Consultation with neuropsychologists?

[tomfooleries]

I'm curious to know more about the frequency and type of consultation neuropsychologists engage in with psychiatrists. Can someone shed some light here for me?

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[erg923]

Most refferals will tend to come from neurologists and priamry care docs in npsych, but we certianly see them from psychs too.

Most common questions tend to be: rule out dementia, tease out what deficts are attributable to the psych condition vs what could be a more "organic" neurodegenerative or neurologic condition (eg., previous head injury) and how it contributes to the clinical picture, describe functional cogntive status to inform treatment planning and follow-up care (strengths and limitations), competency to make medical decisions or live indepedently, or rule out malingering or exaggeration of cognitive deficits.

 

[hkusp]

Most referral sources depend on the kind of questions to be answered.

Most neuropsychological testing referrals would come from a neurologist or neurosurgeon to address psychophysiogocial/biological questions releated to rehabilitation, lesions/behavior, some dementia, etc.

Most neurocognitive testing referrals would come from PCPs or peditricians for cognitive skills, IQ, some dementia, ******ation, autism/aspergers, etc,

Most psychodiagnostic testing referrals would come from psychiatrists and PCPs to address differential diagnosis, treatment modalities, etc.

So biological/behavior questions = neurologist/neurosurgeon
IQ/cognitive = PCPs, peditrician, etc.
Psychiatric questions = psychiatrists.

 

[whopper]

The only times I've had to use them so far was for testing of a person where there was evidence that the person may have been suffering from psychiatric sx from a head injury, but the person may also have been malingering.

The above is a sticky situation because the person may truly have memory, disinhibition or other problems, but may also be exaggerating them. Its difficult to draw the line.

So far that has been 3 times since I graduated from residency. I have only seen neuropsych testing done once in residency, and IMHO it was inappropraitely requested. The attending that requested it IMHO did not do a thorough enough investigation before he suspected neuropsych problems. In fact I had the same patient a few months later, and stabliized the guy quite well with antipsychotic medication. There was no history of head trauma. Given the lack of head trauma, history, that the guy's psychosis was well within a presentation not different from other psychosis, and lack of other sx suggesting neuro problems (labs were normal, no delirium, no meds or medical conditions that could cause neuro problems), I don't know what that guy was thinking.



The 2 main tests are the Luria Nebraska & the Hastead Reitan Battery.

 

[erg923]

The 2 main tests are the Luria Nebraska & the Hastead Reitan Battery.

Um..not really.

Very few practioners use fixed batteries of tests such as the Halstead-Reitan and Luria now days. A recent salary and practice survey conducted by Jerry Sweet in 2006 found about 7 percent of neuropsych practioners using a fixed battery such as the Halstaed or Luria-Nebraska. Flexible batteries using a wide variety of measures is by far the most common approach to the practice of clinical npsych, although pieces from the Halstead-Retain are often still used (ie., Trail Making Test, Sensory Imperception Test).

The Repeatable Battery for the Assessment of Neuropsychologisal status (RBANS; Randolph, 1999) is probably most popular fixed battery utilized today...and its really just a screnning measure to determine if for more testing is warranted/needed. The RBANS is a 30 minute screening measure that is perfect for using in inpatient psych units, where conditions are not ideal for extensive testing and with who pts cant tolerate alot of testing.

I always think its funny that Alex Luria's tests were turned into a "fixed battery" when he was so adamatly against the psychometrically hardlined fixed battery approach. He was very much on the process and behavioral neurology side of neuropsych. The fact that his tests were put into a standardized fixed battery with some of the norms based on linear regression models must have him rolling over in his grave....

PS: In regards to the case you were discussing, maybe the attending wanted to rule-out a dementia that he thought was superimposed on top of the psychosis. In other words, maybe he just wanted to make sure that the cognitive deficits in the pt were consitent with what would be expected in schizophrenia and not something more marked/severe that would suggest the presence of a degenerative dementia in addition to the schiz. Coversely, sometimes it is nice to be able to know (and objectively quantify) the persons cogintive stregths and weakness for treatment planning purposes (ie., can they remember to take their meds?, are they a good candidate for traditonal psychotherapy?, are they competent, do they have the appopriate judegment and cogntive skills to remain independent or would asssited living or a more stuctured living enviorment be optimal?

 

[whopper]

Thanks for the new info on the neuropsych testing. I'll have to talk to the neuropsychologist where I work about the tests you mentioned.

PS: In regards to the case you were discussing, maybe the attending wanted to rule-out a dementia that he thought was superimposed on top of the psychosis.

I doubt it. The guy was under 40. Actually I think he was in his late 20s. The specific psychiatrist I wrote about practiced what I call "guttcheck" psychiatry. He would look at a person, and draw a conclusion based on an inner feeling. While a guttcheck IMHO does have a place in diagnosis, evidenced based practice based on history, and DSM criteria are 99% of the schema, guttcheck is only 1%. Even the times where I had a feeling about a diagnosis that wasn't supported by the superficial investigation, I did the work to find the evidence based data to back it up instead of just putting down a new diagnosis based on the hairs on my neck. This guy practiced as if it were 50-50 (needless to say I didn't think much of him as a psychiatrist. By the time I reached PGY-2 in hindsight I think I was better than him, and I'm not patting my own back because there's plenty of docs where I did residency where I know they are still much better than I am now). I had a case about 1 year ago where I took over a new unit at the forensic place, and the attending I took over had ordered neuropsych testing of a woman who was 30 years old to rule out dementia. I saw no signs of dementia, though I did see plenty of manic sx. I stabilized her on a regimen appropriate for bipolar.

The only way I could've seen why this guy would've thought she lady had dementia is because the kept demanding disability (she was not appropriate for it) because she said she couldn't concentrate. The way this guy practiced, he took whatever the patients said too literally. E.g. if someone wanted ativan, he gave them as much as they wanted & labelled them as having an anxiety disorder, as he did with this same patient.

(For about 1 month after I started on the new unit, I had to wean off about 1/4 of the patients on that unit from high doses of ativan. Out of all of them, none of them IMHO needed ativan.)

 

[erg923]

The only way I could've seen why this guy would've thought she lady had dementia is because the kept demanding disability (she was not appropriate for it) because she said she couldn't concentrate.

Well then there you go. I think it is good he didnt just take her words for it and reffered her to npsych. Npsych assessment methods are sensitive to people who atempt to exaggerate cognitive symptomatology (we have discused this before). People claiminmg disabiloity due to cognitive deficit have to show objective evidence for it in order to be approved. Hence the npsych eval.

 

[Therapist4Chnge]

Well then there you go. I think it is good he didnt just take her words for it and reffered her to npsych. Npsych assessment methods are sensitive to people who atempt to exaggerate cognitive symptomatology (we have discused this before). People claiminmg disabiloity due to cognitive deficit have to show objective evidence for it in order to be approved. Hence the npsych eval.

These happen frequently in the VA in regard to Compensation & Pension claims.

We don't use standard batteries, as it is more effective to pick and choose assessments that will address the referral question(s). Our turnaround times for a report are pretty tight (especially for C&Ps), so we have to make the best of our time.

 

[howelljolly]

One of my patients on my 3rd year Psych rotation had NP testing, to determine if he could take care of himself, possibly had dementia. Turned out that the only marked abnormality that the patient had was a deficit in cognitive flexibility. It was interesting to go back to the patient with that data and see that much of his lousy decisions and strange behaviors were related to that underlying cause.

Seems like the NP guys get to have all the fun. Taking apart the patients cognitive processes to see how they think and how that relates to their behavior is fascinating.