disorders Istvan Bitter 17 October 2016 Purpose of Diagnosis in Psychiatry Order and Structure Communication Predict Outcome Decide Appropriate Treatment Research Assist in the search for pathophysiology and etiology ID: 916689
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Slide1
Classification of mental disorders
Istvan
Bitter
17
October
, 2016
Slide2Purpose of Diagnosis in PsychiatryOrder and Structure
Communication
Predict Outcome
Decide Appropriate Treatment
Research:
Assist
in the search for pathophysiology and etiology
Slide3Procedural considerations for AssessmentClassification and diagnosis usually follow clinical interviewing to determine diagnosis
A
diagnostic
interview
is t
he
most widely used assessment tool in clinical psych
iatry
.
Slide4Assessments
Psychological
:
Clinical
interviews and
reports
Tests
(
psychological
incl
.
neuropsychological
)
Biological:
Scanning
brain function
(
e.g
.
CT,
CT,
MRI
,
f
MRI
, EEG,
PET)
Neurochemical
Genetic
Psychohysiological
measures
Slide5Components of Psychiatric AssessmentIdentifying dataChief Complaint
History of Present Illness
Past Psychiatric History
Past Medical
History
Family
History
Social History
Mental Status Exam
Assessment
: Main
diagnosis
and
comorbidities
(
psychiatric
and
somatic
)
Slide6Mental status examination incl
.
General appearance
Consciousness
Orientation
Speech and thought
(
speed
,
content
)
Perception MoodAnxietyAttention/concentration MemoryInsight and judgement Intelligence/higher intellectual functioningSuicidality
Slide7General Appearance and BehaviorDescribe appearance/behaviorGrooming, hygiene, facial expressionsJewelry, tattoos,Attitude towards examiner
Does
pt
look stated
age
?
Slide8Psychomotor ActivityPosture
Describe motor activity
Does s/he
s
eat
quietly
or
agitated
?
Note abnormal movements
Tics EPS (extrapyramidal symptoms)mannerisms catatoniaTD (tardive dyskinesia)
Slide9SpeechNote patient’s speechRRR (regular in rate and rhythm)Pressured, slow, normal
Loud, soft
Poverty of speech/content of speech
Latent
Echolalia
Aphasia
Slide10Thought FormDescribe thought process—this is inferred by pattern of speechSlow vs.
fast
Logical
and goal directed
Concrete
Preservative
Circumstantial, tangential
Thought
blocking
Slide11Thought ContentDescribe Content of ThoughtDelusions
Ideas of Reference
Obsessions and Compulsions
Phobia
Distorted body image
Poverty of content
Passive
death
wish
Suicidal/Self Harm/Homicidal Ideation
Slide12MoodMood is an emotional attitude that is relatively sustained (based on patient’s report)Euthymic
Depressed
Hyperthymic
(English: euphoric – however „
phoria
” is not a
e
qu
i
valent to „
thymia
” . Which is mood!)Irritable (mixed states – suicidality!)
Slide13AffectAffect refers to way pt conveys her/his emotional state (
based
on
observation
)
Appropriate vs inappropriate
Full
blunted
flat
Slide14Sensorium and Cognition 1.Mini Mental Status Exam covers most of the
components
Describe level of alertness
Orientation
(
time
,
space
,
self
and others) Memory Very short term: repeat 3 itemsShort term: recall 3 itemsLong term: events that occurred in past
Slide15Sensorium and Cognitive Function 2.
General Information
List 5 past presidents, current events
Calculations
Serial 7’s vs
3’s
,
spell
WORLD
backwards
Capacity to Read and Write
Read text, write a sentenceVisuospatial AbilityCopy designProverbs
Slide16Insight and JudgmentInsight: does the patient understand her/his illness, t
he
need for treatment?
Judgment: does the person make good choices?
Slide17PANSS: Positive and Negative Syndrome Scale
Copyright
protected
Slide18PANSS: Positive and Negative Syndrome Scale
http://egret.psychol.cam.ac.uk/medicine
/
scales
/PANSS
Slide19The Mini Mental State Examination (MMSE)
Permission is hereby granted to reproduce this
material for not-for-profit educational purposes only, provided
The Hartford Institute for Geriatric Nursing, Division of Nursing, New York University
is cited as the source.
Available on the internet at www.hartfordign.org. E-mail notification of usage to: hartford.ign@nyu.edu.
Slide20MMSE (2)Copy the design shown.
_____
Total Score
ASSESS level of consciousness along a continuum ____________
Alert Drowsy Stupor Coma
Slide21Clock test Please draw a clock which shows quarter to 3.
Slide22Diagnostic Manuals Diagnostic and Statistical Manual of Mental Disorders
,
(5th
Edition
2013
)
–
DSM-5,
American Psychiatric Association
International Statistical Classification of Diseases, Injuries and Causes of Death (10th version - 1993)
– ICD-10, World Health Organization
Slide23History of DSM
DSM I (1952)
established mainly by psychoanalysts to distinguish groups of psychoneurotic disorders, such as anxiety.
Interpretations of psychoneurotic disorders were mainstream Freudian
(
defense
mechanisms
).
Discourses of ‘reactions’ predominated.
Slide24DSM II (1968)1950’s - 1960’s - psychoanalysis still dominated. Psychoneurotic problems became defined as ‘neurotic’ disturbances (e.g. hysteria)
In 1973, homosexuality was removed, replaced by ‘sexual orientation disturbance’
There was little in the way of clear descriptions of ‘disorders’. All ‘symptoms’ were defined as ‘symbolic’ (of unconscious processes)
Slide25DSM III (1980)Completely new directions in psychiatry - instead of symptoms defined as ‘symbols’ - they were viewed as natural disease categories
Return to the world of medicine
Aims: research driven; operational criteria; based on ‘symptoms’ check list, not symbolic gestures
Outcome: the production of a science driven document – ego-dystonic homosexuality still included
Translated into
many
languages
Slide26ICD – 11 in 2018?http://apps.who.int/classifications/icd11/browse/f/en
Slide27http://apps.who.int/classifications/icd11/browse/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f405565289
BNO – 11
Slide28http://apps.who.int/classifications/icd11/browse/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f405565289
BNO – 11
Slide29DSM-III Paradigm Shift
Descriptive
Non-etiologic focus
Diagnostic criteria
Multiaxial system
Multiple
diagnoses
(
increase
in
comorbidities)
Reliability
Slide30DSM III R (1987)+ self-defeating personality disordersPost-traumatic stress disorder was introduced to account for repeated trauma in Vietnam veteransPressure groups altered the course of the DSM – ego-dystonic homosexuality removed
Slide31DSM IV (1994)Neurosis as a term is no longer in existenceMental
disorders included
DSM II = 85 disorders
DSM III = 265 disorders
DSM
III
-R
= 292 disorders
DSM IV = 297 disorders
Slide32DSM-IV TR, 2000Minor changes
Slide33DSM-IV: Multi-Axial Classification System
Axis
I lists the majority of mental disorders.
Axis II is reserved for persistent or chronic conditions
(
e.g
.
personality
disorders
)
The separation was intended to assure that more chronic conditions are not overlooked.Axis III is designed to present general medical information
Slide34DSM-IV: Multi-Axial Classification SystemAxis IV is designed to present specific information about the client’s current psychosocial environment.A number of global categories of problems are suggested in the DSM text.
Practitioners are encouraged to include specific information on Axis IV in addition to such global characterizations.
Slide35Multi-Axial Classification SystemGlobal Assessment Functioning (GAF) score is listed on Axis V.This 100-point scale is presented in
DSM
-IV
.
In some situations, an individual’s functioning can be at very different levels depending on which aspect is emphasized.
It is recommended that in those instances, the client’s potential for danger to self or others should take precedence in determining the GAF score.
Slide36Global
Assessment
of
Functioning
Scale
GAF – DSM IV
Copyright
protected
Slide37Slide38DSM-5, 2013Controversies about both the process of creating DSM-5 and about its content as well.Two out of the major challengers:1.
Thomas
Insel
,
Director
of
the
National Institute of Mental Health
2. Allan Frances, Chair of the DSM-IV Task Force of the American Psychiatric Association
Slide39Reseach Domain Criteria (RDoC)Thomas
Insel
,
Former
d
irector
of
NIMH
*
http://www.behavioral.net/sites/behavioral.net/files/imagecache/570x360/RDoC2.PNG
*
This year Thomas Insel announced
his
decision
to
move
to
Google
Slide40NIH: RDOC and APA : DSM-5May 13, 2013 • Press Release
http://www.nimh.nih.gov/news/science-news/2013/dsm-5-and-rdoc-shared-interests.shtml
Thomas R.
Insel
, M.D., Director, NIMH
Jeffrey A. Lieberman, M.D., President-elect, APA
NIMH and APA have a shared interest in ensuring that patients and health providers have the best available tools and information today to identify and treat mental health issues, while we continue to invest in improving and advancing mental disorder diagnostics for the future.
Today, the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), along with the International Classification of Diseases (ICD) represents the best information currently available for clinical diagnosis of mental disorders. Patients, families, and insurers can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care. The National Institute of Mental Health (NIMH) has not changed its position on DSM-5. As NIMH's
Research Domain Criteria (
RDoC
) project website states, "The diagnostic categories represented in the DSM-IV and the International Classification of Diseases-10 (ICD-10, containing virtually identical disorder codes) remain the contemporary consensus standard for how mental disorders are diagnosed and treated."Yet, what may be realistically feasible today for practitioners is no longer sufficient for researchers. Looking forward, laying the groundwork for a future diagnostic system that more directly reflects modern brain science will require openness to rethinking traditional categories. It is increasingly evident that mental illness will be best understood as disorders of brain structure and function that implicate specific domains of cognition, emotion, and behavior. This is the focus of the NIMH’s Research Domain Criteria (
RDoC) project. RDoC is an attempt to create a new kind of taxonomy for mental disorders by bringing the power of modern research approaches in genetics, neuroscience, and behavioral science to the problem of mental illness.
The evolution of diagnosis does not mean that mental disorders are any less real and serious than other illnesses. Indeed, the science of diagnosis has been evolving throughout medicine. For example, subtypes of cancers once defined by where they occurred in the body are now classified on the basis of their underlying genetic and molecular causes.All medical disciplines advance through research progress in characterizing diseases and disorders. DSM-5 and RDoC represent complementary, not competing, frameworks for this goal. DSM-5, which will be released May 18, reflects the scientific progress seen since the manual's last edition was published in 1994.
RDoC
is a new, comprehensive effort to redefine the research agenda for mental illness. As research findings begin to emerge from the
RDoC
effort, these findings may be incorporated into future DSM revisions and clinical practice guidelines. But this is a long-term undertaking. It will take years to fulfill the promise that this research effort represents for transforming the diagnosis and treatment of mental disorders.
By continuing to work together, our two organizations are committed to improving outcomes for people with some of the most disabling disorders in all of medicine.
###
About the National Institute of Mental Health (NIMH):
The mission of the NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery and cure. For more information, visit the
NIMH website
.
About the National Institutes of Health (NIH)
: NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit the
NIH website
.
Slide41Too Loose criteria?
Slide42Parts of a psychiatric disorder definition
1.
Symptoms
2
.
Time
– onset (e.g. ADHD: before age 12)
and/
or
length (e.g. major depressive episode: min 2 weeks)
3. Significant distress and/or impairment in social, occupational or other important areas of functioning. 4. Exclusion criteria (substance or an other medical condition)
Slide43Reliability and ValidityReliability
Consistent diagnoses
Interrater
reliability
Clear methods of assessment, standardised symptoms
Validity
Construct validity
Etiological Validity: Consistent Causal Factors
Predictive
Validity: Successful prognosis - most people with bi-polar respond well to lithium carbonate, suggesting coherence in diagnostic group
Slide44DSM and ICDAdvantages
Improve reliability of dx
Clarify dx and
facilitate history
taking
Clarify and facilitate process of differential diagnosis
Disadvantages
False sense of certainty
May sacrifice
validity
for reliability
RELIABILITY: capacity of individuals to agreeVALIDITY: capacity to make useful predictions
Treat dx like checklist and forget about patient as a person