How to Properly Work up a Mental Illness.

because it is easy to overlook a treatable encephalopathy.
It is very important to understand the range of physiological problems that can cause an encephalopathy. The patient will not be able to tell you that they probably have an encephalopathy so the doctor must know how to do a medical workup to check out these very common diagnosis.

Psychiatrists and even neurologists and , other kind of doctors have learnt about this in their neurology rotations, but clearly do not know that this diagnosis is to be considered in every kind of new or longstanding mental condition. The possibility of an undiagnosed metabolic encephalopathy must always be kept in mind for the entire period of illness even if the cause has not been discovered on the first pass.

A simple review of respiratory rate, blood pressure, heart rate [and heart signs] and body temperature will signal an internal physical problem that is to be explored further.

Table 38-1Classification of the Major Metabolic Encephalopathies

Due to lack of glucose, oxygen or metabolic cofactors
  Hypoglycemia
  Ischemia
  Hypoxia
  Hypercapnia
  Vitamin deficiencies
Due to peripheral organ dysfunction
  Hepatic encephalopathy
  Uremic and dialysis encephalopathies

From: Chapter 38, Metabolic Encephalopathies Basic Neurochemistry: Molecular, Cellular and Medical Aspects. 6th edition.Siegel GJ, Agranoff BW, Albers RW, et al., editors.Philadelphia: Lippincott-Raven; 1999.Copyright © 1999, American Society for Neurochemistry. NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Jerry is one of the people who I mentioned who presented to the hospital with a combative, manic type presentation about 53 years ago when he was 19 years old. Jerry’s parents knew his birth and paediatric medical history and were convinced that his breakdown was caused by a unlooked for medical problem. The doctors in emergency would not hear of it, he was presenting as a classic manic depressive patient and they knew better. They did not examine him physically, they did not check his physiology; his respiratory rate or the other vital signs and so they never discovered his ventilatory defect seeming from his difficult hypoxic birth. He was evaluated forever after, only by psychiatrists because of the initial category error and because of assumptions based on looking at behaviours which are nonspecific signs . [which tell you nothing except that you have seen this pattern before in this age group.]

Jerry was looked after by only psychiatrists for his entire life [he is in his 70’s now] and any physical problems he has developed in the interim were considered to be separate from his mood disorder. It is likely that all of his health problems are due to the same thing- an encephalopathy, due to his unlooked for and unrecognized difficult moving air in and out of his body. They never checked his baseline respiratory rate, which was too slow in quiet depressive states [the first physical signs he had around the age of 16, 17 years of age] and then the chaotic, too fast breathing rate of his psychotic manic attack at the age of 19 when he fell into the hands of psychiatric [non medical] care. It was tragic. He suffered a lot, as did his whole family. No one would listen to his parents and they knew best , even if they did not know the term “metabolic encephalopathy”. Jerry needed supportive medical care and respiratory rehabilitation and more, instead he got medications that did a lot of harm [kidney damage] and never really solved the physiological problem completely.

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