1

Assessment methods(except psychodiagnostics)

Aim of assessment

to determine whether a subject has a mental disorder symptoms / signs syndromes

differential diagnosis diagnostic conclusion

establish a therapeutic relationship with the patient

therapeutic plan Immediate measures in case of an acute

condition

Preparation for examination

security for the patient for staff

obtain information from documentation previous examinations manipulative tendencies, simulation non-cooperation, lack of insight

risk of aggressive behavior

information from relatives, colleagues

2

Interview

open questions Are you sleeping well? How did you sleep?

alternative questions Is it rather a dislike or inability?

do use not suggestive questions (only if they are targeted)

"forced“, confrontational questions at the end

Basic assessment

An objective (collateral) medical history close persons, health records

interview observation not only during the interview - in the waiting

room, at the department, observation by nurses

physical examination laboratory assessments imaging / EEG psychodiagnostics

Interview

to explain or discuss the situation

leave the patient autonomous (could you ... what do you think ...)

customize voacabulary

3

Empathic listening empathy

verbal hmm ... hmm ...

nonverbal signaling nod ... nod ...

personal questions sexual life, relationship problems, self-evaluation)

empathic reflection, but not confirmation of pathological content (delusions)

summary and rewording authenticity vs. poker face acceptance vs. approval

demanding patient aggressive - insulting patient, "hysterical", narcissistic,

"professional", simulating, dissimulating, aggravating, "annoying" transmission and counter-transmission mechanisms

Identification of the symptom

interview

observation

halucinations

patients says to have “voices”(ideal case)

hallucinatory behavior(monologization, blocking

paramimics)

objectivehistory

information fromrelatives – patient was

talking to himself

1. základné identifikačnéúdaje

1. základné identifikačnéúdaje

2. objektívna anamnéza2. objektívna anamnéza

3. subjektívneúdaje3. subjektívneúdaje

4. objektívny nález4. objektívny nález

5. somatické vyšetrenie5. somatické vyšetrenie

6. psychopatologickésymptómy6. psychopatologickésymptómy

7. psychopatologickýrozbor7. psychopatologickýrozbor

8. diagnostickézávery 8. diagnostickézávery

9. plán vyšetrení9. plán vyšetrení

10. plán liečby10. plán liečby

4

„dedičnosť“„dedičnosť“

autizmusMRADDH

autizmusMRADDHposledná menštruácia

posledný pohlavný stykposledná menštruáciaposledný pohlavný styk

Abúzy - kedy, koľko,naposledy .... Abúzy - kedy, koľko,naposledy ....

zlom v životnej línii, osobnosť, paranoidita .... zlom v životnej línii, osobnosť, paranoidita ....

vždy! (takmer)vždy! (takmer)dg. kritériá!dg. kritériá!

osobnosť, D, Schi, demenciaosobnosť, D, Schi, demencia

osobnosť, mánia, D dg. kritériá!osobnosť, mánia, D dg. kritériá!

môže byť v TO,podobne lieková anamnézamôže byť v TO,podobne lieková anamnéza

TO – na začiatku?TO – na začiatku?

nemusíme používaťodborné termíny, tie patria do VI., myslíme na opis symptómu, ktorý tam uvedieme

nemusíme používaťodborné termíny, tie patria do VI., myslíme na opis symptómu, ktorý tam uvedieme

Niekedy hodnotenie vyplýva z kontextu,pacienta by sa to mohlo dotknúť.Pri pochybnostiach, organických poruchách,schizofrénii vždy.

Niekedy hodnotenie vyplýva z kontextu,pacienta by sa to mohlo dotknúť.Pri pochybnostiach, organických poruchách,schizofrénii vždy.

Každý symptómmusí byť podložený predchádzajúcimi

časťami.Uviesť aj negatívne nálezy (napr. nálada euthýmna).

Ilustrovať

Každý symptómmusí byť podložený predchádzajúcimi

časťami.Uviesť aj negatívne nálezy (napr. nálada euthýmna).

Ilustrovať

everything else =additional workup, assessment

DSM-5Diagnostic criteria do not include the

results of ancillary examinations

(only as exclusion criteria)

exception: hypokretin 1 (orexin)

in cerebrospinal fluid in the case of narcolepsy

Additional laboratory examinations

he extent depends on the state, age, and acuten Basic examinations are often extended after

consultations with other disciplines alcoholism

delirium

Elderly patients dehydratácia !!!!

eating disorders anorexia

intoxications

KO, FW, BWRglykémia, urea, kreatinín, AST, ALT, GMT, NA, K, Cl,

urea chemical and sediment

5

Additional examination

differential diagnosis or verification of the diagnostic conclusion somatic causes of psychiatric disorders

hypothyroidism - depression

hypovitaminosis B12, folic acid - reversible dementia

CT, MRI, EEG, USG carotid brain tumors, encephalitis, epilepsy - atypical affective,

psychotic symptoms, hypoxia

confirmation of diagnosis: neurodegenerative disorders -dementia

Additional examination

Treatment of basic somatic disease or typical associated symptoms in psychiatric disorders diabetes

syphilis

ionic dysbalance in withdrawal syndrome

Additional examination

treatment - initiation, monitoring, side effects drug levels

lithium!

antiepileptics - valproate, carbamazepine, clozapine

tricyclic antidepressants, clozapine

blood count agranulocytosis - clozapine, carbamazepine

kidney function - lithium

signs of metabolic syndrome - antipsychotics

ECG and QTc interval - antipsychotics, a combination of drugs

6

Biochemical examinations

glucose diabetes treatment-induced hyperglycemia

Na, K, Cl elderly patients, alcohol addiction, delirium hyponatremia when using SSRI antidepressants warning for SIADH (syndrome of inappropriate antidiuretic

hormone secretion) polydipsia water intoxication in schizophrenia, association

with clozapine hepatic enzymes

Alcoholism - AST, ALT (ratio greater than 2), GMT ammonia! at low values of hepatic enzymes alcohol - carbohydrate-deficient transferrin (CDT)

Hematologic workup

Blood count depression, cognitive disorders,

psychotic conditions

differential blood count klozapín !!!

serotonin-mediated anti-platelet effect serotonergic antidepressants

possible effect on warfarin metabolism

1900

1600

18

1650

0

1150

1500

56

1450 1400

1790

1400

770

12601450

0

1000

2000

3000

4000

5000

pati ent ` s No

Lk

c/N

Gr

in m

m3

Lkc withdNGr withd

agranulocytosis 3 patients

leukopenia 3 patientsgranulocytopenia 9 patients

Database from our clinic

7

Further laboratory examinations

malignant neuroleptic syndrome (MNS) creatine phosphokinase

Wilson's disease ceruloplasmin

serological examinations BWR HIV / AIDS

examination of liquor in cooperation with the neurologist Creutzfeldt - Jakob's disease (CJd)

positive protein 14-3-3 in liquor meningitis, encephalitis

Hormones testing

thyroid hormones deficit - depression, cognitive disorders

increased levels - mania-like, sleeping disorders

prolactin antipsychotics

menstrual disorders, sexual dysfunction

sexual identity

effect of triiodothyronine in euthyreotic patients

8

Prolactin

versatilinomnipotin

oxytocín

vazopresín

terminál tuberoinfudibulárnej dráhytvorba releasing (liberíny) a inhibiting (statíny) hormónov

(napr. TRH, GnRH, GHRH, CRH, SRIF - inhibičný)

ACTH

TSH

GH

FSH,LH

PROLAKTÍN

tuberoinfundibularDA neurons

portal veins

D2 receptors on lactotrophs

9

Normal values

men: 7 ng/ml women: 12 ng/ml upper limit: 20 - 25 ng/ml significant increas: > 50 ng/ml

3 samples for three days 3 samples after 20 minutes from the catheterized vein

Hyperprolactinemia

What we can expect: 100 μg / l - hypogonadism, galactorrhea, amenorrhea ~ 51-75 μg / l - oligomenorrhea ~ 50 μg / ml - decreased libido and infertility

If the prolactin is shown to be higher, then the second dose:

apply the cannula, wait 30 min.

two groups where the effect of hyperprolactinaemia should be considered: Risk of osteoporosis breast carcinoma

Peveler et al., J Psychopharmacol 2008; 22; 98 - 103

DSTdexamethasone suppression test

dexamethason1mg

23.00 16.00 23.00

cortisol levels

> 50 – 60 mg/l=

non-supression

sensitivity for MDD 50%, specificity 90%

10

Toxicology

cannabinoids up to 4 weeks

opiates 2 – 3 days

amphetamine 2 – 4 days

cocaine 2 – 3 days

benzodiazepines up to 2 weeks

ECG

QTc interval

arrythmias

e.g. sertindole

pharmacokinetic interactions !!!

EEG

EEG – JCch; Režnáková V., 2017

absence in childrenMedscape

generalized seizureScielo

11

qEEGLORETA

low resolution electromagnetic tomography

http://www.ifn.net.au

25 ročná pacientka s diagnózou schizofrénie. Prítomný celý komplex príznakov, vedúcou symptomatikou sú verbálne akustické halucinácie – pacientka počuje dva mužské hlasy s jasnou senzorialitou, niekoľkokrát za minútu. Obsah halucinácií je pre pacientku príjemný, sprevádzané sú religiózno-spasiteľskými bludmi. Dva roky trvá ambulantná liečba antipsychotikami, postupná funkčné a sociálne postihnutie. Vyšetrenie magnetickou rezonanciou bolo negatívne. Až vyšetrenie pomocou EEG a PET prinieslo výsledky s uvedenými nálezmi (Horáček et al., 2004 reprodukcia so súhlasom autora).

Vyšetrenie EEG – 10 minútový záznam. Šípkou je označenáepileptiformná hrotová aktivita lokalizovaná v oblasti pravej hemisféry.

Zobrazenie hodnotenia kvantifikovanéhoEEG (spektrálne frekvencie). Šípky označujú zmnoženie aktivity v pomalomdelta pásem 1,5 – 2 Hz v zadnej temporálnej oblasti, čo zodpovedá nálezu hrotovej aktivitypri vizuálnom popise EEG.

Mapovanie tzv. EEG kordancie (pomer absolútneho a relatívneho frekvenčného autospektra na jednej elektróde – je vo vzťahu k mozgovej metabolickej aktivite a perfúzii).Objavujú sa miesta dyskordancie v oblasti pravej zdanej temporálnej elektródy vo frekvenčnom pásme 0,5 – 7,5 Hz a v mediofrontálnej a okcipitálnej oblasti v pásme8 – 12,5 Hz.

magnetoencephalography(wikipedia)

12

CT scan

www.pbs.org

MRI

structural MRIVBM – voxel based morphometry EEG MEG combined with sMRI

fMRI PET, SPECT

13

Diffusion Tension Imagingtractography

The human connectome project

e+

15O 2 min.13N 10 min.11C 20 min.18F 110 min.

e-

PET

gama pohoton

gama photon

PET - amyloid and tau in Alzheimer's dementia

79 y. menwith ADA,B - tau protein (florbetapir 18F)C,D – amyloid (Pittsburgh compound B)

14

fMRIBOLD - blood-oxygen-level dependent

Differences in brain regions activation in patients with schizophrenia (A) and reference group (B)

when watching photos with a negative emotional charge.

Singh et al., 2015

Imaging in dementia

A - FDG-PET ([18F] -fluorodeoxyglucose) in dementiaB - FDG-PET at clinically symptomatic 71 year old male - C - MRI in dementiaD - MRI in a non-symptomatic patientE - Pittsburgh compound B? 71 year old patient with dementiaF - Pittsburgh Compound B, 93 year old patient

15

Cho = cytosól s obsahom cholínu; Cr/PCr = kreatín, fosfokreatín;NAA = N - acetyl aspartát

MRS - Magnetic Resonance Spectroscopy

Genetics

APOE gene in Alzheimer's dementia chromosome 19q13.2, regulation of cholesterol transport in the brain APOE ε2, ε3, ε4

Three times higher risk for carriers of one APOE e4 allele 12x higher risk for two APOE e4 alleles

Kralova M., 2017

CYP isoenzymes poor, intermediate, extensive, and

ultrarapid metabolizers

CYP1A2, CYP2D6, CYP3A3/4

amplichip

Actimetry

16

Circadian rythms

Future?