howapsychiatricmedicaldoctorstartstomake

How a Psychiatric Medical Doctor starts to make a Diagnosis Q and A

What is the difference between the way a Psychiatrist makes a diagnosis and other mental health professionals?

Much of it has to do with professional training. Even in this enlightened age many people don’t know that a psychiatrist is a medically or osteopathically trained, educated and graduated physician like their primary care doctor. A psychiatrist is a Medical or Osteopathic Doctor, who has 4 years of pre medical college education, and then 4 years of medical school, studying all the same things any MD studies, Anatomy, Physiology, Pathology, Pharmacology, Medicine, Surgery, Pediatrics, Obstetrics, and Psychiatry. Then to be a Psychiatrist there is more training, a minimum of 3 more years for Adult psychiatry, and 2 more added years for Child psychiatry. The emphasis for all these years is on the biological basis of physical and mental disorders, with special emphasis on using biological treatments mostly medications. No other specialist in medicine, or other mental health fields like psychology, social work has this kind of education, experience and training to make biologically based diagnoses and to prescribe treatment, especially medication. The psychiatrist is a medical doctor first and thinks like one, making diagnoses based on three basic things, 1. The symptom picture and its course or history in an individual, 2. The family history of the individual, because most disorders have a biological, genetic, biochemical basis, passed on in families, and lastly 3. An expected treatment response. These three factors make up the core of diagnosis. How to make a Diagnosis

Why do you have to know about physical disorders, and all that biological stuff, if you are dealing with the mind?

First to make sure the problems or symptoms are not being causes by some general medical, surgical or neurological disorder or treatment for those disorders. Many non psychiatric disorders and treatments for them may cause symptoms, or syndromes, that look like the usual mental health problem but are not, and thus the treatment is vastly different. Knowledge and experience in general medicine is necessary for this, the kind you can only get from going to medical school.

Can you give some examples of these symptoms or syndromes that are not psychiatric?

A person presents with depression, sad, tired, no energy but is otherwise has no other physical complaints or a child with poor concentration and hyperactivity thought to have ADHD. Part of the routine differential diagnosis, fancy words, for a list of diagnosis that might be causing these symptoms that could be major depression or ADHD, would be thyroid disease, anemia, drug and alcohol induced, medication induced, toxic substances like lead, rarely a brain lesion like a pituitary tumor, some types of seizure problems, just to name a few.

What do you do now as medically trained psychiatric physician?

If I thought any of these might be causing what looks like a depression or ADHD , I would either refer back to the primary care practioners for further evaluation, or I could start that evaluation myself by ordering some routine laboratory studies, an EEG, to measure brain waves, and do during my office visit with the patient a brief neurological screen to rule out brain structural causes. A child could have an elevated lead level could look like ADHD or present depressed, a teen could be using inhalants from his mother kitchen and look depressed, an adult could have early onset dementia presenting with depression, a young women or teen with irregular menstrual cycle and depression may have a non cancerous pituitary tumor and be depressed, and all of these need to be considered and screened for during the first evaluation.

Do you ever do physical examination yourself?

Rarely would a psychiatrist do a complete physical examination, though parts of one could be done, and certainly what one is observing physically, fitting it together with the patients history, and symptom picture, based on what I know about the physical causes of these symptoms, is being used on a regular basis. For example if the patient had puffy thick skin, purplish nail beds, slow movements, with slow reaction time, with some problems with concentration and recent memory, facial features being not equal on both sides, a mild tremor being present, these things and many more could be observed or elicited during the initial evaluate, giving potential clues to the medically trained professional of medically caused syndrome, if you know what to look for, and you know what to ask.

Can you summarize what we went over so far about how a psychiatrist approach is different?

Being a medical doctor, first I what to rule out any non psychiatric condition that might be causing the presenting symptoms, like medical –surgical-neurological diagnoses, medical treatments like drugs that might be causative, abuse-able drugs, over the counter drugs, food supplement, and alcohol as contributing factors. Much of this can be gotten from a thorough individual and family medical history, doing a brief neurological screen, using the main tool of the psychiatrist the Mental Status Exam, and then if needed ordering some lab test, and referring to primary care or specialist for more evaluation and treatment. If one is not sure one refers and takes more history to rule in and rule out all possible causes for the presenting problems. This ruling in and out process in ongoing throughout the diagnostic and treatment process, for things change all the time and new diagnoses can cause the same or new or more symptoms. The more medical training one has the better one can do this.

Is there some short cut way to keep all of this in mind?

What I do is always think of what things can cause two of the most serious brain syndromes, dementia and delirium. By thinking of what might cause these syndromes and screening for them, I am going over in my mind, the usual physical non psychiatric causes of any significant mental health symptoms, signs, or syndromes. Delirium is in a sense acute, that is a quick ,usually reversible, brain decompensation, or disorganization due to something physical or chemical. The person suddenly is not thinking right, with changes in the ability to pay attention, and either your mind is too fast , or too slow, with a changing memory pattern. Basically a quick onset of poor concentration or shifting concentration, either too little or too much that is hyper attentive, bad memory for recent things, with some confusion not being sure who you are , where you are, and what you’re supposed to be doing. A good example of this is being plain old drunk on something. In dementia the major problem is with short term memory, that happens slowly, not quickly like delirium, and unlike delirium isn’t usually quickly reversible, though there are some reversible causes. In dementia concentration may be poor, but doesn’t change rapidly. There is a progressive decline in memory, thinking abilities and solving problems, and not until it progresses is there confusion over who the person believes they are, or where they are, or what they are doing. I use the memory aide I WATCH DEATH to help be remember the causes of these non psychiatric causes of mental health symptoms and syndromes.

Infections- (Especially if effecting the brain with fever like a Flu, Pneumonia, or Urinary Tract Infections)

Withdrawal ( and medication or substance of abuse like alcohol, nicotine, marijuana, etc,)

Acute Metabolic- ( the kidneys or liver or some other organ system needed for life in not working right)

Trauma- (injury when severe to the body, especially to the brain, and sudden and severe pain)

Central nervous system diseases- (seizures, bleeding into your brain)

Hypoxia –not enough oxygen for example some brain some forms of sleep apnea,

Deficiencies like Vitamins for example B 12, thiamine)

Endocrine diseases- (thyroid, problems with blood sugar, too much or little of male and female hormones.)

Acute vascular (Stroke or heart failure)