The Psychiatric Examination of the Neurologic Patient

A well-conducted psychiatric evaluation is central to the care of neurologic patients with psychiatric disorders. The evaluation is aimed at defining the psychiatric condition in the context of the patient’s past psychiatric history and current neurologic disease. The information derived from the evaluation is used to develop a formulation, establish a diagnosis, and form a basis for treatment planning. This chapter discusses the psychiatric evaluation of the neurologic patient in detail. It includes examination techniques and questions as well as practical approaches to conducting an assessment of the patient’s cognitive state. Along the way, common psychiatric symptoms encountered in neurologic patients are defined and differentiated from related symptoms. The chapter concludes by illustrating how to generate a formulation and differential diagnosis. The psychiatric evaluation consists of three parts: the history; the mental status examination (MSE); and the formulation, including the differential diagnosis. The history, which is essential to defining the problem, is taken from the patient and from one or more informants. The importance of taking a history from an informant is underscored in the context of neurologic disease because patients may be forgetful, lack insight, or have language and other cognitive problems that may limit their ability to provide a good history. History-taking begins with defining the psychiatric chief complaint and then obtaining the family and personal history. Starting in this way, rather than with the chief complaint followed by the history of present illness (HPI), makes it easier to see that the psychiatric symptoms may have been caused by, or influenced by, factors other than the neurologic disease—factors that can include psychiatric disorders as such, aspects of patients’ personalities, and responses patients have to the circumstances of their lives. Table 1–1 provides an outline of important elements of the psychiatric history for neurologic patients and can be used as a checklist in clinical practice. Defining the psychiatric chief complaint is the physician’s first task. ‘‘Psychiatric chief complaint’’ in this context refers to the occurrence of cognitive, affective, behavioral, or perceptual phenomena that are brought to the physician’s attention by the patient, a family member or other informant, or by the physician’s own observation.