Classification assesment and diagnosis of mental disorders (asw) new
Classification and Diagnosis of Mental DisordersHelen CrimliskConsultant PsychiatristEastglade Sector Team (Oct 12)
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
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 )
Classification Problems Categorisation can lead to stigma and prejudice
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??
Classification Problems Economy of thought may lead to oversimplification and inhumane action
Categorisation of people makes it “easier” to engage in inhumane behaviour JewsPolish Gypsies Dissidents Homosexuals
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
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
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)
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
History 3 1992 http://www3.who.int/icd/currentversion/fr-icd.htm 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
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
Developed simultaneously inmany languages Arabic Chinese English French German Japanese Portuguese Russian Spanish Translated into 30+ other languages
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
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.
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
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
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.
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.
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.
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
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
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
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”
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
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
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?
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?”
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?
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?”
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?”
Personal History birth early development school - social / academic home environment qualifications relationships and children work
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?”
Past Medical History medical conditions admissions surgical procedures head injuries ?accidents deliberate self harm
Medication, Drugs & Alcohol current medication allergies illicit drug use how much? why? alcohol consumption how much? why? how long?
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?”
Forensic History juvenile crime court appearances convictions length of sentence against person / property experience of prison
Mental State Examination what you objectively observe can be done even where no history available
Mental State Examination 3 Speech quantity rate volume words associations
Mental State Examination 4 Mood (subjective) depressed elated anxious biological features suicidal thoughts or plans Affect (objective) congruent appropriate
Mental State Examination 5 Thoughts slowed or racing thoughts ruminative or intrusive thoughts thought disorder “loosened associations” preoccupations delusions
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?”
Mental State Examination 7 Cognitive orientation in time, place & person registration, attention memory naming following instructions writing copying
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?
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
Risk Assessment risk to self through suicidal behaviour risk to self through neglect / dangerous behaviour risk to others
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
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
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”
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”
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”
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)
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
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….”
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
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
Some common mentaldisorders Depression Mania Anxiety Schizophrenia
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
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
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
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
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
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
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
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
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
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?
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?
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?
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?
Case B (2) He is admitted to the ward and settles down very quickly. A urine drug screen is positive for amphetamines. What now?
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?