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Deep Learning Technology: Sebastian Arnold, Betty van Aken, Paul Grundmann, Felix A. Gers and Alexander Löser. Learning Contextualized Document Representations for Healthcare Answer Retrieval. The Web Conference 2020 (WWW'20)
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Perhaps due to their perceived rarity, the dissociative disorders (including DID) were not initially included in the Structured Clinical Interview for DSM-IV (SCID), which is designed to make psychiatric diagnoses more rigorous and reliable. Instead, shortly after the publication of the initial SCID a freestanding protocol for dissociative disorders (SCID-D) was published. This interview takes about 30 to 90 minutes depending on the subject's experiences. An alternative diagnostic instrument, the Dissociative Disorders Interview Schedule, also exists but the SCID-D is generally considered superior. The Dissociative Disorders Interview Schedule (DDIS) is a highly structured interview that discriminates among various DSM-IV diagnoses. The DDIS can usually be administered in 30–45 minutes.
Other questionnaires include the Dissociative Experiences Scale (DES), Perceptual Alterations Scale, Questionnaire on Experiences of Dissociation, Dissociation Questionnaire, and the Mini-SCIDD. All are strongly intercorrelated and except the Mini-SCIDD, all incorporate absorption, a normal part of personality involving narrowing or broadening of attention. The DES is a simple, quick, and validated questionnaire that has been widely used to screen for dissociative symptoms, with variations for children and adolescents. Tests such as the DES provide a quick method of screening subjects so that the more time-consuming structured clinical interview can be used in the group with high DES scores. Depending on where the cutoff is set, people who would subsequently be diagnosed can be missed. An early recommended cutoff was 15-20. The reliability of the DES in non-clinical samples has been questioned.
The fourth, revised edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) diagnoses DID according to the diagnostic criteria found in section 300.14 (dissociative disorders). It has also been found difficult to diagnose the disorder in the first place, due to there not being a universal agreement of the definition of dissociation. The criteria require that an adult be recurrently controlled by two or more discrete identities or personality states, accompanied by memory lapses for important information that is not caused by alcohol, drugs or medications and other medical conditions such as complex partial seizures. While otherwise similar, the diagnostic criteria for children also specifies symptoms must not be confused with imaginative play. Diagnosis is normally performed by a clinically trained mental health professional such as a psychiatrist or psychologist through clinical evaluation, interviews with family and friends, and consideration of other ancillary material. Specially designed interviews (such as the SCID-D) and personality assessment tools may be used in the evaluation as well. Since most of the symptoms depend on self-report and are not concrete and observable, there is a degree of subjectivity in making the diagnosis. People are often disinclined to seek treatment, especially since their symptoms may not be taken seriously; thus dissociative disorders have been referred to as "diseases of hiddenness".
The diagnosis has been criticized by supporters of therapy as a cause or the sociocognitive hypothesis as they believe it is a culture-bound and often health care induced condition. The social cues involved in diagnosis may be instrumental in shaping patient behavior or attribution, such that symptoms within one context may be linked to DID, while in another time or place the diagnosis could have been something other than DID. Other researchers disagree and argue that the existence of the condition and its inclusion in the DSM is supported by multiple lines of reliable evidence, with diagnostic criteria allowing it to be clearly discriminated from conditions it is often mistaken for (schizophrenia, borderline personality disorder, and seizure disorder). That a large proportion of cases are diagnosed by specific health care providers, and that symptoms have been created in nonclinical research subjects given appropriate cueing has been suggested as evidence that a small number of clinicians who specialize in DID are responsible for the creation of alters through therapy.
There is a significant difference between the number of those who would benefit from treatment and the number of those who are treated. The so-called "treatment gap" is a function of the disinclination of the afflicted to submit for treatment, an underdiagnosing of the disorder by healthcare providers, and the limited availability and access to state-of-the-art treatments. Nonetheless, individuals with BPD accounted for about 20 percent of psychiatric hospitalizations in one survey. The majority of individuals with BPD who are in treatment continue to use outpatient treatment in a sustained manner for several years, but the number using the more restrictive and costly forms of treatment, such as inpatient admission, declines with time.
Experience of services varies. Assessing suicide risk can be a challenge for clinicians, and patients themselves tend to underestimate the lethality of self-injurious behaviors. People with BPD typically have a chronically elevated risk of suicide much above that of the general population and a history of multiple attempts when in crisis. Approximately half the individuals who commit suicide meet criteria for a personality disorder. Borderline personality disorder remains the most commonly associated personality disorder with suicide.
After the death of a patient in 2014 NHS England was criticised by a coroner for the lack of commissioned services to support such patients. Evidence was given that 45% of mentally disordered females had BPD and there was no provision or priority for therapeutic psychological services. There were only 60 specialised inpatient beds in England – all in the North East or London.
The person's appearance, behavior, and history, along with a psychological evaluation, are usually sufficient to establish a diagnosis. There is no test to confirm this diagnosis. Because the criteria are subjective, some people may be wrongly diagnosed.
Diagnosis of borderline personality disorder is based on a clinical assessment by a mental health professional. The best method is to present the criteria of the disorder to a person and to ask them if they feel that these characteristics accurately describe them. Actively involving people with BPD in determining their diagnosis can help them become more willing to accept it. Although some clinicians prefer not to tell people with BPD what their diagnosis is, either from concern about the stigma attached to this condition or because BPD used to be considered untreatable, it is usually helpful for the person with BPD to know their diagnosis. This helps them know that others have had similar experiences and can point them toward effective treatments.
In general, the psychological evaluation includes asking the patient about the beginning and severity of symptoms, as well as other questions about how symptoms impact the patient's quality of life. Issues of particular note are suicidal ideations, experiences with self-harm, and thoughts about harming others. Diagnosis is based both on the person's report of their symptoms and on the clinician's own observations. Additional tests for BPD can include a physical exam and laboratory tests to rule out other possible triggers for symptoms, such as thyroid conditions or substance abuse. The ICD-10 manual refers to the disorder as "emotionally unstable personality disorder" and has similar diagnostic criteria. In the DSM-5, the name of the disorder remains the same as in the previous editions.
The previous edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM IV-TR, defines histrionic personality disorder (in Cluster B) as:
The DSM-IV requires that a diagnosis for any specific personality disorder also satisfies a set of general personality disorder criteria.
There is a considerable personality disorder diagnostic co-occurrence. Patients who meet the DSM-IV-TR diagnostic criteria for one personality disorder are likely to meet the diagnostic criteria for another. Diagnostic categories provide clear, vivid descriptions of discrete personality types but the personality structure of actual patients might be more accurately described by a constellation of maladaptive personality traits.
"Sites used DSM-III-R criterion sets. Data obtained for purposes of informing the development of the DSM-IV-TR personality disorder diagnostic criteria."
Abbreviations used: "PPD – Paranoid Personality Disorder, SzPD – Schizoid Personality Disorder, StPD – Schizotypal Personality Disorder, ASPD – Antisocial Personality Disorder, BPD – Borderline Personality Disorder, HPD – Histrionic Personality Disorder, NPD – Narcissistic Personality Disorder, AvPD – Avoidant Personality Disorder, DPD – Dependent Personality Disorder, OCPD – Obsessive-Compulsive Personality Disorder, PAPD – Passive-Aggressive Personality Disorder."
The psychological mechanism of conversion can be the most difficult aspect of a conversion diagnosis. Even if there is a clear antecedent trauma or other possible psychological trigger, it is still not clear exactly how this gives rise to the symptoms observed. Patients with medically unexplained neurological symptoms may not have any psychological stressor, hence the use of the term "functional neurological symptom disorder" in DSM-V as opposed to "conversion disorder", and DSM-V's removal of the need for a psychological trigger.
Empirical studies have found that the prognosis for conversion disorder varies widely, with some cases resolving in weeks, and others enduring for years or decades. There is also evidence that there is no cure for Conversion Disorder, and that although patients may go into remission, they can relapse at any point. Furthermore, many patients who are 'cured' continue to have some degree of symptoms indefinitely.
Currently, genetic research for the understanding of the development of personality disorders is severely lacking. However, there are a few possible risk factors currently in discovery. Researchers are currently looking into genetic mechanisms for traits such as aggression, fear and anxiety, which are associated with diagnosed individuals. More research is being conducted into disorder specific mechanisms.
The diagnosis of pseudoneurotic schizophrenia can only be made with clinical observation by a mental health professional and by the patient's explanation of his or her experiences. A patient must identify with at least two of these symptoms in order to be distinguished as a pseudoneurotic schizophrenic. The intensity of a symptom may vary with the individual patient's severity of the disorder. The symptoms are organized into disorders of thinking and association, disorders of emotional regulation, disorders of sensorimotor and autonomic functioning, pan-anxiety, pan-neurosis, and pansexuality. The two symptoms can fall under any of these categories.
When pseudoneurotic schizophrenia was still being utilized as a diagnostic term, doctors were expected to be able to magically cure patients. Patients usually had very little understanding of themselves and the complexity of their illness. They were willing to employ any process in order to maintain mental stability. Their perception of mental stability, however, was also impaired, which made it much more difficult to make proper, helpful medication prescriptions.
Patients would often misuse medication in order to receive attention from their families. They would describe the dosage and effects of the medicine in some strange demeanor to demonstrate that their illness was physical rather than psychological. In like manner, taking medication also kept doctors concerned about the possibility of the patient developing substance dependence and/or drug addiction. Patients used this to get attention and sympathy from others.
Psychosis is first and foremost a diagnosis of exclusion. So a new-onset episode of psychosis "cannot" be considered a symptom of a psychiatric disorder until other relevant and known causes of psychosis are properly excluded, or ruled out. Many clinicians improperly perform, or entirely miss this step, introducing avoidable diagnostic error and misdiagnosis.
An initial assessment includes a comprehensive history and physical examination by a physician, psychiatrist, psychiatric nurse practitioner or psychiatric physician assistant. Biological tests should be performed to exclude psychosis associated with or caused by substance use, medication, toxins, surgical complications, or other medical illnesses.
Delirium should be ruled out, which can be distinguished by visual hallucinations, acute onset and fluctuating level of consciousness, indicating other underlying factors, including medical illnesses. Excluding medical illnesses associated with psychosis is performed by using blood tests to measure:
- Thyroid-stimulating hormone to exclude hypo- or hyperthyroidism,
- Basic electrolytes and serum calcium to rule out a metabolic disturbance,
- Full blood count including ESR to rule out a systemic infection or chronic disease, and
- Serology to exclude syphilis or HIV infection.
Other investigations include:
- EEG to exclude epilepsy, and an
- MRI or CT scan of the head to exclude brain lesions.
Because psychosis may be precipitated or exacerbated by common classes of medications, medication-induced psychosis should be ruled out, particularly for first-episode psychosis. Both substance- and medication-induced psychosis can be excluded to a high level of certainty, using a
- Urinalysis and a
- Full serum toxicology screening.
Because some dietary supplements may also induce psychosis or mania, but cannot be ruled out with laboratory tests, a psychotic individual's family, partner, or friends should be asked whether the patient is currently taking any dietary supplements.
Common mistakes made when diagnosing people who are psychotic include:
- Not properly excluding delirium,
- Not appreciating medical abnormalities (e.g., vital signs),
- Not obtaining a medical history and family history,
- Indiscriminate screening without an organizing framework,
- Missing a toxic psychosis by not screening for substances "and" medications
- Not asking family or others about dietary supplements,
- Premature diagnostic closure, and
- Not revisiting or questioning the initial diagnostic impression of primary psychiatric disorder.
Only after relevant and known causes of psychosis are excluded, a mental health clinician may make a psychiatric differential diagnosis using a person's family history, incorporating information from the person with psychosis, and information from family, friends, or significant others.
Types of psychosis in psychiatric disorders may be established by formal rating scales. The Brief Psychiatric Rating Scale (BPRS) assesses the level of 18 symptom constructs of psychosis such as hostility, suspicion, hallucination, and grandiosity. It is based on the clinician's interview with the patient and observations of the patient's behavior over the previous 2–3 days. The patient's family can also answer questions on the behavior report. During the initial assessment and the follow-up, both positive and negative symptoms of psychosis can be assessed using the 30 item Positive and Negative Symptom Scale (PANSS).
Neurosis is a class of functional mental disorders involving chronic distress but neither delusions nor hallucinations. The term is no longer used by the professional psychiatric community in the United States, having been eliminated from the "Diagnostic and Statistical Manual of Mental Disorders" in 1980 with the publication of DSM III. It is still used in the .
Neurosis should not be mistaken for psychosis, which refers to a loss of touch with reality. Neither should it be mistaken for neuroticism, a fundamental personality trait proposed in the big Five personality traits theory.
As it has already been mentioned, patients with organic personality disorder show a wide variety of sudden behavioural changes and dysfunctions. There are not a lot of information about the treatment of this mental health disorder. The pharmacological approach is the most common therapy among patients with organic personality disorder. However, the choice of drug therapy relies on the seriousness of patient's situation and what symptoms are shown. The choice and administration of specific drugs contribute to the reduction of symptoms of organic personality disorder. For this reason, it is crucial for patients' treatment to be assessed by clinical psychologists and psychiatrists before the administration of drug.
Additionally, the dysfunctions in expression of behaviour of patients with organic personality disorder and the development of symptom of irritability, which are caused by aggressive and self-injurious behaviours, can be dealt with the administration of carbamazepine. Moreover, the symptoms of this disorder can be decreased by the administration of valproic acid. Also, emotional irritability and signs of depression can be dealt with the use of nortriptyline and low-dose thioridazine. Except from the symptom of irritability, patients express aggressive behaviours. At the onset of drug therapy for effective treatment of anger and aggression, the drug of carbamazepine, phenobarbital, benztropine and haloperidol can be administrated in order to reduce the symptoms of patients with organic personality disorder. In addition, the use of propranolol may decrease the frequent behaviours of rage attacks.
Finally, it is important for patients to take part in psychotherapy sessions during the period of drug therapy. In this way, there is prevention and patients can be protected by negative effects of drugs on their organism and their behaviour. Furthermore, the clinicians can provide useful and helpful support to patients during these psychotherapy sessions. Thus, the combination of drug therapy with psychotherapy can lead to the reduction of symptoms of this disorder and the improvement of patients' situation.
There are many different neuroses: obsessive–compulsive disorder, obsessive–compulsive personality disorder, impulse control disorder, anxiety disorder, hysteria, and a great variety of phobias.
According to C. George Boeree, professor emeritus at Shippensburg University, the symptoms of neurosis may involve:
Neurosis may be defined simply as a "poor ability to adapt to one's environment, an inability to change one's life patterns, and the inability to develop a richer, more complex, more satisfying personality."
The ICD-10 includes a diagnostic guideline for the wide group of personality and behavioural disorders. However, every disorder has its own diagnostic criteria. In case of the organic personality disorder, patient has to show at least three of the following diagnostic criteria over a six or more months period. organic personality disorder is associated with a large variety of symptoms, such as deficits in cognitive function, dysfunctional behaviours, psychosis, neurosis, emotional changes, alterations in expression function and irritability. Patients with organic personality disorder can present emotional lability that means their emotional expressions are unstable and fluctuating. In addition, patients show reduction in ability of perseverance with their goals and they express disinhibited behaviours, which are characterised by inappropriate sexual and antisocial actions. For instance, patients can show dissocial behaviours, like stealing. Moreover, according to diagnostic guideline of ICD-10, patients can suffer from cognitive disturbances and they present signs of suspiciousness and paranoid ideas. Additionally, patients may present alteration in process of language production that means there are changes in language rate and flow. Furthermore, patients may show changes in their sexual preference and hyposexuality symptoms.
Another common feature of personality of patients with organic personality disorder is their dysfunctional and maladaptive behaviour that causes serious problems in these patients, because they face problems with pursuit and achievement of their goals. It is worth to be mentioned that patients with organic personality disorder express a feeling of unreasonable satisfaction and euphoria. Also, the patients show aggressive behaviours sometimes and these serious dysfunctions in their behaviour can have effects on their life and their relationships with other people. Specifically patients show intense signs of anger and aggression because of their inability to handle their impulses. The type of this aggression is called "impulsive aggression". Furthermore, it is worth to be mentioned that the pattern of organic personality disorder presents some similarities with pattern of temporal lobe epilepsy (TLE). Specifically patients who suffer from this chronic disorder type of epilepsy, express aggressive behaviours, likewise it happens to patients with organic personality disorder. Another similar symptom between Temporal lobe epilepsy and organic personality disorder is the epileptic seizure. The symptom of epileptic seizure has influence on patients' personality that means it causes behavioural alterations". The Temporal lobe epilepsy (TLE) is associated with the hyperexcitability of the medial temporal lobe (MTL) of patients. Finally, patients with organic personality disorder may present similar symptoms with patients, who suffer from the Huntington's disease as well. The symptoms of apathy and irritability are common between these two groups of patients.
Examples from a 295-subject study in Lithuania showed that the most common religious delusions were being a saint (in women) and being God (in men).
In one study of 193 people who had previously been admitted to hospital and subsequently diagnosed with schizophrenia, 24% were found to have religious delusions.
A 1999 study identified that religious delusions were often present or expressed in persons with forensic committal to a psychiatric unit.
A 2012 paper suggested that, when compared with experiences today, psychiatric conditions associated with psychotic spectrum symptoms may be possible explanations for some revelatory driven experiences and activities such as those of Abraham, Moses, Jesus, and Saint Paul. However, the paper admits that the study was not aimed to deny supernatural elements, nor was it conclusive on whether their experiences were delusional in part or not at all.
A number of screening instruments are used for screening adults for PTSD, such as the Clinician-Administered PTSD Scale for "DSM-5" (CAPS-5), Primary Care PTSD Screen for "DSM-5" (PC-PTSD-5), PTSD Checklist for DSM-5 (PCL-5), and Dissociative Subtype of PTSD Scale (DSPS). The CAPS-5 is considered the gold-standard assessment recommended for use by the U.S. National Center for PTSD.
There are also several screening and assessment instruments for use with children and adolescents. These include the Child PTSD Symptom Scale (CPSS), Clinician-Administered PTSD Scale for "DSM-5" -Child/Adolescent version (CAPS-CA-5), Child Trauma Screening Questionnaire, and UCLA Posttraumatic Stress Disorder Reaction Index for "DSM-IV".
PTSD was classified as an anxiety disorder in the DSM-IV, but has since been reclassified as a "trauma- and stressor-related disorder" in the DSM-5. The DSM-5 diagnostic criteria for PTSD include four symptom clusters: re-experiencing, avoidance, negative alterations in cognition/mood, and alterations in arousal and reactivity.
Sluggish schizophrenia or slow progressive schizophrenia (, "vyalotekushchaya shizofreniya") was a diagnostic category used in Soviet Union to describe what they claimed was a form of schizophrenia characterized by a slowly progressive course; it was diagnosed even in a patient who showed no symptoms of schizophrenia or other psychotic disorders, on the assumption that these symptoms would appear later. It was developed in the 1960s by Soviet psychiatrist Andrei Snezhnevsky and his colleagues, and was used exclusively in the USSR and several Eastern Bloc countries, until the fall of Communism starting in 1989. The diagnosis has long been discredited because of its scientific inadequacy and its use as a means of confining dissenters. It has never been used or recognized outside of Soviet Union, or by international organizations such as the World Health Organization. It is considered a prime example of the political abuse of psychiatry in the Soviet Union.
Sluggish schizophrenia was the most infamous of diagnoses used by Soviet psychiatrists, due to its usage against political dissidents. After being discharged from a hospital, persons diagnosed with sluggish schizophrenia were deprived of their civic rights, credibility and employability. The usage of this diagnosis has been internationally condemned.
In the Russian version of the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), which has long been used throughout present-day Russia, sluggish schizophrenia is no longer listed as a form of schizophrenia, but it is still included as a schizotypal disorder in section F21 of chapter V.
According to Sergei Jargin, the same Russian term "vyalotekushchaya" for sluggish schizophrenia continues to be used and is now translated in English summaries of articles not as "sluggish" but as "slow progressive".
The evidence for the effectiveness of early interventions to prevent psychosis appeared inconclusive. Whilst early intervention in those with a psychotic episode might improve short term outcomes, little benefit was seen from these measures after five years. However, there is evidence that cognitive behavioral therapy (CBT) may reduce the risk of becoming psychotic in those at high risk, and in 2014 the UK National Institute for Health and Care Excellence (NICE) recommended preventive CBT for people at risk of psychosis.
Diagnostic criteria have been proposed for ORS:
- Persistent (> six months), false belief that one emits an offensive odor, which is not perceived by others. There may be degrees of insight (i.e. the belief may or may not be of delusional intensity).
- This pre-occupation causes clinically significant distress (depression, anxiety, shame), social and occupational disability, or may be time-consuming (i.e. preoccupies the individual at least one hour per day).
- The belief is not a symptom of schizophrenia or other psychotic disorder, and not due to the effects of medication or recreational drug abuse, or any other general medical condition.
In 2016, the United States Preventive Services Task Force (USPSTF) recommended screening in the adult populations with evidence that it increases the detection of people with depression and with proper treatment improves outcomes. They recommend screening in those between the age of 12 to 18 as well.
A Cochrane review from 2005 found screening programs do not significantly improve detection rates, treatment, or outcome.