The Differential Diagnosis of Congenital Disorders that Include Psychosis

Summary: Neuropsychiatrists should be aware of congenital disorders that can present with psychosis, however rarely. Recommends a differential diagnosticapproach based on estimated prevalence of the disorders and their most prominent associated neuropsychiatric features

The Draw-A-Clock Contest: A Strategy for Improving Cognitive Status Assessment by Trainees

Background: Historically, psychiatrists have been less inclined than neurologists to utilize pencil and paper tasks during bedside cognitive assessments. Objective: The Draw-AClock Contest was established in 1986 at the University of Massachusetts to promote use of cognitive assessment tasks by psychiatry residents. Methods: Used in neuropsychological assessments since the 1930’s, clock tasks have been popular screening tools for executive function, praxis, visuospatial and constructive ability, often as part of dementia screening. Given its broad utility as a screening tool and the ease and speed of its administration, the Draw-A-Clock task (with hands set to 11:10 and no circle provided) was selected for use by UMass psychiatry residents, with further bedside assessment encouraged to explore any detected deficits. To encourage participation and foster clinical inquiry, residents are asked to submit clinically interesting de-identified patient clocks. For 21 years, clock contest entries have been collected each spring, with basic demographic, diagnostic, and process notes. Resident names are encoded, and entries are judged by a neuropsychiatrist (SB) and a neuropsychologist (EK). A “clock trophy” and detailed analysis of the submission is presented to the winner at the annual graduation banquet. Results: As a result of this contest, mental status examinations by trainees have become more comprehensive and an atmosphere of neuropsychiatric inquiry has been maintained. Faculty members have also incorporated this task into their mental status assessments, thus establishing a culture of cognitive inquiry and an academic tradition. Examples of winning clocks and common findings will be presented. Published abstract: Sullivan J, Benjamin S, Case Report: CADASIL with Cysteine-Sparing Notch-3 Mutation, American Neuropsychiatric Association, abstract, Journal of Neuropsychiatry and Clinical Neuroscience 21(2):221, 2009. DOI 10.1176/appi.neuropsych.21.2.221

The neurological examination adapted for neuropsychiatry

The neuropsychiatric examination includes standard neurological and cognitive examination techniques with several additional observations and tasks designed to capture abnormalities common among patients with neuropsychiatric disorders or neurocognitive complaints. Although useful as a screening tool, a single standardized rating scale such as the Mini Mental State Examination (MMSE) or the Montreal Cognitive Assessment (MoCA) is insufficient to establish a neuropsychiatric diagnosis. Extra attention is paid to findings commonly seen in the setting of psychiatric disorders, dementias, movement disorders, or dysfunction of cortical or subcortical structures. Dysmorphic features, dermatologic findings, neurodevelopmental signs, signs of embellishment, and expanded neurocognitive testing are included. The neuropsychiatric clinician utilizes the techniques described in this article to adapt the examination to each patient\u27s situation, choosing the most appropriate techniques to supplement the basic neurological and psychiatric examinations in support of diagnostic hypotheses being considered. The added examination techniques facilitate diagnosis of neurocognitive disorders and enable neuropsychiatric formulation

Integrating Neuroscience Knowledge and Neuropsychiatric Skills Into Psychiatry: The Way Forward

Increasing the integration of neuroscience knowledge and neuropsychiatric skills into general psychiatric practice would facilitate expanded approaches to diagnosis, formulation, and treatment while positioning practitioners to utilize findings from emerging brain research. There is growing consensus that the field of psychiatry would benefit from more familiarity with neuroscience and neuropsychiatry. Yet there remain numerous factors impeding the integration of these domains of knowledge into general psychiatry.The authors make recommendations to move the field forward, focusing on the need for advocacy by psychiatry and medical organizations and changes in psychiatry education at all levels. For individual psychiatrists, the recommendations target obstacles to attaining expanded neuroscience and neuropsychiatry education and barriers stemming from widely held, often unspoken beliefs. For the system of psychiatric care, recommendations address the conceptual and physical separation of psychiatry from medicine, overemphasis on the Diagnostic and Statistical Manual of Mental Disorders and on psychopharmacology, and different systems in medicine and psychiatry for handling reimbursement and patient records. For psychiatry residency training, recommendations focus on expanding neuroscience/neuropsychiatry faculty and integrating neuroscience education throughout the curriculum.Psychiatry traditionally concerns itself with helping individuals construct meaningful life narratives. Brain function is one of the fundamental determinants of individuality. It is now possible for psychiatrists to integrate knowledge of neuroscience into understanding the whole person by asking, What person has this brain? How does this brain make this person unique? How does this brain make this disorder unique? What treatment will help this disorder in this person with this brain

Congenital and acquired disorders presenting as psychosis in children and young adults

A review of the published literature found 60 congenital and acquired disorders with symptoms that include psychosis in youth. The prevalence, workup, genetics, and associated neuropsychiatric features of each disorder are described. Eighteen disorders (30%) have distinct phenotypes (doorway diagnoses); 18 disorders (30%) are associated with intellectual disability; and 43 disorders (72%) have prominent neurologic signs. Thirty-one disorders (52%) can present without such distinct characteristics, and are thus more easily overlooked. A systematic and cost-effective differential diagnostic approach based on estimated prevalence and most prominent associated signs is recommended

The differential diagnosis of childhood- and young adult-onset disorders that include psychosis

The evaluation of psychotic individuals for inherited or congenital etiologies is fraught with complexity. The authors reviewed the published literature and found 62 congenital disorders that include psychosis. Their prevalence, workup, genetics, and associated neuropsychiatric features are described. Eighteen disorders (29%) have distinct phenotypes ( doorway diagnoses ); 17 disorders (27%) are associated with mental retardation; and 45 disorders (73%) have prominent neurological signs. Thirty-four disorders (55%) can present without such distinct characteristics, and are thus more readily overlooked. We recommend a systematic and cost-effective differential diagnostic approach based on estimated prevalence and most prominent associated signs

The importance of rare diseases for psychiatry

Expanded knowledge of rare diseases is becomingly increasingly important for psychiatric clinical care and research

Six Landmark Case Reports Essential for Neuropsychiatric Literacy

Well-described clinical case reports have been a core component of the neuropsychiatry literature and have led to: a deepened understanding of brain-behavior relationships and neuropsychiatric phenomenology, new paths for research, and compelling material for physicians who are studying neurology and psychiatry. Six landmark neuropsychiatry cases were selected for being well described, paradigmatic, and illuminating of brain-behavior correlations: Phineas Gage, Louis Victor Leborgne ( Tan ), Auguste Deter, Solomon Shereshevsky ( S ), JP, and Henry Gustav Molaison ( HM ). Each case and its neuropsychiatric lessons are summarized from primary sources, highlighting some less appreciated aspects. Case reports continue to be a valuable resource for neuropsychiatric education. Yet only four of the 10 highest impact factor psychiatry journals accept case reports for publication