CHAPTER 72 The Neurological Examination
OVERVIEW
Why does a psychiatrist need to know how to perform a good neurological examination?
All behavior is an expression of the activity of neural circuitry that has been sculpted through the interplay of the human genetic potential and environmental forces. Neural circuitry is susceptible to malfunction and to damage in a variety of ways; this results in many identifiable patterns of cognitive and behavioral change. These patterns are key manifestations that, when integrated with findings from a thorough neurological examination, may result in the identification of an underlying neurological process that can be treated. Neurological illnesses commonly have psychiatric co-morbidities that may be the result of the stress of illness, a direct result of brain pathology, or a combination of the two. Psychiatric symptoms and behavioral changes that occur as a result of neurological illness may precede other physical manifestations or occur at any time during the course of the disease. Proficiency with the performance of the neurological examination may afford clinical opportunities (e.g., earlier diagnosis of potentially treatable conditions, the ability to anticipate potential psychiatric manifestations, and the ability to avoid the potential adverse effects of some pharmacological agents in sensitive individuals).
By the late nineteenth century the elementary neurological examination was refined with objective, consistent, and reproducible findings.1 The practice of the examination is considered most effective when the clinician has formed a hypothesis that is based on observation and history and is prepared to fluidly adapt both examination and hypothesis as new information and findings appear. A well-rehearsed examination prevents omissions and ensures consistency of technique. A well-reasoned examination with an array of alternative techniques that verify findings ensures greater accuracy and confidence in those findings. The complexity of planning, performing, and interpreting the neurological examination is a challenge that persists throughout the entirety of a physician’s career.
The neurological examination is performed routinely on most psychiatric admissions but is uncommonly performed in outpatient psychiatric settings. In some circumstances, a careful history alone may establish a neurological diagnosis; however, this is often not the case. The examination is helpful for corroborating the history, establishing the severity of a condition, and directing treatment. The overall assessment approach should use a reproducible methodology for obtaining and interpreting the history, performing the examination, and analyzing both. A comprehensive neurological examination is unnecessary in every patient. The clinician must learn to focus, or expand, his or her examination as needed. A good examination can be instrumental in discerning primary psychiatric illness from secondary symptoms that result from diverse neurological conditions (such as stroke, Alzheimer’s disease, Huntington’s disease, Parkinson’s disease, and demyelinating disease). See Table 72-1 for a summary of major neurological findings and associated conditions that frequently have psychiatric symptoms. Malingering and conversion disorder also need to be distinguished from true neurologi-cal deficits.2 Medication side effects, such as parkinsonism and dystonia, need to be identified, treated, and followed clinically.
Table 72-1 Neurological Abnormalities That Suggest Diseases Associated with Psychiatric Symptoms
General principles include the following:
Some of this localization, particularly to the PNS, will exceed the expertise of most psychiatrists. These principles are presented as tools to organize thinking.
There is no clear consensus among experts as to the order of performing and presenting the neurological examination. However, there is little dispute about the mental status portion being performed first followed by examination of the cranial nerves. Thereafter, there are variations in the order, selected components of the examination, terminology used to describe findings, and the interpretation of findings. Clinicians should decide on a sequence, practice and become proficient at it, and then use it consistently. This improves performance and speed, provides a database of variations in responses, and reduces the likelihood of forgetting to perform aspects of the examination. A common approach and examination sequence will be offered along with some options for expanding the examination and validating findings with use of other maneuvers (Tables 72-2, 72-3, and 72-4).
Table 72-2 Components of Elemental Neurological Examination
Table 72-3 Elements of the Psychiatric Mental Status Examination
Table 72-4 Elements of the Neurological Mental Status Examination
THE EXAMINATION
The examination begins when entering a patient’s room or encountering the patient in the hallway. Initial observations are made wherever the patient is found, be it walking down the hall to meet you or lying in bed. Whether the patient knows he or she is being observed can also be important. Behavior may change out of the physician’s view.
Textbooks have been dedicated to various aspects of cognitive assessment. This section will introduce the fundamental aspects of the cognitive examination; some helpful anatomical and neuropsychiatric considerations will also be presented.
The Psychiatric Portion of the Mental Status Examination
The separation of the mental status examination into psychiatric portions and neurological portions represents a historical difference in emphasis rather than purpose; this distinction will be continued for the purpose of clarity. See Table 72-3 for a summary of the components of the psychiatric portion of the mental status examination.
Initial Observations of the Patient
General Appearance.
Observations start with determination as to whether the patient appears morphologically normal. Consider stature, hairline, level of ears, distance between eyes, presence of philtrum, length of neck, and body characteristics (such as gynecomastia, obesity, and digit length). These may be indicative of a genetic syndrome or a genetic disorder. Mention of these characteristics is intended as a reminder rather than a comprehensive review of this topic.
Behavioral Appearance.
Hygiene, body odor, posture, demeanor, cooperativeness, eye contact, speed of movement, the manner of dress, social graces, and attitude toward the examiner should be noted. A patient may be anxious, inattentive, engaged, cooperative, disinhibited, angry, hostile, or extremely courteous.
Speech.
Manifestations of speech include the speed, fluency, volume, and prosody. A person with a history of 4 days of speaking very quickly and being very hard to interrupt in conversation may be manic or be under the influence of drugs. Prosody describes the melodic patterns of intonation in language that convey shades of meaning. Impairment may be in the production of prosody,3 or in the comprehension of another person’s prosody. Testing prosody is uncommonly done. If clinically indicated, appreciation of prosody can be tested by situating oneself behind the patient and saying a short sentence, such as “I’m going home now,” with four different emotional tones (e.g., happy, sad, angry, and neutral). Being positioned behind the patient prevents the patient from interpreting the expression of your face. One should ask the patient to identify the emotional state of each of your theatrical renditions. Prosody production may be tested by asking the patient to repeat the same sentence in each of the emotional states previously listed. Listening for the patient’s spontaneous prosody is also essential.
Mood and Affect.
Mood is the patient’s report of his or her emotional state. Affect is the outward expression of the patient’s mood to the world. Descriptions of affect include the terms flat, constricted, elevated, sad, expansive, and labile.
A patient with a stooped posture, slow speech, and flat affect could be manifesting signs of depression. If his stated mood is “sad” or “depressed,” his mood and affect are congruent. Some neurological conditions may be associated with a disassociation of mood and affect. A condition now known as involuntary emotional expressive disorder (IEED),4 previously named pseudobulbar affect or palsy, is characterized by episodes of involuntary or exaggerated emotional expression that results from brain disorders affecting structures of a neural network involving the frontal lobes, the limbic system, the brainstem, the cerebellum, or the interconnecting white matter tracts of this network. Extremes of emotional expression (from crying to, less often, laughing) occur without the patient actually feeling these emotions or without the patient feeling the concordant degree of the emotion expressed. IEED can occur in association with a number of neurolog-ical conditions including Alzheimer’s disease, amyotrophic lateral sclerosis (ALS), stroke, and traumatic brain injury.
Thought Process.
Normal thought, as demonstrated in casual conversation and most other circumstances, is goal directed; it does not require great effort to follow the logical progression of ideas. Some common descriptive terms include linear thinking, loose associations, circumstantial thought, tangential ideas, flight of ideas, disorganized thinking, incoherent thought, and perseverative thinking.
Thought Content.
This can be derived from what the patient tells you, from what you can infer from the patient’s history, and from your observations of personal interactions. A patient may be extremely guarded and careful about when, and if, to reveal his or her true beliefs. Terms that commonly refer to thought content include preoccupations, ruminations, obsessions, paranoia, delusions, ideas of reference, and suicidal or homicidal ideation. There can also be a poverty of content.
Terms such as paranoia, thought blocking, and ideas of reference may be interpreted as involving perceptions, thought process, or content.5
Perceptions.
Hallucinations may be auditory, visual, tactile, gustatory, or olfactory. They may be simple (as in a flash of light) or complex (as in seeing panoramic scenes or feeling a kiss). The content of hallucinations and their relationship to mood are important to identify. Psychiatric disorders more often than not have mood-congruent hallucinations. Insight regarding the hallucination is an important characteristic. Illusions, or perceptual distortions, may also occur.
Insight/Awareness/Concern.
Insight is commonly referred to as comportment; it is often derived from the patient’s description of his or her circumstances and relates to how the patient’s problems evolved.
Judgment.
Determination of judgment is usually derived from aspects of the history. The patient’s interactions with family, friends, and health care professionals can be used to assess social appropriateness, social graces, and comportment. Disinhibition or poor judgment may be ascertained through observation or elements of the history.
The Neurological Portion of the Cognitive Mental Status Examination
A psychiatric mental status examination should include several major components. The following sequence affords the opportunity to evaluate cognition in a hierarchy of increasing complexity. Subsequent performance on complex tasks requires that more basic aspects of cognition are intact. See Table 72-4 for a more complete summary of the components of the neurological mental status examination.
Level of Consciousness
Consciousness is most commonly viewed as being a function of the level of arousal. The lowest level of consciousness has many descriptive terms, some of which imply a pathological state, such as coma. A patient might appear to be comatose yet actually be in nonconvulsive status epilepticus.6 An awareness of the nuances of descriptive terms will help avoid confusion in most circumstances. One common method is to describe arousability with respect to pain, loud noise, voice, and command. The relative ease or difficulty of arousability with these stimuli is also noted.
Attention
After determination of the level of consciousness, the ability to sustain attention should be assessed. Common tasks used to assess attention include the following:
Performance of Serial 7s.
Ask the patient to subtract 7 from 100. Then ask the patient to continue subtracting 7 (and to state the results); have the patient stop when he or she reaches 65. The patient should be able to remain on task after starting without having the instructions repeated. This test must be interpreted in the context of the patient’s background and education.
Spelling Tests.
Have the patient spell the word “world” or “march” forward, backward, and then alphabetized. Forward-spelling is a test of simple attention. Backward-spelling requires concentration. Alphabetizing the letters is a test of concentration and verbal working memory. This testing presumes a preexisting ability to spell.
Other Tests.
Have the patient state the days of the week (or months) backward. Digit span also tests attention. It is a test during which a patient is presented with successively longer strings of random digits starting at two or three digits and with each rendition increasing the string by one digit until the patient reaches a string between five and seven digits. Performance, to some degree, depends on age; however, there is considered to be little decay in this ability with normal aging. This test may also be performed backward. Normal performance is seven digits forward and five digits backward. However, recalling six digits forward and four digits backward is probably acceptable. It is considered normal to have a difference of two between forward and backward testing.7,8
Language
Language is a term that can refer to a variety of means of thought expression that can include facial expressions, sign language, and symbolic communication, as well as written and spoken language. During a screening examination, concerns should focus on the assessment of spoken and written language. The intent is to determine whether the patient has difficulties producing language, comprehending language, or both. Answering the following questions provides a basic screen.
Does the patient’s speech sound like language? Is the speech fluent or nonfluent? Fluency has been described as speech that is flowing rapidly and effortlessly. Nonfluent speech is uttered in single words or short phrases with frequent pauses and hesitations. Fluency can usually be appreciated during conversation with the patient. The examiner should observe the patient’s use of grammatical structure. Fluency can be independent of content and comprehensibility.
Comprehension.
Comprehension is often easily assessed while taking the history and performing the physical examination. When there is difficulty, one can request that the patient perform a one- to three-step command. If the patient appears impaired, the examiner should start with simple questions that can be answered in a yes/no fashion. Asking a patient to point at objects or to show his or her thumb or another body part are alternatives. Bear in mind that more complex commands will require intact attention and comprehension of grammar and language.

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