Table Of ContentHandbook of
Psychiatric
Diagnostic
Procedures
Handbook of
Psychiatric
Diagnostic
Procedures
Vol. I
RICHARD C. W. HALL, M.D.
Medical Director, Psychiatric Programs
Florida Hospital, Orlando
Director of Research, Monarch Health Corp.
Clinical Professor of Psychiatry
University of Florida, Gainesville
THOMAS P. BERESFORD, M.D.
Chief, Psychiatric Service
Veterans Administration Medical Center
Associate Professor of Psychiatry
University of Tennessee Center for the Health Sciences
Memphis, Tennessee
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PREss LIMITED
International Medical Publishers
ISBN-13: 978-94-011-6727-7 e-ISBN-13: 978-94-011-6725-3
001: 10.1007/978-94-011-6725-3
Published in the UK and Europe by
MTP Press Limited
Falcon House
Lancaster, England
Published in the US by
SPECTRUM PUBLICATIONS, INC.
175-20 Wexford Terrace
Jamaica, NY 11432
Copyright © 1984 by Spectrum Publications, Inc.
Softcover reprint of the hardcover 1s t edition 1984
All rights reserved. No part of this book may
be reproduced in any form, by photostat, mi
crofilm, retrieval system, or any other means
without prior written permission of the copy
right holder or his licensee.
THIS BOOK IS DEDICATED TO:
Anne and Ryan
and
Carol, Eddie, Hal, and Charlie
v
Contributors
Thomas P. Beresford, M.D. Chief, Psychiatry Service, Veterans Administration
Medical Center; Associate Professor of Psychiatry, University of Tennessee Center
for the Health Sciences, Memphis, Tennessee
Bernard J. Carroll, M.D., Ph.D. Professor and Chairman, Department of Psy-
chiatry, Duke University Medical Center, Durham, North Carolina
John M. Davis, M.D. Director of Research, Illinois State Psychiatric Institute; and
Gilman Research Professor in Psychiatry, University of Illinois College of Medicine,
Chicago, Illinois
Neil Edwards, M.D. Associate Professor, University of Tennessee Center for the
Health Sciences; Director, Clinical Services, Department of Psychiatry, University
of Tennessee, Memphis, Tennessee
Jan Fawcett, M.D. Professor and· Chairman, Department of Psychiatry, Rush-
Presbyterian St. Luke's Medical Center, Chicago, Illinois
Donald L Feinsilver, M.D. Assistant Professor of Psychiatry and Emergency
Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
Arthur M. Freeman m, M.D. Professor and Vice-Chairman, Department of
Psychiatry, University of Alabama in Birmingham, Birmingham, Alabama
Mark S. Gold, M.D. Director of Research, Fair Oaks Hospital, Summit, New
Jersey
vii
viii Contributors
Richard C. W. Hall, M.D. Medical Director, Psychiatric Programs, Florida Hospital,
Orlando; Clinical Professor of Psychiatry , University of Florida, Gainesville; Director
of Research, Monarch Health Corp.
Javaid I. Javaid, Ph.D. Assistant Director of Biological Services, Research De-
partment, Illinois Psychiatric Institute, Chicago, Illinois
James W. Jefferson, M.D. Co-Director, Lithium Information Center, and Pro
fessor of Psychiatry, University of Wisconsin Center for the Health Sciences, Madi
son, Wisconsin
Howard M. Kravits, D.O. Assistant Professor, Department of Psychiatry, Psy
chology, and Social Sciences, Rush-Presbyterian St. Luke's Medical Center, Chica
go, Illinois
Michael H. Kronig, M.D. Staff Physician, Department of Psychiatry, Research
Facilities, Fair Oaks Hospital, Summit, New Jersey
William Matuzas, M.D. Assistant Professor of Psychiatry, University of Chicago,
Chicago, Illinois
Robert J. PerchaIski, M.D. Research Chemist, Veterans Administration Medical
Center; Assistant Professor, Department of Medicinal Chemistry, College of Phar
macy, University of Florida, Gainesville, Florida
Hector C. Sabelli, M.D., Ph.D. Assistant Professor, Department of Psychiatry,
and Director, Psychobiology Laboratory, Rush-Presbyterian St. Luke's Medical
Center, Chicago, Illinois
Carl B. Shory, M.D. Department of Psychiatry, University Hospital, Birming-
ham, Alabama
B. J. Wilder, M.D. Chief, Neurology Service, Veterans Administration Medi
cal Center; Professor of Neurology and Neuroscience, University of Florida College
of Medicine, Gainesville, Florida
Contents
Contributors vii
Introduction: The Science of Psychiatry xi
NEUROENDOCRINE DIAGNOSTIC TESTS
1. Dexamethasone Suppression Test 3
Bernard J. Carroll
2. Comprehensive Thyroid Evaluation in Psychiatric Patients 29
Mark S. Gold and Michael H. Kronig
TESTS INVOLVING CNS AMINE METABOLITES
3. CNS Amine Metabolites 49
Jan Fawcett, Howard M. Kravitz, and Hector C. Sabelli
TOXICOLOGY EVALUATION
4. Laboratory Procedures Related to the Metals 111
Neil B. Edwards
LABORATORY EVALUATION OF TREATMENT
5. Plasma Concentration Monitoring of Antipsychotic
and Tricyclic Antidepressant Treatment 131
John M. Davis, Javaid I. Javaid, and William Matuzas
ix
x Contents
6. Lithium Monitoring 161
James W. Jefferson
7. Blood Level Determinations of Commonly Prescribed
Medical Drugs 183
Arthur M. Freeman III and Carl B. Shory
8. Blood Level Monitoring of Antiepileptic Drugs 207
B. J. Wilder and Robert J. Perchalski
9. Stimulant Challenge Tests 223
Jan Fawcett, Howard M. Kravitz, and Hector C. Sabelli
LABORATORY EVALUATIONS IN SPECIFIC
PSYCHIATRIC ENVIRONMENTS
10. Laboratory Evaluation of Newly Admitted Psychiatric Patients 255
Richard C. W. Hall and Thomas P. Beresford
11. Psychiatric Diagnostic Procedures in the Emergency Department 315
Donald L. Feinsilver
Index 331
Introduction
The Science of Psychiatry
We live in exciting times. Psychiatrists practicing their specialty are beset as
never before with news of developments in the field. The conduits of news to the
practicing clinician are usually either stories written in the popular medical press
such as news circulars and advertisements from commercial concerns, or from de
tailed scientific articles written for the scientific community. In both forms, the
news has been coming thick and fast.
The problem encountered most often by practicing psychiatrists and clini
cians responsible for hospital facilities is integrating this material into a coherent
whole, with sufficient technical detail to permit the appropriate development or
use of the new tests and procedures in the clinical setting.
The two volumes comprising the Handbook of Psychiatric Diagnostic Pro
cedures represent an attempt to provide a clinically useful review of the current
accepted applicability of these tests and procedures, to enable the clinician to
properly implement and evaluate the procedures as well as the results obtained.
A few chapters, such as that by Dr. Salzburg, deal with highly technical mathe
matical constructs as they relate to signal analysis. Such material is not immediately
applicable to clinical practice. Other chapters, however, such as Weinberger's
chapter on the CT scan, Hall's chapter on laboratory diagnosis in psychiatry, Car
roll's on dexamethasone suppression tests, Gold's on comprehensive thyroid evalu
ation, and Fawcett's on CNS amine metabolites, have a broader clinical application
to general psychiatric practice. Included also is a section dealing with laboratory
evaluation for special groups of patients, such as alcoholics, the elderly, and sub
stance abusers.
Psychiatry no longer views itself as the domain of the single practitioner sit
ting quietly in the consultation room with no need of diagnostic instruments and
rarely of a prescription blank. Research into the biological cuases and correlations
of mental illness, foreseen by Adolph Meyer and Sigmund Freud long ago, is
xi
xii HALL AND BERESFORD
coming of age and moving from the laboratory and academic center to the general
hospital. To name but a few areas of import, current research is examining the use
fulness of MHPG as a clinical indicator in depression, the use of 5-HIAA as a pre
dictor of suicidal behavior, adrenal and thyroid function in depression, brain recep
tor physiology in the major psychotic illnesses, sleep measurement and its relation
to depression and other mental illnesses, the clinical usefulness of serum and intra
cellular levels of psychoactive drugs, and the physiology of the brain itself seen
through new technolOgies such as the PETT scan, nuclear magnetic resonance, and
sophisticated new methods of signal analysis.
The office practitioner is bombarded by glossy literature from commercial
concerns who already offer tests designed to provide the clinician with data useful
in his office practice. The number of tests offered by the more sophisticated com
mercial laboratories catering to the office psychiatrist approximates a hundred.
Similarly, few medical news publications cross the practitioner's desk without some
mention of a new investigation in neuropsychiatry. The busy psychiatrist will gener
ally react in one of two ways to the latest medical sales pitch or news story.
The fIrst is enthusiasm. Truly, the new diagnostic and treatment methods being
brought to fruition are causes of wonder. Perhaps the most striking example is the
cinematic display provided by the PETT scan. This graphic display of altered brain
physiology in mental illness is both dramatic in its technicolor presentation and
convincing in its evident concreteness. Only the technical difficulty and sophisti
cated equipment required for performing the PETT scan save it from becoming an
extension of the mass media.
The practitioner's second reaction may be one of apathy disguised as studied
skepticism. The PETT scan may be colorful, but what does it mean? The PETT scan
may demonstrate altered brain physiology in schizophrenia but how does that
help in treating the schizophrenic patient and his family? Technology is all very
well, but psychiatry will require several more years, if not decades, to properly
integrate it.
Our hope in providing these volumes is that a compromise between these two
positions is possible. The office clinician must be aware of his own enthusiasm and
the harm it could do his patients were he to listen to it uncritically. At the same
time the practicing psychiatrist is the very person who must do the hard work of
integrating the new knowledge science brings us into the careful treatment of pa
tients. We have assembled a series of discussions of new diagnostic approaches and
their technologies by physicians and scientists well versed in their respective sub
jects. We have specifIcally requested each of them to address their comments in
the language of the office practitioner or scientist rather than the language of
either the lay news media or the technical journalist. Each has, in our view, re
sponded to the greatest extent in their specifIc fields.
Our hope is that this volume will provide an accessible reference to the office
practitioner of psychiatry and that it will take advantage both of enthusiasm and
