Diagnosis in psychiatry

Question 1

What are the 3 types of classification present within nosology?

Answer 1

1. By symptoms = syndrome approach
   - almost all psychiatric disorders
2. By pathogenesis = biological mechanism underlying the disorder (e.g. infections, cancer, inflammatory disorders)
3. By causes = ‘etiological’ approach

Question 2

What are the problems with the concept of disease?

Answer 2

1. How well do we understand disease?
   - infections: what makes someone susceptible?
   - cancers: causal factors underlying cancers (BRCA1-BRCA2 genes associated with breast and ovarian cancer, reponsible for 5-10% of breast cancers -> what about the other 95%
   - diabetes: factors underlying Type 1 and Type 2?
   - why is there an increase in asthma and an epidemic of peanut allergy
2. What are the boundaries between ‘normal’ and ‘abnormal’?
   - blood tension: 110/70 mmHg = normal ; 140/90 mmHg = abnormal -> hypertension?
   (‘mmHg’ = millimetre of mercury)
   - Body Mass Index: BMI 22 = normal ; BMI 30 = abnormal -> is obesity an illness
   (people in affluent countries put on weight, paradoxically more often when they’re poor)
   - Osteoporosis in 1993 is considered normal with aging ; 1994 is considered a disease
   - Homosexuality was in the DSM-II (=abnormal) but removed in the DSM-III (=normal)
3. Can what you are be a disease or a disorder?

Question 3

How does the examples of Alison Lapper, congenital deafness and autism show a problem in the concept of disease?

Answer 3

Alison Lapper:

• lives with phocomelia: a rare condition that is either genetic or caused by exposure to the drug thalidomide during pregnancy
• she’s an artist, a parent, and was awarded an MBE (Member of the Order of the British Empire)
• > Does she have a ‘disease’, a ‘disorder’ or is she just herself?

Congenital Deafness:
- some live a very rich life: sign languages have a rich literature of their own

Autism:
- a disorder or a different way of being?

Question 4

What is a diagnosis for?

Answer 4

1. a basis for predictions about the future: Prognosis
2. a basis for therapeutics : to alleviate a problem we must have decided what the problem is
3. an analytic tool for increasing our understanding of the aetiology: to research a problem we must have defined what we want to look at
4. a means for identifying the distribution of disease within populations: Epidemiology
   - can inform our understanding of illnesses ad help identify therapeutic avenues

Question 5

What is the historical evolution of classifications in psychiatry?

Answer 5

1. Pre-history
2. 19th Century developments - Kraepelinian dichotomy
3. US-UK diagnostic study
4. Move towards ‘operational’ definitions (contemporary classificatory systems)

Question 6

How did descriptions of mental disorders present in Babylonian textes be now present in a journal of neurology - Brain (2014)?
How did these descriptions evolve?

Answer 6

Descriptions of mental disorders in Babylonian texts
-> translated by Edward Reynolds and James Wilson -> Brain (2014)

Babylon c.3500 BC

• wrote on clay tablets
• accurate descriptions of actual mental and neurological disorders
• BUT no systematisation

Ancient Greece
- different mental disorders identified: mania, melancholia, hysteria

14th Century common law distinguished between:

• lunacy (you could get better)
• idiocy (thought congenital -> you would not get better)

Question 7

What is the evolution of the early approaches to nosology?

Answer 7

Multiple aetiologically-based diagnostic systems
- particularly elaborated by German scientists

Identification of specific organic mental disorders

• General Paralysis of the Insane
• Alzheimer’s Disease
• Korsakoff’s Psychosis

Moral insanity and Personality disorder
- socially abnormal behavior without insanity or mental deficiency

Distinction between ‘psychosis’ and ‘neurosis’

The Kraepelinian dichotomy and Functional psychoses

• dementia praecox (schizophrenia)
• manic-depressive psychosis (bipolar disorder)

Question 8

What is the progression of the US-UK diagnostic study in the 1960s?

Answer 8

> 1960s: diagnosis of schizophrenia more in the US than in the UK psychiatric hospitals
Affective disorders were more diagnosed in the UK than in the US
Diagnostic criteria employed at this time were unclear
UK psychiatrists were trained in the descriptive psychopathological approach
Clear phenomenologically-based criteria were employed along with standardised interviewing techniques
-> research showed that shizophrenia was equally common in the US and UK psychiatric population
= wake-up call to US psychiatry
=> DSM-III

Question 9

What are contemporary classifications characterised by?

What’s the role of Aubrey Lewis?

Answer 9

> Operational definitions
Aubrey Lewis (first director of Institute of Psychiatry, UK)
- 1961 seminar about classificatory systems:
“we should eschew categories based on theoretical concepts and restrict ourselves to the operational, descriptive type of classification”

Question 10

What is the evolution of the DSM?

When did it change in character?

Answer 10

DSM I: 1952
DSM II: 1968
[changed in character]
DSM III: 1980
DSM III-R : 1987
DSM-IV: 1994
DSM-IV TR: 2000
DSM-5:2013

Question 11

Which important innovations did the DSM-III introduce?

Answer 11

> Explicit diagnostic criteria
Multiaxial diagnostic assessment system
- diagnosis
- personality
- social
Neutral with respect to the causes of mental disorders

Question 12

What did Kupfer et al. present in their 2002 paper?

From their paper, what do we have now?

Answer 12

> They were planning DSM-5
in their 2002 paper they summarised the strength and a crucial weakness of DSM-III:
“it was recognised the primary strength of a descriptive approach was its ability to improve communication and conditions in researchers, not its established validity.”
Now, we have a diagnostic system favouring agreement between professionals upon a diagnostic (e.g. schizophrenia) on the basis of a proper assessment, without a platonic ideal of a disorder

Question 13

What characterises the DSM-IV?

What is its relationship with the ICD-10?

Answer 13

> Published in 1994
Six-year effort: conducting comprehensive review of the literature to establish a firm empirical basis for making modifications
1,000 individuals
Numerous professional organisations
Numerous changes:
- the classification: disorders added, deleted and reorganised to the diagnostic criteria sets and the descriptive text
Developers of DSM-IV and ICD-10 worked closely together
- increase congruence
- reduce meaningless differences in wording between the two
-> DSM-IV was more of the same, just a bit different

Question 14

What characterises the DSM-5?

What became of the ambition of finding bio-markers for or underlying the phenotypes of mental disorder

Answer 14

> Was supposed to be different
Started with grand ambitions described by Nemeroff and Weinberger in a paper
- an introduction to a whole series of responses to DSM-5 as it was published by experts in the field looking for particular disorders
-> DSM-5 was unable to use new technologies: genetic and functional imaging (that led much promise at the start of the project)
<=> DSM-5 wasn’t much different. from its predecessors, the grand ambition of finding bio-markers didn’t happen

> However, a lot of detailed changes to the classification system from emerging evidence and expert opinion
… the edifice stayed the same

Question 15

What does it mean to have schizophrenia?

Answer 15

You meet the diagnostic criteria in terms of:
- symptoms
- illness
- cause
- behavior
=> diagnostic label “schizophrenic”, with a common set of symptoms

Question 16

What’s positive and negative about the diagnostic label?

Answer 16

• Helps define interventions that will be helpful (relative high degree of certainty)
• BUT it doesn’t inform about the person (e.g. on the biology - despite a high degree of certainty in schizophrenia)
  Example: Schizophrenia is a useful label but there is not platonic ideal

Question 17

What is the DSM-5 checklist of schizophrenia?

Answer 17

At least one of the following symptoms:
- delusions
- hallucinations
- disorganised speech
(at least on of the above core symptoms)
- disorganised / catatonic behavior
- negative symptoms

> Continuous signs of 2 symptoms must persist for at least 6 months
Experience at least one month of active symptoms
Social or occupational deterioration problems occurring over a significant amount of time
These problems must not be attributed to another condition

Question 18

What are the problems with schizophrenia?

Are treatments disorder specific?

Answer 18

> Is there a POINT OF RARITY between schizophrenia and bipolar disorder?
- in terms of phenomenology or genetics or other biological markers
… not really
Are the SYMPTOMS of schizophrenia better captured in terms of CATEGORIES or DIMENSIONS?
- some symptoms are found frequently in the general population (people hearing voices go on to never have a diagnostic label)
- many SYMPTOMS are NOT SPECIFIC (eclusive) to a particular disorder (hearing voices present in depression, mania, emotionally unstable personality disorder)
In reality, TREATMENTS are LARGELY SYMPTOMATIC, rather than disorder specific
- antipsychotic medication are quite effective for delusions and hallucinations but less so for thought disorder, whatever the diagnostic label

Question 19

What is the situation of the contemporary nosologies of depression?

Answer 19

Depression occurs to people BUT the nosology is a mess!
- No clear pathological mechanisms -> How do we validate diagnosis?
- How do we sub-categorise depressive disorders?
- How do we deal with depression and anxiety occurring together?
- When does it become an illness? (understandable reaction vs. illness)
=> Contemporary nosologies of depression remain a ‘working hypothesis’ (Cole et al.)

Question 20

What’s the place of the categorical and dimensional approaches for depression?

Answer 20

> Dimensional: the severity of the disorder may determine the best treatment approach
There is evidence for a categorical difference between unipolar and bipolar depression (i.e. depression that occurs with or without episodes of elevated mood)
-> genetic studies
-> therapeutically relevant

> Psychotic depression responds to specific treatments - - antipsychotics
- electroconvulsive therapy (ECT)

Question 21

What’s criticised about psychiatry?

Answer 21

> There are ‘novel’ diagnostic categories
- PTSD
- Autism
Diagnostic creep
- e.g. ADHD diagnosis went up 3 times after the publication of DSM-IV (slight changes in the diagnostic categorisation)
Overdiagnosis
- e.g. ‘childhood bipolar disorder’ (American concept)

Question 22

To which movement does Ronald David Laing belong to?
What is his core argument as presented his work ‘The Divided Self’ (1960)?
What followed his argument in the 1960’s?

Answer 22

> Anti-psychiatry
‘The Divided Self’ (1960)
- “…psychosis is not a medical condition, but an outcome of the ‘divided self’, or the tension between the two personas within us: our authentic, private identity, and the other the false, ‘sane’ self that we present to the world.”
-> Are ‘mad people more sane than us’?

> Uncommon trends that saw madness as something to aspire to, increased in the 1960’s

Question 23

To which movement does Thomas Stephen Szasz belong to?

What are his core arguments in ‘The Myth of Mental Illness’ (1961)?

Answer 23

> Anti-psychiatry
‘The Myth of Mental Illness’ (1961)
- mental illness doesn’t exist
- ‘Proper illnesses’ have a clear-cut pathophysiological basis
- only a small proportion of mental disorders demonstrate this clear-cut pathophysiological basis
(General paralysis of the insane (GPI), Huntington’s Chorea, Myxodematous madness)

=> Mental illness is a metaphor

Question 24

What are the core arguments of Critical Psychiatry?

Answer 24

> Psychiatric practice should not be dependant on
- diagnostic classification
- and psychopharmacology
There is poor construct validity amongst psychiatric diagnoses
They are skeptical about the effectiveness of pharmacological treatments
Psychiatric diagnosis should not be used to justify civil detention
Diagnostic constructs do not add much to scientific knowledge in psychiatry

Question 25

What is the approach of Kinderman (2013)?

What are his core arguments against psychiatry and his answer to the problems he mentions?

Answer 25

‘Formulation-based approaches’ (he’s a psychological critique)
> Core arguments:
- distress is a normal part of human life
- humans respond to difficult circumstances by becoming distressed
-> any system should reflect this position
- psychiatric symptoms lie on a continua with less unusual and distressing mental states
- There is no easy ‘cut-off’ between ‘normal’ experience and ‘disorder’
- Psychosocial factors are the most strongly- evidenced causal factors for psychological distress
- Genetics and developmental factors influence the magnitude of an individual’s reaction
=> Distress is normal, it’s on a continuum and precipitated by life circumstances (social factors)

> His answer:

• Develop individual formulations, with the individual’s problems, circumstances, origins, therapeutic solutions
• A ‘problem definition formulation’ (vs. a ‘diagnosis treatment’ approach) would yield all the benefits of a diagnoses treatment without the dangers
• New ways of thinking must be adopted by all clinicians, doctors, nurses, …
• Rewrite most of the standard psychopathology textbooks (which use DSM diagnoses as chapter headings)

Question 26

What is the problem with the psychological formulation-based approach?

Answer 26

In reality, it is based on a research agenda of pseudo-diagnoses (e.g. CBT for psychosis)
- however, the psychological formulation-based approach is not incompatible with psychiatric practice

Question 27

What did the psychodynamic approaches bring to Kinderman’s proposition of formulation-based approach?

Answer 27

How can you learn if everything you do is based at the individual level?

Question 28

Where does the Research Domain Criteria (RDoC) matrix come from and who set it out?

Answer 28

A different way of assessing mental disorder -> Psychiatric establishment: RDoC matrix
-> Thomas Insel, director of the National Institute of Mental Health (NIMH) at the time

Question 29

What is the Research Domain Criteria (RDoC) matrix?

Who set it out and what did he/she wanted to explore?

Answer 29

A new framework underpinning mental health research
New ways to look at things, through:
- genes
- molecules
- cells
- circuits
- physiology
- behaviour
- self-report

Thomas Insel (director of the NIMH) wants to explore systems, including these 5:

1. Negative Valence system (fear, anxiety, sustained threat)
2. Positive Valence system (initial responsiveness to reward)
3. Cognitive systems (perception, memory)
4. Social systems (social communication, understanding of self)
5. Arousal and regulatory systems (arousal, circadian rythms)

Question 30

What is the position of the NIMH regarding the Research Domain Criteria (RDoC) matrix?
What question emerges with the RDoC?
What is the advantage of using the RDoC, with the example of the dopamine theory of schizophrenia?

Answer 30

NIMH, with the RDoC matrix, funds research based on the ability to pinpoint a particular system of interest.
- can we look at the social process system (impaired in autism) through the lense of genetics or disrupted circuits?

> We can draw things together that otherwise may have been missed
- e.g. we know that the dopamine theory of schizophrenia is wrong because antipsychotics which block dopamine receptors are effective against hallucinations whatever the diagnostic entity they appear in, whatever the cause

Question 31

What are the early outputs from the RDoC matrix as shown by Clementz et al. (2015)?

Answer 31

> Using DSM-5: they found no phenomenological ‘point of rarity’ between bipolar, schizoaffective and shizophrenia
- symptoms are pretty evenly spread across these diagnostic categories
Using RDoC: significant homogeneity of biomarker-based groupings

Question 32

Which conclusions can be drawn about diagnosis in psychiatry?

Answer 32

> There are limitations of contemporary diagnostic systems
Diagnosis is associated with stigma
There is a positive value of diagnosis
- it improves our understanding
- it allows us to improve what we can do in order to help treat the problems we face

Question 33

What argument did Mayer-Gross, Slater and Roth (1969) give in defence of diagnosis in psychiatry?

Answer 33

“If we forgo the making of a diagnosis, we also forgo all application of the extensive knowledge which has been accumulated in the past. This would be sheer folly […].
If we refrain from diagnosis we shall be left in the individual case without the help of general concepts…”

Question 34

What argument does Heckers (2015) presents in a set of articles for and against the RDoC framework?

Answer 34

“The true value of a psychiatric diagnosis is the ability to predict course of illness, responses to treatment, and, ultimately, quality of life and level of function in society” Good clinicians use diagnoses in the service of best patient care […].”

Question 35

What arguments do Craddock and Mynors-Wallis (2014) present in the British Journal of Psychiatry, in defence of psychiatric diagnosis?

Answer 35

‘Psychiatric diagnosis: impersonal, imperfect, and important’ (2014):

• “When used well, diagnosis is a key to assisting patients in making informed decisions about their care.
• It can ensure a patient gets effective help as quickly as possible and can benefit from the body of knowledge that has been built up from those who have had similar experiences previously.
• […] When a patient consults a psychiatrist they have a right to expect an expert diagnostic assessment and the psychiatrist has a professional responsibility to provide such an assessment and use it to guide available evidence-based treatments.”

=> “This is not an issue of personal choice for a practitioner. It is a professional responsibility to the patient.”