Bosch-Boonstra-Schaaf optic atrophy syndrome (BBSOAS) is a recently described autosomal dominant disorder caused by mutations in the nuclear receptor subfamily 2 group F member 1 (NR2F1) gene. Its common features include optic atrophy and/or hypoplasia, developmental delay, intellectual disability, attention deficit disorder, autism spectrum disorder, seizures, hearing defects, spasticity, hypotonia, and thinning of the corpus callosum. Mitochondrial involvement has also been described with BBSOAS. Currently, 31 cases of BBSOAS have been described in the literature. Here we report a case of undiagnosed BBSOAS presenting as psychosis in a 32-year-old man with a history of bilateral optic nerve atrophy, intellectual disability, epilepsy, and mitochondrial complex I abnormality on muscle biopsy. Whole-genome sequencing identified a heterozygous de novo nonsense mutation in the NR2F1 gene [c.253 G>T (guanine to thymine mutation in coding position 253) in exon 1, p.E85X variant (GAG>TAG) (glutamic acid to stop codon mutation; protein truncated to 85 amino acids)]. A pathogenic nonsense mutation has not previously been reported in the literature in association with BBSOAS and represents an expansion of clinically relevant variants. Psychosis has also not been previously reported in this syndrome and may represent a phenotypic expansion of BBSOAS, a manifestation of prolonged disease, or a result of disease management.

Encephalitis related to antibodies against the N-methyl-D-aspartate receptor (NMDAr) is a recently described clinical entity in which IgG autoantibodies against the NR1 subunit of the NMDAr lead to the appearance of complex neuropsychiatric symptoms. As psychiatric symptoms predominate in early stages, anti-NMDAr encephalitis is frequently mistaken as a primary psychiatric disorder which delays treatment and has serious consequences for patients. This report presents the case of a 24-year-old woman with a subacute onset of psychotic and catatonic symptoms in whom current diagnostic criteria for probable anti-NMDAr encephalitis were not fulfilled. On the basis of the red flags that have been proposed to raise suspicion of anti-NMDAr encephalitis, a study of fluorodeoxyglucose positron emission tomography was requested and demonstrated bilateral occipital hypometabolism consistent with clinical suspicion of anti-NMDAr encephalitis. Once the appropriate treatment was established, the patient recovered completely. This case supports the need to maintain clinical suspicion of anti-NMDAr encephalitis, even when conventional diagnostic tests have been normal. Psychiatrists should be familiar with this entity to promote timely diagnosis and prompt treatment.

Three cases are presented describing unique clinical responses to aripiprazole in comparison with other second-generation antipsychotics taken by each patient. One case involved an adverse reaction of problem gambling behavior, the second an enhanced antipsychotic response in delusional disorder, and the third a reversal of weight gain that occurred while the patient continued taking olanzapine. Aripiprazole was the first of a subgroup of atypical antipsychotics that are mixed agonists and antagonists of dopamine, likely contributing to unusual responses in some patients.

Two case reports explore opiate use in relation to 2 different psychiatric disorders. In the first case report, the authors reported the finding that opiate abuse appeared to mitigate premorbid Tourette syndrome in a small series of patients with opiate addiction and that this benefit was maintained with medically supervised opiate agonist therapy. In the second case report, the authors noted a significant correlation between prescription opiate use and delusions of infestation in a large psychodermatology clinic (as well as a separate, stronger correlation with stimulant use). These reports highlight the importance of the opiate system in a range of psychiatric disorders, suggesting that there is much more to learn about the role of the endogenous opiate system in brain functioning, and its potential as a target for therapeutic intervention in psychiatric disorders other than addiction.

In this issue of the journal, 2 case reports are presented that illustrate explicit influences of structural brain lesions on psychiatric symptoms. In both cases, the patients had preexisting, classically diagnosed psychiatric disorders—schizophrenia in the first case and bipolar I disorder in the second case. In the first case, a 61-year-old woman with chronic paranoid schizophrenia experienced a marked reduction in psychotic symptoms after bilateral frontal strokes. In the second case, a 60-year-old man who had experienced manic and depressive episodes since his 20s developed partial complex seizures after having repeated head trauma in his 40s, with subsequent onset of chronic personality changes associated with temporal lobe epilepsy that made his psychiatric treatment a greater challenge. The presentations in these 2 cases raise intriguing neuropsychiatric questions concerning the effects on regional brain activity of a variety of nonpharmacological psychiatric interventions (eg, stereotactic neurosurgical techniques, deep brain stimulation, electroconvulsive therapy, certain types of psychotherapy), and concerning possible physiological pathways shared by seizure kindling in epilepsy and recurrent episodes of bipolar disorder.

In this issue of the journal, 2 case reports are presented that describe rare but serious side effects of commonly used medications. These cases illustrate dilemmas in clinical decision-making. The first describes the induction of seizures by low-dose venlafaxine in a predisposed individual, and the second describes the development of mild but significant leukopenia with sequential trials of olanzapine and risperidone. The association between a drug and a rare but potentially serious side effect in an individual patient can be difficult to determine with precision, and the decision to press ahead and try to work around the reaction, versus stopping the likely offender and finding a substitute, is a matter for seasoned clinical judgment.

Ketamine has shown effectiveness as a rapid-acting antidepressant with antisuicidal effects in terms of reduction of suicidal ideation in the short term. However, the evidence for long-term maintenance ketamine therapy for treatment-resistant depression (TRD) and suicidal behavior is limited. This case series (N=13) highlights the role of adjunctive serial maintenance ketamine infusions in restoring functionality in treatment-resistant unipolar and bipolar (mixed) depression with significant suicide risk and multiple comorbidities, including alcohol dependence. Two cases of TRD achieved functional remission with long-term maintenance ketamine treatment. The first case illustrates the potential synergistic interaction between ketamine and lamotrigine to achieve a sustained antidepressant response in the patient for 7 months. The second case may possibly be the longest reported case of maintenance ketamine therapy, with treatment continuing for 5 years to date. Ketamine treatment showed acute effectiveness in another 7 cases, especially in terms of reduction of suicidal ideation, albeit without significant long-term antidepressant effect. Factors that may contribute to lack of effectiveness of serial ketamine include inadequate mood stabilization in TRD in bipolar spectrum diagnoses, concomitant benzodiazepine use, complex comorbidities, and adverse effects such as significant hypertension and severe dissociation. Future systematic controlled studies are warranted to establish the efficacy and safety profile of long-term ketamine as maintenance therapy for TRD with suicidal behavior.

OBJECTIVE:The manic spectrum is thought to be characterized by a hypersensitive biobehavioral reward system, the behavioral activation system. Evidence for this framework comes from questionnaire-based, self-report data collected in cross-sectional and prospective studies of mania, mania in remission, and proneness to hypomania, and from functional neuroimaging investigations of brain reward circuit activity during incentivized choice protocols. Although heightened reward anticipation is consistently documented, the status of later goal attainment activity, hedonic responses, and satiety reactions is less clear. This report examines the status of such reward receipt processes as they operate in the manic spectrum.METHODS:A case report of a typical subject with bipolar II disorder with a hyperthymic temperament is presented using longitudinal, biographical data.RESULTS:Diminished reward receipt, pleasure, and satiety were demonstrated indicating impaired hedonic processing in hyperthymic temperament. This impairment indicates a dissociation between early, intensified reward pursuit processes and later, blunted, reward attainment activity.CONCLUSIONS:The experience and neural correlates of hedonic processing may be impaired in the manic spectrum. Possible mechanisms for this impairment and its dissociation from the earlier stage of reward processing characterized by hyperactive reward pursuit are considered. Clinical reports and longitudinal, life-based follow-up can provide important data to supplement more experimentally based neurobiological models of reward dysfunction in bipolar disorders.

Tardive dyskinesias (TD) are serious, often irreversible side effects of dopamine blocking agents, most commonly first-generation antipsychotics. No definitive treatment exists, with different interventions showing inconsistent results. We report a case of TD presenting after 12 years of olanzapine therapy in a 66-year-old Hispanic male with paranoid schizophrenia. The TD symptoms were successfully treated within a few weeks by switching to clozapine. Two cases of olanzapine-induced TD treated with clozapine have previously been reported, but in those cases, the symptom onset was quicker, ranging from a few months to a few years after initiation of olanzapine therapy, and the treatment response was relatively slower. Clinicians should carefully monitor for symptoms of TD after prolonged treatment with olanzapine and other antipsychotics. If otherwise indicated for psychiatric treatment, clozapine can be considered a good choice for patients with TD in preventing or reversing the debilitating consequences of this condition.

Squalor-dwelling behavior has been characterized as living in conditions so unsanitary that feelings of revulsion are elicited among visitors. This behavior is commonly associated with an insensitivity to distress/disgust and a failure to understand the direness of one’s living situation, which leads to social isolation and impairment in quality of life. Etiologically, several associations have been described in the literature, including age-related decline, lower socioeconomic status, and rural dwelling status. Primary neuropsychiatric disorders, such as psychosis, alcoholism, dementia, personality disorders, developmental delays, and learning or physical disabilities are frequently seen in squalor-dwelling individuals. However, none of these disorders seems to be necessary or sufficient to explain the behavior. Neurobiologically, squalor-dwelling behavior has been associated with frontal lobe dysfunction as evidenced by executive dysfunction; however, cognitive impairments also fail to completely explain this behavior. The purpose of this report is to describe a typical case of squalor-dwelling behavior and use it as an example to illustrate the complexity of uncovering the neurobiological basis for this maladaptive personal and public health threat. Neuroimaging findings from our case and a review of the literature point toward decreased activity in the insular cortex and the amygdala as a unifying biological explanation for squalor-dwelling behaviors.

Well-established practice guidelines and a solid body of evidence underpin the safe and effective use of electroconvulsive therapy (ECT), primarily in mood disorders. In this issue of the journal, 3 case reports deal with situations that fall outside of the usual guidelines: treatment resistance to ECT overcome by combined use with antidepressant medication; use of ECT in the presence of polymyositis; and use of ECT for an unusually severe case of neuroleptic malignant syndrome, assisted by consultation from an online expert resource. The value of case reports and expert consultation in situations in which there is little or no evidence from clinical trials is also discussed.

Two cases of unusual situations are discussed: one involving feigned suicide detected as false only after a comparison of surveillance systems, and one involving monozygotic triplets who all developed psychosis with shared delusions. Although these 2 cases involve presentations most of us will never encounter as clinicians, they nevertheless serve to highlight fundamental questions about the nature of psychopathology. Both cases also have compelling parallels in literature and film.

Back to table of contents Previous article Next article Communications and UpdatesFull AccessThe American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of AdultsJoel J. Silverman, M.D., Marc Galanter, M.D., Maga Jackson-Triche, M.D., M.S.H.S., Douglas G. Jacobs, M.D., James W. Lomax II, M.D., Michelle B. Riba, M.D., Lowell D. Tong, M.D., Katherine E. Watkins, M.D., M.S.H.S., Laura J. Fochtmann, M.D., M.B.I., Richard S. Rhoads, M.D., Joel Yager, M.D.Joel J. SilvermanSearch for more papers by this author, M.D., Marc GalanterSearch for more papers by this author, M.D., Maga Jackson-TricheSearch for more papers by this author, M.D., M.S.H.S., Douglas G. JacobsSearch for more papers by this author, M.D., James W. Lomax IISearch for more papers by this author, M.D., Michelle B. RibaSearch for more papers by this author, M.D., Lowell D. TongSearch for more papers by this author, M.D., Katherine E. WatkinsSearch for more papers by this author, M.D., M.S.H.S., Laura J. FochtmannSearch for more papers by this author, M.D., M.B.I., Richard S. RhoadsSearch for more papers by this author, M.D., Joel YagerSearch for more papers by this author, M.D.Published Online:1 Aug 2015https://doi.org/10.1176/appi.ajp.2015.1720501AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail At its December meeting, The APA Board of Trustees approved the APA Work Group on Psychiatric Evaluation’s Practice Guidelines for the Psychiatric Evaluation of Adults. [The full guideline is available at http://psychiatryonline.org/doi/book/10.1176/appi.books.9780890426760].Background and Development ProcessThese Practice Guidelines for the Psychiatric Evaluation of Adults mark a transition in the American Psychiatric Association's Practice Guidelines. Since the publication of the 2011 Institute of Medicine report Clinical Practice Guidelines We Can Trust, there has been an increasing focus on using clearly defined, transparent processes for rating the quality of evidence and the strength of the overall body of evidence in systematic reviews of the scientific literature. These guidelines were developed using a process intended to be consistent with the recommendations of the Institute of Medicine (2011), the Principles for the Development of Specialty Society Clinical Guidelines of the Council of Medical Specialty Societies (2012), and the requirements of the Agency for Healthcare Research and Quality (AHRQ) for inclusion of a guideline in the National Guideline Clearinghouse. Parameters used for the guidelines' systematic review are included with the full text of the guidelines; the development process is fully described in a document available on the APA website: http://www.psychiatry.org/File%20Library/Practice/APA-Guideline-Development-Process–updated-2011-.pdf. To supplement the expertise of members of the guideline work group, we used a “snowball” survey methodology to identify experts on psychiatric evaluation and solicit their input on aspects of the psychiatric evaluation that they saw as likely to improve specific patient outcomes (Yager 2014). Results of this expert survey are included with the full text of the practice guideline.Rating the strength of research evidence and recommendationsThe new guideline recommendations are rated using GRADE (Grading of Recommendations Assessment, Development and Evaluation), an approach adopted by multiple professional organizations around the world to develop practice guideline recommendations (Guyatt et al., 2013). With the GRADE approach, the strength of a guideline statement reflects the level of confidence that potential benefits of an intervention outweigh the potential harms (Andrews et al., 2013). This level of confidence is informed by available evidence, which includes evidence from clinical trials as well as expert opinion and patient values and preferences. Evidence for the benefit of a particular intervention within a specific clinical context is identified through systematic review and is then balanced against the evidence for harms. In this regard, harms are broadly defined and might include direct and indirect costs of the intervention (including opportunity costs) as well as potential for adverse effects from the intervention. Whenever possible, we have followed the admonition to current guideline development groups to avoid using words such as “might” or “consider” in drafting these recommendations as they can be difficult for clinicians to interpret (Shiffman et al., 2005).As described under “Guideline Development Process,” each final rating is a consensus judgment of the authors of the guidelines and is endorsed by the APA Board of Trustees. A “recommendation” (denoted by the numeral 1 after the guideline statement) indicates confidence that the benefits of the intervention clearly outweigh harms. A “suggestion” (denoted by the numeral 2 after the guideline statement) indicates uncertainty (i.e., the balance of benefits and harms is difficult to judge, or either the benefits or the harms are unclear). Each guideline statement also has an associated rating for the “strength of supporting research evidence.” Three ratings are used: high, moderate, or low (denoted by the letters A, B and C, respectively) and reflect the level of confidence that the evidence reflects a true effect based on consistency of findings across studies, directness of the effect on a specific health outcome, and precision of the estimate of effect and risk of bias in available studies (AHRQ 2014; Balshem et al. 2011; Guyatt et al. 2006).It is well recognized that there are guideline topics and clinical circumstances for which high quality evidence from clinical trials is not possible or is unethical to obtain (Council of Medical Specialty Societies, 2012). For example, it would not be ethical to randomly assign only half of patients with depression to be asked about suicidal ideas. Many questions need to be asked as part of the assessment, and inquiring about a particular symptom or element of the history cannot be separated out for study as a discrete intervention. It would also be impossible to separate changes in outcome due to assessment from changes in outcomes due to ensuing treatment. Research on psychiatric assessment is also complicated by multiple confounding factors such as the interaction between the clinician and the patient or the patient's unique circumstances and experiences. For these and other reasons, the vast majority of topics covered in these guidelines on psychiatric evaluation have relied on forms of evidence such as consensus opinions of experienced clinicians or indirect findings from observational studies rather than being based on research from randomized trials. The GRADE working group and guidelines developed by other professional organizations have noted that a strong recommendation may be appropriate even in the absence of research evidence when sensible alternatives do not exist (Andrews et al. 2013; Brito et al. 2013; Djulbegovic et al. 2009; Hazlehurst et al. 2013).Goals and scope of guidelines for the psychiatric evaluation of adultsDespite the difficulties in obtaining quantitative evidence from randomized trials for practice guidelines such as psychiatric evaluation, guidance to clinicians can still be beneficial in enhancing care to patients. Thus, in the context of an initial psychiatric evaluation, a major goal of these guidelines is to improve the identification of psychiatric signs and symptoms, psychiatric disorders (including substance use disorders), other medical conditions (that could affect the accuracy of a psychiatric diagnosis), and patients who are at increased risk for suicidal or aggressive behaviors. Additional goals relate to identifying factors that could influence the therapeutic alliance, enhance clinical decisionmaking, enable safe and appropriate treatment planning, and promote better treatment outcomes. Finally, the psychiatric evaluation is the start of a dialog with patients about many factors, including diagnosis and treatment options. Further goals of these guidelines are to improve collaborative decisionmaking between patients and clinicians about treatment-related decisions as well as to increase coordination of psychiatric treatment with other clinicians who may be involved in the patient's care.Time required to complete a psychiatric evaluationIt is essential to note that these guidelines are not intended to be comprehensive in scope. Many critical aspects of the psychiatric evaluation are not addressed by these guidelines. For example, it is assumed that initial psychiatric or other medical assessments will need to identify the reason that the patient is presenting for evaluation. It is similarly important to understand the patient's background, relationships, life circumstances, strengths and vulnerabilities.Furthermore, depending on the context, recommended areas of inquiry may need to be postponed until later visits, and recommended questions will not always be indicated for a specific patient. The findings of the expert survey reiterate that experts vary in the extent to which particular elements of the initial psychiatric evaluation are assessed. This also highlights the importance of clinical judgment in tailoring the psychiatric evaluation to the unique circumstances of the patient and in determining which questions are most important to ask as part of an initial assessment.Proper use of guidelinesThe American Psychiatric Association Practice Guidelines are not intended to serve or be construed as a “standard of medical care.” Judgments concerning clinical care depend on the clinical circumstances and data available for an individual patient and are subject to change as scientific knowledge and technology advance and practice patterns evolve. These guideline statements were determined on the basis of the relative balance of potential benefits and harms of a specific assessment, intervention or other approach to care. As such, it is not possible to draw conclusions about the effects of omitting a particular recommendation, either in general or for a specific patient. Furthermore, adherence to these guidelines will not ensure a successful outcome for every individual, nor should these guidelines be interpreted as including all proper methods of evaluation and care or excluding other acceptable methods of evaluation and care aimed at the same results. The ultimate recommendation regarding a particular assessment, clinical procedure, or treatment plan must be made by the psychiatrist in light of the psychiatric evaluation, other clinical data, and the diagnostic and treatment options available. Such recommendations should be made in collaboration with the patient and family, whenever possible, and incorporate the patient's personal and sociocultural preferences and values in order to enhance the therapeutic alliance, adherence to treatment, and treatment outcomes.Organization of the practice guidelines for the psychiatric evaluation of adultsAs part of aligning the practice guidelines' development process with national standards, we have transitioned to a new guideline format. Each set of Practice Guidelines will consist of multiple discrete topics of relevance to an overall subject area. In the Practice Guidelines for the Psychiatric Evaluation of Adults, these topics consist of Review of Psychiatric Symptoms, Trauma History, and Psychiatric Treatment History; Substance Use Assessment; Assessment of Suicide Risk; Assessment of Risk for Aggressive Behaviors; Assessment of Cultural Factors; Assessment of Medical Health; Quantitative Assessment; Involvement of the Patient in Treatment DecisionMaking; and Documentation of the Psychiatric Evaluation. For each topic, guideline statements will be followed by a discussion of the rationale, potential benefits and harms, and approaches to implementing the guideline statements. This portion of the Practice Guidelines is expected have the greatest utility for clinicians. A second section of the Practice Guidelines provides a detailed review of the evidence for guideline statements in accord with national guideline development standards. This review of research evidence and data from the expert survey is followed by a discussion of quality measurement considerations, including their appropriateness for each topic.Guidelines and StatementsThe following represents a summary of the recommendations and suggestions compiled from all Practice Guidelines for the Psychiatric Evaluation of Adults (Table 1), with some statements being a part of more than one of these guidelines. In the context of these guideline statements, it is important to note that assessment is not limited to direct examination of the patient. Rather, it is defined as “the process of obtaining information about a patient through any of a variety of methods, including face-to-face interview, review of medical records, physical examination (by the psychiatrist, another physician, or a medically trained clinician), diagnostic testing, or history-taking from collateral sources.” The evaluation may also require several meetings, with the patient, family, or others, before it can be completed. The amount of time spent depends on the complexity of the problem, the clinical setting, and the patient’s ability and willingness to cooperate with the assessment.Table 1. Practice Guidelines for the Psychiatric Evaluation of AdultsGuidelineTitleIReview of Psychiatric Symptoms, Trauma History, and Psychiatric Treatment HistoryIISubstance Use AssessmentIIIAssessment of Suicide RiskIVAssessment of Risk for Aggressive BehaviorsVAssessment of Cultural FactorsVIAssessment of Medical HealthVIIQuantitative AssessmentVIIIInvolvement of the Patient in Treatment Decision-MakingIXDocumentation of the Psychiatric EvaluationTable 1. Practice Guidelines for the Psychiatric Evaluation of AdultsEnlarge tableThis summary is organized according to common headings of an evaluation note. As noted above, the guidelines are not intended to be comprehensive, and many aspects of the psychiatric evaluation are not addressed by these recommendations and suggestions. The strength of supporting research evidence for these recommendations and suggestions is given rating C (low) because of the difficulties in studying psychiatric assessment approaches in controlled studies as described in the “Background and Development Process.” The specific guideline(s) in which the recommendation or suggestion is found is denoted by its Roman numeral from Table 1.History of present illnessIn addition to reasons that the patient is presenting for evaluation, APA recommends (1C) that the initial psychiatric evaluation of a patient include:Psychiatric review of systems (I), including anxiety symptoms and panic attacks (III)Assessment of past or current sleep abnormalities, including sleep apnea (VI)Assessment of impulsivity (III, IV)Psychiatric historyAPA recommends (1C) that the initial psychiatric evaluation of a patient include assessment of the following:Past and current psychiatric diagnoses (I, III)Prior psychotic or aggressive ideas, including thoughts of physical or sexual aggression or homicide (IV)Prior aggressive behaviors (e.g., homicide, domestic or workplace violence, other physically or sexually aggressive threats or acts) (IV)Prior suicidal ideas, suicide plans, and suicide attempts, including attempts that were aborted or interrupted as well as the details of each attempt (e.g., context, method, damage, potential lethality, intent) (III)Prior intentional self-injury in which there was no suicidal intent (III)APA recommends (1C) that the initial psychiatric evaluation of a patient include review of the following aspects of the patient’s psychiatric treatment history:History of psychiatric hospitalization and emergency department visits for psychiatric issues (I, III, IV)Past psychiatric treatments (type, duration, and, where applicable, doses) (I)Response to past psychiatric treatments (I)Adherence to past and current pharmacological and nonpharmacological psychiatric treatments (I)Substance use historyAPA recommends (1C) that the initial psychiatric evaluation of a patient include assessment of the following:The patient’s use of tobacco, alcohol, and other substances (e.g., marijuana, cocaine, heroin, hallucinogens) and any misuse of prescribed or over-the-counter medications or supplements (II)Current or recent substance use disorder or change in use of alcohol or other substances (III, IV)Medical history (VI)APA recommends (1C) that the initial psychiatric evaluation of a patient include assessment of the following:Allergies or drug sensitivitiesAll medications the patient is currently or recently taking and the side effects of these medications (i.e., both prescribed and nonprescribed medications, herbal and nutritional supplements, and vitamins)Whether or not the patient has an ongoing relationship with a primary care health professionalPast or current medical illnesses and related hospitalizationsRelevant past or current treatments, including surgeries, other procedures, or complementary and alternative medical treatmentsPast or current neurological or neurocognitive disorders or symptoms (IV)Physical trauma, including head injuriesSexual and reproductive historyAPA suggests (2C) that the initial psychiatric evaluation of a patient also include assessment of the following:Cardiopulmonary statusPast or current endocrinological diseasePast or current infectious disease, including sexually transmitted diseases, HIV, tuberculosis, hepatitis C, and locally endemic infectious diseases such as Lyme diseasePast or current symptoms or conditions associated with significant pain and discomfortReview of systems (VI)APA recommends (1C) that the initial psychiatric evaluation of a patient include a psychiatric review of systems (if not already included with history of present illness)In addition to a psychiatric review of systems, APA suggests (2C) that the initial psychiatric evaluation of a patient include a review of the following systems:Constitutional symptoms (e.g., fever, weight loss)EyesEars, Nose, Mouth, ThroatCardiovascularRespiratoryGastrointestinalGenitourinaryMusculoskeletalIntegumentary (skin and/or breast)NeurologicalEndocrineHematological/LymphaticAllergic/ImmunologicalFamily historyAPA recommends (1C) that the initial psychiatric evaluation of a patient who reports current suicidal ideas include assessment of history of suicidal behaviors in biological relatives (for patients with current suicidal ideas) (III)When it is determined during an initial psychiatric evaluation that the patient has aggressive ideas, APA recommends (1C) assessment of history of violent behaviors in biological relatives (for patients with current aggressive ideas) (IV)Personal and social historyAPA recommends (1C) that the initial psychiatric evaluation of a patient include assessment of the following:Presence of psychosocial stressors, (e.g. financial, housing, legal, school/occupational or interpersonal/relationship problems; lack of social support; painful, disfiguring, or terminal medical illness) (III, IV)Review of the patient's trauma history (I, III)Exposure to violence or aggressive behavior, including combat exposure or childhood abuse (IV)Legal or disciplinary consequences of past aggressive behaviors (IV)Cultural factors related to the patient's social environment (V)Patient's need for an interpreter (V)APA suggests (2C) that the initial psychiatric evaluation of a patient include assessment of the patient’s Personal/cultural beliefs and cultural explanations of psychiatric illness (V)Examination, including mental status examinationAPA suggests (2C) that the initial psychiatric evaluation of a patient also include assessment of the following:Height, weight, and body mass index (BMI) (VI)Vital signs (VI)Skin, including any stigmata of trauma, self-injury, or drug use (VI)APA recommends (1C) that the initial psychiatric evaluation of a patient include assessment of the following:General appearance and nutritional status (VI)Coordination and gait (VI)Involuntary movements or abnormalities of motor tone (VI)Sight and hearing (VI)Speech, including fluency and articulation (VI)Mood, level of anxiety, thought content and process, and perception and cognition (I, III)Hopelessness (III)Current suicidal ideas, suicide plans, and suicide attempts, including active or passive thoughts of suicide or death (III): If current suicidal ideas are present, assess:∘ Patient's intended course of action if current symptoms worsen∘ Access to suicide methods including firearms∘ Patient's possible motivations for suicide (e.g. attention or reaction from others, revenge, shame, humiliation, delusional guilt, command hallucinations)∘ Reasons for living (e.g. sense of responsibility to children or others, religious beliefs)∘ Quality and strength of the therapeutic allianceCurrent aggressive or psychotic ideas, including thoughts of physical or sexual aggression or homicide (III, IV): If current aggressive ideas are present, assess:∘ Specific individuals or groups toward whom homicidal or aggressive ideas or behaviors have been directed in the past or at present∘ Impulsivity, including anger management issues∘ Access to firearmsImpression and planAPA recommends (1C) that the clinician who conducts the initial psychiatric evaluation document:An estimate of the patient's suicide risk, including factors influencing risk (III)The rationale for treatment selection, including discussion of the specific factors that influenced the treatment choice (IX)APA recommends (1C) that the initial psychiatric evaluation of a patient who is seen include:Asking the patient about treatment-related preferences (VIII)An explanation to the patient of the following: the differential diagnosis, risks of untreated illness, treatment options, and benefits and risks of treatment (VIII)Collaboration between the clinician and the patient about decisions pertinent to treatment (VIII)APA suggests (2C) that the initial psychiatric evaluation of a patient include:Quantitative measures of symptoms, level of functioning, and quality of life (VII)Documentation of an estimated risk of aggressive behavior (including homicide), including factors influencing risk (IV)Documentation of the rationale for clinical tests (IX)From the APA Workgroup on Psychiatric Evaluation (Joel J. Silverman, Chair). Address correspondence to Kristin Kroeger ([email protected]).APA wishes to acknowledge the contributions of the former APA staff; Robert Kunkle, M.A., Robert Plovnick, M.D., Sara Reid, M.A., Seung-Hee Hong, and William E. Narrow, M.D., M.P.H. APA and the Work Group on Psychiatric Evaluation especially thank Laura J. Fochtmann, M.D., M.B.I, and Robert Kunkle, M.A. for their outstanding work and effort on developing these guidelines. APA also thanks the APA Steering Committee on Practice Guidelines and liaisons from the APA Assembly for their input and assistance.ReferencesAgency for Healthcare Research and Quality: Methods Guide for Effectiveness and Comparative Effectiveness Reviews. AHRQ Publication No. 10(14)-EHC063-EF. Rockville, MD: Agency for Healthcare Research and Quality. Jan 2014. Chapters available at: www.effectivehealthcare.ahrq.gov.Google ScholarAndrews JC, Schünemann HJ, Oxman AD, et al.: GRADE guidelines: 15. 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Narrow, M.D., M.P.H. APA and the Work Group on Psychiatric Evaluation especially thank Laura J. Fochtmann, M.D., M.B.I, and Robert Kunkle, M.A. for their outstanding work and effort on developing these guidelines. APA also thanks the APA Steering Committee on Practice Guidelines and liaisons from the APA Assembly for their input and assistance.PDF download History Published online 1 August 2015 Published in print 1 August 2015

The concept that fevers can improve the condition of patients with certain medical and psychiatric diseases dates back to Hippocrates. Over the centuries, it has been observed that fevers and infectious agents have been beneficial for a broad spectrum of diseases, including neurologic conditions such as epilepsy and psychiatric illnesses including melancholy and psychosis. Interest in the concept of fever as a treatment for disease, termed pyrotherapy or pyretotherapy, peaked in the late 1800s and early 1900s thanks to the Nobel Prize winning work of Julius Wagner-Jauregg for his studies with malaria therapy for general paralysis of the insane, now more commonly referred to as neurosyphilis. The use of inoculations of infectious agents for their fever-inducing effects in the treatment of neurosyphilis quickly spread throughout the world, and, by the 1920s, it was considered by many to be the treatment of choice for neurosyphilis as well as other psychotic disorders. However, with the discovery of penicillin for the treatment of syphilis, which coincided with the advent of convulsion-oriented practices including electroconvulsive therapy and insulin coma for the treatment of psychotic disorders, pyrotherapy soon lost favor among psychiatrists and, since the 1950s, it has largely been overlooked by the scientific community. In this article, the authors provide a brief literature review of the history of pyrotherapy and present a case report of a woman with schizoaffective disorder and severe psychotic symptoms who experienced a remarkable resolution of psychotic symptoms following an episode of bacteremia with high fever.

Although some studies have reported a relationship between hoarding and bipolar disorder, we are unaware of any previous description of how they may interact with each other and how they should be managed appropriately. A 48-year-old male depressed patient with hoarding symptoms and obsessive-compulsive disorder (OCD) was diagnosed with bipolar II disorder after 2 hypomanic episodes. The patient was treated unsuccessfully with different high-dose serotonin reuptake inhibitors and atypical antipsychotics, maintaining a pattern of 6 to 8 discrete, but severe, depressive episodes each year, always in association with a drastic worsening of his OCD and hoarding symptoms. T.he patient did not improve until the dose of the serotonin reuptake inhibitor was decreased and a combination of lamotrigine and methylphenidate was initiated. On this treatment regimen, the patient did not show clinically significant levels of depression or hoarding or other OCD symptoms. This case suggests that, in some patients, (1) hoarding-related cognitions and behaviors may be a part of bipolar depression, (2) the episodic nature of rapid cycling bipolar II disorder may protect against the development of severe clutter, and (3) treatment focusing on bipolar depression (eg, lamotrigine plus methylphenidate) may result in an improvement of hoarding symptoms when these are present in patients with rapid cycling bipolar II disorder.

Organ transplantation may be complicated by a range of psychiatric difficulties. We present 1 case reporting that tacrolimus-induced catatonic delirium after liver transplant responded to memantine, and another case illustrating the need for ongoing psychosocial assessment and support after heart transplant.

Chronic neurotoxicity caused by lithium salts can be reversible or irreversible and may appear after years of treatment, even at serum levels considered within the usual therapeutic range. The authors present the case of a patient with bipolar disorder who developed dementia at the age of 54 after being treated with lithium carbonate at therapeutic levels for 4 years. Nevertheless, lithium treatment was continued. At age 56, the patient presented with an acute encephalopathy caused by toxic lithium levels, which resolved only after lithium carbonate was discontinued. Full recovery from the dementia, which had started 2 years earlier, occurred only after cessation of lithium. The authors conclude that when patients treated with lithium develop subacute cognitive impairment, the possibility of lithium toxicity should be considered, even if the serum levels are considered within the therapeutic range. A long duration of neurotoxicity associated with lithium treatment does not necessarily indicate an irreversible prognosis.

We describe the case of a 17-year-old male who presented with acute onset of seizures and malignant catatonia with psychosis, agitation, and hypermetabolism, who responded to electroconvulsive therapy (ECT). Soon after he began to respond, he was diagnosed with anti-N-methyl-D-aspartate (NMDA) receptor encephalitis and then given immunosuppressive therapy. Anti-NMDA receptor encephalitis is an increasingly recognized autoimmune disorder that often presents with neuropsychiatric symptoms. The mainstays for treatment have been early diagnosis, tumor work-up and removal if found, and initiation of immunosuppressive therapy. Treatment response is often slow and residual symptoms common. In this case, ECT produced clinical stabilization before the underlying diagnosis of anti-NMDA receptor encephalitis was made and standard treatment initiated. We suggest that ECT may be highly beneficial for stabilizing life-threatening neuropsychiatric symptoms in this syndrome and should be considered as a potentially additive treatment to immunotherapy when rapid relief is sought.

Routine assessment of psychiatric patient outcomes is rare, despite growing evidence that feedback to clinicians and patients concerning patient progress improves treatment outcomes. The authors present a case in which real-time feedback proved beneficial in the treatment of a woman with a personality disorder admitted for inpatient treatment due to worsening depression, anxiety, severe suicide risk, and decline in functioning. During the course of her 10-week hospitalization, she completed standardized assessments of symptoms/functioning at admission, at 2 week intervals, and at discharge. The distinctive feature of this case is the way in which real-time feedback to the treatment team, psychiatrist, and patient exposed hidden treatment barriers. In the midst of an improving profile with decreasing symptom severity, the patient experienced a spike in distress and symptoms, prompting her treatment team to examine the treatment plan and to engage the patient around understanding the decline in functioning. This intervention revealed a replay of a familiar pattern in the patient's life that led to the identification and repair of a rupture in the therapeutic alliance and to an improvement in the patient's functioning. This case expands on previous research concerning the integration of individualized assessments into outpatient treatment and it illustrates the need to extend outpatient research to inpatient settings.

David A. Kahn, MD, is the Diane Goldman Kemper Family Clinical Professor of Psychiatry Emeritus, Columbia University Medical Center and attending psychiatrist, New York Presbyterian Hospital, New York, NY Marcia L. Verduin, MD, Book Editor