Q. Diagnosis and treatment of mental illnesses. Could you please answer a few questions?

Answered by
Dr. Ravi M Soni
and medically reviewed by iCliniq medical review team.
Published on Nov 17, 2014 and last reviewed on: Jan 01, 2019

Hello doctor,

I am doing research regarding diagnosis and treatment of mental illnesses. Please answer a few questions of mine. What routine medical examinations apart from MMSE and history would you conduct? By this I mean standard routine blood investigations plus other investigations. What clinical signs would suggest performing MRI scan and would you order it with every patient? What clinical signs would suggest performing thyroid hormone tests? Would you do the thyroid hormone test with every patient admitted to the ward? Would it be a standard psychiatric procedure? What neurological and physical examinations would you conduct to rule out any other medical or neurological disorders? Schizophrenia is a dysfunction of brain’s physiology; the functioning through neurotransmitters and through hormones but actually genetic problem is always there; means there is a dysfunction at cellular level. Which neurotransmitters and hormones would be responsible for this dysfunction? What kind of dysfunction of cellular level is that? What does an elevated level of homocysteine found in schizophrenic patients tell the psychiatrist?

Dr. Ravi M Soni

Geriatrics Psychiatry Psychologist/ Counsellor Sexology
#

Hi,

Welcome to icliniq.com.

I have read your queries and shall answer accordingly. Keep in mind that standard procedures for management may differ in different countries. Answers for your questions:

  • In blood investigations we usually go for complete blood count (CBC), liver function tests (LFT) and renal function test. Also we go for EKG and chest x-ray of the patient. This is the standard protocol. Other investigations depend upon the patient's profile.
  • Brain imaging is usually ordered for children and elderly patients. In adult patient we usually do not order brain imaging unless there is definite signs in the body for damage in the brain.
  • We usually do not go for imaging in cases of headache, depression, anxiety disorder, schizophrenia, somatoform disorders and other psychiatric disorders. Sometimes in patients with migraine we order for MRI but with advice from a neurologist.
  • If someone has head trauma, then we have to go for CT scan head. So, whenever patient presents with some neurological symptoms and after interview and examination when we find that it is not functional, but of some organic origin we order imaging for confirmation.
  • Most of the time in a woman presenting with depression and lots of anxiety, we usually go for thyroid function test (TFT).
  • Recent weight gain is the most common symptom we ask for. In other patients if the psychiatric illness particularly depression and anxiety is not improving for a long time with drugs, we go for TFT.
  • Hypothyroidism is the most common finding in TFT. Hypothyroidism itself is a risk factor for depression. Usually we do not go for TFT in each and every patient admitted to the ward. It should be a standard procedure.
  • Usually when we examine a patient, we go for a general physical examination in which we just inspect the patient, looking for pallor, icterus (jaundice), cyanosis (bluish discoloration of skin due to low levels of oxygen), clubbing (deformity of the fingers due to several diseases), edema (abnormal accumulation of fluid), lymph node swelling and any other prominent abnormality. We also inspect general appearance and built of the patient.
  • Then we go for system wise examination in brief. Like respiratory system, cardiovascular system, central nervous system, gastro-intestinal system, abdominal examination, genitourinary system, coordination of movements, gait, etc.
  • This examination has to be conducted depending upon the history of presenting illness. From the history of presenting illness we get an idea about the problems and we give more concentration to that system.
  • Neurotransmitters involved in schizophrenia predominantly are dopamine and serotonin. There is no significant role of hormones.
  • Genetic studies have shown that it can be genetic origin, but it does not mean that all children of schizophrenic patient will have schizophrenia.
  • There are many genes involved in development of schizophrenia, with complex interactions between them. It is very difficult to tell about which kind of cellular dysfunction is responsible, as it depends and varies with genetic abnormality.
  • Elevated homocysteine levels can be found in patients with schizophrenia. By this means we can understand that it has role in pathophysiology of schizophrenia and more in the cognitive dysfunction in patients with schizophrenia.
  • It has been found that simple supplement of vitamin B complex decreases the homocysteine level and somewhat improves cognitive problems in patients with schizophrenia. Increased homocysteine level is associated with cognitive impairment in dementias and it is a risk factor for cardiovascular and cerebrovascular disorders.

All the best for your research.

For further clarifications, consult a psychiatrist online -->https://www.icliniq.com/ask-a-doctor-online/psychiatrist

Hi doctor,

Thank you for answering my questions. I am very grateful for your time and help. I have some more to ask you. What is the difference between brief reactive psychosis and brief acute psychotic episode? Explain about the medication, treatment, duration of stay in hospital and recovery. Psychiatrists observe patients behavior and mood. How would you describe behavior and mood of an agitated patient? For example, is this person tired or contrary is full of energy? When patient is described as having suicidal thoughts, and there is a risk of self-harm what kind of behavior and mood would this patient generally present? Would family history of suicide attempts be an indicator as well? Thyroid disorders mainly cause neurotic disorders. Neurotic disorders are those psychiatric illnesses in which patient maintains contact with reality and they have insight about that they have experienced mental health problems. Disorders last like psychotic patient do not have contact with reality, they live in their mind created world like in schizophrenia and patients do not have insight regarding their mental illness. Is this correct? There is no investigation to diagnose any psychiatric illness. The investigations which we do in wards are not to make psychiatric diagnosis but to monitor the side effects of different psychotropic medications. How would you comment on that? What brain changes would you observe in children and elderly patients? Why only for them? There is a connection between mental illness and sleep disorders. What kind of sleep disorders would you observe in patients? What physical symptoms would you observe in sleep deprived person? Why are you saying that TFT should be a standard procedure? What kind of imbalance is there in neurotransmitters? Is it too much dopamine and not enough serotonin, or too much serotonin and not enough dopamine? Can I use the received information in my research?

Dr. Ravi M Soni

Geriatrics Psychiatry Psychologist/ Counsellor Sexology
#

Hi,

Welcome back to icliniq.com.

  • As such there is no difference between brief reactive psychosis and acute psychotic episode. Both are similar in terms of treatment, medication, duration of stay in hospital. But, brief reactive psychosis has somewhat better prognosis.
  • Both have same symptoms, but in brief reactive psychosis there is presence of stress before the onset of episode.
  • We usually describe in terms of mental status examination. Points included are general appearance, behavior, activity level, speech, gait, built, mood, thought disturbance both in content (delusion, preoccupation, obsessions, etc.,) and form (flight of ideas, circumstantiality, loosening, tangentiality, etc.,) and perception (hallucinations and illusions).
  • It may be like 25 years old male conscious but uncooperative, looking sick, uncomfortably sitting on table, moving to and fro, looking aimlessly, continuously speaking even when not asked, irritable, trying to run away and not giving answers. So, this is a person with irritable mania.
  • Suicidal thoughts are present in severe depression. So mood is mostly dysthymic, depressed, sad, dysphoric, etc. Suicidal thoughts are present due to hopelessness, helplessness and worthlessness.
  • Behavior will be suicidal means planning for suicide like making a plan with timing of suicide, which objects to be used, at which place, by which method, in home or outside etc.
  • Past history of suicidal attempt is a risk factor for further suicide attempts. Family history important for the psychiatric illness. Suicide can be in psychosis due to hallucination.
  • You are right about psychotic and neurotic illness.
  • The psychotropic drugs are mainly metabolized by liver so we go for liver function tests. If there is a history of fever with onset of symptoms then we have to go for blood counts.
  • Any illness affecting brain can present as psychiatric illness with physical findings. Physical examination and blood investigation along with brain imaging are more important for elderly after 55 years of age. Psychiatric disorders are diagnosed according to symptoms present currently in a patient.
  • In elderly we advise to rule out any organic illness affecting brain. So depending upon the illness the findings will differ. Usually in elder normally we find atrophy of the brain parenchyma.
  • Similarly in children also mostly in those who are mentally retarded, patients of seizure disorder, autism, other developmental disorders we go for brain imaging. What we would find is very big topic to comment.
  • Mostly in psychiatric patients sleep problems are due to psychiatric illness like depression, anxiety, psychosis, mania etc. The problems can be increased sleep latency, problems in maintenance of sleep, early morning awakening.
  • If a person is sleep deprived then mostly he has heaviness over head, slowness in activities, fatigability, difficulty in concentrating, irritability, lethargy etc. Sleep disorders are primary and secondary. Read the classification of sleep disorders in DSM 5.
  • TFT should be done in each and every patient that should be the standard procedure. But we usually go for resistant cases, in women etc. This is because of affordability of patients.
  • The role of neurotransmitters in schizophrenia is complicated. There are different areas in brain associated with development of symptoms of schizophrenia. So, it usually the excess of dopamine in mesolimbic pathway and deficiency of dopamine in mesocortical pathway.
  • Yes, you can use it for research but be clear for the some of the findings like for role of serotonin, dopamine. You should always have an explanation for what you are writing in research, so be prepared for that.

For further information consult a psychiatrist online --> https://www.icliniq.com/ask-a-doctor-online/psychiatrist

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