Psychiatric Diagnosis and Classification - ResearchGate

222 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION
IS PRIMARY CARE DIFFERENT
Comparisons between Illnesses Seen in Primary Care and
those Seen by the Specialist Services
The typical presentation of anxiety and depressive symptoms in primary
care does differ from that seen in specialist clinics. Primary care patients are
more likely to present with somatic complaints or concerns regarding undiagnosed
medical illness [5, 6]. A useful primary care classification should
give greater emphasis to these somatic presentations. While primary care
patients may present with somatic symptoms, many will readily acknowledge
psychological distress when askedÐa process referred to as ``facultative
somatization'' [5±7]. Somatic symptoms may serve as a ``ticket of
admission'' to the primary care consultation, because the patient believes
that such symptoms are a more legitimate reason for seeking health care.
Overt presentation of psychological distress can be facilitated or discouraged)
by specific physician behaviors during the consultation [6, 8]. The
much-described ``somatization'' of primary care patients might be more
accurately described as a collaboration between patients and doctors [7].
While the presentation of anxiety or depressive disorders may differ significantly
between primary care and specialist services, the form or structure
of common mental disorders does not appear to. Epidemiological surveys in
primary care find that the DSM and ICD criteria used to define common
mental disorders in specialty care appear equally valid and reliable in primary
care [9, 10]. The latent structure of anxiety and depressive symptoms does not
seem to vary significantly across different levels of care community, primary
care, or specialty practice). This consistency of syndromes or symptom patterns
has important implications for the development of primary care classifications.
Adaptation of existing specialist classifications for use in primary care
should not require definition of new syndromes or significant revision of
existing ones. Instead, adaptation should focus on condensation or simplification
to make specialist classifications more useful in primary care practice.
Patients' tendencies to present with psychological or somatic symptoms
may also be influenced by education or by linguistic and cultural differences.
We should recognize that physicians as well as patients bring their
educational and cultural backgrounds to the doctor±patient encounter.
Comparisons between Primary Care Physicians' Diagnoses
and Research Diagnoses
Studies where independent assessments have been made by research psychiatrists
typically show two sorts of discrepancyÐpatients who are deemed