and obviously whenever
substance abuse, intoxication, or overdose is suspected. Because blood tests for syphilis, thyroid
disease, and deficiencies of vitamin B12 and folic
acid (conditions that are curable) are readily available, they warrant a low threshold for their use. In
patients with a history of exposures, HIV infection
should not be overlooked. Obtaining a pregnancy
test is often wise in women of childbearing age to
inform diagnostically as well as to guide treatment
options. Urinalysis, chest radiography, and electrocardiography are particularly important screening
tools in the geriatric population. Although it is not

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a first-line test, cerebrospinal fluid analysis should

be considered in cases of mental status changes
associated with fever, leukocytosis, meningismus,
or unknown etiology. Increased intracranial pressure should be ruled out before a lumbar puncture
is performed, however. More detailed discussion of
specific tests is provided in relevant chapters
throughout this text.

INFLUENTIAL
P U B L I C AT I O N S

Withdrawal, hyperthyroidism
Wernickes encephalopathy, brain stem dysfunction, dystonic reaction
Increased intracranial pressure
EPS, NMS
Parkinsons disease, Huntingtons disease, EPS
Normal pressure hydrocephalus, Parkinsons disease,
Wernickes encephalopathy
Vitamin B12 deficiency

Neuroimaging
The psychiatric consultant must also be familiar
with neuroimaging studies. Neuroimaging may aid
in fleshing out the differential diagnosis of neuropsychiatric conditions, although it rarely establishes the diagnosis by itself (Dougherty and Rauch
2004). In most situations, magnetic resonance
imaging (MRI) is preferred over computed tomography (CT). MRI provides greater resolution of
subcortical structures (e.g., basal ganglia, amygdala, and other limbic structures) of particular
interest to psychiatrists. It is also superior for detec-

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Common Tests in Psychiatric

Consultation
Table 6.

Complete blood cell count

Serum chemistry panel
Thyroid-stimulating hormone (thyrotropin) concentration
Vitamin B12 (cyanocobalamin) concentration
Folic acid (folate) concentration
Human chorionic gonadotropin (pregnancy) test
Toxicology
Serum
Urine
Serological tests for syphilis
HIV tests
Urinalysis
Chest X ray
Electrocardiogram

tion of abnormalities of the brain stem and posterior fossa. Furthermore, MRI is better able to distinguish between gray-matter and white-matter
lesions. CT is most useful in cases of suspected acute
intracranial hemorrhage (having occurred within the
past 72 hours) and when MRI is contraindicated (in
patients with metallic implants). Dougherty and
Rauch (2004) suggest that the following conditions
and situations merit consideration of neuroimaging:
new-onset psychosis, new-onset dementia, delirium
of unknown cause, prior to an initial course of electroconvulsive therapy, and an acute mental status
change with an abnormal neurological examination
in a patient with either a history of head trauma or an
age of 50 years or older. Regardless of the modality,
the consultant should read the radiologists report,
because other physicians tend to dismiss all but acute
focal findings or changes and as a result misleadingly
record the results of the study as normal in the chart.
Psychiatrists recognize, however, that even small
abnormalities (e.g., periventricular white-matter
changes) or chronic changes (e.g., cortical atrophy)
have diagnostic and therapeutic implications (see
Chapter 7, Dementia, Chapter 9, Depression,
and Chapter 32, Neurology and Neurosurgery).

Electrophysiological tests
The electroencephalogram (EEG) is the most
widely available test that can assess brain activity. The
EEG is most often indicated in patients with paroxysmal or other symptoms suggestive of a seizure disorder, especially complex partial seizures, or

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pseudoseizures (see Chapter 32, Neurology and

Neurosurgery). An EEG may also be helpful in distinguishing between neurological and psychiatric etiologies for a mute, uncommunicative patient. An
EEG may be helpful in documenting the presence of
generalized slowing in a delirious patient, but it rarely
indicates a specific etiology of delirium and it is not
indicated in every delirious patient. However, when
the diagnosis of delirium is uncertain, electroencephalographic evidence of dysrhythmia may prove
useful. For example, when the primary treatment
team insists that a patient should be transferred to a
psychiatric inpatient service because of a mistaken
belief that the symptoms of delirium represent schizophrenia or depression, an EEG may provide concrete data to support the correct diagnosis. EEGs
may also facilitate the evaluation of rapidly progressive dementia or profound coma; but because findings are neither sensitive nor specific, they are not
often helpful in the evaluation of space-occupying
lesions, cerebral infarctions, or head injury (Bostwick
and Philbrick 2002). Continuous electroencephalographic recordings with video monitoring or ambulatory electroencephalographic monitoring may be
necessary in order to document abnormal electrical
activity in cases of complex partial seizures or when
factitious seizures are suspected. As with neuroimaging reports, the psychiatric consultant must read the
electroencephalographic report, because nonpsychiatrists often misinterpret the absence of dramatic focal
abnormalities (e.g., spikes) as indicative of normality,
even though psychiatrically significant brain dysfunction may manifest as focal or generalized slowing or
as sharp waves. Other electrophysiological tests may
be helpful in specific situations; for example, sensory
evoked potentials to distinguish multiple sclerosis
from conversion disorder, or electromyography with
nerve conduction velocities to differentiate neuropathy from malingering.

Other tests
Other diagnostic tools may also prove useful as
adjuncts. Neuropsychological testing may be helpful in diagnosis, prognosis, and treatment planning
in patients with neuropsychiatric disorders.
Psychological testing can help the consultant better
understand a patients emotional functioning and
personality style. For example, elevations on the
Hypochondriasis and Hysteria scales of the
Minnesota Multiphasic Personality Inventory and
a normal or minimally elevated result on the
Depression scale constitute the so-called conversion V or psychosomatic V pattern, classically
regarded as indicative of a significant psychological
contribution to the etiology of somatic symptoms

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SMITH ET AL.

but now recognized as confounded by medical illness. (See Chapter 2, Neuropsychological and
Psychological Evaluation, for a full description of
neuropsychological and psychological testing.)
The amobarbital interview has been used as a tool
in the diagnosis and treatment of a variety of psychiatric conditions (e.g., conversion disorder, posttraumatic stress disorder, factitious disorder, psychogenic
amnesia, neurosis, and catatonia) for the past 70
years (Kavarirajan 1999). The psychiatric literature
has been mixed, however, on the utility of the amobarbital interview, and intravenous lorazepam is now
generally regarded as a safer alternative. However, the
diagnostic validity of amobarbital and lorazepam
interviews has not been systematically assessed.

WRITE

A NOTE

focus.psychiatryonline.org

SPEAK

DIRECTLY WITH THE REFERRING CLINICIAN

The consultation ends in the same way that it

beganwith a conversation with the referring clinician. Personal contact is especially crucial if diagnostic or therapeutic suggestions are time sensitive.
Some information or recommendations may be
especially sensitive, whether for reasons of confidentiality or risk management, and are better conveyed verbally than fully documented in the chart.
The medical chart is read by a variety of individuals, including the patient at times, and, thus, discretion is warranted.

PROVIDE

PERIODIC FOLLOW-UP

INFLUENTIAL
P U B L I C AT I O N S

The consultation note should be clear, concise,

and free of jargon and should focus on specific
diagnostic and therapeutic recommendations.
Although an understanding of the patients psychodynamics may be helpful, the consultant should
usually avoid speculations in the chart regarding
unconscious motivations. Consultees fundamentally want to know what is going on with the
patient and what they should and can do about it;
these themes should dominate the note. Mental
health professionals are trained to construct full
developmental and psychosocial formulations, but
these do not belong in a consultation note
(although they may inform key elements of the
assessment and recommendations). Finger-pointing and criticism of the primary team or other
providers should be avoided. The consultant
should also avoid rigid insistence on a preferred
mode of management if there is an equally suitable
alternative (Kontos et al. 2003).
The consultation note should include a condensed version of all the elements of a general psychiatric note with a few additions (Querques et al.
2004). The consultant should begin the note with
a summary of the patients medical and psychiatric
history, the reason for the current admission, and
the reason for the consultation. Next should be a
brief summary of the present medical illness with
pertinent findings and hospital course; this summary is meant to demonstrate an appreciation for
the current medical issues rather than to repeat
what has already been documented in the chart. It
is often helpful for the consultant to include a
description of the patients typical patterns of
response to stress and illness, if known. Physical
and neurological examinations, as well as germane
laboratory results or imaging studies, should also
be summarized. The consultant should then list

the differential diagnosis in order of decreasing

likelihood, making clear which is the working
diagnosis or diagnoses. If the patients symptoms
are not likely to be due to a psychiatric disorder,
this should be explicitly stated. Finally, the consultant should make recommendations or clearly
describe plans in order of decreasing importance.
Recommendations include ways to further elucidate the diagnosis as well as therapeutic suggestions. It is especially important to anticipate and
address problems that may appear at a later time
(e.g., offering a medication recommendation for
treatment of agitation in a delirious patient who is
currently calm). For medication recommendations, brief notation of side effects and their management is useful. The inclusion of a statement
indicating that the consultant will provide followup will reassure the consulting team, and the consultant should include contact information in the
event that they have further questions.

Many consultations cannot be completed in a

single visit. Rather, several encounters may be
required before the problems identified by both the
consultee and the consultant are resolved.
Moreover, new issues commonly arise during the
course of the consultative process, and a single consultation request often necessitates frequent visits,
disciplined follow-up, and easy accessibility. All follow-up visits should be documented in the chart.
Finally, it may be appropriate to sign off of a case
when the patient stabilizes or when the consultants
opinion and recommendations are being disregarded (Kontos et al. 2003).

ROLE

OF OTHER PROVIDERS

Although the emphasis of this chapter is on the

psychiatrist as consultant, the value of members of
other professions, working together as a team,

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SMITH ET AL.

should not be overlooked. Psychologists play an

essential role in performing neuropsychological
and psychological testing and providing psychotherapeutic and behavioral interventions.
Psychiatric clinical nurse specialists provide services to the nursing staff that parallel those that
the psychiatrist provides to the medical team.
They are especially helpful in organizing interdisciplinary care conferences and nursing behavioral
treatment plans that include behavioral contracts
with patients. Case managers facilitate transfers
and set up aftercare. Chaplains address the spiritual needs of patients in distress. Finally, communication with primary care physicians remains of
utmost importance, since the primary care physician is well positioned to oversee and coordinate
ongoing care after discharge.

SCREENING
Screening tools may also be helpful in specific
situations. Although a comprehensive survey of
cognitive function is not required for every patient,
even a slim suspicion of the possibility of a cognitive deficit should prompt performance of cognitive screening. Although individualized mental
status examinations performed as part of a psychiatrists clinical interview are much preferred to
standardized tests, screening tests have been useful
in case finding and research.
Tests such as the MMSE or the Mini-Cog
(Borson et al. 2000) are helpful adjuncts in the
hands of nonpsychiatrists to quickly identify
potential cognitive disorders. The MMSE is a 19question test that provides an overview of a
patients cognitive function at a moment in time; it
includes assessment of orientation, attention, and
memory. It is of limited use without modification,
however, in patients who are deaf or blind, are
intubated, or do not speak English. The MMSE is
also particularly insensitive in measuring cognitive
decline in very intelligent patients, who may
appear less impaired than they really are. The MiniCog, on the other hand, combines a portion of the
MMSE (3-minute recall) with the Clock Drawing
Test, as described by Critchley in 1953 (Scanlan
and Borson 2001). In screening for dementia, the
MMSE and the Mini-Cog have been shown to
have similar sensitivity (76%79%) and specificity
rates (88%89%) (Borson et al. 2003). However,
the Mini-Cog is significantly shorter and enables
screening temporoparietal and frontal cortical areas
via the Clock Drawing Testareas that are not
fully assessed by the MMSE.
In addition, these tests may be supplemented
with othersincluding Luria maneuvers and cog-

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nitive estimations (e.g., How many slices are there

in an average loaf of white bread? How long is the
human spinal cord?)that further assess the functioning of frontal-subcortical networks. A formal
neuropsychological battery may be useful if these
bedside tests produce abnormal results (see
Chapter 2, Neuropsychological and Psychological
Evaluation). In a patient with an altered level of
awareness or attention, formal cognitive tests
should be deferred until the sensorium clears,
because clouding of consciousness will produce
uninterpretable results.
Other screening instruments may also prove beneficial, especially in research, for identifying patients
in medical settings who could benefit from a comprehensive psychiatric interview. The Primary Care
Evaluation of Mental Disorders (PRIME-MD) is a
two-stage evaluation tool developed for primary
care physicians to screen for five of the most common psychiatric disorders seen in the primary care
setting: major depression, substance use disorders,
anxiety, somatoform disorders, and eating disorders
(Spitzer et al. 1999). The first stage involves a
patient questionnaire, and the second stage consists
of a clinician-guided evaluation that takes roughly 8
minutes to administer. The PRIME-MD Patient
Health Questionnaire (PHQ), an abbreviated form
of the PRIME-MD, consists of a shorter three-page
questionnaire that can be entirely self-administered
by the patient (Spitzer et al. 1999). In addition to
the assessment of mood, anxiety, eating, alcohol,
and somatoform disorders (as in the original
PRIME-MD), the PHQ screens for posttraumatic
stress disorder and common psychosocial stressors
and also provides a pregnancy history. Although it
has also been shown to be a valid screening tool, the
PHQ is more efficient, given that the amount of the
physicians time required to administer the tool is
diminished. Both the PRIME-MD and the PHQ
have improved the diagnosis of psychiatric conditions in primary care settings (Spitzer et al. 1999)
and may find a role at the bedside as well.
The General Health Questionnaire is another
screening instrument originally developed in the
1970s to help identify the possibility that a medical
outpatient has symptoms suggestive of a psychiatric
disorder (Goldberg and Blackwell 1970). The original 60-item version has been replaced with wellvalidated 28- and 12-item versions, and it has been
translated into numerous languages worldwide and
been cross-culturally validated (Tait et al. 2003).
Because of its emphasis on identifying new symptoms, the General Health Questionnaire examines
state rather than trait conditions (Tait et al. 2003).
The CAGE is a well-known screening device
developed by Ewing (1984) to identify alcohol

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SMITH ET AL.

abuse. A total of two or more positive responses on

the four-question screen correlates with an 89%
chance of alcohol abuse (Mayfield et al. 1974) (see
Chapter 18, Substance-Related Disorders).

BENEFITS

OF PSYCHIATRIC SERVICES

CONCLUSION
Psychiatric assessment and consultation can be
crucial to seriously ill medical patients. The psychosomatic medicine psychiatrist is an expert in
the diagnosis and care of psychopathology in the
medically ill. Psychiatric consultation affords a
unique ability to offer a panoramic view of the
patient, the illness, and the relationship between
the two. The psychiatric consultant will be called
on to help diagnose, understand, and manage a
wide array of conditions; when effective, the consultant addresses the needs of both the patient and
the medical-surgical team. In this manner, psychiatric consultation is essential to the provision of
comprehensive care in the medical setting.

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INFLUENTIAL
P U B L I C AT I O N S

The benefits of psychiatric services in health

care delivery are significant. A growing body of
evidence suggests a link between comorbid psychopathology and increased length of hospital stay
and, consequently, increased inpatient costs.
Levenson et al. (1990) described a longer median
length of hospital stay (a 40% increase) and hospital costs that were 35% higher in a group of medical inpatients with depression, anxiety, cognitive
dysfunction, or high levels of pain (independent of
severity of medical illness). Cognitively impaired
geriatric patients were shown to have an increased
length of stay compared with those without cognitive impairment (Fulop et al. 1998), whereas
depressed elderly patients in another sample had
more hospitalizations and longer hospital stays
(Koenig and Kuchibhatla 1998). Although some
have suggested that psychiatric consultation
might decrease length of stay and inpatient costs
(Levitan and Kornfeld 1981; Strain et al. 1991),
that is not where its primary value lies. Patients
benefit from reductions in mental suffering and
improvements in psychological well-being, from
more accurate diagnosis, and from more appropriate treatment. Providers of health care profit
from the added diagnostic and therapeutic expertise of the psychiatric consultant as well as from a
better understanding of health behaviors. The
hospital milieu benefits from assistance with disruptive and dangerous patients and is enriched by
a safer and more pleasant work environment and
better risk management.

REFERENCES

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