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PBBSC SY MENTAL HEALTH NURSING UNIT 2

  • Classification and assessment of mental disorders

Classification and Assessment of Mental Disorders

The classification and assessment of mental disorders are essential components of psychiatric practice, enabling the diagnosis, treatment, and understanding of various mental health conditions. These processes are standardized by widely recognized classification systems and diagnostic criteria.

Classification Systems

  1. DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition)
    • Published by the American Psychiatric Association (APA).
    • Widely used in the United States and other countries.
    • Provides a common language and standard criteria for mental health professionals.
    • Major Categories in DSM-5:
      • Neurodevelopmental Disorders (e.g., Autism Spectrum Disorder, ADHD)
      • Schizophrenia Spectrum and Other Psychotic Disorders
      • Bipolar and Related Disorders
      • Depressive Disorders
      • Anxiety Disorders
      • Obsessive-Compulsive and Related Disorders
      • Trauma- and Stressor-Related Disorders (e.g., PTSD)
      • Dissociative Disorders
      • Somatic Symptom and Related Disorders
      • Feeding and Eating Disorders
      • Sleep-Wake Disorders
      • Substance-Related and Addictive Disorders
      • Neurocognitive Disorders (e.g., Dementia)
      • Personality Disorders
      • Paraphilic Disorders
  2. ICD-11 (International Classification of Diseases, 11th Revision)
    • Published by the World Health Organization (WHO).
    • Used globally for health statistics, insurance coding, and clinical practice.
    • Chapter 06 focuses on mental, behavioral, or neurodevelopmental disorders.
    • Categories align closely with DSM-5 but include global perspectives.

Assessment of Mental Disorders

Assessment involves gathering information to understand the patient’s mental health status, aiding diagnosis and treatment planning.

  1. Clinical Interview
    • Most important tool in mental health assessment.
    • Can be structured, semi-structured, or unstructured.
    • Focuses on:
      • Presenting complaints
      • History of present illness
      • Past psychiatric and medical history
      • Family history
      • Social and developmental history
  2. Mental Status Examination (MSE)
    • A systematic evaluation of mental functioning.
    • Key components:
      • Appearance and Behavior: Observations about grooming, posture, and psychomotor activity.
      • Mood and Affect: Mood (subjective) and affect (objective).
      • Speech: Rate, volume, and coherence.
      • Thought Process: Logical or illogical, coherent or disorganized.
      • Thought Content: Presence of delusions, obsessions, or suicidal thoughts.
      • Perception: Hallucinations or illusions.
      • Cognition: Orientation, attention, memory, and judgment.
      • Insight and Judgment: Awareness of the illness and decision-making ability.
  3. Psychological Testing
    • Standardized tools for evaluating specific mental health conditions.
    • Examples:
      • Personality Tests: MMPI (Minnesota Multiphasic Personality Inventory).
      • Cognitive Tests: WAIS (Wechsler Adult Intelligence Scale).
      • Projective Tests: Rorschach Inkblot Test, TAT (Thematic Apperception Test).
  4. Rating Scales and Inventories
    • Commonly used to assess severity and monitor progress.
    • Examples:
      • Beck Depression Inventory (BDI)
      • Hamilton Anxiety Rating Scale (HAM-A)
      • Positive and Negative Syndrome Scale (PANSS) for schizophrenia.
  5. Neuroimaging and Laboratory Tests
    • Used to rule out organic causes or co-morbid medical conditions.
    • Examples:
      • MRI, CT scan, EEG for brain structure and function.
      • Blood tests for metabolic disorders or drug screening.
  6. Behavioral Observations
    • Monitoring in natural or clinical settings to evaluate functioning and symptoms.

Importance of Classification and Assessment

  • Diagnosis: Helps determine the specific disorder.
  • Treatment Planning: Guides therapy, medication, and interventions.
  • Research: Facilitates understanding and development of new treatments.
  • Communication: Provides a standardized language for professionals.
  • Terminologies used in psychiatry

Terminologies Used in Psychiatry

Psychiatry involves a wide range of terms to describe mental processes, disorders, symptoms, and treatment approaches. Below is a categorized list of key psychiatric terminologies:

1. General Terms

  • Mental Health: A state of well-being in which an individual can cope with normal life stresses, work productively, and contribute to the community.
  • Mental Illness: A condition that affects an individual’s thinking, mood, or behavior.
  • Psychiatry: A branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders.

2. Symptoms and Signs

Mood and Affect

  • Euphoria: An exaggerated sense of well-being or happiness.
  • Dysphoria: A state of unease or dissatisfaction.
  • Flat Affect: Lack of emotional expression.
  • Labile Affect: Rapid and extreme changes in emotions.

Thought Processes

  • Delusion: A false belief held despite evidence to the contrary (e.g., delusions of persecution or grandeur).
  • Obsessions: Recurrent, persistent thoughts or urges causing distress.
  • Compulsions: Repetitive behaviors performed to reduce anxiety caused by obsessions.
  • Hallucination: A perception in the absence of external stimuli (e.g., auditory or visual hallucinations).

Cognition

  • Confabulation: Fabricated or distorted memories without intent to deceive.
  • Amnesia: Loss of memory.
  • Aphasia: Inability to express or understand speech.
  • Agnosia: Inability to recognize objects, people, or sounds.

Behavior

  • Catatonia: Abnormal motor behavior characterized by rigidity or stupor.
  • Akathisia: Restlessness and an inability to stay still.
  • Stereotypy: Repetitive, purposeless movements.
  • Tics: Sudden, repetitive, non-rhythmic motor movements or vocalizations.

Perception

  • Illusion: Misinterpretation of real external stimuli.
  • Depersonalization: Feeling detached from oneself.
  • Derealization: A sense of unreality about the external world.

3. Disorders

  • Schizophrenia: A psychotic disorder involving delusions, hallucinations, disorganized speech, and impaired functioning.
  • Bipolar Disorder: A mood disorder with alternating episodes of mania and depression.
  • Major Depressive Disorder: A mood disorder characterized by persistent sadness and loss of interest.
  • Obsessive-Compulsive Disorder (OCD): A disorder with obsessions and compulsions.
  • Post-Traumatic Stress Disorder (PTSD): Anxiety disorder triggered by traumatic events.
  • Anorexia Nervosa: Eating disorder involving extreme restriction of food intake.
  • Autism Spectrum Disorder: Neurodevelopmental disorder affecting communication and behavior.

4. Psychiatric Interventions

  • Psychotherapy: Treatment involving psychological methods (e.g., cognitive-behavioral therapy).
  • Psychopharmacology: Use of medications to manage mental disorders (e.g., antidepressants, antipsychotics).
  • Electroconvulsive Therapy (ECT): Electrical stimulation of the brain to treat severe depression or other conditions.
  • Behavior Therapy: Focuses on modifying maladaptive behaviors.
  • Cognitive Therapy: Addresses distorted thinking patterns.

5. Specific Terms for Disorders and States

Anxiety-Related

  • Panic Attack: Sudden, intense fear or discomfort.
  • Phobia: An intense, irrational fear of specific objects or situations.
  • Agoraphobia: Fear of open or crowded places.

Substance-Related

  • Addiction: Compulsive substance use despite harmful consequences.
  • Withdrawal: Symptoms occurring after cessation of substance use.
  • Tolerance: Need for increasing amounts of a substance to achieve the same effect.

Personality and Behavior

  • Antisocial Personality: Disregard for others’ rights and lack of remorse.
  • Borderline Personality: Instability in relationships, self-image, and emotions.
  • Paranoia: Irrational mistrust or suspicion of others.

Sexual and Gender-Related

  • Gender Dysphoria: Distress due to a mismatch between one’s gender identity and assigned sex.
  • Paraphilia: Atypical sexual interests that may cause distress or harm.

6. Psychiatric Tools and Techniques

  • Mental Status Examination (MSE): A systematic assessment of an individual’s mental state.
  • DSM-5: Diagnostic and Statistical Manual of Mental Disorders, used for diagnosis.
  • ICD-11: International Classification of Diseases, used for mental and physical health diagnosis.

7. Legal and Ethical Terms

  • Informed Consent: Agreement for treatment after being informed of the risks and benefits.
  • Competency: A legal term referring to the ability to make informed decisions.
  • Confidentiality: Ethical principle of keeping patient information private.
  • Classification of mental disorders

Classification of Mental Disorders

Mental disorders are systematically categorized based on their symptoms, causes, and diagnostic criteria. Classification helps in diagnosing, researching, and treating these disorders. Two primary classification systems are used worldwide:

1. Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

  • Published by the American Psychiatric Association (APA).
  • Commonly used in the United States.
  • Offers standardized diagnostic criteria and definitions.

Major DSM-5 Categories:

  1. Neurodevelopmental Disorders:
    • Examples: Autism Spectrum Disorder, Attention-Deficit/Hyperactivity Disorder (ADHD), Intellectual Disability.
  2. Schizophrenia Spectrum and Other Psychotic Disorders:
    • Examples: Schizophrenia, Schizoaffective Disorder, Delusional Disorder.
  3. Bipolar and Related Disorders:
    • Examples: Bipolar I Disorder, Bipolar II Disorder, Cyclothymic Disorder.
  4. Depressive Disorders:
    • Examples: Major Depressive Disorder, Persistent Depressive Disorder (Dysthymia).
  5. Anxiety Disorders:
    • Examples: Generalized Anxiety Disorder, Panic Disorder, Phobias.
  6. Obsessive-Compulsive and Related Disorders:
    • Examples: Obsessive-Compulsive Disorder (OCD), Hoarding Disorder, Body Dysmorphic Disorder.
  7. Trauma- and Stressor-Related Disorders:
    • Examples: Post-Traumatic Stress Disorder (PTSD), Acute Stress Disorder.
  8. Dissociative Disorders:
    • Examples: Dissociative Identity Disorder, Dissociative Amnesia.
  9. Somatic Symptom and Related Disorders:
    • Examples: Somatic Symptom Disorder, Conversion Disorder.
  10. Feeding and Eating Disorders:
    • Examples: Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder.
  11. Elimination Disorders:
    • Examples: Enuresis (bedwetting), Encopresis (fecal incontinence).
  12. Sleep-Wake Disorders:
    • Examples: Insomnia Disorder, Narcolepsy, Sleep Apnea.
  13. Sexual Dysfunctions:
    • Examples: Erectile Disorder, Premature Ejaculation.
  14. Gender Dysphoria:
    • Distress related to a mismatch between one’s gender identity and assigned sex.
  15. Disruptive, Impulse-Control, and Conduct Disorders:
    • Examples: Oppositional Defiant Disorder, Intermittent Explosive Disorder.
  16. Substance-Related and Addictive Disorders:
    • Examples: Alcohol Use Disorder, Opioid Use Disorder, Gambling Disorder.
  17. Neurocognitive Disorders:
    • Examples: Dementia, Delirium, Alzheimer’s Disease.
  18. Personality Disorders:
    • Examples: Borderline Personality Disorder, Antisocial Personality Disorder, Narcissistic Personality Disorder.
  19. Paraphilic Disorders:
    • Examples: Pedophilic Disorder, Voyeuristic Disorder.
  20. Other Disorders:
    • Includes disorders not otherwise specified, such as unspecified mental conditions.

2. International Classification of Diseases (ICD-11)

  • Published by the World Health Organization (WHO).
  • Used globally for health statistics and clinical diagnosis.
  • Chapter 06 focuses on mental, behavioral, or neurodevelopmental disorders.

Major ICD-11 Categories:

  1. Neurodevelopmental Disorders:
    • Similar to DSM-5 but includes global perspectives.
  2. Schizophrenia and Primary Psychotic Disorders.
  3. Mood Disorders:
    • Depressive and Bipolar Disorders.
  4. Anxiety and Fear-Related Disorders.
  5. Obsessive-Compulsive or Related Disorders.
  6. Disorders Specifically Associated with Stress.
  7. Dissociative Disorders.
  8. Feeding and Eating Disorders.
  9. Elimination Disorders.
  10. Sleep-Wake Disorders.
  11. Sexual Disorders:
    • Includes both dysfunctions and paraphilias.
  12. Impulse Control Disorders.
  13. Substance Use Disorders.
  14. Neurocognitive Disorders.
  15. Personality Disorders.
  16. Developmental and Behavioral Disorders:
    • Includes conditions like ADHD and conduct disorders.

Key Differences Between DSM-5 and ICD-11

AspectDSM-5ICD-11
OriginAmerican Psychiatric AssociationWorld Health Organization
UsePrimarily in the U.S.Globally used
PurposeClinical practice, researchClinical, research, and statistical use
FocusMore detailedBroader and simpler categories

Significance of Classification

  1. Diagnosis and Treatment:
    • Helps in identifying the disorder and planning appropriate interventions.
  2. Research:
    • Facilitates studies on prevalence, causes, and treatments.
  3. Communication:
    • Provides a common language for mental health professionals worldwide.
  4. Insurance and Legal Matters:
    • Ensures standardized coding for reimbursement and medico-legal documentation.
  • Etiological factors and psychopathology of mental disorders

Etiological Factors and Psychopathology of Mental Disorders

Understanding the causes (etiology) and the mechanisms (psychopathology) of mental disorders is critical for diagnosis, treatment, and prevention. Mental disorders result from complex interactions of biological, psychological, and social factors.

1. Etiological Factors of Mental Disorders

A. Biological Factors

  1. Genetics:
    • Inherited predispositions increase vulnerability to disorders such as schizophrenia, bipolar disorder, and depression.
    • Family and twin studies show higher concordance rates for mental disorders in monozygotic twins.
  2. Neurochemical Imbalances:
    • Dysregulation of neurotransmitters (e.g., dopamine, serotonin, norepinephrine) is implicated in conditions like depression, anxiety, and psychosis.
  3. Brain Structure and Function:
    • Structural abnormalities (e.g., reduced hippocampal volume in PTSD, enlarged ventricles in schizophrenia).
    • Functional abnormalities in brain circuits (e.g., prefrontal cortex dysfunction in ADHD).
  4. Endocrine and Immune System Dysregulation:
    • Hormonal imbalances (e.g., cortisol in depression or anxiety).
    • Immune system activation and inflammation (e.g., autoimmune encephalitis linked to psychosis).
  5. Prenatal and Perinatal Factors:
    • Infections, malnutrition, or hypoxia during pregnancy can lead to developmental disorders.
    • Birth complications are linked to schizophrenia and autism.

B. Psychological Factors

  1. Early Life Experiences:
    • Adverse childhood experiences (ACEs), such as abuse or neglect, increase the risk of developing anxiety, depression, and personality disorders.
  2. Trauma:
    • Physical or emotional trauma can lead to PTSD, dissociative disorders, and depression.
  3. Maladaptive Thought Patterns:
    • Negative automatic thoughts and cognitive distortions contribute to anxiety and depression.
  4. Personality Traits:
    • Traits like neuroticism or low resilience can predispose individuals to mental disorders.

C. Social and Environmental Factors

  1. Socioeconomic Status:
    • Poverty, unemployment, and low education levels are risk factors.
  2. Social Relationships:
    • Isolation and lack of support can exacerbate conditions like depression and anxiety.
  3. Cultural Influences:
    • Cultural norms and stigma can affect how symptoms are expressed and treated.
  4. Substance Abuse:
    • Alcohol and drug use are major risk factors for substance use disorders and can also trigger other mental disorders.

D. Other Factors

  1. Medical Conditions:
    • Chronic illnesses (e.g., diabetes, cardiovascular disease) can lead to depression or anxiety.
  2. Toxins and Drugs:
    • Exposure to environmental toxins or medications (e.g., corticosteroids) can cause psychiatric symptoms.

2. Psychopathology of Mental Disorders

Psychopathology refers to the study of abnormal functioning that underlies mental disorders. It explores mechanisms at various levels:

A. Neurobiological Basis

  1. Schizophrenia:
    • Dopamine hyperactivity in mesolimbic pathways contributes to positive symptoms (e.g., hallucinations).
    • Glutamate dysregulation and structural brain changes (e.g., loss of gray matter) play roles.
  2. Depression:
    • Decreased serotonin and norepinephrine levels.
    • Hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis, leading to excessive cortisol release.
  3. Bipolar Disorder:
    • Dysregulation of neurotransmitters (dopamine, serotonin).
    • Abnormal activity in brain areas regulating mood, such as the amygdala and prefrontal cortex.
  4. Anxiety Disorders:
    • Overactivation of the amygdala (fear center).
    • Dysregulation of the GABA system (reduced inhibitory neurotransmission).

B. Cognitive and Emotional Dysfunctions

  1. Cognitive Models:
    • Faulty thinking patterns, such as catastrophizing or overgeneralization, contribute to anxiety and depression.
    • Cognitive distortions are central to disorders like OCD and PTSD.
  2. Emotional Dysregulation:
    • Difficulty regulating emotions is a hallmark of borderline personality disorder and mood disorders.

C. Behavioral Mechanisms

  1. Conditioning:
    • Phobias and anxiety can result from classical conditioning (e.g., pairing a neutral stimulus with fear).
    • Operant conditioning (negative reinforcement) maintains avoidance behaviors.
  2. Learned Behaviors:
    • Maladaptive behaviors may develop from modeling or reinforcement in childhood.

D. Social and Environmental Pathology

  1. Stress-Diathesis Model:
    • Mental disorders result from the interaction between a genetic predisposition (diathesis) and environmental stressors.
  2. Cultural Psychopathology:
    • Cultural context influences the manifestation of disorders (e.g., somatization in some cultures).

Integrated Approach: Biopsychosocial Model

Mental disorders are rarely caused by a single factor. The biopsychosocial model integrates biological, psychological, and social influences to explain their etiology and psychopathology.

ComponentExample
BiologicalNeurochemical imbalances, genetic vulnerability.
PsychologicalMaladaptive thoughts, trauma, personality traits.
SocialSocioeconomic status, cultural stigma, relationships.

Understanding the etiological factors and psychopathology of mental disorders is vital for personalized and effective treatment. By addressing the interplay of biological, psychological, and social factors, mental health professionals can better diagnose and manage these conditions.

  • History taking and assessment methods for mental disorders

History Taking and Assessment Methods for Mental Disorders

The process of history-taking and assessment is the cornerstone of diagnosing and managing mental disorders. A comprehensive evaluation combines clinical interviews, mental status examination, standardized assessment tools, and collateral information to understand the patient’s mental health.

1. History Taking in Psychiatry

History taking provides detailed insights into the patient’s condition and helps establish a diagnosis and treatment plan. Key components include:

A. Identifying Information

  • Name, age, gender, marital status, occupation, education level.
  • Referral source (self, family, or other healthcare professional).

B. Chief Complaint

  • The primary reason for seeking help, described in the patient’s own words.
  • Example: “I feel anxious all the time.”

C. History of Present Illness (HPI)

  • Onset: When did the symptoms start?
  • Duration: How long have the symptoms been present?
  • Progression: Have the symptoms worsened, improved, or remained the same?
  • Precipitating Factors: Was there any triggering event (e.g., trauma, loss)?
  • Associated Symptoms: Any additional issues, such as sleep disturbances or appetite changes?
  • Impact: How has the condition affected daily functioning (e.g., work, relationships)?

D. Past Psychiatric History

  • Previous diagnoses and treatments (e.g., medications, psychotherapy, hospitalizations).
  • History of suicide attempts or self-harm.
  • History of substance use or abuse.

E. Medical History

  • Comorbid medical conditions (e.g., diabetes, hypertension, neurological disorders).
  • History of head injuries, seizures, or other physical illnesses affecting mental health.

F. Family History

  • Psychiatric illnesses in close relatives (e.g., depression, schizophrenia).
  • History of substance abuse or suicide in the family.

G. Personal and Social History

  • Early Development: Birth history, milestones, and childhood experiences.
  • Education and Occupation: Level of education, job history, and current employment status.
  • Relationships: Marital status, quality of relationships with family and friends.
  • Lifestyle: Social activities, hobbies, and habits.
  • Substance Use: Alcohol, tobacco, or drug use history.

H. Premorbid Personality

  • Patient’s personality traits and coping mechanisms before the onset of illness.
  • Behavioral patterns (e.g., introverted, outgoing, perfectionistic).

I. Sexual History

  • Sexual orientation, activity, and any related concerns.

J. Socioeconomic and Cultural Factors

  • Financial status, cultural background, and religious beliefs influencing mental health.

2. Assessment Methods for Mental Disorders

A. Mental Status Examination (MSE)

The MSE is a structured assessment of the patient’s current mental functioning. Key components include:

  1. Appearance and Behavior:
    • Grooming, posture, psychomotor activity (agitation or retardation), eye contact.
  2. Speech:
    • Rate, volume, tone, coherence (e.g., rapid, soft, slurred).
  3. Mood and Affect:
    • Mood: Patient’s subjective emotional state.
    • Affect: Observed emotional response (e.g., flat, labile, congruent with mood).
  4. Thought Process:
    • Logical, coherent, or disorganized (e.g., tangential, circumstantial).
  5. Thought Content:
    • Delusions, obsessions, suicidal thoughts, phobias.
  6. Perception:
    • Hallucinations (auditory, visual) or illusions.
  7. Cognition:
    • Orientation (time, place, person), memory, attention, concentration.
  8. Insight and Judgment:
    • Insight: Awareness of the illness.
    • Judgment: Ability to make sound decisions.

B. Psychological Testing

  1. Standardized Tests:
    • Personality Tests: MMPI (Minnesota Multiphasic Personality Inventory).
    • Cognitive Tests: WAIS (Wechsler Adult Intelligence Scale).
    • Projective Tests: Rorschach Inkblot Test, TAT (Thematic Apperception Test).
  2. Screening Tools:
    • Beck Depression Inventory (BDI) for depression.
    • Generalized Anxiety Disorder Scale (GAD-7).
    • Positive and Negative Syndrome Scale (PANSS) for schizophrenia.

C. Diagnostic Tools and Structured Interviews

  1. Structured Clinical Interviews:
    • SCID (Structured Clinical Interview for DSM Disorders) for formal diagnosis.
    • MINI (Mini International Neuropsychiatric Interview).
  2. Diagnostic Systems:
    • DSM-5 (Diagnostic and Statistical Manual of Mental Disorders).
    • ICD-11 (International Classification of Diseases).

D. Behavioral Observations

  • Observe the patient’s behavior in natural or clinical settings (e.g., interactions with family or staff).

E. Neuroimaging and Laboratory Investigations

  1. Neuroimaging:
    • MRI or CT scan to rule out structural brain abnormalities.
    • PET scan for functional brain activity.
  2. Laboratory Tests:
    • Thyroid function tests (e.g., hypothyroidism and depression).
    • Drug and toxicology screening.
    • Vitamin deficiencies (e.g., B12 deficiency and cognitive impairment).

F. Collateral Information

  • Gather information from family, caregivers, or close friends to corroborate the patient’s history and assess their reliability.

3. Documentation and Clinical Formulation

  • Summary of Findings: Combine history, MSE, and diagnostic tools to arrive at a provisional or definitive diagnosis.
  • Biopsychosocial Model: Address biological, psychological, and social factors contributing to the disorder.
  • Treatment Plan: Develop individualized interventions based on assessment results.

4. Importance of History and Assessment

  • Accurate Diagnosis: Identify the underlying disorder.
  • Treatment Planning: Tailor therapy and medication to the patient’s needs.
  • Progress Monitoring: Evaluate treatment effectiveness over time.
  • Building Rapport: Establish trust and a therapeutic relationship.

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