Classification and Diagnosis of Mental Disorders

Helen Crimlisk

Consultant Psychiatrist

Eastglade 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

Task

Why do we classify things?

Classification

Why?Aids recognition - improves communicationEconomic - simplification “cognitive economy”Predictive - “heuristic” - leads to ability to test

hypothesesReflect natural processes ( i.e. implies better

understanding e.g. Darwin )

Classification of manhole covers

Evolutionary Tree

Task

How do we classify?

Classification

How?sizeageappearanceprognosissimilar biochemical / genetic factors

Classification by height

Task

What are the problems with classification?

Classification

Problems

Improved scientific understanding makes a mockery of previous attempts to classify (e.g. phrenology)

Phrenology

Classification

Problems

Categorisation means defining thresholds which may be and indeed often are arbitrary

depression / dysthymia / fed up obese / well built / chubby / slender

Eysenck’s 2 dimensional trait theory

Classification

Problems

Categorisation can lead to stigma and prejudice

Terms previously acceptable now gone out of usage because of negative connotations

cretin hypothyroidmongol Down’s

syndromeimbecile moron

mentally retarded mentally

handicappedlearning disabled

Intellectually challenged

idiot savant

autism pervasive developmental disorder

spastic cerebral palsy

insane psychopathic

lunatic schizophrenia

integrative disorder??

Classification

Problems

Economy of thought may lead to oversimplification and inhumane action

Jews

Gypsies

HomosexualsDissidents

Polish

Categorisation of people makes it

“easier” to engage in inhumane

behaviour

What are the benefits of using classification 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

Task

How could we classify mental health?

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 First International classification to include mental

disorders International Classifications of Disease 5 (previously

“death”)

a. mental deficiencyb. schizophreniac. manic depressive psychosisd. 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 in many 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 of ICD-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 patient's 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 = 2D. 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

Coffee etc !!!!

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 only diagnosis!

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 closed questioning

“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 consumptionhow 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 1

Appearancehygieneposturedemeanourdressexpressionmovements

Mental State Examination 2

Behaviour tenserelaxedover-familiar threateningwithdrawn

Mental State Examination 3

Speechquantityratevolumewordsassociations

Mental State Examination 4

Mood (subjective)depressedelatedanxiousbiological featuressuicidal thoughts or plans

Affect (objective)congruentappropriate

Mental State Examination 5

Thoughtsslowed or racing thoughtsruminative or intrusive thoughts thought disorder “loosened associations” preoccupationsdelusions

Mental State Examination 6

PerceptionsHallucinations 2nd 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 & personregistration, attentionmemorynaming following instructionswritingcopying

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 factorse.g. thyroid abnormalitieshead injuries

co morbid factors diabetesasthma

side effects interferon for MSAntiviral 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

“They're 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 don't have any bowels, they’ve been eaten away”

Unusual types of delusions erotomanic (De Clerambault’s syndrome)

patient develops a delusion that a man often of higher social standing is in love with her (cf stalking)

morbid jealousy (Othello syndrome) patient develops a delusion that a sexual partner is

being unfaithful NB high risk of violence delusional misidentification (Capgras syndrome)

delusion that 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) stimulusaffect 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

Types of hallucination(different modalities)

auditory visual olfactory gustatory tactile

hearing

seeing

smelling

tasting

feeling

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 thought withdrawal

insertion

withdrawal

broadcast

Some common mental disorders Depression Mania Anxiety Schizophrenia

Depression

disorder of mood three core symptoms:

pervasive, persistent low mood loss of pleasure (anhedonia) loss of energy (anergia)

psychotic phenomenamood congruenthallucinations 2nd person

Symptoms of depression

Biological symptoms sleep disturbance appetite disturbance diurnal mood variation weight loss loss of libido

Cognitive symptoms poor concentration hopelessness worthlessness guilt loss of confidence

Mania (also hypomania) disorder of mood three core features

elevated or irritable mood increased energy/activityreduced need for sleep/rest

psychotic phenomenagrandiosity, paranoiahallucinations 2nd person

Symptoms of maniaelevated mood feelings of well being, infective affectpoor concentration and attention increased energy, drive, sexual energy irritability, boorish behaviour or conceitr educed need for sleep loss of social inhibitionsgrandiosity, inflated self esteemover spending, rash decisionspromiscuity

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 anxiety

Physical palpitations hyperventilation chest pain dry mouth parasthesiae headache tremor urinary frequency

Psychological sense of impending

doom poor concentration irritability restlessness initial insomnia

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?

Questions???