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Diagnosis of mental disorders
How doctors diagnose: signs                  of the wellbeing of the person’s brain,        ...
Mood disorders                             Anxiety disorders                             Diagnostic classification systems...
The DSM-IV (Diagnostic and                     the primary diagnosis is mentioned first       consequence of the general m...
Axis IV: Psychological stress factors                                                       ICD-10 is similar to DSM-IV in...
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Diagnosis of mental disorders


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Diagnosis of mental disorders

  1. 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. carried out. 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 1
  2. 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 disorders include: (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 person’s mood. changes; the patients feel as if • Psychomotor agitation: an they will die. increased level of activity • Agoraphobia: the fear of crowded and jitteriness. 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. 2
  3. 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 3
  4. 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 (includes dysthymia). • 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 years ago 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 Health Problems) 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 predicting outcome. 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. 4