Substance-related, cognitive and liaison assessment
Substance-related assessment establishes what was used, the amount and pattern reported, timing, route, prescribed and nonprescribed medicines, previous withdrawal, physical illness and the person’s reasons for use. Intoxication, withdrawal, dependence and a substance-induced psychiatric syndrome are distinct possibilities. Tolerance or withdrawal alone does not explain every aspect of a person’s functioning or establish all criteria of a particular diagnosis. An initial account may be incomplete because of memory, fear, stigma or the acute state.
Abrupt cessation of some substances can produce severe withdrawal and requires an appropriate clinical assessment rather than generic advice to stop immediately. Planned treatment considers the substance, prior complications, current physical state and available monitoring. Harm reduction and motivational work can be meaningful even when the person is ambivalent about abstinence. A collaborative discussion explores perceived benefits and harms without equating disagreement with dishonesty or using confrontation as the default method.
Delirium is an acute disturbance involving attention and awareness with a fluctuating course and additional cognitive changes. Hypoactive presentations can be missed when a quiet patient is assumed simply to be depressed or cooperative. Medical illness, pain, medicines, dehydration and other precipitants need investigation and management by the relevant team. Reorientation, communication, sensory aids and environmental support complement treatment of the cause. A new delirium can occur in someone who already has dementia; the previous diagnosis does not explain away an acute change.
Neurocognitive assessment considers the trajectory of memory, executive function, language, visuospatial abilities and day-to-day independence. A screening result is interpreted with education, language, sensory impairment, mood, attention and baseline functioning. Cognitive difficulty does not automatically eliminate decision-making capacity. Clinical patterns can suggest a differential diagnosis, but a single symptom, score or imaging result should not be converted into definitive pathology without the relevant evidence.
Liaison work connects psychiatric and physical care. A person with functional neurological symptoms needs validation, appropriate positive diagnostic evidence and coordinated care, rather than a conclusion that normal tests prove fabrication. Distress in serious medical illness may involve pain, demoralization, depression, fear and practical concerns in different combinations. The clinician should communicate the formulation and uncertainty clearly, assess immediate needs and coordinate with the treating team. No medication dose, withdrawal protocol or diagnosis of intentional deception is prescribed by this chapter.