Assessment of Psychiatric Disorders in Consultation-Liaison Setting.

INTRODUCTION

In the chapter of Overview of Practice of Consultation - Liaison Psychiatry by Gautam et al., we have understood the concept of consultation-liaison-psychiatry (CL-psychiatry)-its need, various models and settings in which they operate. Next, we move on to the assessment in CL-psychiatry settings. The basic structure of psychiatric assessment remains the same with detailed history taking, review of previous treatment documents, and the mental status examination (MSE). However, apart from these, there remains certain uniqueness in the assessment of patients in CL-psychiatry settings.

THE UNIQUENESS IN PSYCHIATRIC ASSESSMENT AND COMMUNICATION IN CONSULTATION-LIAISON-SETTINGS[12]

The uniqueness remains within the name itself. While in individual clinical practice, it is only “consultation”-that is assessment followed by advice; in CL-psychiatry setting, there remains both “consultation” and “liaison” with the primary treating team to form a collaborative opinion regarding the condition and management of the patient. Thus, in CL-psychiatry assessment, this liaison or communication holds the key which should be followed in its every step. We would discuss these steps of liaison under following headings:

THE MODE OF APPOINTMENT OF A PSYCHIATRIST WITH THE PATIENT IN CONSULTATION-LIAISON SETTINGS

In individual consultation, a patient comes directly to a consultant of personal choice, while in CL-setting, a patient comes to the contact of only the designated consultants who are either integral part of the treating team or being referred to.

THE NEED OF APPOINTMENT OF A PSYCHIATRIST IN CONSULTATION-LIAISON SETTINGS

In individual consultation, the need to contact a psychiatrist is a felt-need of the patient or the relative either by themselves or being guided by anybody. However, in CL-setting, the need of appointment of a psychiatrist is felt by the primary treating team who feel that there are certain issues where a psychiatrist would guide them better toward management of the patient.

Psychiatric assessment in CL-setting in a flow chart

THE FOCUS OF ASSESSMENT BY A PSYCHIATRIST IN CONSULTATION-LIAISON-SETTINGS [CHART 1]

In individual consultation, the focus of assessment of a psychiatrist is diagnosis and management of psychiatric disorders or problems which have caused impairment or difficulties in the personal-socio-occupational functioning of the patient.

However, in CL-settings, apart from the above, there can be many other areas of focus of assessment by a psychiatrist:

Whether the presenting psychiatric conditions in the medical setting are of primary psychiatric origin or secondary to the existing medical illness or its ongoing treatment

Whether ongoing psychotropic medications for patients with diagnosed psychiatric morbidity have impact on management of the ongoing medical illness

Whether the abnormal or uncooperative behaviors of the patients in wards are due to some psychiatric disorders or fall out of any bio-psycho-social issues

Whether there is any immediate risk of self-harm or harm to others by the patient

Whether there is any need to transfer the patient to psychiatric ward

Whether there are any issues of privacy or medicolegal issues attached to particular cases (suicidal attempt vs. accidental injury; any homicidal or sexual urge or advances; history of sexual abuse; any use of surreptitious medicines, etc.)

Assessment of mental conditions of patients whose sustained treatment compliance is matter of concern, like MDR Tb, ART in HIV

Assessment of motivation and eligibility preparedness of patients undergoing any major intervention – e.g., organ transplantation, cross-sex medical-surgical gender-affirmation interventions.

THE PREPARATORY PHASE OF ASSESSMENT IN CONSULTATION-LIAISON-SETTING

In individual consultation, there is no preparatory phase between appointment and contact with the patient. However, in CL-setting, there should be a compulsory preparatory phase when the psychiatrist should do the following review:

Current Medical diagnosis and the ongoing treatment

Chart review of all available papers

Any past or ongoing history of psychiatric illness and their treatment

Direct communication with the treating/referring consultant to understand their conceptualization of the case and their need and focus of psychiatric assessment

For admitted patient, observation of the nursing staff or duty doctor in station

For admitted patient, sending information to the family member to be present at the time of interview.

INTRODUCTION WITH THE PATIENT AND FAMILY

During introduction with the patient in CL-psychiatry, disclosure of identity of the interviewer as psychiatrist at the outset may be little tricky. It might often be unexpected for the patient and relative to be interviewed by a psychiatrist and there may be emotional bias or stigma attached to it. Thus, depending on the situation, identity should be gradually revealed following the establishment of rapport and maintaining optimum privacy.

RAPPORT BUILDING AND ITS PREDICAMENT

During any psychiatric interview, rapport building is the most sensitive and delicate part. In CL-setting, this job may be further difficult as the need for mental health service often remains unexpected here. The psychiatrist should explain the patients with common example that body and mind are inseparable. While anxiety affects our heart rate and respiration in the one hand, changes in body in high-fever affect our mental condition on the other hand. This makes the acceptance of psychiatrist easier for the patient and the family.

Certain situations such as paranoia, disorganized behaviors, substance use disorder, personality disorder or problems, dementia, and delirium pose further problems. Delirium being a very commonly encountered condition in CL-psychiatry, it needs special mention. In delirium, since fluctuating consciousness and attention is the main problem, here psychiatrist should talk gently, loudly, slowly-with one question at a time.

PSYCHIATRIC INTERVIEW AND HISTORY TAKING[3]

Interview should begin with open narrative regarding current health problems and the distress associated with them. Patient’s experience with ongoing medical treatment, particularly any difficulties in adjustment, should be enquired. Unlike individual consultation, in CL-psychiatry, there may not be any spontaneous account on mental and behavioral issues of the patient. Questions in this regard may start with vegetative functions which are common issues for anybody. Then, the internalizing symptoms such as presence of anxiety, somatic distress, and low mood should be inquired. Apart from the ongoing illness, any other recent or ongoing stressor and its impact on the patient not to be missed. Any history of self-injury (suicidal or nonsuicidal) should also be gathered along with any family history of such event. Questions on externalizing symptoms of any agitation, anger, excitement, suspiciousness should follow. Inquiry regarding hallucinatory behavior and disorganization is also important. History of substance intake and their details must not be missed.

Patient’s neuro-cognitive functions in daily-life situations particularly in case of elderly should be gathered. A common mnemonic”Memory-LAPSE” – memory-language-attention-perceptuomotor-socialization-executive function may be helpful. For example, any forgetfulness regarding recent events-where things kept–what is to be done–common names, address; any difficulties in finding right words; difficulties to focus and process information when interacting different persons together; any difficulties in usual activities of cooking-shaving; any recent oddities in socializing; difficulties in finance handling, decision-making.

Family history of any mental illness should be inquired. Patient’s development history and personality features – particularly stress handling capacity, interpersonal relationship, emotional stability, and impulsivity should be enquired.

Any religious and cultural influence on overall behavior or cognition of the patient should also be noted.

MENTAL STATUS EXAMINATION

In CL-psychiatry setting, since delirium is the most common cause of referral, MSE may start with general inspection of behaviors suggestive of lack of touch with the surroundings, hallucinatory behaviors, agitation-floccillation, hands being tied to prevent picking-and-pulling of ports. It should be followed up with questions on orientation and patient’s open narrative on ongoing distress.

During initial interaction, catatonia should be ruled out from motor behavior and speech. Organization of the speech and thought should be noted carefully.

Examination of effect is quintessential because depression, anxiety, adjustment difficulties are very common association in medical setting. Complain of somatic distress or “unexplained physical symptoms” being very common in medical setting, signs of depression-anxiety, obsession-hypochondriasis must be looked for. Apart from them, la-belle-indifference in effect, health-care seeking behavior and anything suggestive of secondary gain should also be looked into.

Other than internalizing symptoms, if any elevated, expansive, irritable effect is noted, that should be followed with relevant examination of psychomotor activity, thought, and perception – suggestive of mania.

Delusion and hallucination should be elicited carefully if the patient is found to be having hallucinatory behavior or showing guarded, evasive, hostile attitude.

There must be customary assessment of any suicidal intent in every patient. For patients with paranoid psychopathology, anger, excitement, any thoughts of causing harm to others should be probed.

A brief assessment of neuro-cognitive functions particularly in elderly and those having presented with such history.

Apart from these issues, assessment must also include patient’s insight regarding the ongoing medical illness and the problems for which psychiatric assessment has been sought.

USE OF SCREENING TOOLS FOR ASSESSMENT

In CL-setting, there may be a paucity of time for detailed psychiatric assessment. For this purpose, few standardized screening tools have been developed for quick screening of common psychopathology in primary-care or other specialized medical setting. These tools can be used by trained mental health professionals or even primary care personnel before confirmatory diagnosis by psychiatrists. Hence, this training of the primary care personnel about proper use of these screening tools is also an essential part of CL-psychiatry practice.

Basic characteristics of the tools should be:

Short, easy, and quick to apply

Locally developed or adapted and translated versions in local language are more appropriate

They should be appropriate for particular age group under examination.

Tools may be of two types:

Targeting broad psychopathology such as internalizing symptoms of depression, anxiety, panic, somatic symptoms, stress-trauma-all in one tool-PRIME-MD-PHQ (primary care evaluation of mental disorders-patient health questionnaire (PHQ) or its brief version brief-PHQ (BPHQ)[4]

Targeting specific psychiatric disorder such as PHQ-9[5] (a 9-item questionnaire for depression), generalized anxiety disorder-7-item (GAD-7)[6] for anxiety, PHQ-15[7] (A 15-item PHQ) for evaluating severity of somatic symptoms. All these self-rated questionnaires are developed from PRIME-MD-PHQ.

There are plenty of other screening tools customized for particular symptoms, age group, and situation of assessment, which will be discussed subsequently.

Apart from general history taking, MSE and application of screening tools – assessment of certain situations warrants special mention in CL-psychiatry assessment. They are as follows.

ASSESSMENT OF IMMEDIATE RISK TO SELF AND OTHERS

Agitation, excitement, and violence in a patient always presses a panic button in a medical setting for which referral comes to psychiatrist for assessment of immediate risk to self and others. That can be clinically assessed by:

Observation

Violent behavior

Possession of weapon

Self-destruction

Extreme agitation or restlessness

Bizarre/disorientated behavior.

Reporting of

Death wish, suicidal urge

Thoughts of hopelessness, intolerability, inescapability, and desperation along with marked anxiety, insomnia

Verbal commands to do harm to self or others, that the person is unable to resist (command hallucinations)

Trait impulsivity and recent violent behavior.

ASSESSMENT OF UNCOOPERATIVE BEHAVIORS CAUSING MANAGEMENT PROBLEM

Another issue of major concern is uncooperative behavior in the ward in apparent clear consciousness-like not following ward norms or treatment advice, pressing for early discharge, giving suicidal threats, complaining against treating staffs, etc. Apart from ruling out underlying depression and psychosis, here, the assessment should focus more on the psycho-social aspects of the patient.

Patients’ understanding of the medical and ward advice communicated to them and their apprehension regarding those issue

Any miscommunication or mistrust with the treating team

Degree of discrepancy in the background milieu of the patient and that of the hospital

Personality – negative affectivity, impulsivity, ability to adjust to a new situation and new persons

Perceived role deficits of the patient when away from home, for example, a patient living alone with pets in home may become anxious and press for discharge to look after them.

REQUEST FOR TRANSFER OF PATIENT TO PSYCHIATRY WARD

This request usually comes for patients with apparent immediate risk to self or others as mentioned above. First thing to rule out is delirium because in delirium patients may turn violent in a state of confusion. The behavioral presentation of delirium may become the major concern for the treating team, but the principal concern for the patient is the underlying medical cause. Another issue is substance intoxication and withdrawal where the apparent behavior abnormality often may have serious medical underpinning and an expression of delirium.

Management of delirium should continue in medical ward with regular psychiatric observation. Substance use disorder patients may be shifted to psychiatry ward after initial stabilization of medical complications.

Patients with depression, suicidality, or psychosis with serious medical morbidity where chance of medical emergency may emerge at any time should also be managed in medical ward with regular psychiatric supervision. In stable medical conditions – like not being put on any ports or requiring oxygen therapy, patient may be shifted to psychiatry ward with provision of regular observation by the medical team.

FORMULATION OF THE DIAGNOSIS AND RELATED NOTES IN CONSULTATION-LIAISON-PSYCHIATRY

Provisional or differential diagnoses of psychiatric disorders or problems as per current nosology of DSM or ICD

Probable etiology of the psychiatric condition in the background of medical illness– any mutual causative role, or comorbidity, or any coincidence

Probable interaction of the required psychiatric treatment with ongoing medical treatment and the treatment milieu

There should be also some comment on biopsychosocial background of the patient which may be relevant regarding overall management of the case, like developmental issues (low intelligence, intellectual disability, autism), any ongoing stressor in personal life, personality, etc.

Any evidence of immediate risk to self and others and need or decision regarding transfer to psychiatry ward

Any adjustment needed on the part of the treating team to manage uncooperative behavior of the patient.

MODE OF COMMUNICATION TO THE REFERRING TEAM

In CL psychiatry, apart from putting down notes on papers, certain additional things are advisable. Psychiatrist should communicate directly to the treating consultant at least through telephonic conversation. Mitigate all the doubts regarding the case from mental health perspective and overall formulation and give suggestion regarding a comprehensive treatment plan.

COMMUNICATION TO THE PATIENT AND FAMILY

In liaison practice, the referred consultant usually does not give any direct therapeutic advice to the patient or family, but there must be some transparent and supportive communication with them regarding the following issues:

Explanation regarding how mental health issues are pertinent in this case

Why the primary treating team has sought for psychiatric assessment and opinion

Impression of CL-psychiatrist regarding presence of any psychiatric morbidity and current severity

If any risk of immediate self-harm or harm to others or any ongoing strain to treatment milieu

Role of family members to help the patient adjust to the treatment milieu, for example, if there is any obligation of the patient back home– that should be taken care properly by relatives

How provision of mental health support or treatment along with the primary treatment services would improve the overall outcome

One very important issue in liaison-practice is to ensure that there is no discrepancy in communication between the primary treating team and the liaison specialist.

PLAN FOR FOLLOW-UP

In cases of confirmed major psychiatric diagnoses where pharmacological treatment needs to be started, follow-up should be there at least within a week. For those patients, regular follow-up at psychiatry outpatient department (OPD) after discharge is also must. Their treatment response can be evaluated by serial MSE or with different rating scales as in case of individual consultation. In cases where definitive psychiatric diagnosis could not be reached, regular follow-up is necessary with need for psychometric evaluation and symptomatic management.

Now we proceed further to.

Flowchart of customized assessment in particular settings

ASSESSMENT OF PSYCHIATRIC CONDITIONS IN INDIVIDUAL CONSULTATION-LIAISON-PSYCHIATRY SETTINGS AS PER THEIR NEED [CHART 2]

Here, discussion would not be done as a psychiatric or medical diagnosis but as a clinical-problem as perceived by the primary treating team in liaison services. We would divide this section under five groups:

Psychiatric assessment at emergency resuscitation (ER) units

Psychiatric assessment at intensive care units (ICU)

Assessment at nonemergency and chronic care units of different specialties

Assessment of need for medical-work-up in patients undergoing treatment in psychiatry units

Multidisciplinary assessment at medical boards.

Psychiatric assessment at emergency resuscitation

In emergency setting, referral is the usual model of CL- psychiatry practice. For quick assessment of urgency of psychiatric attention, the primary care personnel in the ER may be trained with a screening tool named Mental Health Triage Scale (MHTS)[8]. In MHTS, the behavioral problems are arranged in five categories of urgency for psychiatric assessment

Immediate (red) – Immediate need of mental health response along with referral to security or police-due to violent aggression/possessing weapon/self-destruction attempt

Emergency (orange) – Very urgent need of mental health response (usually within 4 h) – clear-cut intent, plan and arrangement for committing harm to self or others;-very high-risk behavior associated with confusion and disorganized behavior

Urgent (yellow) – need of mental health response within 24 h – expression of suicidal intent (no clear-cut plan yet); rapidly increasing confusion, psychotic behavior (delusion, hallucination, disorganization)

Semi-urgent (green)– need within 72 h – major psychiatric disorders of mood or apparent psychosis without any suicidal intent; uncooperative behaviors in ward like wandering, refusing medicines, and other ward norms

Nonurgent (blue) – need within 4 weeks – known psychiatric disorders stable on medication which need regular follow-up

A recent Indian study[9] on emergency psychiatry referral in a tertiary care hospital using MHTS found that the degree of urgency corroborated with the severity of scoring in Brief Psychiatric Rating Scale (BPRS)[10] and yellow was the most common zone of referral.

Now, we discuss some of those conditions according to commonality of their presentation and urgency of assessment in ER:

CONFUSION WITH BEHAVIORAL ABNORMALITIES

These are the most common cause for referral in Indian liaison settings.[911] Such referral raises the possibilities of either a neurocognitive disorder (delirium) where the consciousness, attention, orientation are the primary deficits with psycho-motor and thought-perceptual disturbances; or it may be another primary psychiatric condition with behavioral disorganization where there is inattention and difficulty in assessing consciousness and orientation.

ASSESSMENT FOR DELIRIUM

Delirium is an acute (onset within 2 weeks) neurocognitive syndrome which at times may be prolonged up to 6 months. There may be a plethora of presentation-

Variable psycho-motor disturbances (hyperactive, hypoactive, or mixed)

Perceptual disturbances (hallucination, illusion)

Thought abnormalities (disorganization or delusions).

Thus, the hyperactive variety is often mistaken for psychosis and hypoactive for depression. The hyperactive variety is the more common presentation in ER.[11] However, the primary deficit areas are attention, consciousness, and comprehension leading to disturbed orientation, memory, and other cognitive dysfunctions.

Very important feature of delirium is fleeting and fluctuating presentation with time – particularly worsening after evening or “Sun-downing phenomena.” Another characteristic behavior feature of delirium is floccillation-picking and pulling of objects around

Since primary impairment is inattention, during assessment, one has to talk slowly, clearly and loudly and not many questions at a time.

For early recognition of delirium and to prevent being misdiagnosed as psychosis or depression, health-care personnel at medical setting may be trained with some screening tools.[12] Among them, NEECHAM[13] (Neelon and Champagne) Confusion Scale is one of the most suitable screening instruments in medical and surgical wards.

Delirium always occurs secondary to some medical condition or existing dementia (particularly Lewy body and fronto-temporal dementia). Thus, after clinical confirmation of delirium, causes of delirium should be searched for by history, examination, and investigation. Metabolic, autoimmune, and infective are the three main etiologies behind delirium which would require relevant investigations in blood and cerebrospinal fluid. Neuroimaging should also be done to rule out any cerebral lesion.

Delirium may also occur due to acute intoxication and withdrawal of addictive substances, psychotropic drugs, and exposure or overdose to certain drugs

Anticholinergics (commonly referred as atropine psychosis)

Antimalarials (commonly referred as chloroquine psychosis)

Diuretics and other hyponatremic drugs,

Corticosteroids and other immunosuppressant drugs like azathioprine

Dopaminergic antiparkinsonian drugs like levodopa

Antitubercular (particularly isoniazid, cycloserine, ethambutol)

Antibiotics particularly fluoroquinolones,

Antiretroviral (particularly efavirenz, zidovudine),

Antimetabolite (particularly 5-fluorouracil) etc.

Another important condition is postictal state in epilepsy or nonconvulsive status epilepticus or NCSE, which can only be established by prolonged electroencephalography (EEG) recording with the help expert epileptologists.

ASSESSMENT OF OTHER PRIMARY PSYCHIATRIC CONDITIONS WITH CONFUSION LIKE PRESENTATIONS[14]

Presentation with acute disorganized behavior may appear as confusion. It may be a symptom of psychosis particularly acute psychotic conditions such as acute and transient psychotic disorders with apparent confusion and polymorphic features of psychomotor and thought-perceptual disturbances. Puerperal psychosis very commonly presents like this. However, with increasing knowledge, we are gradually coming to know that many of these acute psychotic conditions are auto-immune origin-particularly NMDA-encephalitis. Thus, in acute onset (few weeks), disorganized behaviors predominantly in young females (age <45 years) with confusion and particularly convulsion – autoimmune encephalitis must be ruled out.

At times, psychotic conditions such as schizophrenia and mania may also present in a grossly nongoal directed excitatory condition with marked hallucinatory behaviors – which may be considered as catatonic excitement historically described as delirious mania by Kraepelin. In these cases, influence of psychoactive substances must also be ruled out.

At times dissociative conditions with anxiety and agitation may also present with experiences of Deja phenomenon and depersonalization-derealization which may appear as confusion-historically described as hysterical psychosis. These often happen in trans-cultural background or may follow acute stressor or trauma. These diagnoses should come only after exclusion of delirium.

INTOXICATION AND WITHDRAWAL OF ADDICTIVE SUBSTANCES[14]

Substance use-related disorders come second to delirium regarding overall cause of referral to psychiatry.[11] For these patients, the need for psychiatric service is because the patients often remain confused, aggressive with immediate threat to self and others. Physicians may need psychiatrists’ knowledge about medical complications of intoxication and withdrawal of different substances and their interactions. After immediate stabilization of patients, psychiatrists’ role would be important for subsequent detoxification. Long-term management plan would depend on assessment of degree of severity of the substance use disorder– like isolated or established harmful use or dependence. This can be done with the help of diagnostic guidelines of ICD/DSM or screening tool like Alcohol Use Disorder Identification Test[15] for the most commonly used substance alcohol.

SELF-INJURIOUS (SI) ATTEMPTS[1416]

Any self-injurious (SI) attempts outside the hospital premises are always brought to the ER first and after initial medical stabilization of the patient, referral to a psychiatrist is obligatory.

In the preparatory phase of assessment, the psychiatrists should enquire about the following:

Observation of any aggressive behavior in ward

Any evidence of substance intoxication or withdrawal

Any records of ongoing or previous mental illnesses and their treatment

Any history of ongoing chronic debilitating or fatal medical illness and their treatment.

With this available information, psychiatrist would further proceed toward interview of relative:

Any history of past and family history of SI

If any previous SI attempts-nature, lethality, and expressed intent in that attempt

Regarding current SI-in what circumstances and time-that occurred

How the patient was recovered

Any suicide note was recovered or not

Any history of psycho-social stressors such as bereavement, financial loss, or acute incident of shame-guilt or anger-altercation or temper-tantrum

Any recent discussion regarding hopelessness, death, or warison

Patient’s family structure, social support

Usual sleep pattern and any recent insomnia

Any behaviors suggestive of impulsivity, emotional dysregulation, aggression in personality

Personality pattern regarding stress handling, adjustment to a new situation, and inter-personal relationship

Any history of developmental delay or diversity.

After talking to the informant, a customary MSE must include examination of:

Affect – any sadness, emptiness, or despondency

Cognition of worthlessness, inescapability, intolerability, desperation

Any persecutory thoughts or hallucinatory experiences (particularly commanding voice)

Detailed interview regarding SI attempt:

Intent of the SI – an attempt to die/or a sudden expression of anger, frustration, protest/or an attempt to relieve anxiety

In case of death wish – reason for that – to get relief from an inescapable, intolerable situation (temporary shame-guilt/or ongoing worthlessness, hopelessness/or helplessness out of fear of harm)/or an attempt to meet a beloved dead person

Whether the commission of the act – at the heat of the moment/or with any prior plan/or any activities as a part of a group/or reaction to some commanding voices from air

If prior plan, or command – how long those were happening

If any previous attempt – what happened in those attempts – either self-restrained due to some reason or aborted by others – how the life was saved.

Apart from MSE, there can be application of standardized tools to determine chance of recurrence of suicide attempt based on the current severity of intent

Beck’s scale for suicidal ideation (SSI)[17] – most commonly applied tool particularly in research – but the tool is not available for free use.

Columbia Suicide Severity Rating scale (C-SSRS)[18]-another increasingly used tool which is free to use and has more extended dimensions. Apart from screening the current suicidal intent and rating of its intensity, it also screens for previous suicidal behavior or attempts which also include nonsuicidal self-injury (NSSI). There is also rating for degree of lethality of previous suicidal attempt.

With all these cross-sectional assessment – formulation should be done as follows:

NSSI

Any influence of substance – intoxication or withdrawal

Any habitual NSSI – related to developmental diversity or personality (borderline) factors

In suicidal SI – ascertain the possibility of grief, acute stress reaction, mood disorders and psychosis, associated anxiety, substance use disorder, personality disorder

Risk of recurrence of suicidal SI – based on previous attempts, persisting thoughts of intolerance-inescapability-desperation and personality features of impulsivity, anxiety, aggression, scores in tools like SSI or C-SSRS

Acceptance of need for hospitalization and adjustment to its milieu subsequent plan for further assessment at Psychiatry department:

Establishing a definitive psychiatric diagnosis with fulfillment of nosological criteria

Need for psychological assessment like personality by standardized tools temperament-character-inventory or international personality disorder examination, if necessary-IQ assessment, for underlying psychodynamic processes projective tests like– thematic apperception test (TAT), Rorschach ink-blot-test

Regular monitoring of suicidal intent by standardized tools by SSI or C-SSRS.

SUDDEN SEVERE CHEST DISCOMFORT, RESPIRATORY DISTRESS, AND MARKED ANXIETY[1419]

This is also a very common presentation in ER where physicians do not find any respiratory or other systemic medical pathology and send referrals to CL-psychiatrists for psychiatric assessment and ruling out psychiatric etiology behind such presentations.

At the initiation of assessment, psychiatrists should keep in mind that they should not jump into searching for any primary psychiatric condition and take it for granted that all the underlying medical emergencies have been ruled out – because that may put the patient’s life in danger. Psychiatrist must rule out from the chart review, medical emergency conditions where respiratory distress with autonomic hyperactivity or nonspecific chest discomfort, palpitation with accompanying worries and anxiety may often be the presentation, like:

Exacerbation of chronic respiratory pathologies,

Myocardial infarction, myocarditis, cardiac arrhythmias

pulmonary embolism, tension pneumo-thorax

anaphylactic condition with respiratory distress

occult severe blood loss (like ruptured ectopic pregnancy)

metabolic acidosis-alkalosis in a known patient of diabetes or kidney disease

catecholamine excess condition such as pheochromocytoma.

Psychiatrist should discuss those possibilities with the attending physician and check whether they have been ruled out for immediate cause or kept in future plan – before proceeding further toward assessment of any psychiatric conditions.

Psychiatrists should also rule out:

Any history of acute substance intoxication (most commonly cannabis and cocaine)

Sudden withdrawal (in chronic heavy opioid use)

Surreptitious attempt of deaddiction (like disulfiram reaction in alcoholics or oral opioid antagonist in opioid dependence).

Next on general observation, patient’s behavior and motor activities should be closely noted, followed by interview of the patient. There may be following possibilities:

If there is restlessness, “looking to escape” out of the place with “as if an air-hunger”– and on interview patient reports “bolt from the blue” appearance of anxiety symptoms which gradually “increased in a crescendo manner” over minutes to a peak where appears a “sense of impending doom”– that raises possibility of panic attacks. In case of panic attack, inquire whether it is an isolated attack or occurring frequently over last 1 month to fulfill panic disorder.

At times, there may be hyperventilation with topsy-turvy movements and verbal responses from groaning to variable utterances – this raises the possibility of conversion symptoms or may be focal seizures of frontal lobe origin.

In focal seizures simulating panic attack, there would be a ball like upward discomfort from epigastric region to chest with respiratory distress, hyperventilation, swallowing and an unexplainable discomfort in head and inability to communicate the distress to surrounding people– lasting for few minutes – proceeding to either gradual recovery or passing into a stage of altered posturing with variable tone of the body with nonresponsiveness for some time and associated amnesia on awakening – this suggests focal seizure of usually temporal lobe origin with or without generalization – which should be evaluated by any neurologist available at that point or later.

After initial assessment and their relevant management, there should be plan for further detailed work-up in psychiatry ward with detailed MSE, psychometry, or use of different screening tools such as BPHQ, PHQ-9, GAD-7, BPRS, etc., as the case may be. In case of panic attack or conversion symptoms, other associated conditions to rule out:

Depression and other mood disorders, GAD, phobia, etc.

Acute stress-trauma (posttraumatic-stress-disorder or adjustment disorder)

Personality disorders.

CERTAIN ACUTE SENSORY-MOTOR PRESENTATIONS CONSIDERED AS “MEDICALLY UNEXPLAINED” [TABLES 1 AND 2]

While attending to this kind of cases on referral, the CL-psychiatrist must not get biased toward dissociative-conversion symptoms from the outset that may lead to overlooking of many underlying organic conditions. Following are the usual presentations and their organic versus psychiatric possibilities:

Diagnostic confusion between seizure versus nonepileptic-psychogenic-events-this will be covered in subsequent chapter of psychiatric disorders in epilepsy

Acute-onset motor disturbances including gait, speech, abnormal involuntary movements[14192021]

Acute onset sensory deficits like vision, hearing, somato-sensory disturbances.[14192021]

Despite all the differences enumerated in the above tables, it is difficult on a single clinical contact to differentiate these conditions with certainty. Hence, treating team at emergency should be communicated about the plan for further evaluation in detail by both neurologist and psychiatrist.

Psychiatric assessment at intensive care unit

In critical care units, most common cause of psychiatric referral is for confusion with behavioral abnormalities which they colloquially refer as “ICU-psychosis.” These conditions are actually delirium which should be assessed as mentioned earlier. Regarding causes of delirium, in case of ICU set up, one important issue is absence of exposure to natural light which may deprive the patient from awareness of day-night change. Primary care personnel at ICU may be trained with screening tool Richmond Agitation Sedation Scale[24] (confusion assessment methods-ICU)[25] for quick screening of delirium. In ICU, hypo-active delirium is often seen which should be differentiated from NCSE by EEG and other neurological evaluation.

Psychiatric assessment at nonemergency and chronic care units of different specialties

In these settings, CL-psychiatry services operate both in collaborative and referral model for both admitted as well as OPD patients. Collaborative medical-n-mental health care is quite common in different super specialty units like neurology, oncology, geriatric medicines while referral model in multidisciplinary hospitals. Subsequent chapters in this CPG will deal with assessment of the particular conditions encountered in different specialties. Here, we would give a general outline.

Among all medical specialties across all ages, stress-anxiety- depression and somatic distress are the most common psychiatric symptoms or morbidities among those patients.

Assessment of Depression: While the prevalence of depression in community ranges around 10%, it goes up to 30% in different medical units which significantly impact the overall outcome.[14] For early recognition of depression, apart from empathic interview regarding one’s prevailing mood, pleasurability, and vegetative functions, there can be quick and effective use of following tools:

PHQ-9[5]– Gold-standard screening tool for depression in most of the settings-part of PRIME-MD-PHQ or BPHQ-with only 9 self-rated question-also used for rating depression in primary care settings

Hospital Anxiety Depression Scale (HADS)[26] is another important tool commonly employed in hospital setting for screening of both anxiety and depression.

Apart from these two tools, there are certain age customized tools for screening of depression:

Geriatric Depression Rating Scale (GDS)[27] – Considering the age variation, both screening and rating of depression in geriatric population are commonly done by GDS. This self-rated tool is not applicable for elderly population with significant cognitive decline or dementia, who fail to respond properly

Childhood Psychopathology Measurement Schedule (CPMS)[28]-Depressive symptoms are also common in childhood population in hospital settings suffering from chronic morbidities such as thalassemia, nephrotic syndrome, or malignancy. They can be screened with CPMS and subsequently rated with Children’s Depression Rating Scale.[29]

Two medical conditions are worth mentioning which merit specific screening tool for depression:

Stroke Aphasic Depression Questionnaire[30]– Nearly one-third of patients of stroke suffer from aphasia who find it difficult to understand and respond to the standard screening tool questionnaire. This scale, based on the response of the attendant, is of immense importance in recognition and monitoring of depression in these patients of stroke with aphasia.

Cornell Scale for Depression in dementia (CSDD)[31]-Depression is a very common comorbidity in dementia where the presentation is different from other depressed patients and there may be co-occurring apathy which masks the usual presentation of depression. This tool is very important for this population of patients.

In all the depressed patients, any Suicidal intent must be screened meticulously as depicted earlier.

Apart from depression, anxiety disorders are also common presentation in medical setting in 20%–30% patients,[14] which either co-occur with different medical morbidities or may mimic complaints of respiratory and chest discomfort. Screening tools for quick recognition of anxiety disorders:

Anxiety questionnaire of– BPHQ[4] and HADS[26]

GAD7[6] (Generalized Anxiety Disorder-7 item)

PDSR[32] (Panic Disorder Self Report)-An effective screening tool for panic disorder yet to be translated and used in Indian studies.

Variable and multiple somatic complaints are another important issue with which patients frequently visit different departments in hospital setting, which cause significant impairment and health-care utilization. In these patients, depression is to be ruled out first by the above appropriate screening tools because depression often presents with somatic distress and untreated depression causes serious health hazards. After ruling out depression, following tools can be used for the assessment of patients with Somatic distress:

PHQ-15[7] items: A self-rated screening tool developed from PRIME-MD-PHQ for recognition and severity of somatic symptoms

SSS8[33] (Somatic Symptoms Scale 8 item): This is another self-rated tool based on PHQ-15, which divides the symptoms burden questionnaire into 4 domains-cardio-pulmonary, gastro-intestinal, pain, and general. However, Indian translation or studies are not available.

IBQ[34] (Illness Behavior Questionnaire) – Apart from subjective distress, another important aspect of these complaints is health-care utilization. This tool gives an idea about this health-care seeking behaviors.

Chronic and serious medical morbidities along with hospitalization increase stress of an individual which in a vicious cycle further worsen the outcome of those illnesses. To cope with that stress, one should have resilience which in turn predict good outcome. Perceived stress and resilience can be screened with tools like:

Perceived Stress Scale[35]

Connor Davidson Resilience Scale[36]

These tools are particularly useful in specialties such as oncology, trauma, burn, patients waiting for transplant.

Apart from the commonly encountered internalizing symptoms, there may be exacerbation of already existing or newly appearing psychotic conditions and their related agitation, aggression which can be most effectively screened as well as rated by BPRS.[10]

Screening for cognitive decline should also be done particularly in elderly population and patients with chronic neurological illnesses – such as epilepsy, movement disorders, stroke, head injury, HAND (HIV associated neurological illnesses); post-COVID patients. They can be done with different standardized tools such as Mini Mental State Examination[37] and Montreal Cognitive Assessment test (MoCA)[38], both of which has validated Hindi version– H-MSE[39] and H-MoCA;[40] or neuropsychological batteries developed by NIMHANS[41] or PGI, Chandigarh.[42] Another screening tool has been developed in Kolkata, West Bengal in Bengali language to screen for nondemented early cognitive impairment subjects from urban community which is known as Kolkata Cognitive Screening Battery which also includes B-MSE (Bengali-Mental State Examination).[43] This tool has a corresponding Hindi version applicable for rural Hindi-speaking population of India.[44]

In case of diagnosed dementia, behavioral and psychological symptoms (BPSD) can be assessed by neuropsychiatric inventory,[45] BPRS, CSDD, Apathy Evaluation Scale.

There can be many more specific psychiatric issues and their customized screening and evaluation tools associated with different medical units which would be discussed in subsequent chapters.

Assessment of need for medical-work-up in patients undergoing treatment in psychiatry units

CL-psychiatrists should be cautious about the tell-tale signs of organicity in patients presented to psychiatric units, some notable examples:[1920]

Psychosis – confusion, seizure, subacute onset – autoimmune encephalitis

Depression – weight loss, severe pain– multiple myeloma

Depression– anorexia, nausea, pain abdomen – gastric, pancreatic carcinoma

Depression/Anxiety – panic attack like autonomic features, flushing – paraneoplastic conditions in lung carcinoma in elderly or pheochromocytoma in young

Late-onset mood disorder– neuroleptic sensitivity, subtle movement disorders – degenerative conditions of the brain

Apparent dissociative conditions – localization-related epilepsy or nonmotoric vascular lesions of brain – Balint’s/Gerstman/Anton syndrome.

Assessment for medical comorbidities and psychotropic- induced medical complications can follow Maudsley practice guidelines for physical health conditions in psychiatry.[46] The mantra is regular medically vigilant clinical (general and systemic) examination coupled with investigations—details of which will be dealt in subsequent chapters.

Multidisciplinary Assessment at medical boards

Psychiatrists often act as member in a multidisciplinary medical board for the assessment of following conditions:

Physical and mental state assessment of a victim of sexual assault, particularly children – immediate stress, trauma and subsequent PTSD, depression

Examination of children in conflict with law referred by Juvenile Justice Board to assess their capacity to understand the nature and consequence of their acts and their need for protection and care.

NIMHANS – child and adolescent department of psychiatry has detailed guidelines on child protection issues which can be looked into their designated website https://www.nimhanschildproject.in.

Assessment of fitness or capacity of a person to pursue certain works after long absenteeism, or giving testaments or stand trial in legal cases in terms of physical and mental abilities – like cognitive functions and major psychiatric-disorders like psychosis, unremitting mood disorders, or OCD. These can be assessed by scrutiny of previous treatment papers, current MSE, psychometric assessment, application of appropriate screening tools, and rating scales

If the above conditions become unremitting, persistent with significant deterioration in quality-of-life and psycho-social-impairment – the patients qualify for disability certificate after assessment with Indian Disability Evaluation and Assessment Scale[47]

Another important issue in this board is to assess for malingering. During skillful interview, “too perfect” a tale almost taken out of diagnostic criteria, or too vague or unrealistic tale – raise suspicion of malingering. There is no fixed and authentic protocol to deal with such cases. Before giving final opinion, the incumbent should be observed regularly over the next 6–8 weeks with serial MSE, application with screening tools, and application of psychometry [Table 3].

Table 3

Some important psychiatric-assessment-tools in CL-settings and their use in Indian studies

Name of the tool	Focus of assessment	Indian validation and adaptation	Source of availability
AUDIT[15]	WHO guideline For primary health-care screening for degree of problematic alcohol use–hazardous-harmful-dependence 10 questions by interviewer over few minutes Also contain information on associated health hazards and brief intervention	Translation and validation of the tool in Hindi[48] Studies have been done to validate the tool both North Indian[49] and South Indian[50] population Used in Indian study on patients admitted with suicidal attempt in a tertiary care general hospital[51]	Manual https://apps.who.int/iris/handle/10665/67205
Beck’s SSI[17]	Interviewer rated 21-item scale-scoring on 19 items 5 items for screening If positive 14 items for severity Current intensity on the day of interview Two major dimensions of suicidal desire and preparation Total time about 5 min		Copyright1979by the American Psychological Association, Inc. 0022-006X/79/4702-0343$00,75 (manual sold by Pearson assessment publication)
BPHQ[4]	Self-rated 2-page questionnaire Quick and easy to apply in primary care setting Adapted from PRIME-MD-PHQ Targets depression-anxiety-panic-somatic complaints-stress-trauma-	Adapted and translated in 11 Indian Languages Standardized with DSM IV depression criteria in Indian study[52]	Indian translation-copyright Pfizer India and PRIME-MD study group with reference to Indian study
BPRS[10]	Interviewer rated questionnaire Gold standard for screening and rating of wide range of symptoms including psychosis, agitation, catatonia, anxiety, mood, self-harm 24 items – 0-7 scoring 20-30 min	Applied in innumerable Indian studies Corroborate with severity and urgency of psychiatric assessment as found in Indian study[9]	Manual https://usermanual.wiki/Pdf/Brief20Psychiatric20Rating20Scale20BPRS20Instructions. 1342467641/view
CAM-ICU[25]	Screening tool for delirium in ICU by physician, nurses Start with RASS for Arousal then progress further Assess presence, severity, and fluctuation Both verbal and nonverbal (ventilated patient) Nonverbal ratings have high specificity but low sensitivity and low inter-rater reliability	Indian study on incidence and outcome of delirium in nonintubated ICU patients in a tertiary care private hospital with this tool[53]	Manual http://tetaf.org/wp-content/uploads/2016/03/CAM_ICU_training.pdf
CDRS[29]	17-item clinician rated Children of age 6–12 years (may be extended up to 18) Validated in medical settings A revised version CDRS-R is there for extended range of severity scoring	Indian study has been done in CMC Vellore to validate CDRS-R for adolescents in in primary care[54]	Manual http://www.scalesandmeasures.net/files/files/Childrens%20Depression%20Rating%20Scale%20Revised%20 (1995).pdf
CPMS[28]	Clinician rated screening tool for 4–14 years Total 85-item schedule with 8 factorially derived domains of syndromic psychopathology-such as low intelligence, conduct, anxiety, depression, psychosis May screen for individual domain or overall score	Indian tool developed at PGI Chandigarh Based on CBCL	Scale with author’s citation
CD-RISC[35]	A measure of stress coping Applied in wide range of setting including hospitals Important indicator of improvement for patients of trauma, stress of serious illness Interviewer assisted self-rated questionnaire of 10 or 25 item–quick to apply	Psychometric evaluation of the scale has been done in studies on Indian student population[55] No Indian translation found	Manual http://www.connordavidson-resiliencescale.com/CD-RISC%20Manual%2008-19-18.pdf due reference to author
CSDD[30]	Interviewer rated scale with interview of both patient and informant Screening tool with multiple domains comprising 19 items About 20 min interview	Indian studies with CSDD not found	Manual https://dementiaresearch.org.au/wp-content/uploads/2016/06/CSDD.pdf due reference to author
	Final score on overall impression of clinician
	More valid and commonly used than GDS in BPSD studies
C-SSRS[18]	Interviewer rated Two screening domains-suicidal ideation and behavior Two rating domains-intensity of ideation and lethality of behavior Also includes NSSI More extended domain–quick to apply but scoring is complicated	It has translated version in 7 Indian languages-for free use under Columbia lighthouse project for suicide prevention to contact posnerk@nyspi.columbia.edu No Indian study could be found	Manual https://suicidepreventionlifeline.org/wp-content/uploads/2016/09/Suicide-Risk-Assessment-C-SSRS-Lifeline-Version-2014.pdf
GAD-7[6] (item questionnaire)	7-item both self-report and interviewer-administered questionnaire for screening of GAD Developed from PRIME-MD-PHQ Matches clinician’s diagnosis by DSMIV	Study done on suitability of this tool and PHQ9 on large sample of Indian patients under diabetes care[56]	Hindi translated version is available with Pfizer India website
GDS[27]	Self-rated screening tool long (30 item), short (15 item) -yes/no response Extensively used in geriatric medical setting except dementia Response “no” on question 1, 5, 7, 11, 13 and “yes” on rest 10 question-gets score 1 Score 5 probable depression, 10 definite Also used as rating of depression-5-8 mild; 9-11 moderate; 12-15 severe	Validated Hindi Translated tool H-GDS[57] Also available in other language, like Bengali[43]	Original scale manual https://hign.org/sites/default/files/2020-06/Try_This_General_Assessment_4.pdf Indian version with author
HADS[26]	Separate anxiety and depression screening questionnaire 7 questions in both group with scoring 0-3 for each Cut-off score >10-definite, 8-10-doubtful 4-5 min self-rated Developed for hospital setting–like anxiety for syringe	Study on cancer patients with Malayalam version[58]	Officially distributed by https://eprovide.mapi-trust.org/instruments/hospital-anxiety-and-depression-scale#languages
IBQ[33]	62 self-rated yes/no questions Patient’s attitudes, ideas, affects, and attributions in relation to illness Delineation between care-seeking versus assuming self-responsibility	Indian study did translation and validation of this tool in Hindi Language[59]	Questionnaire athttps://psychology.okstate.edu/faculty/jgrice/psyc5314/ibq.pdf
KCSB[43]	Screening of mild cognitive impairment or decline in Bengali Initially obtained normative data on urban elderly population Contains B-MSE, verbal, visuo-constructional and memory items	Validated with Hindi version in rural Hindi-speaking population of Ballabgarh, North-India[44]	Tool and the cut-off score are given in appendix of original article
MMSE[36]	Most commonly employed tool for cognitive screening 12 item with 30 score-sets cut-off for dementia (<20) versus Mild cognitive impairment (<25) Remained gold standard for 5 decades	Translated and validated Hindi tool-HMSE[38] for Rural, illiterate population Pilot study[60] done on urban elderly-but validity inconclusive on illiterate people	MMSE copyrighted for all use in 2000 to PAR HMSE in public domain with author citation
MoCA[37]	Newer screening tool with domain-specific cognitive assessment More sensitive for mild impairment Gives importance to educational status of the patient in scoring Pictorial representation	Translated and validated in Hindi-H-MoCA[39]	Manual https://geriatrictoolkit.missouri.edu/cog/MoCA-8.3-English-Instructions-2018-02.pdf
NEECHAM[13]Confusion Scale	Delirium screening instrument in medical, surgical wards, and also ICU For nurses–takes 10 min 3 subscales-cognitive functions/behavior/physiological state (temperature, respiration)	Indian study was conducted to corroborate NEECHAM confusion scale and RASS among ICU patients[61]	Manual https://www.mnhospitals.org/Portals/0/Documents/patientsafety/Delirium/Neecham%20Confusion%20Tool.pdf
NPI[45]	Tool for assessing broad array of 12 domains of psychopathology in BPSD over last month Informant’s self-rated questionnaire-yes/no If “yes”–the rating of severity 0-3 and rating of distress/care-giver burden 0-5 in each domain Average time 5 min	Indian study has been done with NPI to compare BPSD in Alzheimer’s, vascular and bvFT dementia[62]	Manual https://download.lww.com/wolterskluwer_vitalstream_com/permalink/cont/a/cont_21_3_2015_02_26_kaufer_2015-10_sdc2.pdf
PHQ-9[5] (9-item PHQ for depression)	Quick self-rated tool 9 items-each scoring 0 (not at all) –to-3 (nearly every day) over the last 2 weeks Cut off score is variable 7-15, most common being 10 Also used as rating scale in primary care settings–with score 5, 10, 15, 20 indicating mild, moderate, moderately, and severe depression	Translated in 11 Indian languages Plenty of Indian studies in different languages Indian study[63] with Malayalam language found cut-off score as 9	Indian version available with Pfizer India Website
PHQ-15[7]	Brief-interviewer assisted-self rated tool for somatic complaints Each item score 0 (not bothered) -2 (highly bothered) over the last 4 weeks 5, 10, 15-cut-off for low-medium-severe Applicable in multiple health settings-general medicine to obstetrics	Indian study[64] used PHQ-15 for somatic complaints in depression and dementia	Free at file:///C:/Users/Ray/Downloads/PHQ_15%20 (1).pdf
PSS[34]	Interviewer assisted self-rated tool Quick to apply 10 questions with 0-4 score Screen stress over last 1 month Scores beyond 20 found to be associated with health hazards	No Indian version available with the designated website of Sheldon Cohen One Indian study[65] on 37 Medical personnel for validation of Bengali translation of PSS-10	Questionnaire and scoring https://das.nh.gov/wellness/docs/percieved%20stress%20scale.pdf
SADQ[29]	For clients with significant aphasia (minimum understanding and response) Interviewer assisted ratings of observation by caregiver Initial 21-item, later revised 10 item and for hospital use to be rated by hospital staff Few minutes screening tool with cut-off score around 14	Translation and adaptation in Hindi language done[66] for SADQ-10	Details of scale https://strokengine.ca/en/assessments/stroke-aphasic-depression-questionnaire-sadq/

All websites were searched on October 31, 2021; Always use the scales with citation of original article and the source. Check for the updated copyright status. AUDIT – Alcohol use disorder identification test; SSI – Scale for suicidal ideation; BPHQ – Brief-patient health questionnaire; BPRS – Brief Psychiatric Rating Scale; CAM – Confusion assessment methods; ICU – Intensive care units; CDRS – Childhood depression Rating Scale; CPMS – Childhood psychopathology measurement schedule; CD-RISC – Connor Davidson Resilience Scale; CSDD – Cornell Scale for depression in dementia; C-SSRS – Columbia-Suicide Severity Rating Scale; GAD-7 – Generalized anxiety disorder-7; GDS – Geriatric Depression Rating Scale; HADS – Hospital Anxiety Depression Scale; IBQ – Illness behavior questionnaire; KCSB – Kolkata cognitive screening battery; MMSE – Mini Mental State Examination; MoCA – Montreal cognitive assessment test; NEECHAM – Neelon and champagne; NPI – Neuropsychiatry inventory; PHQ-15 – Patient health questionnaire-15 items; PSS – Perceived Stress Scale; SADQ – Stroke aphasic depressive questionnaire; RASS – Richmond Agitation Sedation Scale; CBCL – Childhood behavior checklist; PAR – Psychological assessment resources; BPSD – Behavioral and psychological symptoms; NSSI – Nonsuicidal self injury; HMSE – Hindi Mental State Examination

SUMMARY

For psychiatric assessment in CL settings, there should be a preparatory phase and a distinct way of introduction and communication with patients compared to individual clinical practice

Focus of assessment is guided by the need of the primary treating team for better management of patient, as well as to relieve the strain perceived by them to handle the mal-adaptive behaviors of patient

Apart from skillful interview and MSE, multiple screening tools are of utmost importance

In CL-psychiatry practice, psychiatrists should have a sound medical knowledge parallel to their knowledge in psychiatry for proper assessment of the condition

The three “C” – conceptualization, communication, and control in CL-psychiatry practice hold some definite uniqueness than individual clinical practice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Table 1

Assessment of acute onset motor disturbances

	Organic	Psychogenic
Sudden gait difficulties	Sudden gait difficulties with organic etiology–rare	Sudden appearance is a suspicion for psychological origin but never a surety
	History of fever raises suspicion of acute postinfection demyelinating polyneuropathy (Guillain–Barre syndrome)	Usually, no definitive gait pattern or difficulties–gait appears chaotic in nature–appears as if would fall without support–but usually no fall or injury–astasia-abasia-may be with complain of extreme pain and attention-seeking behavior (but not the classical antalgic pattern for any focal lesion)
	Any ongoing clinical state suggestive of	History of any fall and injury on the head due to movement difficulties–very much unlikely to be psychogenic
	Nutritional (thiamin) deficiency	Neurological examination either normal or inconsistent
	Hyponatremia and subsequent rapid correction-osmotic demyelination
	Toxic condition-neuro-lathyrism which may present like poliomyelitis
	Intoxication or withdrawal of substances-particularly alcohol
	Loading dose or rapid escalation of psychotropics (particularly lithium, carbamazepine, valproate, low potency antipsychotics
	Must carry out
	Detailed neurological examination of pyramidal and extra-pyramidal system, cerebellum, posterior column, ocular gaze, frontal lobe, bladder-bowel control etc.
	Postural hypotension and vertigo to be ruled out
Sudden speech difficulties	To rule out nonfluent aphasia, ability of comprehension, word naming, repetition to be tested	Conversions usually present with acute aphonia rather than aphasia
	In case of sudden aphasia–stroke, TIA, postictal state to rule out	In psychogenic aphonia, patient has no dysphagia or stridor and either refuses to cough or cough normally; may whisper without strain
	In true aphonia, patient is unable to cough and whisper with strain and stridor	In mutism, other features of catatonia (disturbance of tone, waxy flexibility, maintenance of posturing, automatic obedience) to rule out
	In mutism with catatonia like presentation and associated fever-rigidity infective and other metabolic encephalopathy to rule out
Sudden in voluntary movement sand posture	Acute onset drug-induced dystonia is a common condition on exposure to typical antipsychotics or injectable antiemetic like metoclopramide	Unlike dystonia, psychogenic posturing is not painful
	Sudden involuntary movements are rare-may be focal seizures; sudden choreiform movements in fever with autoimmune condition (rheumatic fever), pregnancy, nonketotic hyperosmolar hyperglycemia, or drug induced tremor, etc.	Psychogenic posturing to be differentiated from catatonia by other associated features
	In case of sudden appearance of abnormal movements during sleep initiation or middle of the sleep with abnormal behaviors and vocalization–raise suspicion of RLS or REM-BD	Psychogenic abnormal movements get reduced on distraction, have chaotic pattern–settles with sleep–but should be confirmed by sleep electrophysiology whether the patient was actually sleeping or not
Presentation with gross reduction in spontaneous movements and reactivity–Stupor	History of	Presentation of Stuporous condition with a history of antipsychotic exposure is the trickiest condition between NMS and psychogenic presentation
	Head injury-fall	Catatonia to be established by motoric signs of altered muscle tone like rigidity-lead-pipe/gegenhalten-resistance, waxy flexibility; or altered responses like negativism, automatic/passive obedience, grasp reflex, echolalia-echopraxia, etc., (vide Busch Francis Catatonia scale)[22]
	Remaining in closed room with source of fire-carbon monoxide poisoning	Catatonia my at time present with fever (lethal catatonia-starts with extreme excitement–progresses with exhaustion and fever)
	Substances intoxication	Differentiation lethal catatonia versus NMS
	Fever–vomiting–convulsion	Autonomic instability commoner in NMS
	Known diabetes–insulin treatment	In lethal catatonia excitement-exhaustion-fever
	Chronic liver, kidney disease	In NMS, rigidity-fever
	Parkinsonism	Dissociative stupor
	Chance of electrolyte imbalance	Rare
	Must rule out psychotropic exposure and life-threatening NMS	Rule out organic conditions, NMS, catatonia
	Examination of	Here muscle tone usually normal or low
	Pulse-BP–respiration	A common test of passive raising of hand over face and letting it fall usually does not fall on face in dissociation
	Pupil-planter
	Glasgow Coma Scale
	Muscle tone-jerks-power
	Focal lateralizing signs
	Signs of meningeal irritation
	Brainstem reflexes
	Investigation of
	CBG
	ABG analysis
	Cerebral imaging
	Serum electrolyte, urea, creatinine liver function test with serum-ammonia
	Serum CPK and cell count (CBC)
	CSF study
	To be kept in mind
	Anoxic and metabolic stupor is a diagnostic problem
	Psychogenic stupor is a rarity

TIA – Transient ischemic attack; RLS – Restless leg syndrome; NMS – Neuroleptic malignant syndrome; MS – multiple sclerosis; CBG – Capillary blood glucose; ABG – Arterial blood gas; CPK – Creatinine phosphokinase; CBC – Complete blood count; BP – Blood pressure; CSF – Cerebrospinal fluid; REM-BD – Behavior disorder associated with rapid eye movement sleep

Table 2

Assessment of acute onset sensory disturbances

	Organic	Psychogenic
Visual loss	Detailed ophthalmological and neurological workup (visual evoked potential) is a must	NOVL[23]–in either visual acuity or field loss – should be a diagnosis of exclusion after detailed ophthalmological evaluation
	Optokinetic Nystagmus is often a differentiating feature for organic lesion	Altered test of proprioception in a patient with complaints of visual difficulty is a strong suspicion of psychogenic condition, as that does not involve any role of vision but does not rule out organic lesion at sensory parietal cortex
	Clinical conditions like hemineglect, alexia without agraphia, Balint’s syndrome (simultanagnosia–missing the forest for the wood; oculomotor apraxia–inability to fix the eyes at the intended area; optic ataxia–inability to move the hand to a specific object using vision), etc., may well appear psychogenic, but actually are result of stroke at nondominant or bilateral parietal and occipital lobes
	On the contrary, in Anton syndrome, there may be visual loss but patient remains unaware of it (bilateral occipital lobe damage-stroke)	Recognition of NOVL as either conversion or malingering is more of circumstantial (in situations of conflict with law) on the basis of moral accusation rather than medical
Hearing loss	Detailed examination of hearing pathology is a must, but some of the audiometry tests reports may become unreliable because of improper response of patients, where attention-distraction procedure would be needed	Complain of sudden complete hearing loss with no restriction of activities and la belle indifference effect may raise suspicion of psychogenic origin
		Patients usually show no distress or effort to listen what is being said to him or her
Cutaneous sensory disturbances with dysthesia, numbness or pain	In acute neuropathy or peripheral, spinal, or cranial nerves, there would specific dermatomal rule of distribution	Localization of pain is vague
	Reflex function for the region is helpful	No motor involvement which may be associated with neuropathy
	In case of plexopathy a wide area of involvement like complete limb with both sensory and motor involvement	Variable emotional expression–from marked restlessness, anxiety, crying out for help in case of pain to apparent la-belle-indifference in complain of cutaneous anesthesia
	Variable and fleeting presentation of dysthesia – numbness, pin pricking, electrical sensation in different unrelated areas – may be tricky – needs to rule out MS	Preceding psychological stressor may raise suspicion but organicity must be ruled out

MS – Multiple sclerosis; NOVL – Nonorganic visual loss