Laboratory Testing and Imaging Studies in Psychiatry

The American Psychiatric Publishing
TEXTBOOK OF PSYCHIATRY
Fifth Edition
Edited 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
Laboratory Testing and Imaging

Studies in Psychiatry
H. Florence Kim, M.D., Paul E. Schulz, M.D.,
Elisabeth A. Wilde, Ph.D., Stuart C. Yudofsky, M.D.
Slide show includes…

Topic Headings
Tables and Figures
Key Points
The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC, 1
Gabbard GO. © 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
CHAPTER 2 • Topic Headings
APPROACH TO SCREENING LABORATORY NEUROENDOCRINE TESTING
AND DIAGNOSTIC TESTING OF PSYCHIATRIC
ELECTROPHYSIOLOGICAL TESTING
PATIENTS
Standard Electroencephalogram
Screening Laboratory Testing
Polysomnography
Screening Chest Radiographs
Evoked Potentials
Screening Electrocardiograms
Quantitative EEG
Screening Electroencephalograms
Screening Structural Neuroimaging Examinations NEUROIMAGING STUDIES IN PSYCHIATRY
Overall Role of Screening Laboratory and Structural Neuroimaging Modalities
Diagnostic Testing Computed Tomography
Magnetic Resonance Imaging
LABORATORY APPROACH TO SPECIFIC CLINICAL
Comparison of CT and MRI
SITUATIONS IN PSYCHIATRY
Clinical Use of CT and MRI in Psychiatry
New-Onset Psychosis
Other Structural Imaging Techniques
Mood Disturbance: Depressive or Manic Symptoms
Magnetic Resonance Spectroscopy
Anxiety
Diffusion Tensor Imaging
Altered Mental Status
Functional Neuroimaging Modalities
Cognitive Decline
Single Photon Emission Computed Tomography
Dementias
Positron Emission Tomography
Mild Cognitive Impairment
Comparison of SPECT and PET
Substance Abuse
Clinical Use of PET and SPECT in Psychiatry
MEDICATION MONITORING AND MAINTENANCE Cognitive Decline and Dementia
Mood Stabilizers Epilepsy
Tricyclic Antidepressants Stroke
Neuroleptics Traumatic Brain Injury
Neuroreceptor Imaging
PHARMACOGENETICS AND PHARMACOGENOMICS
Functional Magnetic Resonance Imaging
CEREBROSPINAL FLUID STUDIES Magnetoencephalography
INVESTIGATIONAL BIOLOGICAL AND GENETIC Neuroimaging of Psychiatric Disorders
MARKERS CONCLUSION
CHAPTER 2 • Tables and Figures
Table 2–1. Selected medical conditions with psychiatric manifestations

Table 2–2. Useful screening labs in the workup of the neuropsychiatric patient
Table 2–3. Recommended diagnostic workup for a patient with new-onset psychosis
Table 2–4. Recommended diagnostic workup for a patient with new-onset depressive or manic symptoms
Table 2–5. Recommended diagnostic workup for a patient with new-onset anxiety symptoms
Table 2–6. Recommended diagnostic workup for a patient with altered mental status
Table 2–7. Recommended diagnostic workup for a patient with cognitive decline
Table 2–8. Substances of abuse
Table 2–9. Medication monitoring
Table 2–10. Psychiatric drug metabolism by specific P450 enzymes
Table 2–11. Drug metabolizer phenotype classification
Table 2–12. Selected investigational biological and genetic markers
Figure 2–1. Computed tomography (CT) tissue attenuation values and appearance.
Table 2–13. Tissue signal on T1 versus T2 weighting
Figure 2–2. MRI comparison axial cuts, bipolar disorder patient versus matched control.
Table 2–14. Comparison of computed tomography (CT) and magnetic resonance imaging (MRI)
Figure 2–3. Side-by-side comparison of structural imaging modalities: CT and MRI.
Table 2–15. Indications for computed tomography (CT), prior to or instead of magnetic resonance imaging (MRI)
(continued)
CHAPTER 2 • Tables and Figures (continued)
Figure 2–4. Diffusion tensor imaging (DTI).

Figure 2–5. Diffusion tensor imaging (DTI) in traumatic brain injury and bipolar disorder.
Table 2–16. Comparison of SPECT, PET, and fMRI
Figure 2–6. Side-by-side comparison of structural and functional neuroimaging: magnetic resonance imaging
(MRI) and positron emission tomography (PET).
Figure 2–7. Side-by-side comparison of single photon emission computed tomography (SPECT) versus
positron emission tomography (PET).
Figure 2–8. Structural magnetic resonance imaging (MRI) and positron emission tomography (PET) imaging
of a healthy control subject and a patient with traumatic brain injury.
Figure 2–9. Structural magnetic resonance imaging (MRI) and positron emission tomography (PET) imaging
of a patient with hypoxic brain injury.
Figure 2–10. Single photon emission computed tomography (SPECT), structural magnetic resonance
imaging (MRI), and magnetoencephalography (MEG) imaging of a patient with traumatic brain injury.
Figure 2–11. Neuroreceptor imaging.
Figure 2–12. Functional magnetic resonance imaging of working memory.
Figure 2–13. Functional magnetic resonance (fMRI) and transcranial magnetic stimulation (TMS) as a
neuroscience tool.
Table 2–17. Summary of neuroimaging findings in selected psychiatric disorders
Summary Key Points
Table 2–1 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 the
many potential causes is responsible
for a patient’s symptoms. Because a
number of these etiologies may have
potentially curative remediations,
accurate diagnosis is critical.
TABLE 2–1. Selected medical

conditions with psychiatric
manifestations
Source. Adapted from Ringholz 2001; Sadock and Sadock

2007; Wallach 2000.
(continued)
TABLE 2–1. (continued)
Table 2–2 presents a list of screening laboratory tests that clinicians often use during the initial
evaluation of the patient with psychiatric complaints.
TABLE 2–2. Useful screening labs in the workup of the neuropsychiatric patient
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)
(continued)
(continued)
(continued)
(continued)
(continued)
(continued)
(continued)
(continued)
(continued)
(continued)
(continued)
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 2–3 summarizes some of the
recommended tests in the diagnostic approach to a
patient with new-onset psychosis.
TABLE 2–3. Recommended diagnostic

workup for a patient with new-onset
psychosis
Neuroimaging and electroencephalography are often helpful as well in understanding the etiology of
a patient’s 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 2–4.
TABLE 2–4. Recommended diagnostic

workup for a patient with new-onset
depressive or manic 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 2–5.
TABLE 2–5. Recommended

diagnostic workup for a patient with
new-onset anxiety symptoms
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 diagnostic
testing are indicated on an emergency basis, as
summarized in Table 2–6.
TABLE 2–6. Recommended

diagnostic workup for a patient with
altered mental status
Table 2–7 lists the laboratory and diagnostic tests that
would be included in the workup of a patient with cognitive
impairment.
TABLE 2–7. Recommended diagnostic workup for a

patient with cognitive decline
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 2–8
reviews common drugs of abuse, toxic levels, and length of detection time.
TABLE 2–8. Substances of abuse
Source. Adapted from Wallach 2000.
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 2–9. 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.
TABLE 2–9. Medication monitoring
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.
0
Table 2–10 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.
TABLE 2–10. Psychiatric drug metabolism by

specific P450 enzymes
Source. Data adapted from Kirchheiner et al. 2001; Streetman 2000.
Four general phenotypes have been used to describe the outcomes of CYP genetic polymorphisms
(Table 2–11): 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
the functional enzyme allele, resulting in increased rate of drug metabolism, and may not reach
therapeutic concentrations at the recommended dosage.
TABLE 2–11. Drug metabolizer phenotype classification
Source. Adapted from Ingelman-Sundberg 1999; Mrazek 2006.
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 2–12 lists some of the biomarkers
being researched at this time.
TABLE 2–12. Selected investigational biological and genetic markers
(continued)
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 of
radiopacity (Figure 2–1).
FIGURE 2–1. Computed tomography (CT) tissue attenuation values and appearance.
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.
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 2–13 lists the characteristic appearance of tissue signals on T1- and T2-weighted MRI
images.
TABLE 2–13. Tissue signal on T1 versus T2 weighting
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.
Figure 2–2 illustrates axial MRI images of a patient with bipolar disorder compared with an age-
matched control patient.
FIGURE 2–2. MRI comparison axial cuts, bipolar disorder patient versus matched control.
MRI (T1-weighted) images

of a 58-year-old healthy
control patient (left) as
compared with a patient of
comparable age with
bipolar disorder (right) but
without any significant
medical or substance
abuse history. Although
not diagnostic, common
findings in neuroimaging
research studies with
bipolar disorder patients
include diffuse gray matter
loss, enlargement of the
ventricles, and mild
prefrontal volume loss.
Source. Images courtesy of Elisabeth

A. Wilde, PhD, Department of Physical
Medicine and Rehabilitation, Baylor
College of Medicine, Houston, Texas.
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 2–14 provides a summary
comparison of CT and MRI imaging modalities.
TABLE 2–14. Comparison of computed tomography (CT) and magnetic resonance

imaging (MRI)
Figure 2–3 is a comparison of images available with CT versus MRI.
FIGURE 2–3. Side-by-side comparison of structural imaging modalities: CT and 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 left shows a large area of decreased density
consistent with edema. It is difficult to ascertain whether there is an underlying mass or what its shape
might be. The image on the right is from a brain MRI (T2 image) and also demonstrates an area of
increased intensity of about the same shape as the CT abnormality. The patient was found to be HIV
positive, 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.
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 2–15).
TABLE 2–15.
Indications for
computed
tomography (CT),
prior to or instead of
magnetic resonance
imaging (MRI)
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.
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 2–4 and 2–5 illustrate the white
matter tracts that can be visualized with DTI in
various disorders.
FIGURE 2–4. Diffusion tensor

imaging (DTI).
A, Fractional anisotropy color map derived from DTI in

the sagittal plane. Red indicates white matter fibers
coursing in a right-left direction, blue indicates fibers
running in a superior-inferior direction, and green reflects
fibers oriented in an anterior-posterior direction. B, Fiber
tracking using DTI of the total corpus callosum overlaid
on a T1-weighted inversion recovery image from the
same brain.
Source. Images courtesy of Elisabeth A. Wilde, PhD, Department of Physical
Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas.
FIGURE 2–5. 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 and
B, an uninjured young man of the same age. The arrow indicates 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 the
corpus 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 to
examine aberrant fiber patterns such as that demonstrated in a 55-year-old female bipolar patient ( C) as compared
with the expected pattern demonstrated in a woman of comparable age without history of illness ( D). Interestingly, the
patient 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.
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 4–6 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, insurance
reimbursement, 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 2–16 provides a comparison of SPECT, PET, and functional MRI modalities.
TABLE 2–16.
Comparison of SPECT,
PET, and fMRI
TABLE 2–16. (enlarged)
Increasingly, structural and functional imaging are used together in the evaluation of neuropsychiatric
and neurological disorders. Figure 2–6 provides a comparison of structural versus functional
neuroimaging modalities.
FIGURE 2–6. Side-by-side comparison of structural and functional neuroimaging:

magnetic resonance imaging (MRI) and positron emission tomography (PET).
Axial image of brain MRI (fluid attenuated inversion recovery images [FLAIR] sequence) and corresponding PET
scan of a patient with Alzheimer’s disease. The MRI image on the left shows prominent atrophic change in the
posterior regions of the brain, consistent with striking reduction of metabolic activity in the posterior parietal lobes
on PET imaging.
Source. Image courtesy of Ziad Nahas, MD, MSCR, Department of Psychiatry, Medical College of South Carolina, Charleston, South Carolina.
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 2–7
compares SPECT and PET images from patients with mild cognitive impairment.
FIGURE 2–7. Side-

by-side comparison
of single photon
emission computed
tomography
(SPECT) versus
positron emission
tomography (PET).
SPECT (top row) and PET images from two patients with clinically similar degrees of mild cognitive impairment. The
PET scan demonstrates parietal changes, suggesting that this patient is at greater risk of developing Alzheimer’s
disease. 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.
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 2–8, 2–9, and 2–10 illustrate the uses of neuroimaging in brain-injured patients.
FIGURE 2–8. Structural magnetic resonance

imaging (MRI) and positron emission
tomography (PET) imaging of a healthy
control subject and a patient with traumatic
brain injury.
Coronal slices (MRI) and three-dimensional reconstruction of

the cortical surface (pink) and hippocampi (yellow) of a
typically developing adolescent male (left) and an adolescent
male with traumatic brain injury (right). Note the significant
cortical and hippocampal atrophy in the patient as compared
with the age-matched control. The top right image portrays
PET findings overlaid on the MRI. PET reveals significant
bilateral metabolic defects in the patient’s mesial temporal
areas as indicated by the absence of “warm” colors. Red
represents areas of the greatest metabolic activity, followed
by orange, yellow, green, blue, and violet.
Source. Images courtesy of Erin Bigler, PhD, University of Utah, Salt Lake City, Utah.
FIGURE 2–8. (enlarged)
FIGURE 2–9. 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 significant
hypometabolism in the left temporal area as indicated by the arrow. Red represents areas of the greatest
metabolic activity, followed by orange, yellow, green, blue, and violet. The center image is a fusion of the MRI
and PET images.
FIGURE 2–10. 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 a
patient with traumatic brain
injury reveal structural and
functional deficits in the inferior
frontal and temporal regions,
common sites of focal injury in
head trauma. Functional
imaging reveals even more
extensive defects in perfusion
(SPECT, left) and dipole
abnormality (MEG, right) than
the areas of focal injury
evident on structural MRI
(center). The fused image
(bottom) displays the results of
the SPECT and MEG overlaid
on the MRI.
Source. Images courtesy of Erin Bigler, PhD,

University of Utah, Salt Lake City, Utah.
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 2–11, 2–12, and 2–13 illustrate research uses of fMRI.
FIGURE 2–11.
Neuroreceptor
imaging.
Magnetic resonance imaging (top) and co-registered positron emission tomography images (bottom) acquired
from 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 in
thalamus and striatum. E, F: Transaxial plane at the level of the midbrain. The very high activity concentration
is seen at the level of the dorsal raphe. The amygdala is also seen on this plane. G, H: Coronal plane at the
level of the anterior striatum, illustrating the ventrodorsal gradient of SERT in the striatum. This view also
shows activity concentration in cingulate and temporal cortices. I, J: Coronal plane at the level of the
postcommissural striatum, 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.
FIGURE 2–11. (enlarged)
Source. Images courtesy of Gordon Frankle, MD, Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania.
FIGURE 2–12. Functional magnetic resonance imaging of working memory.
Increased regional blood flow evident in prefrontal cortex while a subject is performing the Sternberg Task (left
image). Corresponding images in Brainsight™ Frameless used for stereotactic targeting with transcranial magnetic
stimulation (right images).
Source. Images courtesy of Ziad Nahas, MD, MSCR, Department of Psychiatry, Medical College of South Carolina, Charleston, South Carolina.
FIGURE 2–13. 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 both
local and transsynaptic functional connectivity
of cortical–subcortical networks.
Source. Images courtesy of Ziad Nahas, MD, MSCR, Department

of Psychiatry, Medical College of South Carolina, Charleston, South
Carolina.
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 2–17 summarizes the
structural and functional neuroimaging findings in selected psychiatric disorders that may be of
interest to the psychiatric clinician.
TABLE 2–17. Summary of neuroimaging findings in selected psychiatric disorders
(continued)
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 and
testing 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)
CHAPTER 2 • Key Points (continued)
 Imaging may also be helpful when atypical features are present, such as an
older age at onset of psychiatric illness, or when cognitive impairment is
present.
 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 data
about 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.

Laboratory Testing and Imaging Studies in Psychiatry

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Laboratory Testing and Imaging Studies in Psychiatry

Uploaded by

Copyright:

Available Formats

The American Psychiatric Publishing

Laboratory Testing and Imaging

Slide show includes…

Table 2–1. Selected medical conditions with psychiatric manifestations

Figure 2–4. Diffusion tensor imaging (DTI).

TABLE 2–1. Selected medical

Source. Adapted from Ringholz 2001; Sadock and Sadock

TABLE 2–3. Recommended diagnostic

TABLE 2–4. Recommended diagnostic

TABLE 2–5. Recommended

TABLE 2–6. Recommended

TABLE 2–7. Recommended diagnostic workup for a

TABLE 2–8. Substances of abuse

Source. Adapted from Wallach 2000.

TABLE 2–10. Psychiatric drug metabolism by

Source. Data adapted from Kirchheiner et al. 2001; Streetman 2000.

TABLE 2–11. Drug metabolizer phenotype classification

Source. Adapted from Ingelman-Sundberg 1999; Mrazek 2006.

TABLE 2–13. Tissue signal on T1 versus T2 weighting

MRI (T1-weighted) images

Source. Images courtesy of Elisabeth

TABLE 2–14. Comparison of computed tomography (CT) and magnetic resonance

FIGURE 2–3. Side-by-side comparison of structural imaging modalities: CT and MRI.

Source. Adapted from J Levine lecture

FIGURE 2–4. Diffusion tensor

A, Fractional anisotropy color map derived from DTI in

FIGURE 2–6. Side-by-side comparison of structural and functional neuroimaging:

FIGURE 2–7. Side-

FIGURE 2–8. Structural magnetic resonance

Coronal slices (MRI) and three-dimensional reconstruction of

Findings from multiple

Source. Images courtesy of Erin Bigler, PhD,

fMRI interleaved with TMS over left prefrontal

Source. Images courtesy of Ziad Nahas, MD, MSCR, Department

TABLE 2–17. Summary of neuroimaging findings in selected psychiatric disorders

You might also like