by NeoMed Clinic
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11 February 2021
Assessment Screening assessments are advisable when evaluating psychiatric symptoms when the possibility of LB may be present. Screening questions: • Do you live, vacation or engage in activities in areas that may expose you to ticks? • Have family members, neighbors, or the family dog or cat been infected? • Is there a history of a tick bite, possibly with a flu-like illness and/or a bull’s eye or other rash? • Is there a point at which your health declined, followed by a fluctuating progression and development of multi-systemic symptoms, including cognitive, psychiatric, neurological, and somatic symptoms adversely impacting school, social life, family life? • Have you ever been treated for Lyme disease, suspected you had Lyme disease but was told it was ruled out? • Have antibiotics ever caused a sudden worsening followed by an improvement of symptoms? If the screening assessment increases diagnostic suspicion a further assessment is indicated. LB is diagnosed just like any other neuropsychiatric condition by a comprehensive psychiatric clinical exam relevant to patient’s complaints and findings with a thorough history, mental status exam, review of systems, neurological exam, physical exam, a knowledgeable interpretation of laboratory findings, pattern recognition and clinical judgment. In considering the diagnosis it is important to look for relapsing progressive multi-systemic symptoms, including cognitive, psychiatric, neurological, and somatic symptoms and to remember the greater the multisystemic comorbidity, the greater the likelihood of a condition impacting the entire body such as a complex infectious disease. The presence of a comorbid condition does not rule out the presence of LB A comprehensive assessment includes an assessment of the following: • Cognitive: Attention (sustained attention, allocation of attention, distracted by frustration), hypersensitivity (auditory, visual, tactile, olfactory); inability to filter sensory input resulting in stimulation overload; memory (working memory, working spatial memory, short-term memory, long-term memory, word retrieval, number retrieval, name recall, facial recognition, procedural memory, geographical memory); processing (slow processing, letter reversals, spelling errors, word substitution errors, number reversals, reading comprehension impairments, auditory comprehension impairments, sound localization impairments, spatial perceptual distortions, optic ataxia, impaired transposition of laterality, left-right confusion, impaired calculation abilities, impaired fluency of speech, stuttering, slurred speech, impaired fluency of writing, impaired handwriting); executive functioning (unfocused concentration, brain fog, prioritizing multiple tasks, multitasking, racing thoughts, intrusive thoughts, obsessive thoughts, mental apathy, abstract reasoning impairments, time management impairments) • Imagery: depersonalization, derealization, capacity for visual imagery, hypnagogic hallucinations, vivid nightmares, illusions (auditory, visual), hallucinations (auditory, especially musical, visual, olfactory, sensory). • Emotional: decreased frustration tolerance, abrupt mood swings, hypervigilance, paranoia, anhedonia • Behavioral: disinhibition, exaggerated startle reflex, explosive anger, suicidal, homicidal, accident prone, decreased social functioning, decreases school or job productivity, family and marital conflicts, substance abuse, legal difficulties, dissociative episodes, compensatory compulsions, dropping objects, crying spells, self-mutilation • Psychiatric syndromes: depression, rapid cycling bipolar illness, panic disorder, obsessive compulsive disorder, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder • Sleep disorders: non-restorative sleep, early insomnia, middle of night insomnia, early morning insomnia, excessive daytime sleepiness, loss or reversal of circadian rhythm, restless leg, paroxysmal nocturnal limb movements, sleep apnea (central and/or obstructive), sleep paralysis, hypnagogic hallucinations, sleep attacks, cataplexy, narcolepsy • Eating disorders: anorexia, weight loss, emotional overeating, carbohydrate craving, weight gain (with or without increased food intake) • Sexual: decreased libido, increased libido, decrease capacity for arousal, decreased capacity for orgasm, altered sexual imagery • Temperature control: body temperature fluctuations, flushing, intolerance to heat, intolerance to cold, decreased body temperature, low grade fevers, night sweats, chills • Headaches: cervical radiculopathy, migraine, thunderclap, tension, cluster, sinus, scalp tenderness, temporal mandibular joint, coital cephalalgia • Cranial nerves: I: loss of smell, altered taste; II/eye: blurred vision, photophobia, intolerance of fluorescent or flickering light, floaters, flashes, conjunctivitis, eye pain, dry eyes, blind spots, night blindness, peripheral shadows, panopsia, papilledema, iritis, uveitis, optic neuritis; II, IV, VI: double vision, eye drifts when tired, ptosis; V: sensory loss and/or pain in any of the three branches on either side; VII: Bell’s Palsy; VIII: tinnitus, hearing loss, dizziness, vertigo, motion sickness, Tulio’s sign, mal de debarquement; IX, X: episodic loss of speech, choking on food, difficulty swallowing; XI: sternocleidomastoid, trapezius pain and/or weakness; XII: tongue deviates to side • Seizures: complex partial, grand mal • Neuropathy: numbness, tingling, sensory loss, burning, crawling sensation (formication), static electricity sensation, stabbing sensation, weakness • Other neurological: fatigue, tremor, twitching, muscle tightness, myoclonic jerks, tics, Tourette’s, ataxia, spasticity, meningismus, disc disease, positive Romberg, postural tachycardia syndrome (POTS), ortho static hypotension, gait disturbances, spinal cord signs, white matter lesions, sensation of vibration • Musculoskeletal: Joint pain, migratory joint pain, swelling, tightness, crepitations, neck and back discomfort; periostitis and bone tenderness of tibia, ribs, iliac crest, sternum, clavicle; epicondylitis; plantar fasciitis, foot tenderness; fibromyalgia; myalgia, costochondritis (ear, nose, costochondral junctions, xyphoid); tendonitis; carpal tunnel syndrome • Cardiac: chest pain, heart block, irregular heart rate, mitral valve prolapse, racing pulse, POTS, pericarditis, cardiomyopathy, murmur, hypertension, hypertensive crisis • Pulmonary/upper respiratory: shortness of breath, air hunger, cough, sore throats, swollen glands, asthma • Gastrointestinal: Reflux, irritable gut, nervous stomach, irritable bowel, abdominal bloating, reduced gastrointestinal motility, gastroparesis, cholecystitis, gall stones • Genitourinary: Spastic bladder, genital pain (testicular/pelvic), menstrual irregularity, breast tenderness, sexual dysfunction, decreased libido, urinary incontinence, interstitial cystitis • Immune: fevers, sweats, chills • Other: alcohol intolerance, hair loss, thyroid disease, adrenal insufficiency, hypoglycemia, ankle edema, tooth pain, periodontal disease, nose bleeds, ecchymoses, splenomegaly, multiple chemical sensitivities, allergies, lymphocytoma, stria, acrodermatitis chronicum atrophicans The more common symptoms seen in LB include poor attention span, being easily distracted by frustration, sensory hypersensitivity causing patients to feel overwhelmed, poor short-term memory, dyslexia symptoms, slow processing, executive dysfunction, brain fog, poor time management, depersonalization, intrusive images and thoughts, musical hallucinations, low frustration tolerance, abrupt mood swings, impulsivity, paranoia, explosive anger, suicidality, anhedonia, decreased productivity, depression, long duration panic attacks, social anxiety, generalized anxiety, obsessiveness, non-restorative sleep, appetite disturbances, decreased libido, headaches, cranial nerve symptoms, neuropathy, autonomic nervous system symptoms, musculoskeletal symptoms, gastrointestinal symptoms, genitourinary symptoms, cardiovascular symptoms, fatigue, chronic pain and alcohol intolerance