Psychiatric diagnosis

1
Psychiatric diagnosis

• No laboratory tests can be used
• (except in organic mental disorders)
• B. Mainly relies on
• Careful experienced observation
• Skilled clinical interview

2
Main diagnostic groups (ICD-10)

• Organic mental disorders (F00-09)
• Mental and behavioural disorders due to
  psychoactive substance use (F10-19)
• Schizophrenia, schizotypal and delusional
  disorders (F20-F29)
• Mood disorders (F30-F39)
• Neurotic, stress-related and somatoform disorders
  (F40-F48)
• Behavioural syndromes associated with
  phtsiological disturbances and physical factors
  (F50-F59)
• Disorders of adult personality and behaviour
  (F60-F69)
• Mental retardation (F70-F79)
• Disorders of psychological development (F80-F89)
• Behavioural and emotional disorders with onset
  usually occurring in childhood and adolescence
  (F90-F98)

3
Schizophrenia categorical definition

• Schizophrenia is defined by characteristic
• but nonspecific disturbances in the form
• and content of thought, perception, emotion,
• sense of self, volition, social relationships,
• and psychomotor behavior
• Subtypes include paranoid, disorganized
• (hebephrenic), catatonic, undifferentiated,
• residual and simple (ICD-10)

4
Schizophrenia

• gt 2 of the following
• Delusions
• Hallucinations
• Disorganized speech (e.g., frequent irrelevance
  or incoherence)
• Grossly disorganized or catatonic behaviour
• Negative symptoms, i.e., affective flattening,
  poverty of speech, or avolition
• Social/occupational dysfunction
• Duration gt 6 months

5
Schizotypal personality disorder

• Ideas of reference, suspiciousness or paranoid
  ideation
• odd beliefs or magical thinking (e.g.,
  superstitiousness, bizarre fantasies)
• inappropriate or constricted affect
• odd, eccentric or peculiar behavior
• lack of close froends or confidants
• excessive social anxiety

6
Paranoid personality disorder

• Suspects, without sufficient basis, that others
  are
• exploiting, harming or deceiving him/her
• preoccupied with unjustified doubts about the
• loyalty. Trustworthiness of friends/associates
• persistently bears grudges, unforgiving of
  insults,
• injuries, or slights
• is reluctant to confide in others
• perceives attacks on his/her character or
  reputation
• that are not apparent to others
• recurrent suspicions without justification
  regarding
• fidelity of spouse or sexual partner

7
Affective disorders

• Bipolar disorder episodes of mania or
• both mania and depression occur
• - Bipolar I Mania or mixed
• - Bipolar II recurrent major depression
• hypomania
• Unipolar depressive disorder
• - where episodes of depression alone occur.

8
Manic episode (DSM-IV)

• At least one week with
• Persistently expansive, elevated, or irritable
  mood
• gt 3 of the following symptoms
• (1) inflated self-esteem or grandiosity
• (2) decreased need for sleep
• (3) increased talkativeness or pressure of
  speech
• (4) racing thoughts or flight of ideas
• (5) distractibility
• (6) increased goal-directed activity or
  agitation
• (7) excessive involvement in pleasurable
  activities with a high potential for painful
  consequences
• C. Marked social dysfunction, need
  hospitalization, or with psychotic features

9
Hypomanic episode

• Symptoms gt 3 items and duration gt 4 days
• A clear change of usual functioning
• The Change in mood and functioning are observable
  by others
• No marked social dysfunction, no need for
  hospitalization, and no psychotic features

10
Depressive episode (DSM-IV)

• gt 5 items (most of the day and nearly everyday),
  with duration gt 2 weeks
• Depressed mood
• Diminished interest or pleasure in activities
• Insomnia or hypersomnia
• Marked increase or decrease in appetite or weight
  
• psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or excessive guilt
• Inability to concentrate or act decisively
• Recurrent thoughts of death or suicide

11
Dysthymic disorder (dysthymia)

• Depressed mood, most of the day, more days
• than not for gt 2 years (gt 1 year in children and
  
• adelescents)
• gt 3 of the following
• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-seteem
• Poor concentration or indecisive
• feelings of hopelessness
• c. During the 2-year, never been without the
  symptoms in A and B for gt 2 months at a time
• D. Rule out bipolar and hypomanic, and not
  preceded by major depressive episode

12
Generalized Anxiety Disorder (GAD)

• A. Excessive anxiety and worry (apprehensive
• expectation), occurring more days than not for
  at
• least 6 months, over a number of events or
• activities (e.g., work or school)
• B. gt 3 items of the following symptoms
• Restlessness or feeling keyed up or on edge
• Being easily fatigued
• Poor concentration
• Irritability
• Muscle tension
• Sleep disturbance

13
Definition of panic attack

• The presence of recurrent and unexpected panic
  attacks, each of which is characterized by a
  discrete period lasting from minutes to hours
  of intense fear or discomfort accompanied by
  several physiological symptoms, including
  palpitations, accelerated heart rate, sweating,
  trembling or shaking, shortness of breath,
  choking sensations, chest pain, nausea,
  dizziness, chills hot flashes, and fear of losing
  control or dying. Panic attacks are followed by
  persistent concerns about having additional
  attacks, worry about the implications of the
  attack or its consequences, and significant
  changes in behavior related to the attacks
  (DSM-IV).

14
Definition of panic disorder

• ICD-10
• Recurrent, at least 4 attacks in a 4-week period
• DSM-IV
• Phobic avoidance or agoraphobia (gt I month)
• worrying about further attacks (gt I month)

15
Agoraphobia

• Anxiety about being in places or situations
• from which escape might be difficult (or
• embarrassing) or help may not be available
• should panic attack occurs (being outside
• the home alone being in a crowd or
• standing in a line being on a bridge and
• traveling in a bus, train, or automobile)
• The situations are avoided or are endured
• with marked distress or with anxiety about
• having a panic attack, or require the
• presence of a companion

16
Adjustment disorders

• A. Emotional or behavioural symptoms in
• response to an identifiable stressor(s) that
• occurred in the past 3 months
• B. Causing either marked subjective distress
• or social/occupational impairment
• C. for any other mental disorder (excluding PD)
• D. Excluding bereavement
• E. Symptoms do not last for more than 6
• months once the stressor(s) terminated

17
Primary (non-organic) insomnia

• Difficulty initiating or maintaining sleep, or
  nonrestorative sleep, for gt 1 month
• Causing either marked subjective distress or
  social/occupational impairment
• Rule out narcolepsy and sleep apnea
• Not occurring during the course of another mental
  disorder (major depression, GAD, delirium)
• Not caused by a substance (drug, alcohol) or a
  general Medical Condition

18
Sleep disorder due to a general medical condition
(780)

• Significant sleep disturbance
• Directly caused by a general medical condition
  (history, physical examination, or laboratory
  findings)
• Not due to another mental disorder
• Not during the course of a delirium
• Rule out narcolepsy and sleep apnea
• Causing either marked subjective distress or
  social/occupational impairment

19
Harmful use of alcohol (ICD-10, F1x.1)

• Physical or psychological harm, including
  impaired judgement or dysfunctional behaviour,
  which may lead to disability or have adverse
  consequences for interpersonal relationships
• The nature of the harm clearly identifiable
• Persisted for at least 1 month or has occurred
  repeatedly in 12 months
• Does not meet the criteria for any other mental
  or behavioural disorder related to substance
  (except acute intoxication)

20
DSM-4 substance abuse

• At least one (or more) of the following,
  occurring within a 12-month period recurrently
• Failure to fulfill major role obligations at
  work, school, or home
• Risk-taking behaviour
• Legal problems
• Social or interpersonal harm
• Never met the criteria for substance dependence

21
Comparison between different systems

• ICD-10-CDDG ICD-10-DCR DSM-4
• Harm
• Physical () () (-)
• Psychological () () (-)
• Social/legal (-) () ()
• Risk taking (-) () ()
• Duration (-) 1 yr/1 month 1
  yr
• continuously

22
Alcohol dependence ICD-10-DCR

• Three or more from the following occurring
  together
• (persisting for 1 month or repeatedly in
  12-month)
• Desire/compulsion to take
• Impairment in control/unable to cut down
• Physiological withdrawal state/use of the
  substance to relieve or avoid withdrawal symptoms
• Tolerance
• Priority/time spent
• Physical/psychological/social harm

23
Alcohol dependence DSM-IV

• Three or more from the following occurring at any
• time in the same 12-month period
• Tolerance
• (a) increased amount
• (b) diminished effect with the same amount
• Withdrawal
• (a) Withdrawal syndrome
• (b) use of the substance to relieve
• Control over amount and time
• Desire/unable to cut down
• Time spent
• Priority
• Physical or psychological harm

24
Comparison between different systems
ICD-10 (gt 3) DSM-4 (gt 3) Craving
(desire) 1 (a), 5 (e) (4), (5), (6) Control 2
(b), 6 (f) (3), (4), (7) Withdrawal 3
(c) (2) Tolerance 4 (d) (1)