Tag Archives: diagnosis

Schizophrenia, social care and the tripartite recovery model

What is schizophrenia? How do reasonable attempts to cope with symptoms like voice-hearing come to be thought of as symptoms of illness in themselves? Why is it so easy to get diagnosed with schizophrenia? More importantly, how can we use an understanding of the diagnostic process to aid recovery?

In this short video Stuart Sorensen introduces the basic idea behind the tripartite recovery model and shows how meaningful recovery is really all about coping. It’s not magical and it’s not complicated. Like most of mental health work in social care it’s about doing relatively simple things, repeatedly and well. Do the things that help people to feel valued and to cope with their experiences and you’re more than half way there.

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Psychosis 2: Delusions, illusions and hallucinations

Don't let yourself off the hook thumbnailPart 2 of the psychosis mini-series looks at delusions (AKA ‘Fixed, false beliefs – not amenable to reason’). Delusions are more than just vague ideas – they’re the things people hold to be most certain. Here we look at some of the ways that delusions form, the relationship between delusions, illusions and hallucinations and we begin to think about some of the ways that we can help delusional people.

I have long maintained that this connection is vital to our understanding of psychosis and yet not a word about it was uttered during my nurse training.The student nurses of 1992-95 never heard a peep about these vital links. The student nurses of 2017… well… We consider the role of memory and familiarity in perception and how the self-fulfilling prophecy of expectation can create mistakes, not only in our five senses but in the beliefs we form that so often rely upon that sense data to begin with.

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Should psychiatrists diagnose personality disorder?

Personality disorder is a controversial diagnosis. There are no blood tests or physical criteria confirming personality disorder. In fact there’s no real evidence to suggest that personality disorder is a medical condition at all. So why do psychiatrists diagnose personality disorder? More importantly… should they?

Here we consider the roots of personality disorder diagnoses from the Moral defective of a century ago to the 3 personality disorder clusters of today. We look at the way personality disorder is diagnosed through behaviours, emotions and enduring patterns of response to society and we consider the advantages of understanding a person’s personality traits. Knowledge is power.

The more we know the more likely we are to be able to help. But we must be careful. Too often the diagnosis of personality disorder is used as an excuse to write a person off as incurable, hopeless or even undeserving. That’s the legacy we’ve been left by our Edwardian and Victorian predecessors.

If we are to do right by the personality disordered patients of today and in the future we need to embrace the understanding this diagnosis can bring but reject the pejorative notions of undeservingness, incurability and hopelesness that all too often come along with it.

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Mental disorders made simple for students and others

I often get to take student mental health nurses around in my day to day practice. It’s part of their training to spend time ‘in the field’ so to speak and learn their craft. We don’t just drag them around and let them watch what we do though. We try to help them understand what seems at first to be a very complicated world of diagnoses and disorders, mindsets and medications.

This short video is intended to reassure new students and others that mental disorders don’t need to be complicated. It’s true that we can (and often do) make the world of mental health as complex and convoluted as we like. But there are still some basic principles that can help guide us all through the maze.

This is how I explain the basics of diagnosis and disorder to those students unfortunate enough to cross my path. We should always begin with simple principles and then build upon those foundations. That way, when things start to get complicated there’s something straightforward to rely upon as we go.

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The meaning of psychiatric diagnoses

One of the most common concerns among social care workers, at least those I meet is around diagnosis. There are so very many different psychiatric diagnoses, all with their own particular symptoms and they seem almost impossible to remember.

I can sympathise with that view – there really are a lot of diagnoses and the differences between them sometimes seem so very subtle that it’s hardly worth mentioning at all. However – that doesn’t need to be such a problem in social care.

Support workers aren’t diagnosticians and they don’t need to be able to fit everyone they work with into the particular boxes of psychiatric diagnosis. It’s enough to know what the service-user’s actual problems are without worrying about pigeon holing them. After all – there really is much more to life than diagnosis.

So here’s a breakdown of what really matters in psychiatric diagnosis.

Diagnosis meaning and purpose

The word ‘diagnosis’ comes from Greek. It’s made up of two words:

  1. Dia – through
  2. Gnosis – knowledge

Diagnosis means ‘through knowledge’ and yet we know much less than we’d like to for sure. In fact there are those who argue that diagnosis is little better than useless in mental health care and should be replaced by a different system known as ‘formulation’ instead. This is because whereas diagnosis seeks to place sufferers and their conditions into predefined ‘boxes’, formulation seeks to construct a new explanation for each individual regardless of the experiences of other people and the ‘boxes’ they may have occupied in the past.

Perhaps the biggest criticism of diagnosis in mental health care is based upon the established purpose of diagnosis. It is intended to:

  1. Predict outcome (prognosis);
  2. Inform treatment.

In the case of diseases like Alzheimer’s dementia or Parkinson’s disease diagnosis can (to a greater or lesser extent) fulfil both of these promises. In the case of ‘Schizophrenia’ or ‘Brief Psychotic Episode’ it seems far less effective and in the opinion of many far less plausible too.

It’s important to be clear about what this means in practice. There’s a set order (a syntax) to psychiatric diagnosis and it really only works in one direction. This is different from many other sorts of diagnosis, the diagnosis of physical illness for example. That’s because whereas physical illnesses tend to be diagnosed ‘through knowledge’ of measurable physical processes with very specific, known (or at least likely) and predictable specific effects, psychiatric diagnoses tend to be based upon ‘clinical judgement’ with little or no physical tests available to support them.

Psychiatrists don’t rely upon measurable evidence to support their diagnosis and so they can’t really say for sure that one symptom will follow another. For example…

The physical diagnosis of COPD (Chronic Obstructive Pulmonary Disease) is diagnosed using specific tests that show that a person’s lung function is impaired. The inevitable result of significantly impaired lung function is breathlessness when exercising. So, because of this measurable condition and the inevitability of breathlessness we can reasonably say…

“Of course John gets breathless – he has COPD”

We can say this because we have excellent evidence of impaired lung function and because we know what happens to respiration when people with COPD exert themselves. We have good, testable information about the causes ranging from oxygen saturation levels in the blood to peak flow measurements of respiration itself to name but two. We know exactly what we’re looking at in other words.

Psychiatric diagnosis is different. It isn’t usually based upon blood tests or sophisticated scans. Instead the psychiatrist takes a history, observes the current ‘presentation’ of the patient and then makes a diagnosis based upon how closely the person’s ‘symptoms’ match the descriptions in the psychiatric diagnostic manual.

This means that diagnosis only shows what ‘symptoms’ are already apparent – it can’t predict other symptoms that aren’t already there. This means that we can only say something like:

“John has a diagnosis of schizophrenia because he has visions.”

We cannot say:

“Of course John has visions. He has a diagnosis of schizophrenia.”

Not everyone diagnosed with schizophrenia has visions. So the symptoms might explain the diagnosis but the diagnosis can’t explain the symptoms. It’s just a name, a label and names don’t explain things – they simply classify them.

For example, on my office wall I have a large clock. I know it is a clock because it has the observable characteristics of a clock (hands that rotate, a numbered face and it ticks). However naming it as a ‘clock’ doesn’t tell me anything about how it works. I am no closer to understanding the intricate mechanisms of the various cogs and springs inside the clock just because I know what to call it.

Many psychiatric diagnoses are just like that. We don’t get any closer to understanding the workings of schizophrenia just because we can name it. That’s why we must be careful to let symptoms explain the diagnosis but not to delude ourselves into thinking that the diagnosis explains the symptom.

Syntax of psych diagnosis

Generally speaking we can only go one way with psychiatric diagnosis. It doesn’t usually work well ‘in reverse’.

The symptoms explain the diagnosis

The diagnosis does not explain the symptoms

But diagnosis isn’t entirely useless. My own view is that it is too reductionist. Diagnostic psychiatry reduces people to component parts to be ‘fixed’ rather like a mechanic working on an engine. Diagnosis has its place although, like many other people working in mental health services, I’d welcome a more widespread use of psychological formulation alongside the ‘boxes’ of traditional psychiatric practice.

5 types of mental disorder

In the simplest terms mental disorder is really only a combination of three types of symptom:

  • Anxiety – physical and psychological arousal
  • Depression – physical and psychological de-arousal
  • Psychosis – hallucinations, delusions and thought disorders

All mental disorders (except the dementias which also include memory and orientation problems) are made up of combinations of these three types of experience or people’s vulnerability to them.

Personality disorders are diagnoses based upon the way people usually think and behave and upon their susceptibility to anxiety, depression and psychosis. Remember that those personality disorders that are categorised by anger are really anxiety based. Both anger and anxiety (as we shall see later) are products of the same ‘freeze, flight or fight’ response. The only difference is in the way we think about the situation but in biomedical (physiological) terms the bodily processes are identical.