The Mental Status Exam

MDOD has a new post, complete with CT scan, on a fella who came into ER c/o (complaining of) altered mental status. Of course in the outpatient private practice of clinical psychology, one rarely--if ever-- sees such dramatic cases. Nevertheless, it's a good reminder that whenever we do see a really whack MSE (Mental Status Exam) we should always, always have the patient seen by a physician to rule out physical causes before we assume that they are "just" being paranoid, or are schizophrenic or whatever. Talk therapy won't work on tumors.

Mom once lost a friend that way: He'd been in treatment for months for "depression" when what he actually had was a brain tumor. This happened when I was still an undergrad (yeah, yeah, I know--back before the Flood), but it's remained in the forefront of my mind whenever I am doing an initial assessment or when an ongoing patient's status changes. Mom's friend had never been depressed before, even though he was by that time in middle age, and there was no family history of it. Furthermore, there were no apparent environmental causes (e.g., illness or death in the family, work stress, etc.). Which should have been big ol' red flags right there.

In a practice like mine what we are more likely to see is someone who is physically quite ill, but the medical folks, having failed to find the cause, refer them to us for psychotherapy for imaginary or manufactured illness. One such fella I had certainly had an altered mental status--he kept passing out!--but there was no discernible psychosocial causation, no family history of anything remotely similar, and his personality profile from psychological testing was completely inconsistent with any sort of histrionic or psychosomatic disorder. And a friend's son was once referred to a psychiatrist before it was finally discovered that he really was having trouble breathing: The poor kid had tuberculosis!

Point being, I guess, that mistakes get made on both sides of the professional aisle. Medical people should listen to us when we tell them we don't think the problem is psychological, and we must consult with them, too.