A Patient-Centered, Evidence-Based
Diagnostic and Treatment Process
A Presentation for SOMC Medical Education
Kendall L. Stewart, MD, MBA, DFAPA
December 16, 2011
1 My aim is to offer practical insights you can put to use.
2 Please let me know whether I have succeeded when you complete your evaluation form.

• About 1 in 100 people will develop this devastating disorder in their lifetime.
1,2
• Schizophrenia is found in every society and in every country.
• It is best thought of a group of disorders with
– Unknown cause,
– Similar presentation,
– Bizarre behavior,
– Hallucinations ,
– Delusions , and
– Deterioration in overall functioning
• You can view a brief documentary here .
• After listening to this presentation, you will be able to answer the following questions:
– Why is this important?
– How do these patients present?
– What are the diagnostic criteria?
– What is the differential diagnosis?
– What is the treatment?
– What are some of the treatment challenges?
1 This is the cancer of mental illness.
2 The families are the experts; you are at best a caring and knowledgeable consultant.

• Adopt a quiet, calm demeanor.
• Isolate your own emotional arousal .
• Avoid perceived intrusion.
• Observe carefully.
• Listen intently.
• Know the diagnostic criteria .
• Ask brief clarifying questions.
• Avoid painful exploration.
• Review available records.
• Engage the patient’s family and social support network.
• Consider the differential diagnoses.
• Convey understanding, confidence and intent to help.
• Recommend the most appropriate medications.
• Explain most common side effects briefly.
• Explain treatment plan briefly.
• Invite questions.
• Begin educating the family about what to expect.
• Arrange for social support.
• Communicate with stakeholders.
• Arrange for follow up.
1 Begin with the result you want—this patient to receive the best possible care—then focus on those behaviors necessary.
2 The only behaviors you can really control are your own!

• The patient is 22 years old.
• He is withdrawn and hesitant to talk.
• He was brought in for evaluation “against my will.”
• The history is obtained primarily from his parents.
1,2
• “During his senor year of college he became more and more convinced that his roommates were making fun of him.”
• “He observed that they would cough, sneeze or look away when he came into the room.”
• “When his girlfriend broke it off with him, he decided that she had been replaced with a lookalike.”
• “He called the police to report her kidnapping.”
• “He stopped going to class because he believed that the professors were taking thoughts out of his mind.”
• “He stopping showering and shaving.”
• “He thought someone was putting something in his food and he lost weight.”
• “We just can’t reason with him.”
1 When families are involved, I obtain the patient’s consent and view myself as their consultant.
2 One of my patient’s elderly mother comes in with her son every time.

• Schizophrenia (lasts at least 6 months)
• Schizophreniform Disorder (lasts 1-6 months)
• Schizoaffective Disorder (includes mood episode)
• Delusional Disorder (delusions without other symptoms of schizophrenia)
• Brief Psychotic Disorder (1-30 days)
• Shared Psychotic Disorder (shared delusional system) 1,2
• Psychotic Disorder due to a General Medical
Disorder (GMD)
• Substance-Induced Psychotic Disorder
• Psychotic Disorder Not Otherwise Specified
(NOS)
1 This is fairly uncommon.
2 I was surprised by a patient with anorexia nervosa.

• Two of more of the following:
– Delusions
– Hallucinations
– Disorganized speech
– Grossly disorganized or catatonic behavior
– Negative symptoms such as affective flattening, alogia 1,2 or absence of volition
• Social or occupational dysfunction
• Continuous symptoms for
6 months
• Schizoaffective and Mood
Disorder have been ruled out
• Substance Disorder or an underlying General
Medical Disorder has been ruled out.
1 This is a common symptom in hospitals—and now—prisons.
2 A mute patient suddenly told me about Rapid City, SD.

• Inappropriate affect (smiling, giggling or weird facial expressions)
• Loss of interest or pleasure
• Dysphoric mood
• Sleep disturbances
• Abnormal psychomotor behavior
• Diminished concentration, memory and attention
• 80-90% of these patients smoke
• Comorbid mental disorders
• Poor insight
• Noncompliance
• Somatic concerns
• Motor abnormalities
• Decreased life expectancy
• Increased risk for suicide
• Higher incidence of assault and violence among males, younger age, people with prior history of violence and noncompliant patients 1,2
1 Eminent violence is very hard to predict in these patients.
2 A patient nearly killed a patient who had attacked a fellow psychiatrist.

1,2
• Psychosis due to a General
Medical Condition
• Delirium
• Dementia
• Schizotypal , Schizoid and
Paranoid Personality Disorders
• Substance-Induced Psychotic
Disorder
• Substance-Induced Delirium
• Substance-Induced Dementia
• Substance-Related Disorders
• Mood Disorder with Psychotic
Features
• Schizoaffective Disorder
• Depressive Disorder Not
Otherwise Specified (NOS)
• Bipolar Disorder NOS
• Delusional Disorder
• Pervasive Developmental
Disorders
1 At a moment in time, this can be a very difficult diagnosis to make.
2 The diagnosis becomes increasingly clear over time.

• Combination treatment
– Biological
– Psychological
– Social
• Biological
– Typical antipsychotics
• Phenothiazines
• Haloperidol
– Atypical antipsychotics 1
• Clozapine
• Risperidone
• Olanzapine
• Quetiapine
• Psychological
– Prevent harm
– Minimize stress
– Minimize risk of relapse
• Social
– Social support
– Good alliance with patient and the family
1 These are now usually the psychiatrist’s initial choices.

• Stage 1 Olanzapine, quetiapine or resperidone
• Stage 2 Switch to another atypical agent; for noncompliant patients use decanoate preparations
• Stage 3 Switch to a third atypical antipsychotic
• Stage 4 Switch to a typical antipsychotic
• Stage 5 Use clozapine
• Stage 5a Augment clozapine
• Stage 6 Augment with additional drugs and or
ECT.
1 Chiles, et. Al., “The Texas Medication Algorithm Project: Development and Implementation of the Schizophrenia Algorithm,”
Psychiatric Services , January 1999, Vol 40 No. 1

• These patients have a hard time building and sustaining a therapeutic relationship.
• Families often burn out and opt out.
• Noncompliance is a constant challenge.
• Maintaining hope is not always easy.
• Setting realistic expectations is difficult.
• These patients are often desperately poor.
1
• The medications often seem to cause more harm than benefit.
1 One of my patients brought one card from his collection to each visit as a gift to my sons.

• The first descriptions of schizophrenia date back to 1400 BC.
• Schizophrenia is currently viewed as a devastating group of disorders that involve
– Deterioration from a previous level of functioning,
– Characteristic symptoms involving multiple mental processes,
– Typical psychotic symptoms during the active phases of the illness, and
– A demoralizing, chronic course.
• Onset usually is in the patient’s teens and 20s.
• The treatment challenges are daunting.
• Antipsychotic medications are helpful but not dramatically so, and side effects are real problems in themselves.
• Only clozapine stands out; 1 the rest differ only in expense and side effects.
• Multi-modal intervention is the key to maximizing recovery and preventing relapse.
1 Lieberman, et. al., “Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia,”
Journal of Medicine , September 22, 2005, Volume 353;1209-1223 (CATIE)
The New England

A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process
• Introduce yourself using AIDET 1 .
• Sit down.
• Make me comfortable by asking some routine demographic questions.
• Ask me to list all of problems and concerns.
• Using my problem list as a guide, ask me clarifying questions about my current illness(es).
• Using evidence-based diagnostic criteria, make accurate preliminary diagnoses.
• Ask about my past psychiatric history.
• Ask about my family and social histories.
• Clarify my pertinent medical history.
• Perform an appropriate mental status examination.
• Review my laboratory data and other available records.
• Tell me what diagnoses you have made.
• Reassure me.
• Outline your recommended treatment plan while making sure that I understand.
• Repeatedly invite my clarifying questions.
• Be patient with me.
• Provide me with the appropriate educational resources.
• Invite me to call you with any additional questions I may have.
• Make a follow up appointment.
• Communicate with my other physicians.
1
A cknowledge the patient. I ntroduce yourself. Inform the patient about the D uration of tests or treatment.
E xplain what is going to happen next. T hank your patients for the opportunity to serve them.

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision , 2000
• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third
Edition , 2008
• Stern, et. al., Massachusetts General Hospital Comprehensive Clinical
Psychiatry, 2008. You can read this text online here .
• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology , April
2007
• Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship,
Second Edition , March 2005
• Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review,
Twelfth Edition , March 2009 3
• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry , March 2007
• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain ,
January 2008
• Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home,
Work and School , February 2008
• Stewart KL, “ Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000

• Explore the site maintained by the organization where evidence-based medicine began at McMaster University here .
• Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here .
• Subscribe to Evidence-Based Mental Health and search a database at the
National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here .
• Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here .
• Download this presentation and related presentations and white papers at www.KendallLStewartMD.com
.
• Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org
.
• Review the exceptional medical education training opportunities at Southern
Ohio Medical Center here .

1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
StewartK@somc.org
KendallLStewartMD@yahoo.com
www.somc.org
www.KendallLStewartMD.com
1 Speaking and consultation fees benefit the SOMC Endowment Fund.

Phillip Roberts, DO
Sarah Porter, DO
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