Week 1 - Introduction to assessment and diagnosis

Question 1

Definitions of mental disorders

Answer 1

1) Demonology model (Possession by the devil or spirits)+ Treatment (Exorcism) 2) The medical model - Hippocrates - Mental disorders = disease / brain disorders (Neurophysiological) 3)Philippe Pinel -nosographie philosophique ou méthode de l’analyse appliquée à la médecine. - still use

Question 2

ICD development

Answer 2

1893 Bertillon Classification of Causes of Death – Jacques Bertillon -1900 International Lists of Causes of Death – 1st revision (ILCD‐1) (revised every 10 years) -1935 AMA’s Standard Classified Nomenclature of Disease -1948 WHO International Classification of Diseases (ICD‐6) includes classification of mental disorders

Question 3

DSM Development

Answer 3

DSM = Diagnostic and STATISTICAL manual -Psychodynamically influenced -Continuum of behaviour -Distinction between Neuroses and Psychoses 1968 DSM‐II (182) ◦ Based on ICD‐8 classifications – a glossary ◦ Comorbid diagnoses encouraged ◦ Combat‐related neuroses removed in DSM‐II Homosexuality in DSM‐II voted out in 1973 https://www.thisamericanlife.org/204/81‐words 1980 DSM‐III (265) ◦ Psychodynamic view abandoned for biomedical model. ◦Neurosis vs Psychosis distinction abandoned ◦ Clearer distinction between normal and abnormal. ◦ Atheoretical with no preferred aetiology for mental disorders ◦ Descriptive approach to classification – use of criteria to improve reliability 1987 DSM‐III‐R (292) -Criteria for many disorders developed and changed. -Multiaxial diagnosis introduced -PTSD and Borderline PD 1994 DSM‐IV (297) -masochistic and sadistic personality disorders excluded -Acute stress disorder, bipolar II, Asperger’s -clinically significant distress or impairment criteria 2000 DSM‐IV‐TR (297). Majority of criteria unchanged. Text updated.

Question 4

DSM-V specifics

Answer 4

2013 DSM‐5 -No multiaxial diagnoses -Categorical -New disorders, new categories… e.g., ◦ Obsessive‐compulsive and related disorders ◦ Hoarding disorder ◦ Binge eating disorder ◦ Premenstrual dysphoric disorder Preface: Summary of all diagnoses and codes Section I: DSM‐5 Basics -Introduction -History of the manual -Use of the manual/cautionary statements -Definition of a mental disorder

Question 5

Mental disorder?

Answer 5

Syndrome characterized by clinically significant disturbance in: ◦Cognition, emotion regulation, behaviour ◦Reflects dysfunction in psychological, biological, developmental process ◦Associated with significant distress and disability

Question 6

Under DSM-V - Not mental disorder

Answer 6

-Expected or culturally approved response to common stress or loss -Socially deviant behaviour -Conflict between individual and society

Question 7

DSM‐5 Manual (contd)

Answer 7

Section II: Diagnostic Criteria and Codes 20 chapters describing recognised disorders DSM‐5 Manual (cont) Section III: Emerging measures and models -Emerging assessment measures -Cultural formulation -Alternative DSM‐5 model for personality disorders -Conditions for future study

Question 8

US National Institute of Mental Health Research Domain Criteria (RDoC)

Answer 8

Negative Valence Systems Positive Valence Systems Cognitive Systems Systems for Social Processes Arousal/Regulatory Systems Sensorimotor Systems

Question 9

A Diagnostic and Statistical manual - core features in development

Answer 9

Atheoretical Information based on scientific data Decisions made by working groups Consensus Resource book criteria prototypical: each disorder has certain essential characteristics + certain nonessential variations trends (age, culture, gender), prevalence, risk, course, complications, predisposing conditions, family patterns “DSM is intended to serve as a practical, functional and flexible guide…” “Diagnostic criteria are offered as guidelines for making diagnoses, and their use should be informed by clinical judgment” p.21

Question 10

CD‐11 DSM and ICD systems ◦ Medical model ◦ Descriptive ◦ Categorical

Answer 10

Relevant ICD‐11 chapters Chapter 6 ‐ Mental, behavioural or neurodevelopmental disorders Chapter 7 ‐ Sleep‐wake disorders Chapter 8 ‐ Diseases of the nervous system Chapter 17 ‐ Conditions related to sexual health Chapter 21 ‐ Symptoms, signs or clinical findings, not elsewhere classified Chapter 23 ‐ External causes of morbidity or mortality Chapter 24 ‐ Factors influencing health status or contact with health services

Question 11

Making a diagnosis

Answer 11

Clinical interview + Mental status examination Enquire about the presenting problem  Signs and symptoms (FID/HCB) Note: a symptom ≠ syndrome History and context – rule out other non‐psychiatric explanations Do they fit criteria and course of one (or more)known disorders? – rule out differential diagnoses and determine comorbidities. Relevant history Form your tentative hypothesis Ask about other symptoms to rule out differential diagnoses

Question 12

Diagnostician?

Answer 12

Knowledge of: ◦the criteria ◦ Diagnostic features ◦ Associated features ◦ Prevalence, development and course ◦ Risk and prognostic issues ◦ Cultural/gender/contextual issues ◦ Differential diagnoses and comorbidities

Question 13

Risks to reliability and validity

Answer 13

Client/informant deceit Client/informant inability to accurately report Countertransference Comorbidity Subclinical symptoms cultural/situational factors

Question 14

Types of diagnostic interview

Answer 14

Multimethod, multirater, multisetting ◦ Also see DSM, section III emerging measures Diagnostic interviewing ◦ Unstructured ◦ Semi‐structured and structured interview schedules (ADIS‐5, SCID‐ 5, DIAMOND)

Question 15

Differential diagnosis vs Comorbid disorder

Answer 15

Mutually exclusive diagnoses ◦(e.g., schizoaffective vs bipolar disorder with psychotic features) Comorbidity ◦ common and often necessary to describe full presentation

Question 16

Steps involved in making a diagnosis

Answer 16

Clinical interview Mental status examination Enquire about the presenting problem  Signs and symptoms (FID/HCB)  Note: a symptom ≠ syndrome  History and context – rule out other non‐psychiatric explanations Do they fit criteria and course of one (or more)known disorders? Form your tentative hypothesis Ask about other symptoms to rule out differential diagnoses NB. Use semi‐structured or structured clinical interviews (e.g., SCID, ADIS, DIAMOND) for increased reliability and validity

Question 17

Other specified or Unspecified Disorder

Answer 17

Other specified diagnosis: ‐ Client does not quite meet diagnostic criteria for the disorder. Clinician can specify why. ‐ e.g. ‘311. Other specified depressive disorder, short‐ duration depressive episode (4 – 13 days) Other unspecified diagnosis: ‐ Client experiences significant clinical distress but does not meet the criteria for the disorder (sometimes because too little information) e.g. ‘311. Other unspecified depressive disorder’

Question 18

Differential Diagnosis

Answer 18

Rule out malingering and factitious disorder ◦ Malingering ◦ Factitious disorder Rule out substance aetiology ◦ Using a substance? ◦Is there an aetiological link with symptoms? ◦ Symptoms caused by substance ◦ Substance use caused by symptoms ◦ Relatively independent Rule out general medical condition ◦NB. Due to GMC: Possible in most (if not all) psychiatric presentations. ◦Importance of medical screen ◦ Medical history ◦ Change in mental status ◦ Atypical presentation? Differentiate adjustment disorders from residual other specified or unspecified disorders ◦Maladaptive response to a psychosocial stressor? ◦Other specified vs Unspecified disorder Establish the boundary with no mental disorder Clinically significant distress Impairment in social, occupational, or other important areas of functioning. ◦ Clinical judgement ◦ Contextual

Question 19

DSM‐5: V Codes Categories (p.715) ‘Other Conditions that May be a Focus of Clinical Attention’

Answer 19

Relational problems Abuse and neglect Educational and occupational problems Housing and economic problems Other problems related to the social environment Problems related to crime or interaction with the social system Other health service encounters for counseling and medical advice Problems related to other psychosocial, personal and environmental circumstances Other circumstances of personal history

Question 20

Diagnosis (steps involved)

Answer 20

List primary diagnosis first ◦ Primary diagnosis = Diagnosis responsible for current admission (inpatient setting) or reason for visit (outpatient setting) List remaining disorders in order of focus of attention / treatment Provisional diagnosis ◦ Uncertainty about diagnosis e.g., due to inadequate history ◦Indicate in brackets after the diagnosis

Question 21

Diagnosis Subtypes ◦ Mutually exclusive and jointly exhaustive (‘Specify whether’) Specifiers ◦ Not mutually exclusive: define more homogenous groups within the broader category (‘Specify or specify if’) Severity specifiers (‘Specify severity’) Harmonizing with ICD 10/11 (Codes and Classification)

Answer 21

Diagnosis Subtypes ◦ Mutually exclusive and jointly exhaustive (‘Specify whether’) Specifiers ◦ Not mutually exclusive: define more homogenous groups within the broader category (‘Specify or specify if’) Severity specifiers (‘Specify severity’) Harmonizing with ICD 10/11 (Codes and Classification)

Question 22

Medical model>

Answer 22

From: Symptoms  Syndrome  Diagnosis  Treatment Protocol To: Symptom + context + the individual + history  diagnosis and formulation  processes/mechanisms for change  tailored treatment informed by the evidence.

Question 23

Use diagnosis to inform case formulation

Answer 23

Draw on research & clinical models for formulation and treatment planning (nomothetic approach) Individualise the formulation to reflect individual, problems and their relationship (Idiographic approach)

Question 24

Cultural factors

Answer 24

Cultural identity Cultural conceptualizations of distress Stressors and supports See cultural formulation interview DSM5 Pg 752

Question 25

But what type of formulation?

Answer 25

5‐Ps? Cognitive behavioural? ACT? Schema? Etc etc. etc Consider the evidence‐based treatment model Formulation needs to align with the treatment plan

Question 26

Process‐based therapy Formulation

Answer 26

Affective (how well can they regulate emotions?) Cognitive (what are their thoughts and beliefs? What is their relationship with them? How flexible are these?) Attentional (what are they focusing on? Can they shift their attention?) Motivational (what motivates the client? How motivated is the client?) Overt Behavioural (how do they respond behaviourally; what is their ability to set goals, to adhere to plans?) Self‐processes (how does the client feel about themselves? How ‘entangled’ is the person with defending a particular type of conceptualised self?) Biophysiological and sociocultural level. (What is their level of social support? How are their interpersonal skills?)

Question 27

But why are we not abandoning diagnoses?

Answer 27

still useful for grouping symptoms

Question 28

Making best use of diagnosis

Answer 28

Use clinical judgment in diagnosis DSM diagnoses only as a guide Formulation Formulation Formulation “A case formulation for any given patient must involve a careful clinical history and concise summary of the social, psychological and biological factors that may have contributed to developing a given mental disorder. Hence it is not sufficient to simply check off the symptoms in the diagnostic criteria…” p.19

Question 29

Similarities-and-differences-between-ICD-10-DSM-IV-and-DSM-5.

Answer 29