W1-T3 Diagnosis in Psychiatry Flashcards
define why classification is ubiquitous
taxonomy - used to classify plants and other things
periodic table - used to classify elements
nosology - used to classify disease
how diseases/injury/disorders are classified in nosology
based on symptoms (almost all psychiatric diseases are classified this way)
pathogenesis (biological mechanism underlying the disorder) - cancer, infections
causes (aetiological approach) - scurvy caused by lack of vitamin C
what are the problems with the concept of disease
- How well do we understand them
- is it a disease or just a way of being (i.e. autism)
- what is the boundary between normal and abnormal and how they are changeable (osteoporosis due to aging, now considered disease, homosexuality used to be disease now normal)
what diagnosis in psychiatry is for
prognosis
therapeutic treatment
epidemiology
to understand the cause of disease
history of classification in psychiatry
(1) pre-history
– founded on a tablet from Babylon c3500 era (translated by Reynold & Wilson, 2014) - an accurate description of mental and neurological disorders, no systemization
– Ancient Greek - identify different mental disorders (mania, melancholia, hysteria)
– 14th-century common law (lunacy - can get better, Idiocy - you would not get better)
(2) 19th Century (early approach to nosology)
– multiple complex aetiologically-based diagnostic systems (German psychiatry)
– identification of some organic mental disorder (Alzheimer, Psychosis, general paralysis of the insane)
– moral insanity disorder (socially abnormal behaviour without insanity)
– the distinction between psychosis and neurosis
– The Kraepelinian dichotomy (separation) – functional psychoses
(3) 20th Century (UK-US diagnostic study) - 1960
– kickstart DSM-3 onwards - after phenomenologically-based criteria and standardised interview technique shows schizo are equally common in US and UK
(4) move toward operational definitions
define the history of Diagnostic and Statistical Manual (DSM)
DSM 1 (1952), DSM 2 (1968) —> changed character
DSM 3 - DSM 5 (2013)
what is the changes within DSM 3
- clear (explicit) diagnostic standard
- adopted a multiaxial diagnostic assessment system (including) personality factors, social factor
- neutral with respect to the causes of mental disorder
critics/weakness in DSM 3 (Kupfer et al.)
– adopted a so-call neo-Kraepelinian approach to diagnosis
– avoided organising a diagnostic system around hypothetical but unproven theories about aetiology in favour of a descriptive
approach
– disorders were characterized in terms of symptoms
what is the changes in DSM 4
in term of classifications
disorders were added, deleted and reorganised to the diagnostic criteria sets and the descriptive text.
– similar to DSM 3 just a bit different
how developers of DSM 4 and ICD 10 worked closely together for
– to increase congruence (consistency)
– reduce meaningless differences in wording between the two
describe the ambition in developing DSM 5
supposed to be something different
started with grand ambition (to include bio-markers of the major disorders)
—> it did not happen and pretty much the same as the previous DSM
what is the change in DSM 5
classificatory (category) system on the basis of emerging evidence and expert opinion
what is missing from the current diagnosis system
provide useful labels but there is no absolute understanding of it
i.e. Criteria (symptoms, illness, behaviours) met the result (label of disease (i.e. schizophrenia) but doesn’t provide further explanation about the person (i.e. biology, hereditability)
How DSM 5 diagnose someone with schizophrenia
At least one of the core symptoms
– delusions, hallucinations, disorganized speech
At least two of the whole symptoms
– any core symptoms, disorganized/catatonic behaviour (not responding to others and surrounding), negative symptoms)
– persist for 6 months
– experience at least once a month
– social/occupational detoriation
– not attributed to other condition
define the problems with schizophrenia
– Is it better to label based on category or dimension (2 patients can have the same symptoms and different reactions to intervention (drug/treatment) )
– many symptoms not specific to certain disorders (i.e. hearing voice can be a symptom of schizo, depression, mania)
– treatment is systematic vs specific
– medication works for some diagnoses, not for others
define why depression nosology (classification) is a mess
– how to validate diagnosis without a clear pathological mechanism (underlying causes) - to understand if it’s a reaction or illness?
– How to sub-categorise depressive disorder
1. severity may determine treatment
2. category difference between bipolar and unipolar
3. psychotic depression responds to specific treatment
– how to deal with depression and anxiety that occur together
what are considered novel (new and unknown before) diagnostic categories
PTSD
What is considered diagnostic creep
ADHD - diagnosis increase three times after DSM 4
define over-diagnosis in psychiatry
diagnosis of a medical condition that never caused problems/symptoms
which critics are considered anti-psychiatry
Szasz
Laing
what is Kinderman known for in the field
psychological critic and his formulation-based approach
describe Laing argument in his book The Divided Self (1960)
that psychosis is not a medical condition, but an outcome of the divided self, the tension between two personas within us. authentic self (private), false (‘sane’ self that we present to the world)
describe Szasz core argument in his book The Myth of Mental Illness (1961)
– mental illness doesn’t exist
– mental illness language is metaphorical
– proper illness has a clear-cut pathophysiological basis (i.e. diabetes, stroke)
– only a small portion of mental disorders demonstrate this
define the core argument of the problems with psychiatry according to critical psychiatry
– should not be dependent on diagnostic classification and psychopharmacology
– poor construct validity amongst psychiatric diagnoses
– sceptical about the effectiveness of the drug treatment
– Psychiatric diagnosis should not justify civil detention
– diagnostic constructs do not add much to scientific knowledge
what is Kinderman suggestion to replace diagnostic approach with
formula based approach
how does formula-based approach (according to Kinderman) works
develop an individual formulation that consists of the individual’s problems, circumstance, origin, therapeutic solution
what was Kinderman’s core argument to his psychological critique
acknowledge that distress is a normal part of human life
humans responds to difficult circumstance by becoming distressed
psychiatric symptoms lie on continua with less unusual and distressing mental states
no easy cutoff between normal experience and disorder
recognise social factors such as poverty, unemployment, and trauma are the most strongly evidenced causal factors for psychological distress
genetic and developmental factors– may influence the magnitude of individuals’ reaction to these kinds of circumstance
what are difficulty with Kinderman approach
require new ways of thinking to all staff, clinicians, psychologist
have to rewrite the standard psychopathology textbooks (DSM)
would yield all the benefits without the danger
research agenda use pseudo diagnosis
since it’s an individual formulation, how can you learn, and accumulate data if it’s being done on an individual level?
describe NIMH (Thomas Insel) propose approach to assess mental disorder
Psychiatric Establishment Research domain criteria matrix (RDoC)
what are the advantages of RDoC Matrix
– allow us to look at phenomena (disorders) at different levels
– we can draw things together that otherwise might have been missed
define the difference between RDoC (based on early output) and DSM 5
DSM 5 – no phenomenological point of rarity between bipolar, schizophrenia, or schizoaffective (symptoms are evenly spread across these diagnostic categories)
RDoC – significant homogeneity (similarity) of bio-marker-based groupings
what can be concluded about diagnoses in psychiatry?
– There are limitations in the contemporary diagnostic system
– Diagnoses are associated with stigma – i.e. the label disease stigmatise? are necessary in making the disease demystify (make clear)
– there is positive value in diagnoses – i.e. improve understanding, allow improvement in terms of treatment
define defences value in pyschiatry
–‘If we forego the making of a diagnosis, we also forego all application of the extensive knowledge, which has been accumulated in the past (Mayer-Gross, Slater & Roth, 1969)
–The true value of a psychiatric diagnosis is the ability to predict the course of illness, response to treatment, and
ultimately quality of life and level of function in society. Good clinicians use diagnoses in the service
of best patient care. They balance a paternalistic focus on outcome with respect to personal agency
and encouragement for recovery (Hackers, 2016)
–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’s been built up from those who’ve had similar experiences previously (Nick Craddock & Mynors-Wallis )
