Psychiatric Diagnosis

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Psychiatric Diagnosis

• Goals of classification
• Concepts of health and disease
• Historical context
• What is DSM IV and how does it work?
• Controversies/Polemics/Hype

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Goals of a Classification System

• Communication among clinicians, between science
  and practice
• Clinical facilitate identification treatment,
  and prevention of mental disorders
• Research test treatment efficacy and understand
  etiology
• Education teach psychopathology
• Information Management measure and pay for care

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What is Normal?
Average
Supra-Threshold
Ideal
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What is Pathology?

• Sign/symptom
• Syndrome
• Disease
• Illness

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Terms

• Adjectives
• Mental
• Behavioral
• Emotional
• Social
• Psychological
• Psychosocial
• Biopsychosocial
• Biobehavioral
• Addictive
• Cognitive
• Stress-Related
• Maladaptive

• Nouns
• Brain
• Health
• Symptoms
• Syndromes
• Disorders
• Illnesses
• Conditions
• Problems
• Treatments
• Factors
• Issues
• Diseases

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What is Pathology?

• Sign/symptom
• Syndrome
• Disorder
• Disease
• Illness

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Who
Signs and Symptoms
Pathophysiology/Genetics
Distress
Impairment
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Definition of a Mental Disorder

• Clinically significant.
• Behavioral or psychological.
• Pattern or syndrome.
• Associated with.
• Distress OR .
• Disability/impairment
• Not expectable/culturally sanctioned
• Not conflicts between individual and society

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Epistemology of Mental Disorders
Umpire 1 - There are balls and there are
strikes and I call them as they are Umpire 2 -
There are no balls and no strikes until I call
them Umpire 3 - There are balls and there are
strikes and I call them as I see them
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Conceptual Tensions Past and Present

• Phenomenology vs. course vs. etiology
• Descriptive vs. theoretical
• Categorical vs. dimensional
• Symptom vs. syndrome vs. disease
• Reliability vs. validity vs. clinical utility
• Lumping vs. splitting
• Clinical vs. research vs. administrative purposes

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Hippocrates and Psychiatric Diagnosis
Axis I Phrenitis (fever) Mania (w/o
fever) Melancholia Epilepsy Hysteria Scythian
Disease
Axis II Choleric Sanguine Melancholic Phlegmatic
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Etiological Approach to Psychiatric Classification

• Organized around presumed pathogenic processes
• Historical example Paracelsus (16th cen.)
• Vesania (poisons)
• Lunacy (phases of the moon)
• Insanity (heredity)
• Relatively few diagnostic categories

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Descriptive Approach to Psychiatric Classification

• Relies on descriptions of presenting
  symptomatology
• Many discrete categories - e.g. Boissier de
  Sauvages
• Course e.g. Esquirol, Morel, Kahlbaum
• Symptoms and course e.g. Kraeplin
• Adopted by DSM III

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Early History of DSM Classifications

• Originally for statistical, epidemiological and
  reporting purposes i.e. 1790 census
• First international system ICD-6 (1948)
• U.S. alternative DSM-I (glossary definitions)
• ICD-8/DSM-II (1968)
• ICD-9/DSM-III (1980)

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DSM-III Paradigm Shift

• Descriptive
• Non-etiologic focus
• Diagnostic criteria
• Multiaxial system
• Multiple diagnoses
• Splitting
• Reliability

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DSM-III Advantages

• Improved reliability
• Facilitated communication within and between
  research and clinical communities
• Wide use by clinicians, researchers, educators,
  trainees
• Promoted emphasis on empirical data
• Methodological and content innovations

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DSM-III Disadvantages

• Reification
• Length, complexity, user unfriendly categories
• Pseudoprecision
• Problems in international communication
• Specific controversies
• Limited to expert consensus (BOGSAT) without
  documentation

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Principles of DSM-IV Process

• Quality, breadth, and number participants
• Decentralized, open process
• International collaboration
• Changes based on systematic data collection and
  review three stage process
• Reviewers instructed to act as consensus
  scholars

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Whats in DSM-IV

• Systematic framework for diagnosis (including
  multiaxial system)
• Names and codes (from ICD-9cm)
• Diagnostic criteria
• Detailed text
• Appendices to expand educational/practical
  utility
• Primary Care version

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Multiaxial System

• AXIS I Clinical Disorders
• Other Conditions That May Be a Focus of
  Clinical Attention
• Diagnostic Code DSM-IV Name
• 300.21 Panic Disorder with Agoraphobia,
  Moderate
• 304.10 Diazepam Dependence, Mild
• ___.__ ____________________________________
• AXIS II Personality Disorders
• Diagnostic Code DSM-IV Name
• 301.82 Avoidant Personality Disorder
• ___.__ Dependent Personality Features___________
  
• AXIS III General Medical Conditions
• ICD-9-CM code ICD-9-CM name
• 424.0 Mitral Valve Prolapse
• ___.__ ____________________________________

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Multiaxial System

• Axis IV Psychosocial and Environmental Problems
• Check
• X Problems with primary support group Specify
  Marital Discord
• Problems related to the social environment
  Specify___________
• Educational problems Specify___________________
  __________
• X Occupational problems Specify Excessive Work
  Absences
• Housing problems Specify______________________
  __________
• Economic problems Specify_____________________
  __________
• Problems with access to health care services
  Specify__________
• Problems related to the legal system/crime
  Specify___________
• Other psychosocial and environmental problems
  Specify_______
• Axis V Global Assessment of Functioning
  Scale Code 55 (current)

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Definitions of Depression

• Symptoms
• Episodes
• Disorders
• Major Depressive Disorder
• Bipolar Disorder
• Dysthymia
• Depressive Disorder NOS (e.g. subthreshold
  depression)

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Symptoms of Depression

• Mood Symptoms
• - Depressed mood or irritability
• - Loss of interest or pleasure in most activities
• - Feelings of worthlessness or guilt
• - Thoughts of death or a desire to die
• Cognitive Symptoms
• - Difficulty thinking, concentrating, or making
  decisions

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Symptoms of Depression, cont.

• Physical Symptoms
• Weight loss or weight gain
• Psychomotor agitation or retardation
• Insomnia or hyposomnia
• Fatigue or loss of energy

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Depressive Episodes

• Major Depressive Episode
• Depressed mood or loss of interest or pleasure in
  most activities, plus 5 of 9 symptoms
• Most of the day, nearly every day for a minimum
  of 2 weeks
• Combinations of symptoms may vary significantly
  from individual to individual
• Significant functional impairment or interference
• Manic, Mixed, and Hypomanic Episodes

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Mood Disorders

• Major Depressive Disorder
• One or more Major Depressive Episodes
• Bipolar Disorders
• One or more Major Depressive Episodes, in
  addition to a history of mania or hypomania
• Dysthymia
• Mild but chronic form of major depression,
  lasting 2 years or more
• Depression due to general medical condition or
  substance abuse disorder

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Diagnostic Groupings and Examples

• Disorders Usually Evident in Infancy, Childhood
  or Adolescence
• Autism
• Attention Deficit-Hyperactivity Disorder
• Conduct Disorders
• Mental Retardation (Axis II)
• Tourettes
• Delirium, Dementia and Cognitive Disorders
• Delirium
• Dementia of the Alzheimers Type
• Vascular Dementia
• Amnestic Disorder

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Diagnostic Groupings and Examples

• Substance Related Disorders
• Alcohol Dependence
• Cannabis Abuse
• Hallucinogen-Induced Psychotic Disorder
• Opiate Withdrawal
• Psychotic Disorders
• Schizophrenia
• Delusional Disorder
• Mood Disorders
• Major Depressive Disorder
• Bipolar Disorder
• Dysthymia

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Diagnostic Groupings and Examples

• Anxiety Disorders
• Panic Disorder with Agoraphobia
• Post-Traumatic Stress Disorder
• Obsessive-Compulsive Disorder
• Somatoform Disorders
• Somatization Disorder
• Hypochondriasis
• Factitious Disorders and Malingering
• Factitious Disorder (Munchhausens)0
• Malingering

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Diagnostic Groupings and Examples

• Dissociative Disorders
• Dissociative Identity Disorder
• Depersonalization Disorder
• Eating Disorders
• Anorexia Nervosa
• Bulimia Nervosa
• Sleep Disorders
• Narcolepsy
• Sleep Terror Disorder
• Sexual, Gender Identity Disorders
• Premature Ejaculation
• Paraphilias

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Diagnostic Groupings and Examples

• Adjustment Disorders
• Adjustment Disorder with Mixed Anxiety and
  Depressed Mood
• Personality Disorders (Axis II)
• Borderline Personality Disorder
• Obsessive-Compulsive Personality Disorder
• Impulse Control Disorders
• Trichotillomania
• Pathological Gambling
• Other Conditions (Including V Codes)
• Relational Problems
• Sexual Abuse of a Child
• Bereavement

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DSM-IV Text

• Essential Features
• Associated Features (including physical exam and
  lab findings)
• Recording Procedures
• Age, Gender, and Culture Features
• Prevalence, Course, Familial Pattern
• Differential Diagnosis

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DSM-IV Appendices

• Decision Trees for Differential Diagnosis
• Criteria Sets and Axes Provided for Further Study
• Glossary of Technical Terms
• Alphabetical and Numerical Listings
• Codes for Selected General Medical Conditions
• Cultural Formulation and Glossary

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Diagnostic Approach

• Presenting symptom - e.g. depressed mood
• Rule out disorder due to general medical
  condition e.g. due to hypothyroidism
• Rule out disorder due to direct effects of a
  substance - e.g. alcohol induced, reserpine
  induced
• Determine specific primary disorder(s)
• Multiple diagnoses
• Some hierarchies
• Not better accounted for

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Diagnostic Approach

• Distinguishing Adjustment Disorder from Not
  Otherwise Specified (NOS) e.g. response to
  stressor
• Establishing boundary with no mental disorder -
  i.e. clinical significance/cultural sanction,
  i.e. bereavement
• Add subtypes/specifiers
• severity (mild moderate, severe with or without
  psychotic features)
• treatment relevant (melancholic, a typical, etc.)
• longitudinal course (with/without full
  interepisode recovery, seasonal pattern)

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Controversies

• Brainless vs. Mindless Psychiatry
• Inventing New Diagnoses
• e.g. Premenstrual Dysphoric Disorder
• Social Labeling
• Cultural Relativism
• Primary Care vs. Sepcialty Focus