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Classification assesment and diagnosis of mental disorders (asw) new


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talk to trainee Approved Mental Health practitioners (AMPHs - previously ASWs)

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Classification assesment and diagnosis of mental disorders (asw) new

  1. 1. Classification and Diagnosis of Mental DisordersHelen CrimliskConsultant PsychiatristEastglade Sector Team (Oct 12)
  2. 2. Plan of Talk  Classification  Classification in general  Classification of mental illness  ICD 10  Case example  Break  Diagnosis  Diagnosis  Assessment  History  Mental State Examination  Common Mental Illnesses  Case examples
  3. 3. TaskWhy do we classify things?
  4. 4. Classification Why?  Aids recognition - improves communication  Economic - simplification “cognitive economy”  Predictive - “heuristic” - leads to ability to test hypotheses  Reflect natural processes ( i.e. implies better understanding e.g. Darwin )
  5. 5. Classification of manhole covers
  6. 6. Evolutionary Tree
  7. 7. TaskHow do we classify?
  8. 8. Classification How?  size  age  appearance  prognosis  similar biochemical / genetic factors
  9. 9. Classification by height
  10. 10. TaskWhat are the problems withclassification?
  11. 11. Classification Problems  Improved scientific understanding makes a mockery of previous attempts to classify (e.g. phrenology)
  12. 12. Phrenology
  13. 13. Classification Problems  Categorisationmeans defining thresholds which may be and indeed often are arbitrary  depression / dysthymia / fed up  obese / well built / chubby / slender
  14. 14. Eysenck’s 2 dimensional trait theory
  15. 15. Classification Problems  Categorisation can lead to stigma and prejudice
  16. 16. Terms previously acceptable now gone out of usage because of negative connotations cretin hypothyroid mongol Down’s syndrome mentally retarded imbecile mentally handicapped Intellectually challenged moron learning disabled autismidiot savant pervasive developmental disorder cerebral palsy spastic insane psychopathic lunatic schizophrenia integrative disorder??
  17. 17. Classification Problems Economy of thought may lead to oversimplification and inhumane action
  18. 18. Categorisation of people makes it “easier” to engage in inhumane behaviour JewsPolish Gypsies Dissidents Homosexuals
  19. 19. What are the benefits of usingclassification in mental health? to facilitate reporting and inform public health issues to provide a framework for research to encourage communication among health workers and between them and health care providers /government Promote a feeling of being understood (“we’ve seen this before – your problems are not unique”) Some ability to predict treatment options and natural history
  20. 20. TaskHow could we classify mental health?
  21. 21. Classification in Mental Health  severity severe / moderate / mild depression  characteristics hebephrenic / paranoid / schizophrenia  aetiology endogenous / exogenous depression  prognosis “treatment resistant” personality disorders / depression  age young onset / older onset dementia  treatability personality disorders / schizophrenia
  22. 22. History 1 Cullen (18th Century)  Neurosis  “dysfunction of nervous system in the absence of fever” Freud (19th Century)  Psychoneurosis  “A neurosis that is psychological in origin” Kraepelin (19th Century)  Distinguished between:  Dementia Praecox (schizophrenia) and Manic Depressive Psychosis (bipolar disorder) ICD -European / DSM -American (20th Century)
  23. 23. History 2 1938  FirstInternational classification to include mental disorders  International Classifications of Disease 5 (previously “death”) a. mental deficiency b. schizophrenia c. manic depressive psychosis d. other mental diseases
  24. 24. History 3 1992  ICD 10 published by World Health Organisation  increased number of disorders listed  diagnostic guidelines given  subsections for different professions:  medical / clerical / educational / research personnel  version for primary care  multi-axial classification introduced
  25. 25. Aims of ICD 10 Chapter V To facilitate medical practice and public health action by providing a common language to all concerned. To enable mental health workers, public health decision makers, statisticians and professionals in disciplines relevant to psychiatry:  to understand one another  to share results of research  to improve and unify training strategies  to allow all disciplines to record areas specific to them as fully as they wish to
  26. 26. Developed simultaneously inmany languages Arabic Chinese English French German Japanese Portuguese Russian Spanish  Translated into 30+ other languages
  27. 27. Features of ICD 10 Chapter V based on consensus based on field trials developed in collaboration between a Governmental Organization (WHO) and non-Governmental Organizations (WPA, WFN, AD, etc.) developed simultaneously in many languages compatible with national classifications developed in collaboration with a network of centres around the world participating in relevant research, undertaking translation and providing training and support to users
  28. 28. ICD 10 Classification  22 chapters I – XXII  covering all ailments/conditions/abnormalities etc  Chapter V: Mental and Behavioural Disorders  F0 Organic mental disorders  F1 Disorders due to psychoactive substance misuse  F2 Schizophrenia, schizotypal and delusional disorders  F3 Mood disorders  F4 Neurotic, stress related and somatoform disorders  F5 Behavioural syndromes associated with psychological disturbances  F6 Disorders of adult personality disorder and behaviour  F7 Mental retardation  F8 Disorders of psychological development  F9 Behavioural and emotional disorders with onset usually occurring in childhood and adolescence.
  29. 29. ICD 10 Classification Each chapter has subsections with clinical descriptions  F2 Schizophrenia, schizotypal and delusional disorders  F20 schizophrenia  F21 schizotypal disorder  F22 persistent delusional disorder  F23 Acute and transient psychotic disorder  F24 Induced delusional disorder  F25 schizoaffective disorder  F28 Other non organic psychotic disorders  F29 Unspecified non organic psychosis
  30. 30. Multi-axial presentation ofICD-10 Axis I clinical diagnoses  mental disorders  physical disorders  personality disorders Axis II disability  personal care  occupation  family and household  functioning in broader social context Axis III contextual factors  environmental and life style factors relevant to pathogenesis and course of patients illness
  31. 31. Case History 1 Mr X, a 35-year old Asian factory worker, married, with 3 children, was admitted to hospital, having broken his leg by falling down stairs. On the third day of admission, he grew increasingly nervous and started to tremble. He could not sleep, talked incoherently and was obviously very anxious. According to his wife, Mr X drank large quantities of beer each night until falling asleep, for the last 3 years. This had caused a rift in the relationship.
  32. 32. Case History 2 He had been unhappy at work and was the only Asian. During the past year he had missed work several times and had been threatened with dismissal. He had been in the country for 9 years, arriving as a asylum seeker. On examination Mr X spoke incoherently. He was disoriented in time, place, and at times also in person. He picked at bugs that he could see on his blanket. He trembled and sweated profusely. He was agitated, tried constantly to get out of bed and seemed unaware that his right leg was in plaster.
  33. 33. Axis I: Clinical diagnoses Mr X had a long history of heavy alcohol use and developed severe withdrawal symptoms when he could not get alcohol. He presented with the characteristic symptoms of a delirium: clouding of consciousness, global disturbance of cognition, psychomotor agitation, disturbance of the sleep-wake cycle, rapid onset and fluctuation of the symptoms. There were no convulsions. F10.40 Alcohol withdrawal state with delirium, without convulsions.
  34. 34. Axis I: Clinical diagnoses The information provided by his wife gives evidence pointing to an additional diagnosis of alcohol dependence syndrome: continuous heavy use during the last 3 years, difficulties in controlling the drinking and the presence of a withdrawal state. F10.24 Alcohol dependence syndrome, currently using the substance
  35. 35. Axis II: Disabilities Because of the situation described, it is possible for an assessment to be made of the disabilities suffered by Mr X on a scale defined in ICD 10: A. Personal care =0 B. Occupation =1 C. Family and household =2 D. Broader social context =2
  36. 36. Axis III: Contextual factors It is thought by the assessor that the following contextual factors were important to consider in Mr X: • Z55.0 illiteracy and low-level literacy • Z56.4 discord with boss and workmates • Z60.5 target of perceived adverse discrimination and persecution • Z60.3 acculturation difficulty (Migration & Social transplantation) • Z63.0 problems in relationship with spouse or partner
  37. 37. Coffee etc !!!!
  38. 38. Diagnosis How do we make diagnoses  Man in the street’s terminology  mad / depressed / drunkard  Patients own diagnosis  depression / hyperactivity / “ME”  Rating Scales  Beck Depression Inventory / Aspberger questionnaire  Standardised Clinical Assessment  E.g. SCAN interview ( set questions asked)  History and Mental State Examination “clinical”
  39. 39. Aims of assessment – not onlydiagnosis! make a provisional diagnosis elicit the aetiology of the illness identify maintaining factors clarify the risks – to patient / to others set out a management strategy
  40. 40. Psychiatric Assessment reason for referral history of presenting complaint past psychiatric history family history personal history past medical history use of medication/drugs/alcohol forensic history mental state examination  including cognitive examination physical examination risk assessment management plan
  41. 41. History of presenting complaint what are the current symptoms? how long have they been present? what precipitated them? do the symptoms fluctuate? does anything help or make things worse?
  42. 42. Open Ended Questions “Can you tell me a bit about what the problem is?” “I’d like to ask you a few questions in a minute but perhaps you can start by telling me in your own words what has been happening to you?”
  43. 43. Clarifying and closedquestioning “Can I stop you there and just check a few details - When exactly did this start? – How long did that feeling last?” “Have you ever had anything like this before?” “What exactly brought you into hospital today?
  44. 44. Past Psychiatric History “Have you ever had anything like this before?” “Did you ever seek help for this in the past?” “Have you ever been in hospital for this before” “What treatments have you tried in the past?”
  45. 45. Family History “Has anyone else in the family had anything similar to this?” “Has anyone in the family had problems with their nerves?” “Has anyone in the family seen a psychiatrist that you know about?” “Tell me a bit more about your family – are your parents alive? What did they do for a living? What’s your relationship like with them? – has it always been like that?”
  46. 46. Personal History birth early development school - social / academic home environment qualifications relationships and children work
  47. 47. Personal History -clarifications “Did you complete the training course? Why not – were you finding it difficult or did you have problems with the boss?” “Why did you leave that job after just 3 months?” “Why did you have so much time off school as a child?”
  48. 48. Past Medical History medical conditions admissions surgical procedures head injuries ?accidents deliberate self harm
  49. 49. Medication, Drugs & Alcohol  current medication  allergies  illicit drug use  how much?  why?  alcohol consumption  how much?  why?  how long?
  50. 50. Drug and Alcohol - clarifications  “What age were you when you first started using drugs?”  “Have you ever injected?  Which veins do you use?”  “So what do you actually mean by social drinking?”  “What time do you usually start drinking in the morning?”  “Do you drink every day?”
  51. 51. Forensic History  juvenile crime  court appearances  convictions  length of sentence  against person / property  experience of prison
  52. 52. Mental State Examination  what you objectively observe  can be done even where no history available
  53. 53. Mental State Examination 1 Appearance  hygiene  posture  demeanour  dress  expression  movements
  54. 54. Mental State Examination 2 Behaviour  tense  relaxed  over-familiar  threatening  withdrawn
  55. 55. Mental State Examination 3 Speech  quantity  rate  volume  words  associations
  56. 56. Mental State Examination 4 Mood (subjective)  depressed  elated  anxious  biological features  suicidal thoughts or plans Affect (objective)  congruent  appropriate
  57. 57. Mental State Examination 5  Thoughts  slowed or racing thoughts  ruminative or intrusive thoughts  thought disorder “loosened associations”  preoccupations  delusions
  58. 58. Mental State Examination 6  Perceptions  Hallucinations2nd or 3rd person?  “Do the voices talk to you (2nd) or about you (3rd)?”  Command hallucinations  “Have you ever heard sounds or voices that no one else can hear?”  “Have you ever had any unusual experiences?”
  59. 59. Mental State Examination 7  Cognitive  orientation in time, place & person  registration, attention  memory  naming  following instructions  writing  copying
  60. 60. Insight  how does the patient see their problems?  do they recognise that there is a problem?  Do they recognise problems as relating to mental health?  Are they willing to accept help?  how do they feel about what should be done now?
  61. 61. Physical Examination  aetiological factors  e.g.thyroid abnormalities  head injuries  co morbid factors  diabetes  asthma  side effects  interferon for MS  Antiviral treatment in HIV / hepatitis
  62. 62. Risk Assessment  risk to self through suicidal behaviour  risk to self through neglect / dangerous behaviour  risk to others
  63. 63. Delusions 1 a disorder of thought a belief that is • firmly held • not affected by rational argument or evidence to the contrary • not a conventional belief (not within educational and cultural background) • usually false but not always so
  64. 64. Delusions 2 must differentiate from • normal “eccentric” ideas • overvalued ideas - an isolated belief which can dominate a person’s life for years - often within cultural background - may be swayed by reason, not held with utter conviction
  65. 65. Delusions 3 Persecutory :  patient believes a person or organization are trying to harm him  “Theyre out to get me” Grandiose :  beliefs of inflated self-importance, celebrity, supernaturalness  “I am the true Queen of England”
  66. 66. Delusions 4 Delusions of reference :  certain objects/ events/ actions take on special significance for the patient  “When I hear them talking about pedophiles on the TV, I know they really mean me” Nihilistic delusions :  belief that everything is negated or absent  “I dont have any bowels, they’ve been eaten away”
  67. 67. Unusual types of delusions  erotomanic (De Clerambault’s syndrome)  patientdevelops a delusion that a man often of higher social standing is in love with her (cf stalking)  morbid jealousy (Othello syndrome)  patientdevelops a delusion that a sexual partner is being unfaithful NB high risk of violence  delusional misidentification (Capgras syndrome)  delusionthat a close relative has been replaced by an impersonator (a number of variants possible)  infestation (Ekbom’s syndrome)  folie a deux “induced psychosis”
  68. 68. Hallucinatons 1 Disorder of perception a percept • experienced in the absence of an external stimulus • similar quality to that of a real perception • experienced as originating in the outside world (objective space) not in own mind (subjective space)
  69. 69. Hallucinations 2 It is important to differentiate between hallucination and illusion illusion : misperceptions of external (real) stimulus  affect driven  anxious child who sees a coat hanging on a door and thinks it is a robber  seeing a map of England in a crack on the ceiling
  70. 70. Types of hallucination(different modalities)  auditory hearing  visual seeing  olfactory smelling  gustatory tasting  tactile feeling
  71. 71. Auditory hallucinations 2nd person  “you are an evil person, you deserve to die”  “you are the most important person in the world” 3rd person  running commentary “now he’s picking up the knife and he’s going to ….”  repeating patients thoughts  several voices discussing patient “ I think he’s one of the most wonderful people I’ve ever met” “Yes – he is the true Messiah….”
  72. 72. Passivity phenomena Disorder of both thought and perception The feeling that one’s actions/ thoughts/ feelings are not their own but controlled by an external agency !!! External agency Controls own thoughts
  73. 73. Thought alienation Disorder of thought The feeling that one’s thoughts are being interfered with in some way  thought broadcast  thought insertion broadcast  thought withdrawal insertion withdrawal
  74. 74. Some common mentaldisorders Depression Mania Anxiety Schizophrenia
  75. 75. Depression disorder of mood three core symptoms:  pervasive, persistent low mood  loss of pleasure (anhedonia)  loss of energy (anergia) psychotic phenomena  mood congruent  hallucinations 2nd person
  76. 76. Symptoms of depressionBiological symptoms Cognitive symptoms sleep disturbance  poor concentration appetite disturbance  hopelessness diurnal mood variation  worthlessness weight loss  guilt loss of libido  loss of confidence
  77. 77. Mania (also hypomania)  disorder of mood  three core features  elevated or irritable mood  increased energy/activity  reduced need for sleep/rest  psychotic phenomena  grandiosity, paranoia  hallucinations 2nd person
  78. 78. Symptoms of mania  elevated mood  feelings of well being, infective affect  poor concentration and attention  increased energy, drive, sexual energy  irritability, boorish behaviour or conceit  r educed need for sleep  loss of social inhibitions  grandiosity, inflated self esteem  over spending, rash decisions  promiscuity
  79. 79. Anxiety  can be a symptom of many disorders e.g. psychosis, depression, alcohol dependence  also prominent in the neurotic disorders : • generalized anxiety disorder • panic disorder • phobias
  80. 80. Symptoms of anxietyPhysical Psychological palpitations  sense of impending hyperventilation doom chest pain  poor concentration dry mouth  irritability parasthesiae  restlessness headache  initial insomnia tremor urinary frequency
  81. 81. Schizophrenia Pragmatic definition A severe psychotic illness with onset in early adulthood, characterised by bizarre delusions, auditory hallucinations, thought disorder strange behaviour and progressive deterioration in personal, domestic, social and occupational competence all occurring in clear consciousness
  82. 82. Schizophrenia Schneiderian First Rank symptoms  Symptoms which if present give weight to a diagnosis of schizophrenia  delusional perception  audible thoughts  voices heard arguing  voices giving a running commentary  made actions/impulses/feelings  somatic passivity  thought insertion/broadcast/withdrawal
  83. 83. Diagnoses full assessment needed to be certain diagnosis may need to be revised not static remember this is only axis I of the classification system consider also  disability  contextural aspects
  84. 84. Case A (1) A 34 yr old man presents in A+E saying he is having a heart attack. He is sweaty, shaky, breathless and experiencing palpitations. Investigations rule out “medical” causes. What would you thinking of?
  85. 85. Case A (2) On further questioning he tells you that he has been drinking 1 bottle of vodka and £30 worth of cannabis per day What else would you think about?
  86. 86. Case A (3) After he has calmed down, he tells you that he uses the alcohol and cannabis to “drown out” the voices. They talk about him and control his thoughts and actions. What now?
  87. 87. Case B (1) A 19yr old male is brought in by the police swearing and shouting. He says he is responding to all the people calling him a “bastard”. He believes that the police and Army are involved in a conspiracy to kill him. What are your immediate thoughts?
  88. 88. Case B (2) He is admitted to the ward and settles down very quickly. A urine drug screen is positive for amphetamines. What now?
  89. 89. Case B (3) A few days later he absconds from the ward and returns drowsy and confused. He says he has taken Ecstasy and alcohol. You check his bloods and his LFTs are very high. What now?
  90. 90. Questions???