1. Diagnosis of mental disorders
How doctors diagnose: signs of the wellbeing of the person’s brain, eg in an auditory hallucination the
and symptoms mental function, nerves and muscles. It is patient hears voices in his head.
the tool that physicians use to identify Hallucinations can also be visual
The first step towards making a diagnosis structural and psychiatric abnormality. or involve taste or touch.
is to ask the patient what is wrong. Then
a full history of the presenting condition A psychiatric examination is also • Delusion: a false belief based on
and other relevant facts should be taken. performed to determine the individual’s an external reality eg a firmly held
mental condition. This involves belief, despite proof and logical
After this, a general and detailed medical
investigating the individual’s abilities arguments to the contrary and
examination with specific focus on the
regarding orientation, attention span, one not held by others in the
presenting symptoms should be
concentration and memory. Any patient’s culture or society.
psychopathology must also be identified,
• Grandiose delusion: a belief that
Patients present with or complain about for example abnormalities in perception
one is great, the best, invincible,
certain symptoms. These are subjective of stimuli, thought content, speed of
or of elevated stature eg the
reports. The physician carries out a thoughts and logical thinking.
patient believes he is God, a
medical examination to identify signs Using all of the available evidence, the king, the strongest man in the
related to an illness or the presenting physician is then able to make a world or the richest person alive.
symptoms. The findings from this diagnosis. From a list of the possible
examination are objective. • Somatic delusion: an incorrect
diagnoses based on the symptoms and
belief about one’s body, or part of
signs, the physician identifies the most
it eg that it is diseased, disfigured,
likely cause, and rules out other
disabled or deficient/absent — a
Symptoms — subjective — what a diagnoses. The physician will consider
man might think he is pregnant.
patient can feel and therefore what both psychiatric conditions and
they complain about. physical diseases. • Paranoid (persecutory) delusion:
excessive or irrational suspiciousness;
Signs — objective — what a person distrustfulness with delusion that
can see when looking at a patient. Psychotic disorders
one is being persecuted eg the
Characteristically, psychotic disorders are patient thinks he/she is being
conditions with loss of insight and reality. followed by the FBI.
Patients experience false beliefs and are
The general physical examination • Catatonia: motor immobility,
unable to interpret external stimuli
consists of: waxy rigidity.
correctly. They are not aware that their
• Basic observations, such as the thoughts are abnormal. The main
person’s walk, skin tone, voice psychotic disorders are schizophrenia,
intonation and ability to hold schizoaffective disorder and delusional
a normal conversation. disorders.
• Taking the blood pressure and The common symptoms of psychotic
checking for basic signs of disorders include:
disease such as anaemia or • Psychosis: a complex of symptoms
swelling of the legs. in which the patient has lost touch
• Examining the various organ with reality; experiencing delusions.
systems of the body; the • Illusion: an incorrect perception;
heart, lungs, bowels, etc. false response to a sensory
For a person with a psychiatric disorder, stimulus eg a stick on the
it is also important that a neurological floor is seen as a snake.
examination is performed.This • Hallucination: sensory perception
examination gives an understanding for which there is no external stimulus
2. Mood disorders Anxiety disorders Diagnostic classification systems
Mood disorders are characterised by a Anxiety disorders are mental and physical There are several diagnostic systems in
disturbance of mood or a persistent manifestations of anxiety. The feelings of use worldwide. The two best known and
emotional state that affects how a anxiety are not attributable to real danger most used in the western world are the
patient acts, thinks and perceives their and occur either in attacks (panic DSM-IV and ICD-10. China has developed
environment. Mood disorders are typified disorder) or as a persisting state their own classification system and
by either overwhelming feelings of (generalised anxiety disorder). several other systems are in place in
sadness (depression), or alternating other regions of the world.
The common symptoms of anxiety
periods of mania and depression
(bipolar disorder). Why do we classify psychiatric
• Phobia: an unnatural, irrational fear disorders?
The common symptoms of mood
of an item or situation, which the
disorders include: A classification system provides a
patient realises is not dangerous,
common language with which mental
• Depression: a feeling characterised but still takes measures to avoid.
health professionals can discuss similar
by sadness, apathy, pessimism and
• Egodystonic: thoughts, feelings or patients, regardless of their own
a sense of loneliness.
actions that are unusual to the geographical location. It also allows the
• Mania: a mood elevated above that person or do not fit into the natural history of a particular disorder to
normally considered to be a normal person’s normal behaviour be studied. Classification is also crucial for
level of happiness or pleasure. (ego [self]; dystonic [alien]). administrative and legal documentation
• Apathy: a lack of feeling, emotion • Compulsion: an irresistible impulse, and for research purposes.
and interest. Common in depression. urge, desire to perform an irrational
act, that relieves anxiety and is seen
• Fatigue/loss of drive: low energy
as egodystonic to the patient eg
levels and/or the inability to
washing hands repeatedly or
start a task.
counting steps taken.
• Hypersomnia: an increase in time
• Obsession: an idea, emotion, thought
spent sleeping yet the patient still
or impulse that is repetitive and/or,
feels tired and wants to sleep more.
unwelcome and provokes anxiety
• Insomnia: the inability to eg constant urge to wash hands
sleep restfully. or count objects. The patient may
feel uneasy for having thought
• Suicidal ideation: thoughts of
but not actually done the act.
death and killing oneself.
• Panic: a sudden, overwhelming
• Psychomotor retardation: a
anxiety that produces terror and
slowing of activity due to the
physiological and psychological
changes; the patients feel as if
• Psychomotor agitation: an they will die.
increased level of activity
• Agoraphobia: the fear of crowded
spaces, public places or places
• Anhedonia: the absence of where help cannot be reached
pleasure in acts that are normally which causes a panic attack.
pleasurable. Most common
symptom of depression and a
core symptom of schizophrenia.
3. The DSM-IV (Diagnostic and the primary diagnosis is mentioned first consequence of the general medical
Statistical Manual of Mental and then the subsequent comorbid condition it should be diagnosed on Axis I
diagnoses. and the general medical condition should
Disorders – fourth edition)
be recorded on both Axis I and Axis III. For
The DSM-IV was developed and published Axis II: Developmental diagnoses and example, when hypothyroidism is a direct
by the American Psychiatric Association diagnoses first diagnosed in infancy cause of depressive symptoms, the
(APA), and is only applicable to mental or childhood designation on Axis I is mood disorder
disorders. The first edition (DSM-I) was due to hypothyroidism with depressive
published in 1952 and described the Diagnoses recorded on Axis II include
mental retardation and the personality features, and the hypothyroidism is listed
diagnostic categories of mental disorders. again on Axis III.
There have been four updates since — disorders. Axis II may also be used to note
the most recent is DSM-IV, which was prominent maladaptive personality Some general medical conditions may not
published in 1994. DSM-IV-TR (text features and defence mechanisms. These be directly related to the mental disorder
revision) was released in 2000 and has diagnoses are difficult to make and are but have important prognostic or
significant changes in the descriptions of often only made after several visits to a treatment implications. For example,
the symptoms and the discussion around physician. The listing of personality when the diagnosis on Axis I is major
diagnoses. It is estimated that DSM-V disorders and mental retardation on a depressive disorder and on Axis III is
will be available in 2004. separate axis ensures that consideration is arrhythmia, the choice of
given to the possible presence of these pharmacotherapy for the depressive
The DSM classification system is conditions which might be overlooked disorder is influenced by the arrhythmia.
descriptive, without any reference to when attention is focused on the usually
aetiology. This approach enables clinicians more florid Axis I disorders.
of different theoretical orientations to
use the classification. An Axis II diagnosis should not be made
while the patient is suffering from an
A significant feature of the DSM Axis I diagnosis. For example, a person
classification is the 5-axis diagnostic with depression should not be diagnosed
system. This multi-axial system facilitates with a personality disorder while the
comprehensive and systematic evaluation depression is still present; depression does
of the patient and takes into account not allow a true evaluation of a person’s
various mental disorders, the general personality. In this case the Axis II
medical condition of the patient, any diagnosis is ‘deferred’.
psychosocial and environmental
problems, as well as the level of Axis III: Physical diseases
functioning of the patient. These factors
may otherwise be overlooked if the focus All physical diseases are mentioned here,
of an assessment was to assess a single whether the disease symptoms are
presenting symptom. A multi-axial related to the psychiatric disorders or not.
system provides a convenient format for These general medical conditions are
describing the heterogeneity of potentially relevant to the understanding
individuals presenting with the or management of the individual’s
same symptoms. mental disorder.
General medical conditions can be related
Axis I: Psychiatric diagnosis(es) to mental disorders in a number of ways.
All psychiatric diagnoses are listed on In some cases it is clear that the general
Axis I (except for the personality disorders medical condition is directly related to
and mental retardation, which are the development or worsening of mental
reported on Axis II). If there is more symptoms. When a mental disorder is
than one diagnosis, judged to be a direct physiological
4. Axis IV: Psychological stress factors ICD-10 is similar to DSM-IV in that it
affecting the patient Axis I: psychiatric diagnosis(es) recognises and defines the following:
include major depression, first
This includes all stressors, past and • Manic episodes
episode, moderate severity and
present, which have an influence on the
panic disorder with agoraphobia • Depressive episodes
patient at the time of the evaluation.
These factors may include situations Axis II: developmental diagnoses • Bipolar affective (mood) disorder
dating from childhood up to the of infancy or childhood. Diagnosis
• Recurrent depressive disorders
present day. Possible psychosocial deferred on axis 2
or environmental problems include: • Persistent depressive disorders
Axis III: physical diseases including
• Negative life events epilepsy, headaches, bronchitis
ICD-10 defines two other categories not
• Environmental difficulties Axis IV: psychological stress factors
included in DSM-IV:
or deficiencies affecting the patient including
divorce, death of mother 15 • Other mood disorders (ie disorders
• Familial or other that do not fit any of the
interpersonal stressors categories above)
Axis V: global functioning of the
• Inadequate social support or • Schizoaffective disorder (often
patient, moderate to poor with a
personal resources classed as a subtype
GAF score of 75
• Problems relating to the context of schizophrenia).
in which a person’s difficulties Table1. Psychiatric diagnosis using the 5 axes There was close collaboration between
have developed. the APA and the WHO during the
The ICD-10 (International Classification development of the two systems. This
Axis V: Global functioning of approach helped to reduce unnecessary
of Diseases and Related
the patient differences between the systems and has
This gives a broad evaluation of the enabled fully compatible cross-diagnoses.
Another widely used diagnostic system is
individual’s ability to cope with their
ICD-10 (International Classification of
present life situation and can also be
Diseases and Related Health Problems),
used as a measure of the need for
developed by the World Health
hospital admission. This information is
Organization (WHO). This classification
useful in planning treatment and
system includes diagnoses for all the
measuring its impact as well as in
systems in the human body. The first
edition to include a psychiatric section
The Global Assessment of Functioning was ICD-6. The current edition, ICD-10,
(GAF) scale can be used to quantify this was published in 1992. ICD-10 is less
level of functioning. The GAF scale was widely used in clinical trials than DMS-IV.
developed specifically to rate
psychological, social and occupational
functioning (see fact sheet: ‘Rating
mental disorders’ for more information
on the GAF and other rating scales).
An example of a psychiatric diagnosis
using the 5 axes is given in table 1.