Diagnose en Classificatie Diagnose



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Diagnose en Classificatie

Diagnose

  • Syndroomdiagnose :

  • Kernsymptomen

  • Facultatieve symptomen

  • Aantal symptomen, duur

  • Etiopathogenese :

  • Neurobiologisch / psychologisch

  • Predisponerende factoren

  • Luxerende (uitlokkende) factoren

  • Onderhoudende factoren


Diagnose : voorbeeld

  • Een matig ernstig depressief syndroom met melancholische kenmerken bij een lichamelijk gezonde man met een belaste psychiatrische familieanamnese en met narcistische persoonlijkheidstrekken. Dit beeld is reactief ontstaan na veranderingen op het werk en na een forse griep. Als gevolg hiervan zijn problemen ontstaan in de relatie en belemmeringen in het sociaal functioneren


predisponerend luxerend onderhoudend
Neurobiologisch depressies in de familie griep geen
Psychologisch narcistische trekken problemen op het werk relatieproblemen
Indelingen

  • Organisch versus functionele stoornissen

  • Aantoonbare hersenziekte of verstoring door metabole of endocriene stoornis

  • ????? : meer en meer neurobiologische basis voor psychiatrische stoornissen




  • Geen onderscheid meer kunnen maken tussen objectieve, externe werkelijkheid en de subjectieve

  • ????? : vervormingen van oordeel over realiteit of over eigen mogelijkheden




  • Syndromale versus persoonlijkheidsstoornissen

  • Ontstaan na een tevoren gezonde toestand versus van jongs af aan aanwezig

  • ????? : syndromale stoornissen beginnen jong en persoonlijkheidsstoornissen blijken minder stabiel dan vroeger gedacht


classificatie

  • Uitgebreide diagnostische bevindingen reduceren tot een algemene categorie

  • Hulp voor :

  • Pathofysiologische research

  • Keuze behandeling

  • Voorspellen verloop

  • Communicatie tussen artsen faciliteren !!

  • ... En aanvaarden dat classificatie voorlopig en verre van perfect is !!




  • Descriptieve classificatie

  • gebaseerd op syndroomdiagnosen

  • Categoriale of dimensionale classificatie

  • Onderscheid tussen gezond en ziek ?

  • Onderscheid tussen verschillende psychiatrische stoornissen ?


Differential mortality

Whooley et al 1998


Toekomstig classificatiesysteem

  • Genotype :

  • symptoomgerelateerde, protectieve en farmacogenetische genen

  • Neurobiologisch fenotype :

  • neuroanatomische, neurofunctionele en neurochemische afwijkingen, neuropsychologische disfuncties, emotionele disregulatie

  • Psychologisch fenotype :

  • cognitieve, affectieve en conatieve disfuncties

  • Omgevingsfactoren :

  • Predisponerende, luxerende en onderhoudende factoren

Huidige classificatiesystemen :



  • WHO :

  • Internationale Classification of Diseases (ICD-10)

  • APA :

Diagnostic and Statistical Manual (DSM-IVTR )

  • Alleen beschrijvend

  • Atheoretisch

  • 16 hoofdgroepen


DSM-IV (APA)

  • As I : syndromale stoornissen

  • As II : persoonlijkheidsstoornissen, verstandelijke handicap

  • As III : somatische aandoeningen

  • As IV: psychosociale en omgevingsfactoren

  • As V : hoogste niveau van aangepast functioneren het afgelopen jaar

Criticism of classification



  • Allocating pts to a diagnostic category distracts from the understanding of their unique personal

difficulties

  • Allocating a person to a diagnostic category to label deviant behaviour as illness

  • Individuals do not fit neatly into the available categories

Caseness



  • Case :

Stigma

  • Concerns about dangerousness

  • People with mental illness feel different from the rest of us

  • It is hard to talk to them

  • Mental illness can not be cured

  • It is a lack of will, weak character or laziness rather than an illness




  • Unfortunately, stigma is probably higher in doctors than in the general population !!

Most GPs consider that younger and middle aged patients as well as female patients

find it easier to explain their symptoms.

Depression is very much stigmatised with a quarter of GPs claiming that over 50% of

their depressed patients consider depression as a taboo

 As a doctor, your own beliefs influence your behaviour …PROJECTION…

 The presence of stigma increases patient referrals

On average 32% of GPs refer their patients with depressive symptoms.

However this increases to up to 43% for GPs who have a high proportion of

stigmatised patients

 Key Reasons for referring patients with depressive symptoms / depression.


  • know patient too well/would be embarrassed

  • if patients show symptoms other than mood

  • feel patient might take up too much of my time

  • patient was reluctant to accept diagnosis

Other key reasons for referral are:

    • Patients do not respond to treatment: 83%

    • Feel it is severe depression: 91%

    • Suspect suicidal tendencies: 95%

Notable delay in diagnosis of depression with patients suffering from the symptoms

*40% of GPs admit to waiting for the patient to approach the subject or monitoring the

patient over time when they first suspect depression.

*GPs seeing a very high proportion of patients with stigma were significantly less likely

(65%) to immediately discuss their suspicions with their patients than those seeing fewer

with stigma (81% would immediately discuss).


GPs attitudes towards depression can prolong the time patients suffer before being diagnosed
Treating Depression

GPs identified between 30% (low stigma) a upto 50% (high stigma) of their patients with depression as difficult to treat.


Main reasons DIFFICULT to treat:

  • Patients do not take drugs/compliance

  • Patients do not accept diagnosis

  • Difficult to treat multiple pathologies


Why the diagnosis of MDD can be missed?

  • Preoccupation with organic illness

  • Underrating severity/treatability of depression

  • Failure to elicit the symptoms

  • Fear of hurting/loosing the patient !!!


What factors influence recognition of MDD?

  • Factors decreasing recognition

  • Physical illness comorbidity

none : OR = 1.00

mild : OR = 2.94

serious : OR = 5.04


  • Factors increasing recognition

  • When the patient describes the depressed mood as different from the normal experience

of sadness
Physicians’ attitudes to depression

GPs PSY



  • I feel comfortable with depressed pts’ needs 61% 78%

  • Depression is a pts response which cannot be changed 30% 14%

  • Working with depressed pts is heavy going 71% 45%

  • Little to offer depressed pts not responding 30% 9%

  • Rewarding to look after depressed pts 56% 82%

  • PsychoRx tends to be unsuccessful with depressed pts 44% 27%

  • Depressed pts needing antidepressants are better off 17% 36%

with a PSY than with a GP

  • If psychoRx freely available, would be more beneficial 52% 22%

than antidepressants for most patients
Attitudes and adequate treatment

  • Low dose prescribers:




  • Short term prescribers:

  • Disagree more that there is little to offer to pts not responding to what GPs do

  • Agree less that it is rewarding to spend time with depressed pts

  • Reduced ease in dealing with depressed patients


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