Psychiatric Diagnosis and Classification - ResearchGate

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