talk to trainee Approved Mental Health practitioners (AMPHs - previously ASWs)

1. Classification and
Diagnosis of Mental
Disorders
Helen Crimlisk
Consultant Psychiatrist
Eastglade Sector Team (Oct 12)

2. Plan of Talk
 Classification
 Classification in general
 Classification of mental illness
 ICD 10
 Case example
 Break
 Diagnosis
 Diagnosis
 Assessment
 History
 Mental State Examination
 Common Mental Illnesses
 Case examples

3. Task
Why do we classify things?

4. Classification
 Why?
 Aids recognition - improves communication
 Economic - simplification “cognitive economy”
 Predictive - “heuristic” - leads to ability to test
hypotheses
 Reflect natural processes ( i.e. implies better
understanding e.g. Darwin )

5. Classification of manhole covers

6. Evolutionary Tree

7. Task
How do we classify?

8. Classification
 How?
 size
 age
 appearance
 prognosis
 similar biochemical / genetic factors

9. Classification by height

10. Task
What are the problems with
classification?

11. Classification
Problems
 Improved scientific understanding makes a
mockery of previous attempts to classify (e.g.
phrenology)

12. Phrenology

13. Classification
Problems
 Categorisationmeans defining thresholds
which may be and indeed often are arbitrary
 depression / dysthymia / fed up
 obese / well built / chubby / slender

14. Eysenck’s 2 dimensional trait theory

15. Classification
Problems
 Categorisation can lead to stigma and
prejudice

16. Terms previously acceptable now gone out of usage
because of negative connotations
cretin hypothyroid
mongol Down’s syndrome
mentally retarded
imbecile mentally handicapped Intellectually
challenged
moron
learning disabled
autism
idiot savant pervasive developmental
disorder
cerebral palsy
spastic
insane psychopathic
lunatic schizophrenia integrative
disorder??

17. Classification
Problems
 Economy of thought may lead to
oversimplification and inhumane action

18. Categorisation of people
makes it “easier” to engage
in inhumane behaviour
Jews
Polish Gypsies
Dissidents Homosexuals

19. What are the benefits of using
classification in mental health?
 to facilitate reporting and inform public health issues
 to provide a framework for research
 to encourage communication among health workers and
between them and health care providers /government
 Promote a feeling of being understood (“we’ve seen this
before – your problems are not unique”)
 Some ability to predict treatment options and natural
history

20. Task
How could we classify mental
health?

21. Classification in Mental Health
 severity severe / moderate / mild
depression
 characteristics hebephrenic / paranoid /
schizophrenia
 aetiology endogenous / exogenous
depression
 prognosis “treatment resistant”
personality disorders /
depression
 age young onset / older onset
dementia
 treatability personality disorders /
schizophrenia

22. History 1
 Cullen (18th Century)
 Neurosis
 “dysfunction of nervous system in the absence of fever”
 Freud (19th Century)
 Psychoneurosis
 “A neurosis that is psychological in origin”
 Kraepelin (19th Century)
 Distinguished between:
 Dementia Praecox (schizophrenia) and Manic Depressive Psychosis
(bipolar disorder)
 ICD -European / DSM -American (20th Century)

23. History 2
 1938
 FirstInternational classification to include mental
disorders
 International Classifications of Disease 5 (previously
“death”)
a. mental deficiency
b. schizophrenia
c. manic depressive psychosis
d. other mental diseases

24. History 3
 1992
 http://www3.who.int/icd/currentversion/fr-icd.htm
 ICD 10 published by World Health Organisation
 increased number of disorders listed
 diagnostic guidelines given
 subsections for different professions:
 medical / clerical / educational / research personnel
 version for primary care
 multi-axial classification introduced

25. Aims of ICD 10 Chapter V
To facilitate medical practice and public health
action by providing a common language to all
concerned.
To enable mental health workers, public health
decision makers, statisticians and professionals
in disciplines relevant to psychiatry:
 to understand one another
 to share results of research
 to improve and unify training strategies
 to allow all disciplines to record areas specific to them
as fully as they wish to

26. Developed simultaneously in
many languages
 Arabic
 Chinese
 English
 French
 German
 Japanese
 Portuguese
 Russian
 Spanish
 Translated into 30+ other languages

27. Features of ICD 10 Chapter V
 based on consensus
 based on field trials
 developed in collaboration between a Governmental
Organization (WHO) and non-Governmental
Organizations (WPA, WFN, AD, etc.)
 developed simultaneously in many languages
 compatible with national classifications
 developed in collaboration with a network of centres
around the world participating in relevant research,
undertaking translation and providing training and
support to users

28. ICD 10 Classification
 22 chapters I – XXII
 covering all ailments/conditions/abnormalities etc
 Chapter V: Mental and Behavioural Disorders
 F0 Organic mental disorders
 F1 Disorders due to psychoactive substance misuse
 F2 Schizophrenia, schizotypal and delusional disorders
 F3 Mood disorders
 F4 Neurotic, stress related and somatoform disorders
 F5 Behavioural syndromes associated with psychological
disturbances
 F6 Disorders of adult personality disorder and behaviour
 F7 Mental retardation
 F8 Disorders of psychological development
 F9 Behavioural and emotional disorders with onset usually
occurring in childhood and adolescence.

29. ICD 10 Classification
Each chapter has subsections with
clinical descriptions
 F2 Schizophrenia, schizotypal and delusional
disorders
 F20 schizophrenia
 F21 schizotypal disorder
 F22 persistent delusional disorder
 F23 Acute and transient psychotic disorder
 F24 Induced delusional disorder
 F25 schizoaffective disorder
 F28 Other non organic psychotic disorders
 F29 Unspecified non organic psychosis

30. Multi-axial presentation of
ICD-10
 Axis I clinical diagnoses
 mental disorders
 physical disorders
 personality disorders
 Axis II disability
 personal care
 occupation
 family and household
 functioning in broader social context
 Axis III contextual factors
 environmental and life style factors relevant to
pathogenesis and course of patient's illness

31. Case History 1
 Mr X, a 35-year old Asian factory worker, married, with 3
children, was admitted to hospital, having broken his leg
by falling down stairs.
 On the third day of admission, he grew increasingly
nervous and started to tremble. He could not sleep,
talked incoherently and was obviously very anxious.
 According to his wife, Mr X drank large quantities of beer
each night until falling asleep, for the last 3 years. This
had caused a rift in the relationship.

32. Case History 2
 He had been unhappy at work and was the only Asian.
During the past year he had missed work several times
and had been threatened with dismissal. He had been in
the country for 9 years, arriving as a asylum seeker.
 On examination Mr X spoke incoherently. He was
disoriented in time, place, and at times also in person.
He picked at bugs that he could see on his blanket. He
trembled and sweated profusely. He was agitated, tried
constantly to get out of bed and seemed unaware that
his right leg was in plaster.

33. Axis I: Clinical diagnoses
 Mr X had a long history of heavy alcohol use and
developed severe withdrawal symptoms when he could
not get alcohol.
 He presented with the characteristic symptoms of a
delirium: clouding of consciousness, global disturbance
of cognition, psychomotor agitation, disturbance of the
sleep-wake cycle, rapid onset and fluctuation of the
symptoms.
 There were no convulsions.
F10.40 Alcohol withdrawal state with delirium,
without convulsions.

34. Axis I: Clinical diagnoses
 The information provided by his wife gives
evidence pointing to an additional diagnosis of
alcohol dependence syndrome: continuous
heavy use during the last 3 years, difficulties in
controlling the drinking and the presence of a
withdrawal state.
F10.24 Alcohol dependence syndrome,
currently using the substance

35. Axis II: Disabilities
 Because of the situation described, it is possible
for an assessment to be made of the disabilities
suffered by Mr X on a scale defined in ICD 10:
A. Personal care =0
B. Occupation =1
C. Family and household =2
D. Broader social context =2

36. Axis III: Contextual factors
 It is thought by the assessor that the following
contextual factors were important to consider in
Mr X:
• Z55.0 illiteracy and low-level literacy
• Z56.4 discord with boss and workmates
• Z60.5 target of perceived adverse discrimination and
persecution
• Z60.3 acculturation difficulty (Migration & Social
transplantation)
• Z63.0 problems in relationship with spouse or partner

37. Coffee etc !!!!

38. Diagnosis
 How do we make diagnoses
 Man in the street’s terminology
 mad / depressed / drunkard
 Patients own diagnosis
 depression / hyperactivity / “ME”
 Rating Scales
 Beck Depression Inventory / Aspberger questionnaire
 Standardised Clinical Assessment
 E.g. SCAN interview ( set questions asked)
 History and Mental State Examination “clinical”

39. Aims of assessment – not only
diagnosis!
 make a provisional diagnosis
 elicit the aetiology of the illness
 identify maintaining factors
 clarify the risks – to patient / to others
 set out a management strategy

40. Psychiatric Assessment
 reason for referral
 history of presenting complaint
 past psychiatric history
 family history
 personal history
 past medical history
 use of medication/drugs/alcohol
 forensic history
 mental state examination
 including cognitive examination
 physical examination
 risk assessment
 management plan

41. History of presenting complaint
 what are the current symptoms?
 how long have they been present?
 what precipitated them?
 do the symptoms fluctuate?
 does anything help or make things worse?

42. Open Ended Questions
 “Can you tell me a bit about what the
problem is?”
 “I’d like to ask you a few questions in a
minute but perhaps you can start by
telling me in your own words what has
been happening to you?”

43. Clarifying and closed
questioning
 “Can I stop you there and just check a few
details - When exactly did this start? –
How long did that feeling last?”
 “Have you ever had anything like this
before?”
 “What exactly brought you into hospital
today?

44. Past Psychiatric History
 “Have you ever had anything like this
before?”
 “Did you ever seek help for this in the
past?”
 “Have you ever been in hospital for this
before”
 “What treatments have you tried in the
past?”

45. Family History
 “Has anyone else in the family had anything
similar to this?”
 “Has anyone in the family had problems with
their nerves?”
 “Has anyone in the family seen a psychiatrist
that you know about?”
 “Tell me a bit more about your family – are
your parents alive? What did they do for a
living? What’s your relationship like with
them? – has it always been like that?”

46. Personal History
 birth
 early development
 school - social / academic
 home environment
 qualifications
 relationships and children
 work

47. Personal History -clarifications
 “Did you complete the training course?
Why not – were you finding it difficult or
did you have problems with the boss?”
 “Why did you leave that job after just 3
months?”
 “Why did you have so much time off
school as a child?”

48. Past Medical History
 medical conditions
 admissions
 surgical procedures
 head injuries ?accidents
 deliberate self harm

49. Medication, Drugs & Alcohol
 current medication
 allergies
 illicit drug use
 how much?
 why?
 alcohol consumption
 how much?
 why?
 how long?

50. Drug and Alcohol - clarifications
 “What age were you when you first started
using drugs?”
 “Have you ever injected?
 Which veins do you use?”
 “So what do you actually mean by social
drinking?”
 “What time do you usually start drinking in the
morning?”
 “Do you drink every day?”

51. Forensic History
 juvenile crime
 court appearances
 convictions
 length of sentence
 against person / property
 experience of prison

52. Mental State Examination
 what you objectively observe
 can be done even where no history
available

53. Mental State Examination 1
 Appearance
 hygiene
 posture
 demeanour
 dress
 expression
 movements

54. Mental State Examination 2
 Behaviour
 tense
 relaxed
 over-familiar
 threatening
 withdrawn

55. Mental State Examination 3
 Speech
 quantity
 rate
 volume
 words
 associations

56. Mental State Examination 4
 Mood (subjective)
 depressed
 elated
 anxious
 biological features
 suicidal thoughts or plans
 Affect (objective)
 congruent
 appropriate

57. Mental State Examination 5
 Thoughts
 slowed or racing thoughts
 ruminative or intrusive thoughts
 thought disorder “loosened associations”
 preoccupations
 delusions

58. Mental State Examination 6
 Perceptions
 Hallucinations2nd or 3rd person?
 “Do the voices talk to you (2nd) or about you
(3rd)?”
 Command hallucinations
 “Have you ever heard sounds or voices that
no one else can hear?”
 “Have you ever had any unusual
experiences?”

59. Mental State Examination 7
 Cognitive
 orientation in time, place & person
 registration, attention
 memory
 naming
 following instructions
 writing
 copying

60. Insight
 how does the patient see their problems?
 do they recognise that there is a problem?
 Do they recognise problems as relating to
mental health?
 Are they willing to accept help?
 how do they feel about what should be
done now?

61. Physical Examination
 aetiological factors
 e.g.thyroid abnormalities
 head injuries
 co morbid factors
 diabetes
 asthma
 side effects
 interferon for MS
 Antiviral treatment in HIV / hepatitis

62. Risk Assessment
 risk to self through suicidal behaviour
 risk to self through neglect / dangerous
behaviour
 risk to others

63. Delusions 1
 a disorder of thought
 a belief that is
• firmly held
• not affected by rational argument or evidence
to the contrary
• not a conventional belief (not within
educational and cultural background)
• usually false but not always so

64. Delusions 2
 must differentiate from
• normal “eccentric” ideas
• overvalued ideas - an isolated belief which
can dominate a person’s life for years
- often within cultural background
- may be swayed by reason, not held with utter
conviction

65. Delusions 3
 Persecutory :
 patient believes a person or organization
are trying to harm him
 “They're out to get me”
 Grandiose :
 beliefs of inflated self-importance, celebrity,
supernaturalness
 “I am the true Queen of England”

66. Delusions 4
 Delusions of reference :
 certain objects/ events/ actions take on
special significance for the patient
 “When I hear them talking about pedophiles on
the TV, I know they really mean me”
 Nihilistic delusions :
 belief that everything is negated or absent
 “I don't have any bowels, they’ve been eaten
away”

67. Unusual types of delusions
 erotomanic (De Clerambault’s syndrome)
 patientdevelops a delusion that a man often of
higher social standing is in love with her (cf stalking)
 morbid jealousy (Othello syndrome)
 patientdevelops a delusion that a sexual partner is
being unfaithful NB high risk of violence
 delusional misidentification (Capgras syndrome)
 delusionthat a close relative has been replaced by
an impersonator (a number of variants possible)
 infestation (Ekbom’s syndrome)
 folie a deux “induced psychosis”

68. Hallucinatons 1
 Disorder of perception
 a percept
• experienced in the absence of an external
stimulus
• similar quality to that of a real perception
• experienced as originating in the outside
world (objective space) not in own mind
(subjective space)

69. Hallucinations 2
 It is important to differentiate between
hallucination and illusion
 illusion : misperceptions of external (real)
stimulus
 affect driven
 anxious child who sees a coat hanging on a door
and thinks it is a robber
 seeing a map of England in a crack on the ceiling

70. Types of hallucination
(different modalities)
 auditory hearing
 visual seeing
 olfactory smelling
 gustatory tasting
 tactile feeling

71. Auditory hallucinations
 2nd person
 “you are an evil person, you deserve to die”
 “you are the most important person in the world”
 3rd person
 running commentary “now he’s picking up the
knife and he’s going to ….”
 repeating patients thoughts
 several voices discussing patient “ I think he’s one
of the most wonderful people I’ve ever met” “Yes –
he is the true Messiah….”

72. Passivity phenomena
 Disorder of both thought and perception
 The feeling that one’s actions/ thoughts/ feelings
are not their own but controlled by an external
agency
!!!
External
agency
Controls own
thoughts

73. Thought alienation
 Disorder of thought
 The feeling that one’s thoughts are being
interfered with in some way
 thought broadcast
 thought insertion
broadcast
 thought withdrawal
insertion withdrawal

74. Some common mental
disorders
 Depression
 Mania
 Anxiety
 Schizophrenia

75. Depression
 disorder of mood
 three core symptoms:
 pervasive, persistent low mood
 loss of pleasure (anhedonia)
 loss of energy (anergia)
 psychotic phenomena
 mood congruent
 hallucinations 2nd person

76. Symptoms of depression
Biological symptoms Cognitive symptoms
 sleep disturbance  poor concentration
 appetite disturbance  hopelessness
 diurnal mood variation  worthlessness
 weight loss  guilt
 loss of libido  loss of confidence

77. Mania (also hypomania)
 disorder of mood
 three core features
 elevated or irritable mood
 increased energy/activity
 reduced need for sleep/rest
 psychotic phenomena
 grandiosity, paranoia
 hallucinations 2nd person

78. Symptoms of mania
 elevated mood
 feelings of well being, infective affect
 poor concentration and attention
 increased energy, drive, sexual energy
 irritability, boorish behaviour or conceit
 r educed need for sleep
 loss of social inhibitions
 grandiosity, inflated self esteem
 over spending, rash decisions
 promiscuity

79. Anxiety
 can be a symptom of many disorders e.g.
psychosis, depression, alcohol
dependence
 also prominent in the neurotic disorders :
• generalized anxiety disorder
• panic disorder
• phobias

80. Symptoms of anxiety
Physical Psychological
 palpitations  sense of impending
 hyperventilation doom
 chest pain  poor concentration
 dry mouth  irritability
 parasthesiae  restlessness
 headache  initial insomnia
 tremor
 urinary frequency

81. Schizophrenia
 Pragmatic definition
 A severe psychotic illness with onset in early
adulthood, characterised by bizarre
delusions, auditory hallucinations, thought
disorder strange behaviour and progressive
deterioration in personal, domestic, social
and occupational competence all occurring in
clear consciousness

82. Schizophrenia
 Schneiderian First Rank symptoms
 Symptoms which if present give weight to a
diagnosis of schizophrenia
 delusional perception
 audible thoughts
 voices heard arguing
 voices giving a running commentary
 made actions/impulses/feelings
 somatic passivity
 thought insertion/broadcast/withdrawal

83. Diagnoses
 full assessment needed to be certain
 diagnosis may need to be revised
 not static
 remember this is only axis I of the classification
system
 consider also
 disability
 contextural aspects

84. Case A (1)
A 34 yr old man presents in A+E saying
he is having a heart attack. He is sweaty,
shaky, breathless and experiencing
palpitations. Investigations rule out
“medical” causes.
What would you thinking of?

85. Case A (2)
On further questioning he tells you that he
has been drinking 1 bottle of vodka and
£30 worth of cannabis per day
What else would you think about?

86. Case A (3)
After he has calmed down, he tells you
that he uses the alcohol and cannabis to
“drown out” the voices. They talk about
him and control his thoughts and actions.
What now?

87. Case B (1)
A 19yr old male is brought in by the police
swearing and shouting. He says he is
responding to all the people calling him a
“bastard”. He believes that the police and
Army are involved in a conspiracy to kill
him.
What are your immediate thoughts?

88. Case B (2)
He is admitted to the ward and settles
down very quickly. A urine drug screen is
positive for amphetamines.
What now?

89. Case B (3)
A few days later he absconds from the
ward and returns drowsy and confused.
He says he has taken Ecstasy and
alcohol. You check his bloods and his
LFTs are very high.
What now?

90. Questions???