The Psychiatric Evaluation of Patients With Suspected Toxic Exposure
Alice Armstrong Rahill University of Rochester Medical Center
Ante Lundberg Washington, DC Commission on Mental Health Services.
Chemicals in the environment can affect cognition, mood, and behavior and they are thought to be the main cause of environmental illness (EI). The symptoms are often vague and insidious. This chapter focuses on the neuropsychiatric work-up of patients with suspected toxic exposure and on the manifestations and diagnosis of toxic encephalopathy.
Psychiatrists and psychologists are trained to be aware of their subjective bias; need to remember this part of their training when approaching these patients. Environmental illness is poorly defined and it does not lack for stereotypes and preconceptions. Chemicals seem to be either presumed innocent or presumed guilty. In cases of suspected occupational exposure questions of disability compensation and litigation may cause the patient to exaggerate his or her symptoms. On the other hand, a worker may resist revealing sources of exposure in order to keep his or her job. A patient's personality or presentation may interact with the physician's bias to heighten the suspicion of nonorganic disorder, that is, a histrionic patient claiming exceptional sensitivity.
Patients who maintain that they are sick from chemical exposure are often sent to psychiatrists and neuropsychologists after internists and neurologists have failed to find signs of organic disease. Referring physicians almost always raise the question of secondary gain. It is particularly important that the examination of these patients be rigorous, considers all possible alternative explanations, and methodically supports the final interpretation. The patient must be informed that distinguishing between