Neuropsychiatric assessment proceeds from history to examination to formulation in a manner similar to that used in other fields of medicine but adapted to demonstrate brain-behavior relationships. Findings from the patient history, physical, mental status examination, and available laboratory, neuroimaging, neuropsychological evaluation, and other ancillary data are synthesized to create the neuropsychiatric formulation. This chapter offers an approach to neuropsychiatric assessment that includes both the details and the thought process of the neuropsychiatrist as the examination is conducted. For each major section discussed (history gathering, general physical examination, neurological examination, mental status examination, cognitive examination), please review the corresponding textbox that invites the clinician to maintain an active thinking process, analyzing and synthesizing each section’s information with the aim of reaching an accurate and comprehensive assessment.
The common approach to psychiatric examination, involving phenomenology and descriptive psychopathology emphasizing the patient’s subjective experience, has changed little since it was conceptualized by Karl Jaspers in the early years of the 20th century.1 The neurological examination used today, though expanded by a host of subsequent investigators,2 still follows the form laid down by John Hughlings Jackson in the late 19th century.3 The neuropsychiatric examination combines elements of both methods, in use for over a century.
APPROACH TO NEUROPSYCHIATRIC ASSESSMENT
The neuropsychiatrist dynamically adapts the examination according to the purpose of the assessment, the cognitive capacity of the patient, and the evolving diagnostic hypothesis being considered by the examiner. It is helpful for the examiner to develop a series of different adapted approaches for patients who are, for example, uncooperative, demented, unresponsive, acutely ill, highly intelligent, intellectually disabled, autistic, violent, or catatonic. A different examination approach is required for young children, adolescents, or young adults. The examination is also adapted if it is being done for forensic purposes, risk assessment, rehabilitation planning, or vocational assessment. Just as one would not evaluate calculation deficits by asking a math professor to perform single digit addition, one would not ask an intellectually disabled individual to interpret a complex proverb. When performing a dementia evaluation, one might include a cue to help the patient remember the examiner’s name when introducing oneself.
The neuropsychiatric examination serves several purposes in addition to gathering data for neuropsychiatric formulation. Precisely delineating the patient’s symptoms not only yields useful diagnostic information but also serves to increase the alliance between clinician and patient by demonstrating the clinician’s intention to try to understand the patient’s experience. The examiner formulates a diagnostic hypothesis at the outset of the interaction with the patient and uses the examination to refine the hypothesis in real time. While refining the hypothesis, the clinician mentally plans for ancillary testing, rehabilitation, and treatment.
Neuropsychiatry is occasionally described as a search for “zebra” diagnoses. This is not the case. The neuropsychiatric examination leads to the differential diagnosis of ...