Psychosomatics 48:272-274, June 2007
doi: 10.1176/appi.psy.48.3.272
© 2007 Academy of Psychosomatic Medicine
Neuropsychiatric Assessment
Edited by Stuart C. Yudofsky, M.D., and H. Florence Kim, M.D., American Psychiatric Publishing, Inc. Review of Psychiatry Series, Volume 23, No 2, Arlington, VA, American Psychiatric Publishing, Inc, 2004, 228 pages, ISBN 1-58562-177-3, $41.95
Paula T. Trzepacz, M.D.
The term "neuropsychiatry" is used variably in different contexts, depending on how loosely the term is applied. The more specific definition, for example, as used by psychiatrists who are members of the American Neuropsychiatric Association, is that neuropsychiatry is the subspecialty at the interface of psychiatry and neurology, where understanding the anatomy and function of brain regions and circuits related to cognition, language, behavior, thought, and perception is the foundation of their approach to patients. Furthermore, neuropsychiatrists care for patients with comorbid psychiatric and neurological disorders who "fall through the cracks" of traditional neurology and psychiatry practices—this includes patients with traumatic brain injury, complex partial seizures, movement disorders, all types of dementias, and developmental disorders. Neuropsychiatrists think about the patient’s condition differently than do other psychiatrists: they rely on their knowledge of the brain’s electrophysiological, neurochemical, and structural underpinnings in sorting out causes for symptoms, rather than just using a diagnostic classification system such as the DSM. They do this even when treating more traditional psychiatric patients, such as those with schizophrenia or major depression. To explain the patient’s symptoms, neuropsychiatrists always want to know what’s going on in the brain.
Neuropsychiatrists regularly rely on both mental status and neurological examinations, performed in conjunction with objective laboratory tests, to evaluate the patient and guide patient management. These tests and measurements include electroencephalography, formal neuropsychological tests, brain imaging, and laboratory work. In its five chapters, this book on neuropsychiatric assessment reviews each of these areas of objective assessment (except mental-status examination). Although geared toward students and residents, this book can also be a useful primer for psychiatrists in more traditional practices who need either to learn about or get refreshed and updated on the more directly brain-related assessment approaches. With the ever-increasing knowledge and research about the ways in which the brain is impaired in primary psychiatric disorders, all psychiatrists need to become more conversant with the medical tools of our profession.
Neuropsychiatrists will find this book useful for teaching students, although they themselves will likely be using textbooks of neuropsychiatry for more in-depth information. Most chapters in this book describe how the assessments can be used for primary psychiatric disorders; there is also some mention of delirium and dementia, although the chapters do not include examples of neurologic/psychiatric interface disorders that can be found in textbooks of neuropsychiatry.
The writing style is clear, the figures and tables very helpful, and the information about highly technical topics easily accessible for those who are not already experts in these areas. The book is well-edited, so that the style across the multiple contributors’ chapters offers seamless reading from one chapter to the next. Especially important is the point that the expert authors for each chapter were careful not to over-promise what information these tools can provide. For example, the beautifully colored topographic computerized EEGs or various brain-imaging techniques cannot yet diagnose neuropsychiatric disorders, although they can be useful adjuncts to careful clinical evaluation and may be helpful for monitoring symptom severity over time.
The authors appropriately concede that large-scale clinical trials are needed in those few instances where there might be a signal specific to a disorder, although the approach of combining genotyping with these neurodiagnostic tests may be required to better subtype patients and thereby successfully detect specific diagnostic patterns. And neuropsychologists increasingly prefer the flexible-battery approach over the lengthy fixed-battery approach, although that requires even more sophisticated interpretation of the patient’s likely symptoms from a clinically-skilled neuropsychologist, who then tailors the choice of cognitive tests to the individual patient. Brain imaging, especially, using a variety of forms of MRI and MRS, offers a sensitive window into brain dysfunction and has allowed advances in the understanding of how the brain produces mental disorders in ways not available to early neuropsychiatrists such as Alzheimer, Lewy, and Nissl, who could only "see" the naked brain in their hands or under a microscope.
Several areas of particular excellence in this book deserve special mention. Chapter 1, "Neuropsychiatric Physical Diagnosis," offers a superb review of history-taking and examination, not only for soft signs and primitive reflexes, but also eye findings, paroxysmal attacks, abnormalities of movement and gait, and physical findings suggestive of developmental problems.
Table 2-1, in the chapter "Neuropsychological Examination of the Patient," is a great reference that relates cognitive domains such as memory, attention, and executive functioning, with formal tests of each domain and the clinical meaning of deficits detectable by such tests. Even cutting-edge testing modalities, such as computerized neuropsychological tests and virtual-reality methods are mentioned.
Chapter 3, "Electrophysiological Testing," is one of the best I have ever read on this topic, with a careful discussion of abnormal patterns on standard EEG exams that occur more often in psychiatric patients, such as 14- and 6-positive waves and rhythmic midtemporal discharges, and the P300 and N400 components of the evoked potential that relate to psychological cortical activity like information-processing. Two well-described clinical examples are EEG findings in dementia patients over time and the incidence of epileptiform abnormalities in children and adolescents with attention-deficit hyperactivity disorder (ADHD), a condition once included within the umbrella term "minimal brain dysfunction," where the comorbidity of seizures and attentional deficits was more easily recognized than by today’s psychiatrists.
Chapter 4, "Neuropsychiatric Laboratory Testing," distinguishes screening from diagnostic laboratory tests and includes several excellent reference tables. Table 4–2, listing serum, urine, and CSF tests and their clinical significance, is so thorough that I wonder why it is titled "screening laboratory tests." Table 4–3 lists urine drug screens with the detection time-frames, and Table 4–5 lists biomarkers, including genetic ones, for a number of neuropsychiatric disorders.
And, finally, Chapter 5 describes the family of magnetic resonance-related techniques in a way that makes complex physical chemistry understandable. These include functional MRI (fMRI; magnetic resonance imaging), which measures relative oxygenation of tissue, MRS (magnetic resonance spectroscopy), which measures several markers of cellular integrity and function (e.g., N-acetylaspartate, to assess living neurons; creatine, for high-energy metabolic products; choline, for cell-membrane synthesis; and myoinositol, for glia), and DTI, or diffusion tensor imaging, which measures the pattern of white-matter in axonal pathways through the degree of water molecules’ alignment.
What would I have liked to have been included that was not? Three things:
First, a chapter on "Functional Neuroanatomy of Brain Regions," to familiarize clinicians about how symptoms can be generated by abnormalities of specific brain regions, which would also serve to "anchor" the reader in functional neuroanatomy before reading the chapters on modes of brain assessment and to give more synthetic relevance to assessment methods.
Second, an additional section in Chapter 2 that describes several screening cognitive examinations (also called "bedside testing") assessing a range of domains that could be utilized by psychiatrists—tests that are more broad and in-depth than tests like the Mini-Mental State Exam; for example, the Cognistat, Mattis Dementia Rating Scale, and the RBANS (Repeatable Battery for Assessment of Neuropsychological Status). Psychiatrists need to increase their armamentarium of tools to more specifically assess cognitive domains during routine clinical care, so that when they need to refer to neuropsychologists for more extensive testing, they do so with a better understanding of the patient’s deficits.
Third, a section in Chapter 4 that describes direct laboratory measures of the brain; this could include brain biopsy and its indications, and CSF measures of drugs and whether they relate to serum levels under various conditions.
In summary, this primer on neuropsychiatric assessment offers a glimpse into how neuropsychiatrists approach patient evaluation and includes much valuable information about the five following neurodiagnostic assessment categories: 1) neuropsychiatric physical examination; 2) formal neuropsychological testing; 3) electrophysiological testing; 4) laboratory chemistries; and 5) neuroimaging. Understanding what these methods offer the clinician and how to interpret the data are important. Performing the more advanced neuropsychiatric physical examination and knowing which tests to order are within the proficiency reach of all practicing psychiatrists and will enhance the quality of patient care. This paperback book is a very worthwhile investment for any psychiatrist or trainee.
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FOOTNOTES
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Dr. Trzepacz is a governor of the Academy of Psychosomatic Medicine
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