Building Bridges between Neurology, Psychiatry and Psychology

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(No Transcript)
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Course aims

• Instruct
• Assessment, diagnosis, management of disorders in
  middle ground between neurology and psychiatry
• Entertain
• Always better if one is
• Inspire
• Ideas for your future research and service
  improvements
• Foster excellence
• Might as well do a really good job

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Course aims

• Instruct
• Assessment, diagnosis, management of disorders in
  middle ground between neurology and psychiatry
• Entertain
• Always better if one is
• Inspire
• Ideas for your future research and service
  improvements
• Foster excellence
• Might as well do a really good job

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Course aims

• Instruct
• Assessment, diagnosis, management of disorders in
  middle ground between neurology and psychiatry
• Entertain
• Always better if one is
• Inspire
• Ideas for your future research and service
  improvements
• Foster excellence
• Might as well do a really good job

5
Course aims

• Instruct
• Assessment, diagnosis, management of disorders in
  middle ground between neurology and psychiatry
• Entertain
• Always better if one is
• Inspire
• Ideas for your future research and service
  improvements
• Foster excellence
• Might as well do a really good job

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Neurological History Taking

• Adam Zeman
• Professor of Cognitive and Behavioural Neurology
• Peninsula Medical School Department of
  Psychology
• Exeter

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Neurological history taking

• Predominant importance of history-taking in
  diagnosis
• Importance of a witness history

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Neurological history taking

• Aims
• Information gathering exercise
• Neurological disorder
• Psychosocial background
• Informal examination
• Neurology, cognition, personality, behaviour
• Open up therapeutic relationship
• Interested, sympathetic, receptive

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Neurological history taking

• Presenting complaint
• One or several? Useful to list. Significance of
  many (inverse symptom law)!
• Allow uninterrupted narrative, so far as possible
• Clarify
• Date of onset
• Frequency of recurrence
• Duration of episodes
• Evolution
• Nature of main symptom, in detail
• Tempo
• Associated features
• Triggers
• Exacerbating/relieving factors
• Treatment

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Neurological history taking

• Headache in a 34 yr old woman
• Onset at puberty
• Attacks 1-3/month
• Few hours 2 days
• Increasing frequency/intensity past two years
• Throbbing headache, often unilateral, either side
• 20 minutes scintillating visual disturbance,
  preceding headache nausea, photo- and
  phonophobia with headache
• Sleeping in at the weekend red wine
  pre-menstrual week
• Worse upright, better lying flat in dark room,
  helped by sleep
• Helped by aspirin taken early in attack no help
  if not.

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Neurological history taking

• Further questioning via initial hypothesis, for
  example
• PD handwriting
• MS LHermittes, Uthoffs
• Epilepsy tongue-biting, incontinence
• Syncope three Ps

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Neurological history taking

• Do you need to speak to an eye witness or
  informant?
• Yes, in diagnosis of blackouts, funny turns,
  parasomnias, cognitive disorders
• Sometimes best done with the informant alone
  (warn at start of appointment)

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Neurological history taking

• Some common symptom patterns
• NMJ
• Fatiguable weakness
• LMN
• Dysarthria, dysphagia
• Distal weakness (and numbness)
• UMN
• Dexterity, dragging foot, exertional worsening,
  clonus, spasms (and sphincter disturbance)
• Extrapyramidal
• Aching, slowing up, shuffling, dexterity,
  handwriting
• Cerebellar
• Slurring of speech, clumsiness, unsteadiness

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Neurological history taking

• What do you think is wrong?
• brain tumour (headache)
• Multiple sclerosis (tingling)
• Parkinsons (tremor)
• Alzheimers (forgetfulness)
• Epilepsy (faints)
• What are you hoping for from this consultation?

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Neurological history taking

• Functional enquiry
• Omit?!
• General questions
• Appetite, weight
• Sleep
• Concentration, memory
• Energy
• Pleasure
• Mood
• Anxiety, panic

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Neurological history taking

• Neurological function
• Headache
• Pain
• Sensation
• Limb function weakness, dexterity,
  coordination, gait
• Sphincters bladder, bowel, sexual function
• Cognitive function
• Memory (recent, remote, routes, faces)
• Language
• Arithmetic
• Planning
• ADLs

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Neurological history taking

• Other systems
• Fever, night sweats
• Lumps and bumps, swollen glands
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary

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Neurological history taking

• Past Medical History
• Previous illnesses
• Chronic disorders
• Operations
• Specific queries, eg in epilepsy birth, febrile
  convulsions, head injuries, CNS infections
• Current prescribed medication
• Alcohol, tobacco, recreational drugs

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Neurological history taking

• Old notes!
• A vital source of information
• Past illnesses/operations (eg surgical pathology)
• Opinions (consistent impressions)
• Relevant results (Caeruloplasmin)
• Past response to treatment (epilepsy etc)

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Neurological history taking

• Personal, social, family history
• Developmental milestones
• Childhood sibship, parental occupation, homes,
  education happy, unhappy, abused
• Major relationships including children
• Career
• Family history of illness neurological,
  cognitive, psychiatric

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Neurological history taking

• Summary
• Key features of each element of the history
• Presenting complaint(s)
• Functional enquiry
• Past medical history
• Personal, social, family history
• Formulation

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Neurological history taking

• Diagnostic hypothesis where, then what?
• Where?
• Muscle
• NMJ
• Peripheral nerve
• Spinal cord
• Brain
• Brain stem, cerebellum, thalamus, basal ganglia,
  cortex/lobe

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Neurological history taking

• Some common symptom patterns
• NMJ
• Fatiguable weakness
• LMN
• Dysarthria, dysphagia
• Distal weakness (and numbness)
• UMN
• Dexterity, dragging foot, exertional worsening,
  clonus, spasms (and sphincter disturbance)
• Extrapyramidal
• Aching, slowing up, shuffling, dexterity,
  handwriting
• Cerebellar
• Slurring of speech, clumsiness, unsteadiness

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Neurological history taking

• Diagnostic hypothesis where, then what?
• What?
• eg spinal cord syndrome
• Compression
• Disc
• tumour
• Demyelination
• Stroke

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Neurological history taking

• Whats
• Inherited vs acquired
• Vascular
• Inflammatory
• Neoplastic
• Traumatic
• Allergic
• Metabolic
• Endocrine
• Drugs
• Iatrogenic
• Psychiatric
• Mechanical/Structural
• Degenerative
• Deficiency
• Sleep-related
• Physiological

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Bio-psycho-social analysis- of every case!
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Neurological history taking

• Conclusions
• Predominant importance
• Witness
• Triple purpose data, examination, relationship
• Develop a two-stage hypothesis where? what?
• Biopsychosocial formulation
• Ask what do you think is wrong?
• Examination tests hypothesis from history