Psychiatric Diagnosis and Classification - ResearchGate
Psychiatric Diagnosis and Classification - ResearchGate
Psychiatric Diagnosis and Classification - ResearchGate
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226 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION<br />
referral to specialist services). We would give much lower priority to other<br />
diagnostic distinctions not linked to immediate primary care management.<br />
The list of second-order diagnostic questions might include:<br />
. Is depression superimposed on dysthymic disorder<br />
. Are diagnostic criteria met for recurrent major depression<br />
. Do psychotic symptoms indicate a diagnosis of unipolar depression with<br />
psychosis, schizoaffective disorder, bipolar disorder, or some other condition<br />
. Are criteria met for diagnosis of bipolar disorder<br />
While all of these questions may be relevant to specialist management,<br />
they have little influence on the primary care physician's immediate management<br />
decisions. To specialists, it may seem heretical or negligent) to<br />
sacrifice these diagnostic distinctions. For better or worse, improving the<br />
management of mental disorders in primary care will require that classification<br />
systems <strong>and</strong> educational efforts focus on a brief list of clinical priorities.<br />
Comorbidity <strong>and</strong> Overlap with General Medical Illness<br />
The diagnostic responsibilities of the primary care physician are inherently<br />
more complicated than those of specialists. Many presentations involve a<br />
mixof somatic <strong>and</strong> psychological symptoms. This co-occurrence of somatic<br />
<strong>and</strong> psychological symptoms may reflect several different underlying relationships.<br />
Common mental disorders may present with somatic symptoms suggesting<br />
general medical illness. Somatic distress is a universal component of<br />
anxiety <strong>and</strong> depressive disorders. The structure <strong>and</strong> expectations of primary<br />
care practice often encourage the expression of somatic distress <strong>and</strong> discourage<br />
open expression of psychological symptoms [5±7].<br />
In some cases, general medical disordersÐor side effects of medications<br />
used to treat those disordersÐmay mimic psychiatric disorders. Textbooks<br />
of psychiatry <strong>and</strong> general medicine invariably contain extensive lists of<br />
these medical mimics of psychiatric illness. Conditions commonly included<br />
range from relatively common e.g. hypothyroidism) to extremely rare e.g.<br />
pheochromocytoma). The intended message to students <strong>and</strong> practitioners is<br />
that a covert medical condition may be the primary cause of psychological<br />
symptoms such as depressed mood or anxiety. Detection <strong>and</strong> treatment of<br />
that covert medical condition or discontinuation of the offending medication)<br />
is expected to definitively treat the accompanying psychopathology.<br />
Providers are cautioned that a premature focus on psychiatric symptoms