overlap, who to refer, neuropsych or neurologist

[doctorpsych]

Have a case of an adolescent who has been engaging in antisocial behaviors, he does have pretty strong psycholosocial factors in his hx that suspect psychological underlying problems in relation to his antisocial behaviors. However, he also experienced a pretty significant head trauma during his early teens owing to MVA (can't say for sure when since I'm getting confounding report from family members, dad is alchy, sister is in her teens as a well, mom not in picture but time frame of accident ranged from 3 to 7 years ago). He lost conciousness for at least 2 days (as per family report), spent some time in the ICU and was then discharged. Reportedly he had followup neurological evaluations which were negative (but again as per family report, no objective data here). Family members and adolescent denied any behavioral/emotional changes post trauma and he evinces no overt cognitive deficits. So the referral question is to rule out his head trauma as a cause for his antisocial behaviors. So who does this? Neurologist, clinical neuropsychologist? both?

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[Psyched4life]

Have a case of an adolescent who has been engaging in antisocial behaviors, he does have pretty strong psycholosocial factors in his hx that suspect psychological underlying problems in relation to his antisocial behaviors. However, he also experienced a pretty significant head trauma during his early teens owing to MVA (can't say for sure when since I'm getting confounding report from family members, dad is alchy, sister is in her teens as a well, mom not in picture but time frame of accident ranged from 3 to 7 years ago). He lost conciousness for at least 2 days (as per family report), spent some time in the ICU and was then discharged. Reportedly he had followup neurological evaluations which were negative (but again as per family report, no objective data here). Family members and adolescent denied any behavioral/emotional changes post trauma and he evinces no overt cognitive deficits. So the referral question is to rule out his head trauma as a cause for his antisocial behaviors. So who does this? Neurologist, clinical neuropsychologist? both?

I would recommend that you send him to a neurologist since you have no documentation of past results. Once you receive information from the neurologist then I think you would refer him to a clinical neuropsychologist if his results warrent that referral.

 

[50960]

Definitely think neuropsych would be the best start...

 

[Neuro-Dr]

Sedn to peuropsychology. A neurologist won't do anything with this and since it is a static condition at this point there is little need. The NP will get any needed records from the accident.

 

[docjohng]

Wouldn't it be easier to get a medical release for his previous records first, then make an appropriate referral based upon what thos records say? Working in the dark is one thing, but you should at least make an attempt to verify some of this information since it appears relevant and vital to (a) making a valid diagnosis and (b) helping determine the right course of treatment for him.

A neurologist can basically tell you if there's any physical or brain injury or tumor or such in an individual. Based upon history and such, they'll typically order an appropriate scan (CAT, PET, MRI, etc.) to verify their hypothesis.

A neuropsychologist can suggest there may be specific brain injury, but they are more focused on telling you what the specific strengths and deficits of the individual are based upon such an injury.

But I think you're completely missing the point -- who cares what's causing the antisocial behavior? Isn't it better to focus on what the individual can do now to address the problematic behavior?

Just my two cents...

John

 

[doctorpsych]

Wouldn't it be easier to get a medical release for his previous records first, then make an appropriate referral based upon what thos records say? Working in the dark is one thing, but you should at least make an attempt to verify some of this information since it appears relevant and vital to (a) making a valid diagnosis and (b) helping determine the right course of treatment for him.

A neurologist can basically tell you if there's any physical or brain injury or tumor or such in an individual. Based upon history and such, they'll typically order an appropriate scan (CAT, PET, MRI, etc.) to verify their hypothesis.

A neuropsychologist can suggest there may be specific brain injury, but they are more focused on telling you what the specific strengths and deficits of the individual are based upon such an injury.

But I think you're completely missing the point -- who cares what's causing the antisocial behavior? Isn't it better to focus on what the individual can do now to address the problematic behavior?

Just my two cents...

John

I can loosely see you point if I were to approach this situation from a treatment perspective but my referral question was narrow and specific. I'm approaching this case from a consultative perspective. However, in any case, you should always try to rule out biomedical causes of an illness, as you know--not everything is psychological; and specially in this case, further assessment is warranted given his hx of head trauma and lack of info. In my opinion, it is absolutely appropriate to examine the underlying cause, just think of it's impact on problem conceptualization for the pt., the family, compliance with treatment, treatment itself; if forensic, cause may impact court decision, etc.

As per his medical hx, I'm sure is out there somewhere but family are not good historians. Also, this adolescent is a minority teen who's father does not speak English, he does not keep medical records as per family report, they couldn't even tell me the name of the hospital. It would be much simpler if all our pt's were ideal pts.

 

[Neuro-Dr]

"Wouldn't it be easier to get a medical release for his previous records first, then make an appropriate referral based upon what thos records say? Working in the dark is one thing, but you should at least make an attempt to verify some of this information since it appears relevant and vital to (a) making a valid diagnosis and (b) helping determine the right course of treatment for him."

This assumes the clinician will understand the records they get, doesn't it?

 

[doctorpsych]

"Wouldn't it be easier to get a medical release for his previous records first, then make an appropriate referral based upon what thos records say? Working in the dark is one thing, but you should at least make an attempt to verify some of this information since it appears relevant and vital to (a) making a valid diagnosis and (b) helping determine the right course of treatment for him."

This assumes the clinician will understand the records they get, doesn't it?

Thanks everyone, adolescent was referred to a neuropsych and testing is on its way...

 

[docjohng]

I can loosely see your point, but I suspect the neuropsychologist will tell you largely what everyone already knows -- the patient has deficits based upon the MVA, and the deficits may very well be contributing to his "antisocial" behavior.

Given that there's no clear etiology research backing a differential treatment regimen for "antisocial" pd caused by psychological development or head trauma, you (or the treating clinician) will be left with largely the same challenge -- helping the individual learn ways to deal with the problematic behaviors.

John

 

[doctorpsych]

I can loosely see your point, but I suspect the neuropsychologist will tell you largely what everyone already knows -- the patient has deficits based upon the MVA, and the deficits may very well be contributing to his "antisocial" behavior.

Given that there's no clear etiology research backing a differential treatment regimen for "antisocial" pd caused by psychological development or head trauma, you (or the treating clinician) will be left with largely the same challenge -- helping the individual learn ways to deal with the problematic behaviors.

John

like I said, I don't completely disagree with you. Treatment goals may remain the same but it still important to rule out biomedical causes. That is simply good practice. If not, then you will be working in the dark. That's like treating a headache without knowing what's causing a headache, it could be a simple tension headache or it could be related to a cerebrovascular disorder.

BTW, when I said "antisocial behaviors", that does not automatically mean antisocial PD. Antisocial behaviors are often used in forensics to describe 'illegal' activities. Antisocial personality is a whole different construct. Neuro tests will be able to id deficits that are related to his poor behaviors (e.g. impulsivity, poor judgement, poor comprehension, difficulty processing information, etc). These are all worthy to be examined and considered in treatment and case formulation.