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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,
Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org1
Slide show includes
Topic Headings
Tables and Figures
Key Points
Laboratory Testing and ImagingStudies in PsychiatryH. Florence Kim, M.D., Paul E. Schulz, M.D.,
Elisabeth A. Wilde, Ph.D., Stuart C. Yudofsky, M.D.
The American Psychiatric Publishing
TEXTBOOK OF PSYCHIATRYFifth EditionEdited by Robert E. Hales, M.D., M.B.A., Stuart C. Yudofsky, M.D., Glen O. Gabbard, M.D.
2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
CHAPTER 2
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,
Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org2
CHAPTER 2 Topic Headings
APPROACH TO SCREENING LABORATORY
AND DIAGNOSTIC TESTING OF PSYCHIATRIC
PATIENTSScreening Laboratory Testing
Screening Chest Radiographs
Screening Electrocardiograms
Screening Electroencephalograms
Screening Structural Neuroimaging Examinations
Overall Role of Screening Laboratory and
Diagnostic Testing
LABORATORY APPROACH TO SPECIFIC CLINICAL
SITUATIONS IN PSYCHIATRY
New-Onset PsychosisMood Disturbance: Depressive or Manic Symptoms
Anxiety
Altered Mental Status
Cognitive Decline
Dementias
Mild Cognitive Impairment
Substance Abuse
MEDICATION MONITORING AND MAINTENANCE
Mood StabilizersTricyclic Antidepressants
Neuroleptics
PHARMACOGENETICS AND PHARMACOGENOMICS
CEREBROSPINAL FLUID STUDIES
INVESTIGATIONAL BIOLOGICAL AND GENETICMARKERS
NEUROENDOCRINE TESTING
ELECTROPHYSIOLOGICAL TESTING
Standard Electroencephalogram
Polysomnography
Evoked Potentials
Quantitative EEG
NEUROIMAGING STUDIES IN PSYCHIATRY
Structural Neuroimaging Modalities
Computed Tomography
Magnetic Resonance Imaging
Comparison of CT and MRI
Clinical Use of CT and MRI in PsychiatryOther Structural Imaging Techniques
Magnetic Resonance Spectroscopy
Diffusion Tensor Imaging
Functional Neuroimaging Modalities
Single Photon Emission Computed Tomography
Positron Emission Tomography
Comparison of SPECT and PET
Clinical Use of PET and SPECT in Psychiatry
Cognitive Decline and Dementia
EpilepsyStroke
Traumatic Brain Injury
Neuroreceptor Imaging
Functional Magnetic Resonance Imaging
Magnetoencephalography
Neuroimaging of Psychiatric Disorders
CONCLUSION
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,
Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org3
CHAPTER 2 Tables and Figures
Table 21. Selected medical conditions with psychiatric manifestations
Table 22. Useful screening labs in the workup of the neuropsychiatric patient
Table 23. Recommended diagnostic workup for a patient with new-onset psychosis
Table 24. Recommended diagnostic workup for a patient with new-onset depressive or manic symptoms
Table 25. Recommended diagnostic workup for a patient with new-onset anxiety symptoms
Table 26. Recommended diagnostic workup for a patient with altered mental status
Table 27. Recommended diagnostic workup for a patient with cognitive decline
Table 28. Substances of abuse
Table 29. Medication monitoring
Table 210. Psychiatric drug metabolism by specific P450 enzymes
Table 211. Drug metabolizer phenotype classification
Table 212. Selected investigational biological and genetic markers
Figure 21. Computed tomography (CT) tissue attenuation values and appearance.
Table 213. Tissue signal on T1 versus T2 weighting
Figure 22. MRI comparison axial cuts, bipolar disorder patient versus matched control.
Table 214. Comparison of computed tomography (CT) and magnetic resonance imaging (MRI)
Figure 23. Side-by-side comparison of structural imaging modalities: CT and MRI.
Table 215. Indications for computed tomography (CT), prior to or instead of magnetic resonance imaging (MRI)
(continued)
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Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org4
CHAPTER 2 Tables and Figures (continued)
Figure 24. Diffusion tensor imaging (DTI).
Figure 25. Diffusion tensor imaging (DTI) in traumatic brain injury and bipolar disorder.
Table 216. Comparison of SPECT, PET, and fMRI
Figure 26. Side-by-side comparison of structural and functional neuroimaging: magnetic resonance imaging
(MRI) and positron emission tomography (PET).
Figure 27. Side-by-side comparison of single photon emission computed tomography (SPECT) versus
positron emission tomography (PET).
Figure 28. Structural magnetic resonance imaging (MRI) and positron emission tomography (PET) imaging
of a healthy control subject and a patient with traumatic brain injury.
Figure 29. Structural magnetic resonance imaging (MRI) and positron emission tomography (PET) imaging
of a patient with hypoxic brain injury.
Figure 210. Single photon emission computed tomography (SPECT), structural magnetic resonance
imaging (MRI), and magnetoencephalography (MEG) imaging of a patient with traumatic brain injury.
Figure 211. Neuroreceptor imaging.
Figure 212. Functional magnetic resonance imaging of working memory.
Figure 213. Functional magnetic resonance (fMRI) and transcranial magnetic stimulation (TMS) as a
neuroscience tool.
Table 217. Summary of neuroimaging findings in selected psychiatric disorders
Summary Key Points
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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,
Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org5
TABLE 21. Selected medical
conditions with psychiatricmanifestations
Table 21 lists some of the many
medical and neurological illnesses that
may present with prominent
neuropsychiatric symptoms. Clinical
laboratory assessment and diagnostic
testing can help determine which of themany potential causes is responsible
for a patients symptoms. Because a
number of these etiologies may have
potentially curative remediations,
accurate diagnosis is critical.
Source.Adapted from Ringholz 2001; Sadock and Sadock
2007; Wallach 2000.
(continued)
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TABLE 21. (continued)
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TABLE 22. Useful screening labs in the workup of the neuropsychiatric patient
Table 22 presents a list of screening laboratory tests that clinicians often use during the initial
evaluation of the patient with psychiatric complaints.
Source. Adapted from Alpay and Park 2000; Anfinson and Stoudemire 2000; Fadem and Simring 1998; Methodist Health Care System 2001;
Sadock and Sadock 2007; Wallach 2000.(continued)
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TABLE 22. (continued)
(continued)
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TABLE 22. (continued)
(continued)
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TABLE 22. (continued)
(continued)
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TABLE 22. (continued)
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TABLE 22. (continued)
(continued)
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TABLE 22. (continued)
(continued)
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TABLE 22. (continued)
(continued)
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TABLE 22. (continued)
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TABLE 22. (continued)
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TABLE 22. (continued)
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TABLE 22. (continued)
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TABLE 22. (continued)
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TABLE 23. Recommended diagnostic
workup for a patient with new-onset
psychosis
A careful evaluation is important for a patient with a
first episode of psychosis in order to rule out the
many possible medical and neurological causes of
psychosis. Table 23 summarizes some of the
recommended tests in the diagnostic approach to a
patient with new-onset psychosis.
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TABLE 24. Recommended diagnostic
workup for a patient with new-onsetdepressive or manic symptoms
Neuroimaging and electroencephalography are often helpful as well in understanding the etiology of
a patients mood symptoms. Multiple neurological and medical disorders have mood manifestations
that may often be the presenting complaint. The diagnostic approach to a patient with new-onset
depressive or manic symptoms is summarized in Table 24.
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TABLE 25. Recommended
diagnostic workup for a patient with
new-onset anxiety symptoms
Many different medical diseases can manifest anxiety, including angina and myocardial infarction,
mitral valve prolapse, substance intoxication and withdrawal, and metabolic and endocrine
disorders such as thyroid abnormalities, pheochromocytoma, and hypoglycemia. Neurological
disorders, such as many forms of dementia, can also present with anxiety. The diagnostic approach
to a patient with new-onset anxiety is summarized in Table 25.
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TABLE 26. Recommended
diagnostic workup for a patient with
altered mental status
Patients with a fluctuating mental status of acute
onset most likely will have one or more
underlying medical or neurological causes for
their impaired consciousness. This often
constitutes a medical emergency, and
comprehensive laboratory and diagnostictesting are indicated on an emergency basis, as
summarized in Table 26.
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TABLE 27. Recommended diagnostic workup for a
patient with cognitive decline
Table 27 lists the laboratory and diagnostic tests that
would be included in the workup of a patient with cognitive
impairment.
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TABLE 28. Substances of abuse
The length of time that a drug of abuse is detectable in the urine varies depending on the amount and
duration of substance consumed, kidney and liver function, and the specific drug itself. Table 28
reviews common drugs of abuse, toxic levels, and length of detection time.
Source. Adapted from Wallach 2000.
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TABLE 29. Medication monitoring
Although no clear consensus exists regarding appropriate clinical screening and monitoring regimens during
mood stabilizer treatment, a potential set of guidelines, which most authors appear to support, is listed in
Table 29. The table shows the psychotropic medications for which therapeutic drug monitoring may be
useful, as well as therapeutic and toxic drug levels and ancillary tests that are recommended to monitor for
the prevention of end-organ damage.
Source. Adapted from Wallach 2000; Hyman SE, Arana GW, Rosenbaum JF. Handbook of Psychiatric Drug Therapy, 3rd Edition. Boston, MA, Little, Brown & Co., 1991.
Used with permission.
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TABLE 210. Psychiatric drug metabolism by
specific P450 enzymes
Table 210 lists many of the psychiatric drugs that are
metabolized by selected CYP enzymes (substrates) as
well as those that may decrease enzyme activity
(inhibitors). CYP drug metabolism is highly variable
due to several factors, including genetic
polymorphisms, effects of concomitant medications(inhibition or induction of enzymes), physiological or
disease status, and environmental or exogenous
factors such as toxins and diet.
Source. Data adapted from Kirchheiner et al. 2001; Streetman 2000.
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TABLE 211. Drug metabolizer phenotype classification
Four general phenotypes have been used to describe the outcomes of CYP genetic polymorphisms
(Table 211): ultrarapid metabolizers, extensive metabolizers, intermediate metabolizers, and poor
metabolizers. Extensive metabolizers have the normal two copies of fully active CYP enzyme alleles for a
particular microsomal enzyme. Poor metabolizers do not have the active enzyme gene allele, resulting in
increased concentrations of medications due to reduced metabolism, and may have more adverse effects
at usual, recommended dosages. In contrast, ultrarapid metabolizers will have multiple copies of thefunctional enzyme allele, resulting in increased rate of drug metabolism, and may not reach therapeutic
concentrations at the recommended dosage.
Source. Adapted from Ingelman-Sundberg 1999; Mrazek 2006.
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TABLE 212. Selected investigational biological and genetic markers
There is considerable interest in isolating biological markers for psychiatric illnesses for the purposes
of improving the accuracy of diagnosis, predicting treatment response, identifying patients at risk, and
ultimately preventing the development of these disorders. Table 212 lists some of the biomarkers
being researched at this time.
(continued)
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TABLE 212. (continued)
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FIGURE 21. Computed tomography (CT) tissue attenuation values and appearance.
CT scanning enlists a focused beam of X-rays that passes through the brain at many angles. The many
images evoked are then joined together to provide a cross-sectional view of the brain. The X-rays are
attenuated as they pass through tissue, which absorbs their energy. The degree of energy absorbed
varies, based on the radiodensity of the tissue. This differential X-ray attenuation is transformed into a
two-dimensional grayscale map of the brain by computers, with bone appearing most radiopaque, or
white, and air the least radiopaque, or black. Brain tissue, CSF, and water have varying degrees ofradiopacity (Figure 21).
Source. Adapted from J Levine lecture Structural Neuroimaging in Psychiatry, given as part of the Neuroimaging in Psychiatry lecture series,Department of
Psychiatry, Baylor College of Medicine, March 2006.
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TABLE 213. Tissue signal on T1 versus T2 weighting
In clinical practice, T2-weighted images can be very useful for visualizing lesions because they show
edema as an increase in signal intensity. T1-weighted images are useful for demonstrating structural
anatomy. Table 213 lists the characteristic appearance of tissue signals on T1- and T2-weighted MRI
images.
Source. Adapted from J Levine lecture Structural Neuroimaging in Psychiatry, given as part of the Neuroimaging in Psychiatry lecture series, Department of Psychiatry,
Baylor College of Medicine, March 2006.
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TABLE 214. Comparison of computed tomography (CT) and magnetic resonance
imaging (MRI)
MRI has many advantages over CT. First and foremost, it has superior visualization of brain tissue,
providing enhanced gray/white matter discrimination versus CT and allowing quantitative or volumetric
measurement of brain regions. Deep brain structures such as the cerebellum and brain stem are better
visualized with MRI. Furthermore, axial, coronal, and sagittal images may be acquired. MRI image
acquisition is complex, and depending on parameters, can produce T1-, T2-, or proton density
weighted images, spin-echo, and inversion-recovery images. Table 214 provides a summarycomparison of CT and MRI imaging modalities.
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FIGURE 23. Side-by-side comparison of structural imaging modalities: CT and MRI.
Figure 23 is a comparison of images available with CT versus MRI.
The sensitivity of head CT versus MRI of the brain in the same patient is demonstrated here in a patient
who presented with memory loss. Head CT scan at leftshows a large area of decreased densityconsistent with edema. It is difficult to ascertain whether there is an underlying mass or what its shapemight be. The image on the rightis from a brain MRI (T2 image) and also demonstrates an area ofincreased intensity of about the same shape as the CT abnormality. The patient was found to be HIVpositive, and a subsequent brain biopsy demonstrated that the mass was a B-cell lymphoma.
Source. Images courtesy of Paul E. Schulz, MD, Department of Neurology, Baylor College of Medicine, Houston, Texas.
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TABLE 215.
Indications for
computed
tomography (CT),
prior to or instead of
magnetic resonance
imaging (MRI)
Although evidence is limited, structural neuroimaging appears to be indicated for the following clinical
situations for psychiatric patients: new or unexplained focal neurological signs, cognitive changes or
impairment, new-onset psychosis, or prior to the initiation of electroconvulsive therapy. A CT is
valuable when evaluating for suspected hemorrhage or skull fracture or when MRI is contraindicated
(e.g., metal implants) (Table 215).
Source. Adapted from J Levine lectureStructural Neuroimaging in Psychiatry,
given as part of the Neuroimaging in
Psychiatry lecture series, Department of
Psychiatry, Baylor College of Medicine,
March 2006.
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FIGURE 24. Diffusion tensor
imaging (DTI).
DTI, a fairly new imaging technique, is the
subject of intense research in psychiatric and
neurological disorders, including dementias and
cognitive disorders, schizophrenia, mood
disorders, substance use disorders, and brain
injury. Figures 24 and 25 illustrate the whitematter tracts that can be visualized with DTI in
various disorders.
A, Fractional anisotropy color map derived from DTI inthe sagittal plane. Redindicates white matter fibers
coursing in a right-left direction, blue indicates fibersrunning in a superior-inferior direction, and green reflectsfibers oriented in an anterior-posterior direction. B, Fibertracking using DTI of the total corpus callosum overlaidon aT1-weighted inversion recovery image from thesame brain.
Source. Images courtesy of Elisabeth A. Wilde, PhD, Department of Physical
Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas.
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FIGURE 25. Diffusion
tensor imaging (DTI) in
traumatic brain injury
and bipolar disorder.
Fiber tracking of the corpus callosum in A, a 16-year-old male patient who sustained severe traumatic brain injury andB, an uninjured young man of the same age. The arrowindicates the absence of fibers emanating from the posterior
body of the corpus callosum. Note also the reduced length and number of fibers emanating from other aspects of thecorpus callosum body, likely resulting from injury to the white matter in this area. The mean fractional anisotropy of the
fibers in this system was significantly reduced. In addition to quantitative measures of anisotropy, DTI can be used toexamine aberrant fiber patterns such as that demonstrated in a 55-year-old female bipolar patient (C) as compared withthe expected pattern demonstrated in a woman of comparable age without history of illness (D). Interestingly, thepatient had no significant abnormalities evident on conventional magnetic resonance imaging.
Source. Images courtesy of Elisabeth A. Wilde, PhD, Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas.
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TABLE 216.
Comparison of SPECT,
PET, and fMRI
SPECT is more widely available than other functional imaging modalities, less expensive, and
technically easier than PET imaging. Because PET tracers have much shorter half-lives than those of
SPECT tracers, they require an on-site cyclotron and radiopharmaceutical laboratory for compounding
immediately prior to each study. In comparison, SPECT tracers are stable for 46 hours after
preparation. Thus, although temporal and spatial resolution is generally superior with PET, it is used
less often for clinical reasons due to practical considerations of tracer acquisition, insurancereimbursement, and cost. Both imaging modalities provide only limited visualization of anatomic
structures; thus, they often require structural MRI to be superimposed on the functional scan.
Table 216 provides a comparison of SPECT, PET, and functional MRI modalities.
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TABLE 216. (enlarged)
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FIGURE 26. Side-by-side comparison of structural and functional neuroimaging:
magnetic resonance imaging (MRI) and positron emission tomography (PET).
Increasingly, structural and functional imaging are used together in the evaluation of neuropsychiatric
and neurological disorders. Figure 26 provides a comparison of structural versus functional
neuroimaging modalities.
Axial image of brain MRI (fluid attenuated inversion recovery images [FLAIR] sequence) and corresponding PETscan of a patient with Alzheimers disease. The MRI image on the leftshows prominent atrophic change in theposterior regions of the brain, consistent with striking reduction of metabolic activity in the posterior parietal lobeson PET imaging.
Source. Image courtesy of Ziad Nahas, MD, MSCR, Department of Psychiatry, Medical College of South Carolina, Charleston, South Carolina.
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FIGURE 27. Side-by-side comparison
of single photon
emission computed
tomography
(SPECT) versus
positron emission
tomography (PET).
Functional imaging techniques such as SPECT and PET are now being used in several clinical
situations, including the evaluation of dementia, presurgical evaluation of medically refractory
seizures, vascular disease to localize compromised vascular reserve, and brain injury. Figure 27
compares SPECT and PET images from patients with mild cognitive impairment.
SPECT(top row) and PET images from two patients with clinically similar degrees of mild cognitive impairment. ThePET scan demonstrates parietal changes, suggesting that this patient is at greater risk of developing Alzheimersdisease. The PET scan also demonstrates much better resolution than the SPECT scan.
Source. Images courtesy of Paul E. Schulz, MD, Department of Neurology, Baylor College of Medicine, Houston, Texas.
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FIGURE 28. Structural magnetic resonance
imaging (MRI) and positron emission
tomography (PET) imaging of a healthy
control subject and a patient with traumatic
brain injury.
Studies have found SPECT to be more sensitive than CT or MRI in the diagnosis of traumatic brain
injury. Structural neuroimaging modalities can detect serious head injuries but often do not detect mild
traumatic brain injuries. Patients with mild traumatic brain injuries often complain of persistent
neuropsychiatric symptoms despite having normal CT or MRI scans. Because of its increased
sensitivity, SPECT may show regional cerebral blood flow hypoperfusion not visible on CT or MRI.
Figures 28, 29, and 210 illustrate the uses of neuroimaging in brain-injured patients.
Coronal slices (MRI) and three-dimensional reconstruction ofthe cortical surface (pink) and hippocampi (yellow) of atypically developing adolescent male (left) and an adolescentmale with traumatic brain injury (right). Note the significantcortical and hippocampal atrophy in the patient as comparedwith the age-matched control. The top rightimage portraysPET findings overlaid on the MRI. PET reveals significant
bilateral metabolic defects in the patients mesial temporal
areas as indicated by the absence of warm colors. Redrepresents areas of the greatest metabolic activity, followedby orange, yellow, green, blue, and violet.
Source. Images courtesy of Erin Bigler, PhD, University of Utah, Salt Lake City, Utah.
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FIGURE 28. (enlarged)
Source. Images courtesy of Erin Bigler, PhD, University of Utah, Salt Lake City, Utah.
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FIGURE 29. Structural magnetic resonance imaging (MRI) and positron emission
tomography (PET) imaging of a patient with traumatic brain injury.
Despite the absence of significant findings on structural imaging, PET reveals areas of significanthypometabolism in the left temporal area as indicated by the arrow. Redrepresents areas of the greatestmetabolic activity, followed by orange, yellow, green, blue, and violet. The center image is a fusion of the MRIand PET images.
Source. Images courtesy of Erin Bigler, PhD, University of Utah, Salt Lake City, Utah.
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FIGURE 210. Single photon emission computed tomography (SPECT), structural
magnetic resonance imaging (MRI), and magnetoencephalography (MEG) imaging of a
patient with traumatic brain injury.
Findings from multiple
neuroimaging modalities in apatient with traumatic braininjury reveal structural andfunctional deficits in the inferiorfrontal and temporal regions,common sites of focal injury inhead trauma. Functional
imaging reveals even moreextensive defects in perfusion
(SPECT, left) and dipoleabnormality (MEG, right) thanthe areas of focal injuryevident on structural MRI(center). The fused image(bottom) displays the results ofthe SPECT and MEG overlaidon the MRI.
Source. Images courtesy of Erin Bigler, PhD,
University of Utah, Salt Lake City, Utah.
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FIGURE 211.
Neuroreceptor
imaging.
fMRI has many advantages compared with other functional imaging techniques in that it provides
superior spatial and temporal resolution, is minimally invasive, and does not involve exposure to
harmful ionizing radiation. It is being used extensively in research to understand the neurocircuitry
involved in various psychiatric disorders. Furthermore, the effects of psychotropic medications are
being studied via fMRI, with the hope of understanding the regional brain effects of acute and chronic
treatment with these medications. Figures 211, 212, and 213 illustrate research uses of fMRI.
Magnetic resonance imaging (top) and co-registered positron emission tomography images (bottom) acquiredfrom 40 to 100 minutes following injection of 14.9 mCi [11C]DASB in a 40-year-old healthy male volunteer.A, B: Sagittal plane close to the midline, showing accumulation of activity in the midbrain, thalamus, and
caudate. This picture also illustrates the low level of activity in the cerebellum. Activity concentration is also
seen in the cortical gray matter (cingulate cortex). C, D: Transaxial plane, illustrating activity concentration inthalamus and striatum. E, F: Transaxial plane at the level of the midbrain. The very high activity concentration isseen at the level of the dorsal raphe. The amygdala is also seen on this plane. G, H: Coronal plane at the levelof the anterior striatum, illustrating the ventrodorsal gradient of SERT in the striatum. This view also showsactivity concentration in cingulate and temporal cortices. I, J: Coronal plane at the level of the postcommissuralstriatum, illustrating activity concentrations in the caudate and putamen, in the thalamus, and in the amygdala.
Source. Images courtesy of Gordon Frankle, MD, Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania.
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FIGURE 211. (enlarged)
Source. Images courtesy of Gordon Frankle, MD, Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania.
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FIGURE 212. Functional magnetic resonance imaging of working memory.
Increased regional blood flow evident in prefrontal cortex while a subject is performing the Sternberg Task (leftimage). Corresponding images in Brainsight Frameless used for stereotactic targeting with transcranial magneticstimulation (right images).
Source. Images courtesy of Ziad Nahas, MD, MSCR, Department of Psychiatry, Medical College of South Carolina, Charleston, South Carolina.
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FIGURE 213. Functional magnetic resonance (fMRI) and transcranial magnetic
stimulation (TMS) as a neuroscience tool.
fMRI interleaved with TMS over left prefrontal
cortex in healthy volunteers illustrating bothlocal and transsynaptic functional connectivity
of corticalsubcortical networks.
Source. Images courtesy of Ziad Nahas, MD, MSCR, Department
of Psychiatry, Medical College of South Carolina, Charleston, South
Carolina.
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TABLE 217. Summary of neuroimaging findings in selected psychiatric disorders
Structural and functional neuroimaging of psychiatric disorders has exploded in recent decades, given
the many new and powerful imaging techniques that are now available. Table 217 summarizes the
structural and functional neuroimaging findings in selected psychiatric disorders that may be of
interest to the psychiatric clinician.
(continued)
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TABLE 217. (continued)
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CHAPTER 2 Key Points
Laboratory testing of the psychiatric patient in the past has been utilized
mainly to uncover medical or neurological causes of psychiatric symptoms.
The consensus of studies evaluating the role and value of laboratory testing
is that patients who have psychiatric signs and symptoms but who do not
exhibit other physical complaints or symptoms will benefit from a small
screening battery that includes serum glucose concentration, BUN
concentration, creatinine clearance, and urinalysis. Female patients older
than 50 years will also benefit from a screening TSH test, regardless of the
presence or absence of mood symptoms.
More extensive laboratory screening may be necessary for psychiatric
patients who do have concomitant physical complaints or findings on
physical examination or for patients who are of higher risk, such as elderly
or institutionalized patients or those with low socioeconomic status, self-
neglect, alcohol or drug dependence, or cognitive impairment.
Newer laboratory testing methods such as pharmacogenetic testing andtesting for investigational genetic and biological markers have the potential
to transform and dramatically increase the importance of laboratory testing
in the workup of the psychiatric patient.(continued)
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Imaging may also be helpful when atypical features are present, such as an
older age at onset of psychiatric illness, or when cognitive impairment ispresent.
Neuroimaging does not yet play a diagnostic role for any of the primary
psychiatric disorders, but it is still an integral part of the clinical workup for
psychiatric patients to rule out underlying medical causes of psychiatric
symptoms.
Current neuroimaging methods provide both structural and functional dataabout the brain. Structural imaging techniques such as CT and MRI provide
a fixed image of the brain's anatomy and spatial distribution. Newer
functional neuroimaging techniques such as PET and SPECT provide
information about brain metabolism, blood flow, the presynaptic uptake of
transmitter precursors, neurotransmitter transporter activity, and postsynaptic
receptor activity.
Functional scans should always be interpreted in the context of the
underlying structural images.
CHAPTER 2 Key Points (continued)