2002 Martin Dunitz Ltd

International Journal of Psychiatry in Clinical Practice 2002 Volume 6 Pages 69 ± 72


Physical signs in psychiatry: a step towards evidence-based medicine RK GUPTA,1 R KUMAR 1 AND S KASPER 2 1

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The Canberra Hospital, Canberra, Australia, and 2Department of General Psychiatry, University of Vienna, Vienna, Austria

Correspondence Address Siegfried Kasper, MD, Professor and Chairman, Department of General Psychiatry, University of Vienna, WaÈhringer GuÈ rtel 18-20, A-1090 Wien, Austria Tel: (43) 1 40 400 3568 Fax: (43) 1 40 400 3099

Received 4 December 2000; revised 14 October 2001; accepted for publication 14 January 2002

The descriptive nature of psychiatry is embedde d in the traditions of Kraepelin, Bleuler and Freud. Diagnostic guidelines in both ICD10 and DSM-IV are stated to be based on the ``clinical description of the variety of concepts’’ and are based on the subjective complaints, i.e. symptoms. INTRODUCTION:

In particular, we argue that no significant effort has been made to segregate the presence of accompanyin g physical signs in Major Depressive Illness, DSM-IV 296.2x, and Panic Disorder Without Agoraphobi a, DSM-IV 300.01. METHOD:

These physical signs are psychophysiological correlates of clinically significant depression and anxiety. Advances in structural biology, genetic engineer ing and brain imaging provide an opportunity to narrow the gap between physical signs and psychiatric symptoms in psychiatry. RESULT:

Therefore we suggest that the next revisions of the DSM and the ICD classifications lead the way in incorporating physical signs alongside those symptoms pertaining to each psychiatric illness. (Int J Psych Clin Pract 2002; 6: 69 ± 72) CONCLUSION:

Keywords evidence-bas ed medicine



lmost a quarter of a century ago, Kendell examined the concept of disease and its implications for psychiatry against a background of claims that ``there is no such thing as mental illness; that the conditions psychiatrist s spend their time trying to treat ought not, properly speaking, to be regarded as illness at all, or even to be the concern of physicians. ’’1 Kendell delivered a timely warning, reminding us that psychiatrist s as doctors of medicine were justified in treating affective disorders, schizophren ia and certain other illnesses , the reason given being that these illnesses carried intrinsic biologica l disadvantage s in that they increased mortality and reduced fertility. There was some ambivalence expressed as to whether some neurotic disorders legitimately fell within the realm of psychiatry. Twenty-five years later there are fewer proponents of the antipsychiatr y viewpoint and psychiatrist s are unchallenged in what they treat. In spite of a prolonged search, a clear aetiological basis for biological markers, diagnostic physical symptoms and/or signs and abnormalities has continued to elude psychiatrist s the world over. The question rather now arises as to whether, and if so, within



which range of clinical practice, psychiatrist s treat their patients in adherence with the traditional principle s of medicine. The descriptive nature of our discipline is embedded in traditions, going back to Kraepelin, Bleuler and Freud, of descriptive phenomena of the illness. While these provided an excellent understandin g of the psychopathology, interpretable as the clinical symptoms of the psychoses and neuroses, they have left a very distinct legacy, which is the loss of the `bedside physician’ component of the medical role model in psychiatry. As a result we do not attach importance to the physical signs of the illnesses we treat. The present article in itself does not break any new ground but proposes to draw psychiatrists ’ attention to the need to step forward in the era of evidence-bas ed medicine and account for the physical signs in psychiatric illnesses , even though these are not pathognomonic. In psychiatry, the differentiatio n of symptoms of a psychiatric nature is very difficult to separate from the signs. So for an experienced clinician the process of testing various diagnostic hypotheses starts from the very moment he or she sees the patient, and often this includes noting a striking physical appearance or behaviour.

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RK Gupta et al

In spite of marked advances in the biological understanding of a number of psychiatric conditions , we are still far away from developing a definitive `test’ as the `gold standard’ for a psychiatric disorder. Attempts to develop such diagnostic tests in the past have notably been unsuccessfu l (e.g. the dexamethazone suppressio n test for depression) . Therefore, unfortunately , with our current knowledge the only way to understand psychiatric diagnosi s is by pattern recognition, thus arriving at a syndromal diagnosis. We argue that in addition to this practice, every effort should be made to examine the accompanyin g clearly objective physical signs, whether soft or hard, and incorporat e this in the diagnostic decisionmaking.

IMPORTANCE OF PHYSICAL SIGNS Expanding international contacts and increase d collaboration in undertaking international studies have resulted in a standardizati on of diagnostic practices in the International Classificatio n of Diseases, 10th revision (ICD-10)2 and the Diagnostic and Statistical Manual, 4th edition (DSM-IV). 3 The maxim of the plentiful literature is that `There is much physica l in mental disorder and much mental in physical disorder. ’3 Diagnostic guideline s in both the ICD-10 and the DSM-IV are stated to be based on the ``clinical description of the variety of concepts, for example distress, dyscontrol, disadvantage , disability, inflexibilit y, irrationality , syndromal pattern, aetiology and statistical deviation’’ . For the most part, these diagnostic guidelines are based on the subjective complaints, i.e. symptoms. It is arguable that no significan t effort has been made to segregate the presence of accompanyin g physica l signs, though these may be nonspecific , and, if not always consistent, occur nonetheless as physiologic al concomitants to the psychologica l symptoms. The major textbooks available in psychiatry do not draw a distinction between the symptoms and the signs while describing individua l illness syndromes. This is a significan t departure from conventional medical practice, in that the systematic enunciation of the physical findings in the description of each psychiatric illness has been obviated. Is this perhaps because the physical signs in psychiatric illnesses lack validity, reliabilit y and representative ness? Sanders and Keshavan reviewed the literature on the role of neurologica l examination in adult psychiatry.4 They reported that most of the `soft’ signs can be reliably evaluated, and many have been validated against techniques like EEG, even though the results are inconsistent . The authors highlighted the usefulnes s of including these simple and easily accessible neurologica l examinations in routine clinical practice. Some are important in ruling out organic causes of mental disorders, and others may be associated physical signs. Deahl and Turner pointed out that ``we decided to become psychiatrist s because we liked

talking to people, diagnosing and treating mental illness without gadgets or tests . . ..’’5 As we live in times when the current slogan is getting evidence into medical practice,6 this is a matter of serious concern indeed, as such practices only serve to enhance the decline of routine and basic medical protocol requirement s, in this case clinical observation and the documentation of physical signs.

EXAMPLES Let us examine two examples of different diagnostic illness categories taken from DSM-IV. The first is Major Depressiv e Illness, 296.2x; the second is Panic Disorder without Agoraphobia , 300.01. It is apparent that in both examples the guidelines provided fail to attach importance to the accompanyin g physical signs of the respective categories of illness . It is noticeable that the criteria 1, 3 and 5 for Major Depression contain elements that one would consider the physical signs of depressiv e illness (criterion 1, tearfulness ; criterion 3, weight loss or weight gain; criterion 5, psychomotor agitation or retardation) ; however, all these important signs of depression are dispensabl e and non-essentia l if, as the DSM-IV guideline s suggest, one were to make a diagnosis of an episode of major depression based on the remaining five out of the nine stated criteria. In the second example we have taken, it is noteworthy that although the criteria for Panic Attack include four or more of the symptoms set out, none of the following signs are mentioned: tachycardi a exceeding 90 beats per minute, dry tongue/mouth, sweaty palms and/or bodily extremities, cold clammy skin, skin pallor, pupillary dilatation, tremor, and the fluctuations in blood pressure with wide pulse pressure. These physical signs are psychophysi ological correlates of acute anxiety and hence of panic attack and disorder. Panic disorder has been a focus of intense research over the past decade, seeking to understand the biological underpinnin gs of this relatively common anxiety disorder. The most exciting aspect of this research is that researcher s were able to induce panic attacks using various agents including yohimbine, m-cpp, cholecystokin in, carbon dioxide, lactate, FG-7142 and caffeine.7 Any agents that increase central noradrener gic activity have demonstrable anxiogenic activity: for example, yohimbine, which is a presynaptic alpha-2 autoreceptor blocker which blocks the feedback inhibition of norepinephri ne release, whereas lactate may modulate neuronal metabolism or stimulate medullary chemorecept ors, which release norepinephri ne. In additon to that, we now have a better understandin g of the neurochemic al and neuroanatomical basis of panic disorder. Taking all these together, this type of focussed biological research has improved the number and accuracy of our diagnostic and treatment options. Anxiety symptoms and signs are an integral part of various psychiatric syndromes , and therefore the signs of anxiety should be

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Physical signs in psychiatry

accountable, to support diagnostic practice in psychiatry, which, as we said earlier, is based on symptom descriptions. The concept of `masked depression ’ as promoted by Kielholz 8 is well known, and indicates that patients are more liable to present with physical symptoms than psychologica l ones. Therefore the diagnosis of masked depression should be corroborated by physical signs, for example facial expression , voice and overall appearanc e of preoccupation and gloominess . These illness categories, chosen as pertinent examples, are by no means unique, and one could find appropriat e signs in other psychiatric syndromes . The thrust of our argument is not a critique of DSM-IV but an attempt to enhance the practice of sound medicine in clinical psychiatry. Kutas and Federmeier stated, ``Cognitiv e and affective processes and bodily ones are often closely (if not causally) related. Moreover, even when they are neither, some of the same brain areas take part in both bodily regulation and the cognitive processes, creating an indirect relationshi p between the mind and body that may bear on how various psychophysi ological measures are to be interpreted’’.9 Modern technology, which is precise and accurate, may, if coupled with in-depth understandin g of the physical signs, help us to link up and understand the complex situations in psychiatry, which in the past might not have been possible. A broad range of techniques is increasingl y being employed to study the psychophysi ological processes in the mentally ill. These include electroenceph alography, event-related potentials, magneto-encep halography , positron emission tomography, magnetic resonance imaging, eye tracking, pupillary and cardiovascul ar measurements . We need not continue to neglect this aspect of our clinical practice. Sigmund Freud himself combined scientific empiricism with his psychoanaly tic theories in order to unlock the secrets of psyche in brain physiology . As a physician , he was attempting to explain the physical signs in hysterical conversion reaction, based on the psychic processes. Today, sophisticated physiologica l research is beginning to yield interesting findings. In the study of depression , many advances have been achieved, such as: reduced grey matter density in the left temporal cortex, including the hippocampus , in chronic depression; 10 increased perfusion in the cingulate and paralimbic areas;11 a reduction in altanserin uptake in the right hemisphere , including the posterolateral, orbitofrontal and the anterior insular cortex, in depresse d patients; 12 reduced frontal lobe volume and enlarged lateral ventricles in late-onset depressed patients;13 abnormalities in sleep, as evidenced by decreased REM latency, increased REM density, increased length of time in REM sleep, and difficult y in entering and maintaining slow-wave sleep;14 a significan t correlation between the nocturnal increase in body temperature and REM latency in depression;15 and a subgroup of patients with depression who show a blunted response to stimulation


by thyrotrophin-releasing hormone (TRH), which is a very useful test in differentiati ng depressio n from subclinica l hypothyroidis m.16 It is important to note that sexual problems may be associated with depression and/ or its treatment. It has been emphasized that the discussio n of sexual problems should follow a medical model, because we now have a better understandin g of the biological nature of such problems.17 Researchers have demonstrated decreased testosterone levels in depressed men18 and the role of vasoactive intestinal peptides in the arousal stage of the sexual cycle,19 to mention but a few. These are reassuring advances in pathophysiol ogy, and show that it is now more important than ever before to be aware of the correspondi ng physical state of our patients. The physical signs have their importance in differentia l diagnosis , and as a qualitative care issue have serious clinical and medico-lega l ramifications , providing objective evidence of subjective complaints. The holistic nature of such an approach may allow an insight into patients’ own perspective of their illnesses and treatments. Invariably the prescribe d treatments will modify the physical signs, according to their therapeutic and/or pharmacolo gical profile. Thus, regular observatio n of the physical signs provides a window into the changing mental state as well as into treatment complianc e or its failure. A negative attitude towards treatment compliance is a major problem in psychiatry. In difficult cases, a good rapport and treatment complianc e may be facilitated if the focus of assessmen t and subsequent treatment are shifted to the physical signs, as many patients would readily acknowledge the presence of abnormal physical signs rather than the psychologic al symptoms. A feedback approach, as physical signs ameliorate could help achieve compliance. This strategy would also involve patients as active participants in their treatments rather than passive recipients. Such practice would also tend to reduce the subjective element, inevitable when only one clinician deals with one patient. Clinical decisions as to when to investigate, what tests to use and when to refer to other specialists , would become more rational and account-able in the practice of evidence-bas ed mental health care. Finally, the importance of physical signs can hardly be underestimat ed in subtyping an illness category for diagnostic or specific treatment purposes; for example, Wilhelm and colleague s have separated melancholi c nonpsychotic depressives , on the basis of physical signs of significan t motor agitation or retardation and evidence of some vegetative features, from melancholi c psychotic depressive s who had persistent delusions and/or hallucinations. 20

CONCLUSION The influenc e of managers, the rising costs of healthcare , compulsory case management and the diminishe d role of

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RK Gupta et al

psychiatrist s and the increasin g trend towards the evidence-bas ed practice of medicine, may perhaps in the future pose a new challenge to the medical bona-fide of clinical psychiatric practice. It is therefore in our interest not to disregard the terra firma of medicine, and we suggest that the next revisions of the DSM and ICD classification s should lead the way to the incorporation of physical signs alongside the symptoms pertaining to each psychiatric illness , as we have discussed . This may well require validation studies in internationall y co-ordinated research projects, with the purpose of standardizin g the presence of various clinical signs in the respective categories of illness. Surely in the 21st century this would be fundamental to the practice of evidence-bas ed psychiatry, inasmuch as it would

standardize or empiricize, step-by-step, along the traditional path of general medicine?

KEY POINTS . Concepts of disease . Descriptive nature of psychiatr y . Gap between physical signs and psychiatric symptoms . Incorporation of physical signs pertaining to psychiatric illness

REFERENCES 1. Kendell R (1975) Concept of Disease and Its Implications for Psychiatry. Br J Psychiatry 127: 305 ± 15. 2. World Health Organization (1992) International Classification of Diseases, 10th revision (ICD-10). WHO, Geneva. 3. Diagnostic and Statistical Manual of Mental Disorders (4th edn) (1994) (DSM-IV) American Psychiatric Association, Washington DC. 4. Sanders RD, Keshavan MS (1998), The neurologic examination in adult psychiatry: from soft signs to hard science. J Neuropsychiatry Clin Neurosci 10: 395 ± 404. 5. Deahl M, Turner T (1997) General psychiatry in no man’s land. Br J Psychiatry 171: 6 ± 8. 6. Goldee F (1998) Getting evidence into practice (Editorial) Br Med J 317: 6. 7. Krystal JH, Deutsch DN, Charney DS (1996) The biological basis of panic disorder. J Clin Psychiatry, 57 (suppl 10): 23 ± 31. 8. Kielholz P (1975) Treatment for masked depression. Psychopharmacol Bull 11: 31 ± 34. 9. Kutas M, Federmeier KD (1998) Minding the body. Psychophysiol; 35: 135 ± 150. 10. Shah PI, Ebmeier KP, Glabus MF (1998) Cortical grey matter reductions associated with treatment resistant chronic unipolar depression. Br J Psychiatry 172: 527 ± 32. 11. Ebmeier KP, Cavanagh JTO, Mofoot APR et al (1997) Cerebral perfusion correlates of depressed mood. Br J Psychiatry 170: 77 ± 81. 12. Biver F, Wikler D, Lotstra F et al (1997) Serotonin 5 HT2 receptor imaging in major depression: Focal changes in orbitoinsular cortex. Br J Psychiatry 171: 444 ± 48.

13. Soares JC, Mann JJ (1997) The anatomy of mood disorders ± review of structural neuroimaging studies. Biol Psychiatry 41: 86 ± 106. 14. McDermott OD, Prigerson HG, Reynolds CF et al (1997) Sleep in the wake of complicated grief symptoms: an exploratory study. Biol Psychiatry 41: 710 ± 6. 15. Avery DH, Wildschiditz G, Smallwood RG et al (1986) REM latency and core temperature relationships in primary depression. Acta Psychiatr Scand 74: 269 ± 80. 16. Rush AJ, Giles DE, Schlesser MA et al (1997) Dexamethazone response, thyrotropin-releasing hormone stimulation, rapid eye movement latency, and subtypes of depression. Biol Psychiatry 41: 915 ± 28. 17. Clayton AH (2001) Recognition and assessment of sexual dysfunction associated with depression. J Clin Psychiatry, 62 (suppl 3): 5 ± 9. 18. Persky H, Lief HI, Strauss D et al (1978) Plasma testosterone level and sexual behaviour in couples. Arch Sex Behav 7: 157 ± 75. 19. Levin RJ (1992) The mechanism of human female sexual arousal. Annu Rev Sex Res 3: 1 ± 48. 20. Wilhelm K, Mitchell P, Sengoz A et al (1994) Treatment resistant depression in an Australian context II: Outcome of a series of patients. AustNZ J Psychiatry 28: 23 ± 33.

Physical signs in psychiatry: a step towards evidence-based medicine.

The descriptive nature of psychiatry is embedded in the traditions of Kraepelin, Bleuler and Freud. Diagnostic guidelines in both ICD10 and DSM-IV are...
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