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WCS41 Classification And Diagnosis Of Psychiatric Illness Flashcards

1
Q

History taking

A
  • Open-ended question in history taking
  • Avoid close-ended questions
  • Ask patient to elaborate
  • Focus 1 symptom at a time
  • Following diagnostic criteria e.g. DSM
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2
Q

Subjective experiences

A
  • “Measurable” by clinical interview / self-report
    —> Type
    —> Severity
    —> Duration
    —> Clinical significance (how it affect daily life)
  • Adopt a “time-frame” for assessment e.g. in the past week
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3
Q

Type of symptoms

A
  1. Abnormal experiences and behaviours
    - Hallucination, Delusion, Disorganised speech, Catatonia
  2. Normal experiences but excessive in amount
    - Anhedonia, depressed mood, excessive worries, obsession and compulsion, flashbacks of traumatic events
    - Excessive, irrational, and uncontrollable
  3. Impaired functioning
    - impaired cognitive functioning after traumatic brain injury
    - impaired social functioning e.g. deficits in social-emotional reciprocity in ASD
  4. Impaired attention
    - ADHD
  5. Impaired physiology
    - impaired sleep e.g. insomnia, hypersomnia, circadian sleep-wake disorder
    - impaired sex and gender function e.g. gender dysphoria, ED
    - impaired eating
    - impaired experience of pain and somatic symptoms
    - impaired elimination e.g. enuresis
  6. Behavioural disturbances
    - addiction, including non-substances
    - impulse-control
  7. Personality disorder
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4
Q

Pros and Cons of classification

A

Pros:

  • Bring order to great diversity of phenomena encountered in clinical practice
  • Identify groups of patients with similar clinical features —> suitable treatment can be planned and likely outcome predicted
  • Able to develop a standardised approach in diagnosis

Cons:

  • labelling and stigmatisation
  • benign labels may lead to misunderstanding of severity and treatment
  • diagnostic term can have different meaning to different people
  • distracts from understanding the problem unique to the individual
  • some patients have mixture of disorder
  • some patients cannot fit into a particular category i.e. Not Otherwise Specified
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5
Q

Good classification system

A
  1. High validity
    - limited evidence that different disorders have distinct qualities
    - current system depend heavily on subjective experiences and is based on clinical observation
    - system is valid for most cases except sometimes there are overlap
  2. High reliability
    - clearer criteria —> higher reliability
    - there may be diagnostic disagreement between raters since diagnosis depends on identification of S/S (i.e. there are information and diagnostic variance)
  3. Easy to use
  4. Applicable across settings and cultures (e.g. GP, specialties settings)
  5. Meet the needs of various users
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6
Q

Incorrect diagnosis

A

Causes:

  1. Incomplete / different information obtained in interview
    - lack of rapport and trust
    - feigned / exaggerated symptoms
    - inconsistency / denial
    - lack of informants
    - inadequate interviewing technique (can be improved by training / use of structured interview)
  2. Inadequate use of diagnostic criteria
  3. Wrong interpretation of information
  4. Interviewers may differ in which is more important if 2 categories are both met

Solution:

  1. Elaboration
  2. Clarification
  3. Collateral information collection
  4. Longitudinal assessment
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7
Q

Screening tools

A
  1. PHQ-9
  2. MDQ
  3. Adult Autism Spectrum Quotient
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8
Q

2 most commonly used classification systems in psychiatry care

A
  1. DSM (Diagnostic and Statistical Manual of Mental Disorder)
    - definitions mostly descriptive
    - theoretical statements are avoided
    - etiology included only when clearly demonstrable
    - Multi-axial (5 axis: 1-5) to explain a mental illness
    —> Axis 1: Clinical disorders
    —> Axis 2 : Personality disorders
    —> Axis 3: General medical conditions
    —> Axis 4: Psychosocial and environmental problems
    —> Axis 5: Global assessment of functioning
  2. ICD (International Classification of Diseases)
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9
Q

Common elements of diagnostic criteria

A
  1. Cluster of symptoms
    - Core symptoms (major depressive disorder, depressed mood, loss of interest)
    - Associated symptoms (sleep disturbance, reduced appetite, suicidal idea)
  2. Minimal duration of symptoms (usually duration >1 month)
  3. Distress / Impairment in functioning
  4. Exclusion criteria
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10
Q

Comorbidity in psychiatry

A 
Example:
Bipolar
- personality disorder
- eating disorder
- ADHD
- sleep disorder
- anxiety disorder
- substance use disorder
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11
Q

Diagnostic criteria of Schizophrenia

A

Characteristic symptoms:

  • > =2 of following
  • each present for a significant portion of time during a ***1 month period (or less if successfully treated):
  1. Delusions
  2. Hallucinations
  3. Disorganised speech (e.g. frequent derailment / incoherence)
  4. Grossly disorganised / Catatonic behaviour
  5. Negative symptoms i.e. affective flattening (情感扁平化), alogia (poor thinking inferred from speech), avolition (lack of motivation)

Social / Occupational dysfunction:

  • significant proportion of time
  • > =1 major areas of functioning e.g. work, interpersonal relations, self-care markedly below level before onset

Duration: >=6 months

Exclusion: Schizoaffective, Mood disorder, Substance / General medical condition

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12
Q

Mood disorders

A

Depressive disorders

  • Single / Recurrent episodes
  • Dysthymia (persistent mild depression)
  • Premenstrual dysphoric disorder

Bipolar disorders
- manic / hypomanic / mixed and depressive episodes
(—> Manic: abnormally + persistently elevated / irritable mood
1. Grandiosity
2. **Decreased need for sleep
3. **Intensified speech
4. **Racing thoughts
5. Increased in goal-directed activity / **Psychomotor agitation
6. Excessive involvement in pleasurable activities that have a high-risk consequence
7. Distractibility
—> Hypomanic: similar but less intense to manic)

  • manic / hypomanic / mixed episodes usually last ***1 week
  • depressive episodes can last for ***weeks / months
  • usually symptoms free during inter-episode period
  • Bipolar 1, Bipolar 2, Cyclothymia
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13
Q

Diagnostic criteria of Major Depressive Disorder

A

Characteristic symptoms:

  • > =5 following present during same ***2 week period
  • clear change from previous functioning
  • > =1 symptoms has to be **Depressed mood / **Loss of interest, pleasure
  • Can have ***Seasonal pattern
  1. Depressed mood most of day
  2. ***Marked diminished interest / pleasure in all activities
  3. ***Significant weight loss
  4. ***Insomnia / Hypersomnia
  5. Psychomotor retardation / agitation
  6. Fatigue / ***Loss of energy almost everyday
  7. Feeling of worthlessness / excessive guilt
  8. ***Diminished ability to think / concentrate
  9. Recurrent thoughts of death
  • Symptoms do not meet criteria for ***Bipolar mixed episode
  • Symptoms cause clinically significant distress / impairment in social, occupational, other important areas of functioning
  • Symptoms are NOT due to direct physiological effects of a substance / general medical condition
  • Symptoms are NOT better accounted for by bereavement (persist for >= 2 months)
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14
Q

Anxiety disorders

A
  1. Generalised anxiety disorder
  2. Panic disorder
  3. Agoraphobia
  4. Social phobia
  5. Specific phobia
  6. Separation anxiety disorder
  7. Selective mutism
  8. Anxiety disorder substance-induced / another medical condition
  9. OS / US anxiety disorder
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15
Q

Diagnostic criteria of Generalised Anxiety Disorder

A
  • Excessive anxiety and worry occurring **more days than not for **>= 6 months, about a number of events / activities
  • Difficult to control the worry
  • Anxiety and worry are associated with >=3 of following:
  1. Restlessness / Feeling keyed up / on edge
  2. Easily fatigued
  3. Difficulty concentrating / mind going blank
  4. Irritability
  5. Muscle tension
  6. Sleep disturbance
  • Clinically significant distress / impairment in functioning
  • Disturbance are not due to substance / general medical condition
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16
Q

Diagnostic criteria for Panic disorder

A 
Discrete period of ***intense fear / discomfort, in which >=4 of following developed abruptly and reached a peak within 10 mins:
1. Palpitations
2. Sweating
3. Trembling / Shaking
4. Sensations of SOB
5. Feeling of choking
6. Chest pain / discomfort
Etc.

Recurrent unexpected attacks for >=1 month

17
Q

Feeding and Eating Disorders

A
  1. Anorexia nervosa (significantly low BMI and fat phobia)
  2. Bulimia nervosa (repeated binge eating and fat phobia)
  3. Binge-eating disorder
  4. Pica
  5. Rumination disorder (regurgitation of food)
  6. Avoidant / Restrictive food intake disorder
  7. OS / US feeding and eating disorder
18
Q

Diagnostic criteria for Anorexia nervosa

A
  • Restriction of energy intake relative to requirements
    —> significantly low BW
  • Intense fear of gaining weight / becoming fat / persistent behaviour that interferes with weight gain
  • Disturbance in the way which BW / shape is experienced, undue influence of BW / shape on self-evaluation / persistent lack of recognition of seriousness of current low BW
  • ***3 months
  • Mild BMI >=17, Moderate 16-16.99, Severe 15-15.99, Extreme <15
  • Restricting and binge-eating / purging type
19
Q

Sleep-wake Disorders

A

6 major types
1. Insomnia disorder
2. Parasomnias (e.g. sleepwalking)
3. Hypersomnolence disorder / Narcolepsy
4. Circadian rhythm sleep-wake disorder (e.g. delayed sleep-wake phase)
5. Breathing-related sleep disorders (e.g. OSAS)
6. Movement-related sleep disorders —> Restless leg syndrome / PLMD
(- Substance / medication-induced)
(- OS / US sleep-wake disorders)

20
Q

Diagnostic criteria for Insomnia disorder

A
  • Predominant complaint of dissatisfaction with sleep quantity / quality
    —> >=1 difficulty initiating sleep
    —> difficulty maintaining sleep
    —> early morning awakening
  • Clinically significant distress / impairment in functioning
  • **>=3 nights per week for **>=3 months
  • Despite adequate opportunity for sleep
  • Not better explained by other sleep disorder, substance use, mental, medical conditions

Primary / Comorbid insomnia

21
Q

Diagnostic criteria for Autism Spectrum Disorder

A
  • Persistent deficits in social communication and social interaction across multiple contexts
  • Restricted, repetitive patterns of behaviour, interests / activities
  • Present since childhood
  • Impairment in functioning
  • Not better explained by intellectual disability / developmental delay
22
Q

Diagnostic criteria for ADHD

A
  • Persistent pattern of **Inattention / **Hyperactivity-impulsivity
  • Present prior to ***age 12
  • > =2 settings
  • Impairment in functioning
  • Not occur exclusively during other disorders
23
Q

Disruptive, Impulse-control, Conduct disorders

A
  • Intermittent explosive disorder
  • Oppositional defiant disorder
  • Conduct disorder
  • Antisocial personality disorder
  • Kleptomania (stealing)
  • Pyromania (fire setting)
  • OS / US impulse control disorder
24
Q

Personality disorders

A 
Cluster A (Strange type):
- Paranoid, Schizoid, Schizotypal

Cluster B (Emotional type):
- Antisocial, Borderline, Histrionic, Narcissitic

Cluster C (Anxious type):
- Avoidant, Dependent, Obsessive-compulsive
25
Q

Diagnostic criteria for Borderline Personality Disorder

A

Pervasive pattern of instability of interpersonal relationships, self-image and affects and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by 5 or more of following:

  • Frantic efforts to ***avoid real / imagined abandonment
  • Pattern of ***unstable / intense interpersonal relationship, alternating between extremes of idealisation and devaluation
  • ***Identity disturbance: unstable self image / sense of self
  • ***Affective instability
  • ***Chronic feelings of emptiness
    Etc.
26
Q

Diagnostic criteria for Major Neurocognitive Disorder (Dementia)

A
  • Significant cognitive decline from a previous level of performance in ***>=1 domains (complex attention, executive function, learning and memory, language, perceptual-motor, social cognition) based on informants / cognitive tests
  • Interfere with independent living
  • Not better explained by other mental disorder

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