Hierarchical Model of Diagnosis

• Lecture 2A covers the Hierarchical Model of Diagnosis.

Diagnostic Approaches

• A structured diagnosing approach is desirable when making a diagnosis.
• Bottom-up approach involves identifying likely diagnoses and picking the one that best fits observations.
• Top-down approach involves considering the possible broad category first and then going down to specific disorders.
• There are over 500 diagnostic categories.
• "A competent doctor firstly differentiates the board Yin-Yang balance, before proceeding to finer assessments"

Neurosis and Psychosis

• The terms neurosis and psychosis were abandoned in DSM-III & ICD 10, but still have high practical value and are widely used in professional communication
• Neurosis is considered less severe but is not necessarily true
• Neurosis symptoms are closer to a normal experience, e.g. anxiety
• Neurosis is a quantitative difference only, not qualitative and is related to common mental disorders (CMD)
• Psychosis is considered "more severe"
• Psychosis is not necessarily true, but is "less in touch with reality"
• Psychosis is a qualitative change with psychotic symptoms, such as hallucination and delusion
• Psychosis is related to severe mental illnesses (SMI)

Hallucinations

• Hallucinations are sensory experiences in the absence of a corresponding external stimulus.
• Auditory hallucination is the most common form
  • Occurs in conscious state, 'normal conditions'
  • Is a real hearing sensation, not purely ‘thinking aloud'
  • Subtypes: 2nd person; 3rd person; Running comment
• Visual hallucination is the second most common
• Other forms of hallucinations are olfactory, gustatory, and somatic (tactile, deep).

Delusions

• Delusions are characterized by a false belief
  • Firmly held by the client, even after being disproved
  • Unable to be explained by family, educational & cultural background
• Delusions must be differentiated from overvalued ideas/beliefs that can be accounted for by psychosocial factors
• Delusions are non-psychotic
• Forms include delusion (idea) of reference; Thought broadcasting; Delusion of passivity
• Content can be persecutory; Grandiose; Depressive.

Hierarchies of Diagnosis

• The core idea of hierarchies of diagnosis is that when multiple disorders are present, one can be regarded as the main disorder for recording and treatment
• Most people suffering from depression have anxiety symptoms, but not vice versa; if depression is lifted, anxiety symptoms will also be relieved substantially.

Hierarchical Model of Diagnosis

• The Hierarchical Model of Diagnosis was created by (Goldberg, Benjamin & Creed, 1987)
• Higher level disorders have characterizing symptoms that lower level disorders don't have
  • Delirium – impairment of consciousness
  • Dementia – intellectual impairment
  • Bipolar affective disorder – manic episode
  • Schizophrenia – '1st ranked symptoms'
• Higher level disorders may have symptoms of lower level disorders
• Dementia may have symptoms of schizophrenia
• Depression may have symptoms of anxiety disorders
• One diagnosis principle: As far as possible, make one diagnosis only but make two only when it is absolutely necessary

Four-Level Structure

• Level one (Organic Disorders):
  • Acute brain syndrome (delirium)
  • Chronic brain syndrome (dementia)
  • Korsakow's syndrome
• Level two (Functional Psychoses):
  • Mania
  • Schizophrenia
  • Psychotic depression
• Level three (Non-Psychotic Disorders):
  • Depression
  • Anxiety disorders (generalized anxiety disorder, specific phobias, agoraphobia, panic disorder)
  • Maladaptive behaviors (obsessive compulsive disorder, alcoholism, drug dependence, anorexia nervosa and bulimia, self-poisoning, self-mutilation)
  • Abnormal illness behaviors (hypochondriasis, hysteria, malingering, factitious disorder)
• Level four (Personality Disorders):
  • Schizoid personality
  • Cyclothymic
  • Sensitive
  • Depressive (low self-esteem)
  • Passive dependent
  • Obsessional
  • Histrionic (previously called hysterical)
  • Antisocial (previously called psychopathic)
  • Borderline

Implications for Treatment & Management

• For level 1 & 2 diseases/illnesses, medical treatment is often necessary (but may not be sufficient).
• For level 3 disorders:
  • Relevance of psychotropic medications is decreased
  • Psychotropic medications can be harmful, with anxiolytics & hypnotics leading to dependence & tolerance.
  • Sick role & stigma issues may arise.
• For level 4 disorders, the relevance of psychotropic medications is decreased.