The Vagaries of Clinical Diagnosis and the DSM-5

Dr A J Mander Consultant Psychiatrist

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CONTENTS Introduction 2 Adjustment Disorders 7 Anxiety Disorders 8 Bipolar and Related Disorders 9 Depression (Major Depressive Disorder) 10 Neurocognitive Disorders 11 Personality Disorders 11 Post Traumatic Stress Disorder 12 Somatic Symptom and Related Disorders 14 Substance-Related and Addictive Disorders 16 Traumatic Brain Injury (including mTBI) 18 References 21

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INTRODUCTION

The publication of DSM-5 (The Diagnostic and Statistical Manual of the American Psychiatric Associaton, 5th Edition), in May 2013 was a significant event. It replaced DSM-IV which was more than 20 years old. It remains the medical practitioner’s role to reach a medical diagnosis, and then to explain to interested parties whether that diagnosis fits whatever external criteria the referrer is interested in. It is for the clinician to explain why they would adhere to a diagnosis even if objective diagnostic criteria are not met. The DSM is not the only accepted diagnostic guide in Australia and while it is generally used for forensic work, the International Classification of Disease, version 10 (ICD-10), is used for the coding of attendances at hospital and community health services. To understand the strengths, weaknesses and utility of the DSM it is important to understand:

• Diagnostic fashion; diagnostic differences became more obvious in the 1970’s,

• Diagnostic practice; how expert medical practitioners make a diagnosis and

• Reliability (lack of reliability!) of the DSM criteria, even in expert medical hands. Diagnostic Fashion The original aim of the US/UK Diagnostic Project, founded in 1965, was to examine differences in the national statistics for the diagnostic frequencies among patients aged 19-59 admitted to State Mental Hospitals in the USA and to Area Mental Hospitals in England and Wales. Results showed that the high frequency of schizophrenia, and low frequency of affective disorder in New York, compared to London, were due largely to the diagnostic practices of the Psychiatrists – the American concept of Schizophrenia being more all-embracing than the British. This finding was later confirmed by video-taped studies. The resulting controversy led to the revision of the entire DSM, leading to the publication of the DSM-III in 1980. For the first time the diagnostic criteria were operationalized with the intent of making the diagnostic process more reliable. The criteria in the DSM cannot be used as a checklist and expert medical practitioners do not make a diagnosis in such a manner. One of the downsides of the explicit publication of the criteria is that many non-medical practitioners believe that they can offer legitimate psychiatric diagnoses by ‘ticking the boxes’. It is not uncommon to see in medicolegal reports a non-medical practitioner making a statement such as “Mr X has Post Traumatic Stress Disorder and satisfies the DSM-5 criteria”. DSM-5, like its predecessors, explicitly warns against such an approach, especially by non-medical practitioners. Even in expert hands the diagnostic reliability of some of the criteria are poor. They are therefore meaningless in non-expert hands. Diagnostic Practice So how do expert medical practitioners make a diagnosis? It is a complex process and may be highly individualistic. Even the physician himself may have difficulty in isolating the

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fundamental determinants of his/her diagnosis and may not be able to verbalise his/her method. Two types of reasoning are important (Llewelyn et al, 2009):

• Transparent Reasoning (analytical approach) involves assembling a combination of features that identifies a group of patients within which the frequency of those with a diagnosis would be high. This can be done by first selecting a diagnostic lead. It could be a symptom, a sign, or any test result. One of the leads differential diagnoses is then chosen, and a finding is looked for that appears often in the chosen diagnosis, but less often in others. If a new finding becomes available which is a better lead, with fewer differential diagnoses, then this can be seized upon instead. A single diagnosis will only become final if it can explain all the patient’s findings.

• Intuitive Reasoning (intuitive approach); most of the time experienced doctors use a non-transparent reasoning process. This seems to involve recognising combinations or patterns of findings, consciously or subconsciously, which suggest or confirm a diagnosis, or indicate that some treatment should be given. This is a skill that is improved by experience.

It has been suggested that what is happening is a form of pattern recognition and a given problem is being matched to an illness script. This involves two tasks;

• the creation of a problem representation and

• having a collection of illness scripts with which to make a comparison. As doctors improve diagnostically they expand their ability to develop problem representations and refine illness scripts.

Croskerry (2009) has emphasised the critical importance of clinical judgment. This is the ability of a doctor to integrate the intuitive and analytical approaches. This complexity is likely better understood using the emerging findings from complexity science (Zimmerman et al 2001), rather than the scientific reductionist approach which erroneously suggests a linear process. A vigorous debate exists regarding these factors (Sweeney & Kernick 2002, Andras & Charlton 2002) but no one can doubt that complex reasoning processes are involved in making a medical diagnosis.

What are the implications of this for the application of operational criteria to medicolegal cases? It is for the expert clinician, using their training and experience, to reach a clinical diagnosis using the processes described. It is then appropriate, and reasonable, to consider whether the presentation meets the criteria of a diagnostic system, such as the DSM. If it does, the clinician can confidently assert that they have used those criteria (at least as a minimum data set). If not, then it is for the clinician to clearly describe why they have settled on a clinical diagnosis even if the external criteria have not been met. This recognises that operational criteria are fallible, different systems have different criteria, and some criteria (e.g. DSM-IV) can be significantly outdated and no longer reflect routine clinical practice. Systems such as the DSM also acknowledge that many boundary cases exist and these may be the majority of patients seen. Hence the DSM describes the classic, not necessarily the most common, presentation in clinical practice.

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Operational criteria promote reliability (essential in the medicolegal arena) but this must not be misused in a way that reduces validity.

Some non-medical clinicians have been trained to use approaches such as the DSM. However, under such circumstances, they are required to use a structured clinical interview which ensures that they ask the type of questions, and follow-up probes, that would be used by an expert medical practitioner. This enables them to gain some insight into the diagnostic process in which they have not been trained. Expert medical practitioners start by using open-ended questions “Can you tell me about your problems?” It is widely accepted that this leads to the most powerful and convincing evidence in an interview. Follow-up questions can be increasingly directive “Can you tell me more about your sleep problems?”, “Do you have problems getting off to sleep, is your sleep disturbed, or both?” Often further open-ended questions are used “Can you tell me more about that?” The question can be entirely closed, encouraging only a yes or no answer “Does it take you a long time to get to sleep?” The more directive the question, the less weight will be placed on it by an expert medical practitioner. These issues are rarely appreciated by those who have not been trained in diagnosis, and provide part of the reason why the process cannot be replaced by the use of rating scales.

Reliability Since this is the raison d’etre behind the use of the DSM it is worth considering how it performs in expert hands. A degree of circumspection is appropriate given that the diagnostic reliability of some common psychiatric disorders is low. Kappa coefficients are one way of representing reliability. In the graph:

• < 0.1 - unacceptable agreement

• 0.1-0.4 (orange) - questionable agreement

• 0.4-0.6 (blue) - good agreement

• > 0.6 (green) - very good agreement Major Depressive Disorder (0.28) remains problematic because its criteria encompass a wide range of illness, from gravely disabled melancholic patients to many individuals in the general population who do not seek treatment. Other diagnoses such as Generalised Anxiety Disorder (0.20) and Mild Traumatic Brain Injury (0.36), also show questionable agreement. Mixed Anxiety-Depressive Disorder has not been accidentally missed out but at -0.004 shows no agreement!

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DSM-5 The development of DSM5 has taken twelve years. It builds on the goal of its predecessors of providing “guidelines for diagnoses that can inform treatment and management decisions”. It acknowledges that a too rigid categorical system does not capture clinical experience or important scientific observations. The results of numerous studies of comorbidity and disease transmission in families, including twin studies and molecular genetic studies, make strong arguments for what many astute clinicians have long observed: the boundaries between many disorder ‘categories’ are more fluid over the life course than DSM-IV recognised, and many symptoms assigned to a single disorder may occur, at varying levels of severity, in many other disorders. Clinical training and experience are needed to use DSM for determining a diagnosis. The diagnostic criteria identify symptoms, behaviours, cognitive functions, personality traits, physical signs, syndrome combinations and durations that require clinical expertise to differentiate from normal life variation and transient responses to stress. The DSM can serve clinicians as a guide to identify the most prominent symptoms that should be assessed when diagnosing a disorder. Although some mental disorders may have well-defined

-0.1 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

Mixed Anxiety-Depressive Disorder

Generalised Anxiety Disorder

Antisocial Personality Disorder

Major Depressive Disorder

Obsessive-Compulsive Personality Disorder

Mild Traumatic Brain Injury (MTBI)

Bipolar II Disorder

Alcohol Use Disorder

Mild Neurocognitive Disorder

Attenuated Psychotic Symptoms Syndrome

Schizophrenia

Schizoaffective Disorder

Borderline Personality Disorder

Binge Eating Disorder

Bipolar I Disorder

Hoarding Disorder

Complex Somatic Symptom Disorder

Post Traumatic Stress Disorder

Major Neurocognitive Disorder

Inter-Rater Reliability of Diagnoses fromthe initial DSM-5 Field Trials

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boundaries around symptom clusters, scientific evidence now places many, if not most, disorders on a spectrum. Closely related disorders share symptoms, genetic and environmental risk factors, and possibly neural substrates (perhaps most strongly established for a subset of anxiety disorders by neuroimaging in animal models). In short, DSM now recognises that the boundaries between disorders are more porous than originally perceived. DSM-5 recognises that dimensional approaches, as opposed to its categorical approach, will likely be the way forward with major steps being taken in this direction by organisations such as the National Institutes of Health in the USA. DSM-5 encourages the use of multiple diagnoses. This is contrary to commonly accepted clinical practice. Given the substantial overlap in symptomatology between different conditions, most clinicians are trained to use a hierarchical structure. If symptoms satisfy more than one diagnosis then, unless there are over-riding reasons to the contrary, only the diagnosis highest in the hierarchy is used. In that regard psychosis overrides mood and anxiety disorders, which in turn override adjustment disorders. DSM-5 has replaced the previous NOS (Not Otherwise Specified) designation with two options for clinical use: Other Specified Disorder and Other Unspecified Disorder. The Other Specified Disorder category is provided to allow the clinician to communicate the reason the presentation does not meet the criteria for any specific category within a diagnostic class. If the clinician chooses not to specify the reason, then ‘Unspecified Disorder’ is used. Cautionary Statement for the Forensic Use of DSM-5 DSM-5 stresses that the definition of mental disorder in the manual was developed to meet the needs of clinicians, public health professionals, and research investigators, rather than the technical needs of the courts and legal professionals. Whilst the guide can assist legal decision makers understanding of the relevant characteristics of mental disorders, its use should be informed by an awareness of the risks and limitations. There is an imperfect fit between the questions of ultimate concern to the Law and the information contained in a clinical diagnosis. Clinical diagnoses of mental disorders do not imply that an individual meets legal criteria for the presence of a mental disorder or a specific legal standard (e.g. for competence, criminal responsibility or disability). Assignment of a diagnosis does not imply a specific level of impairment or disability. Further “Use of DSM-5 to assess for the presence of a mental disorder by non-clinical, non-medical, or otherwise insufficiently trained individuals is not advised”. Non-clinical decision makers should be aware that a diagnosis does not carry any necessary implications regarding the aetiology or causes of the individual’s mental disorder or the individual’s degree of control over behaviours that may be associated with the disorder.

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ADJUSTMENT DISORDERS Life events are an essential pre-requisite for a diagnosis of adjustment disorder. It represents a maladaptive but temporary reaction to life stressors:

Features of an Adjustment Disorder

The presence of a stressor is essential to making the diagnosis

The onset of symptoms must proceed the stressor. They do not meet the criteria for another mental

disorder. They do not follow bereavement

Symptoms begin within 3-months of the stressor and resolve within 6 months of its termination

Symptoms may be prolonged if there are continuing consequences resulting from the stressor

The diagnosis cannot be made in the presence of another mental state diagnosis unless that

diagnosis does not explain the symptoms that occur in reaction to the stressor

Symptom severity or numbers are not specified. General principles (marked distress or significant

impairment) are used. This is different from the approach used in other diagnoses

The condition may be acute or chronic, the latter recognized if the stressor remains.

The boundaries of the condition are not well defined. On the one hand, the distinction from normal adaptive reactions is not made clear and, on the other, the distinction from other diagnoses such as mood and anxiety disorders is a matter of debate. ICD-10 does specify that social impairment should be present but there is no such requirement in DSM-5. This raises the possibility that using the latter criteria the diagnosis could be applied in the face of proportionate and adaptive reactions to stressful events. DSM-5 does require that symptoms should be clinically significant, although what this means is not specified. When assessing an individual’s reaction to a stressful event, it is important to take four key aspects into account, to help distinguish adjustment disorder from a normal response to stress:

• The individual’s personal circumstances and the context of the stressful event

• The proportionality between the triggering event and symptom

• Cultural and sub cultural norms for emotional expression and emotional responses

• Severity and duration of resultant functional and social impairment

Adjustment disorder is generally regarded as a mild condition, although the evidence for a distinction based on severity is ambiguous. DSM-5 has reconceptualised this group as a “heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or non-traumatic) event, rather than as a residual category for individuals who exhibit clinically significant distress but whose symptoms do not meet criteria for a more discrete disorder”.

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ANXIETY DISORDERS These diagnoses share features of excessive fear and anxiety and related behavioural disturbances. Fear is the emotional response to real or perceived imminent threat, whereas anxiety is the anticipation of future threat. Obviously, these two states overlap, but they also differ, with fear more often associated with surges of autonomic arousal necessary for fight or flight, thoughts of immediate danger, and escape behaviours; and anxiety more often associated with muscle tension and vigilance in preparation for future danger and cautious or avoidant behaviours. Sometimes the level of fear or anxiety is reduced by pervasive avoidance behaviours. Panic attacks feature prominently within the anxiety disorders as a particular type of fear response. Anxiety disorders differ from developmentally normative fear or anxiety by being excessive or persisting beyond developmentally appropriate periods. They differ from transient fear or anxiety, often stress induced, by being persistent. Since individuals with anxiety disorders typically overestimate the danger in situations they fear or avoid, the primary determination of whether the fear or anxiety is excessive or out of proportion is made by the clinician, taking cultural and contextual factors into account. Generalised Anxiety Disorder

Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at

least six months, about many events or activities (such as work or school performance). It

causes clinically significant distress or impairment.

Features of Generalised Anxiety Disorder

The person finds it difficult to control their worry with at least 3 from items 1-6

1. Restlessness

2. Fatigue

3. Poor concentration

4 Irritability

5. Muscle tension

6. Sleep disturbance

Not better accounted for by another major psychiatric disorder or due to the direct

physiological effects of a substance

Specific fears may warrant a diagnosis of Specific Phobia or Social Phobia. Panic attacks, fear about their consequences, and avoidance are classically associated with Panic Disorder.

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BIPOLAR AND RELATED DISORDERS The Bipolar I disorder criteria represent the modern understanding of the classic Manic-Depressive Disorder or Affective Psychosis described in the 19th Century, differing from that classic description only to the extent that neither Psychosis nor the lifetime experience of a Major Depressive Episode is a requirement. However, most individuals whose symptoms meet the criteria for a fully syndromal Manic Episode also experience Major Depressive Episodes during their their life Bipolar II Disorder, requiring the lifetime experience of at least one episode of Major Depression and at least one Hypomanic Episode, is no longer thought to be a ‘milder’ condition than Bipolar I Disorder, largely because of the amount of time individuals with this condition spend in Depression, and because the instability of mood experienced by individuals with Bipolar II Disorder is typically accompanied by serious impairments in work and social functioning. The diagnosis of Cyclothymic Disorder is given to adults who experience at least two years of both Hypomanic and Depressive periods without ever fulfilling the criteria for an episode of Mania, Hypomania, or Major Depression. A Hypomanic Episode is distinguished from a Manic Episode because of severity. In the former, there is an unequivocal change in functioning that is uncharacteristic of the individual and observable by others. In the latter the mood disturbance is sufficiently severe to cause marked impairment in social or occupational function or to necessitate hospitalisation or there are psychotic features. Symptoms include:

Symptoms of a Hypomanic Episode

1. A distinct period of normally and persistently elevated, expansive, or irritable mood.

2. Inflated self-esteem or grandiosity.

3. Decreased need for sleep.

4. More talkative than usual.

5. Flight of ideas or subjective experience of thoughts racing.

6. Distractibility.

7. Increase in goal-directed activity.

8. Excessive involvement in activities that have a high potential for painful consequences.

9. Marked impairment in social or occupational functioning.

10. Not attributable to the physiological effects of a substance.

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DEPRESSION (MAJOR DEPRESSIVE EPISODE) The diagnostic criteria for Major Depressive Disorder are unchanged in DSM-5, hence the questionable reliability of the diagnosis is also unchanged (Kappa 0.28). It has always been problematic because the criteria encompass a wide range of illness and previous attempts to subdivide the group (e.g. distinguishing between an endogenous and reactive form) have not been successful (eg Copolov, Rubin, Mander et al 1986) and do not form part of current classifications although remain useful clinically. DSM-5 does acknowledge what clinicians do in clinical practice. It stresses that responses to significant loss may include feelings of intense sadness, rumination, insomnia, poor appetite and weight loss which may resemble a depressive episode but which may be understandable or appropriate under the circumstances. Such a decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of the loss.

Symptoms of Depression

1 Depressed mood most of the day.

2 Markedly diminished interest or pleasure in all, or almost all, activities most of the day

3 Loss of energy or fatigue.

4 Unreasonable feelings of self-reproach or excessive or inappropriate guilt.

5 Recurrent thoughts of death or suicide, or any suicidal behavior.

6 Diminished ability to think or concentrate, or indecisiveness.

7 Psychomotor agitation or retardation.

8 Insomnia or hypersomnia.

9 Change in appetite (decrease or increase with corresponding weight change).

Recognised depressive symptoms are similar in DSM-5 and the International Classification of Disease (version 10). For DSM-5, five or more of the symptoms must be present for at least 2 weeks and be a change from previous functioning; at least one of the symptoms is either depressed mood or loss of interest or pleasure. Symptoms cause clinically significant distress or impairment, are not due to the direct physiological effects of a substance and are not better accounted for by bereavement.

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NEUROCOGNITIVE DISORDERS Neurocognitive disorders are now separated into major and minor with specifiers highlighting causation where that is known. Mild neurocognitive disorders are associated with modest cognitive decline which does not interfere with the capacity for independent living. For major neurocognitive disorder there is evidence of significant cognitive decline enough to interfere with independence in everyday activities. The deficits are not better explained by another mental disorder and do not occur exclusively in the context of delirium. Specifiers include traumatic brain injury (TBI) where there is evidence of such an injury and the neurocognitive disorder presents immediately after the occurrence of the TBI, or immediately after recovery of consciousness, and persists past the acute post-injury period. There must have been one of the following:

• Loss of consciousness

• Post traumatic amnesia

• Disorientation or confusion

• Neurological signs.

PERSONALITY DISORDERS

A Personality Disorder is an enduring pattern of inner experience and behaviour that deviates markedly from the expectations from the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment. There are ten specific types.

• Paranoid

• Schizoid

• Schizotypal

• Antisocial

• Borderline

• Histrionic

• Narcissistic

• Avoidant

• Dependent

• Obsessive Compulsive Personality change can occur due to another medical condition as a direct physiological effect of that condition, for instance a frontal lobe lesion. Other recognised causative agents include neoplasms, head trauma, cerebrovascular disease, Huntington’s Disease, epilepsy, infectious (such as HIV), endocrine and auto-immune conditions.

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POST TRAUMATIC STRESS DISORDER (PTSD)

The major change for DSM-5 is that the requirement for an emotional response at the time of the event (criterion A of DSM-IV) has been dropped. Symptoms include:

Features of PTSD

Exposure to actual or threatened death, serious injury or sexual violence and at least 1 of 1-5

1. Recurrent, involuntary, and intrusive distressing memories of the event

2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the

event

3. Dissociative reactions (flashbacks)

4. Intense or prolonged psychological distress at exposure to internal or external cues that

symbolise or resemble an aspect of the event

5. Marked physiological reactions to internal or external cues that symbolise or resemble an aspect

of the event

Persistent avoidance of stimuli associated with, and beginning after, the event as evidenced by

either or both of 6 and 7

6. Avoidance of or efforts to avoid distressing memories, thoughts or feelings about or closely

associated with the event

7. Avoidance of or efforts to avoid external reminders that arouse distressing memories, thoughts

or feelings about or closely associated with the event

Negative alterations in cognition and mood associated with the event and beginning or

worsening after it as evidenced by 2 or more of 8-14

8. Inability to remember an important aspect of the event typically due to dissociative amnesia

9. Persistent and exaggerated negative beliefs or expectations about oneself, others or the world.

10. Persistent, distorted cognitions about the cause or consequences of the event that lead the

individual to blame himself/herself or others

11. Persistent negative emotional state

12. Markedly diminished interest or participation in significant activities

13. Feelings of detachment or estrangement from others

14. Persistent inability to experience positive emotions

Marked alterations in arousal and reactivity associated with the event, beginning or

worsening after the event as evidenced by 2 of 15-21

15. Irritable behaviour and angry outbursts which are unprovoked and typically verbal or physical

16. Reckless or self-destructive behaviour

17. Hypervigilance

18. Exaggerated startle response

19. Problems with concentration

20. Sleep disturbance

The duration is more than a month, causes clinically significant distress or impairment and is

not because of the effects of a substance or another medical condition

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Traumatic events include those that are directly experienced or witnessed and can include learning that a traumatic event has occurred to a close family member or friend if the event was violent or accidental. Experiencing repeated or extreme exposure to aversive details of traumatic events (for instance Police Officers repeatedly exposed to details of child abuse) is recognized, although this does not apply to exposure through electronic media, television, movies or pictures, unless the exposure was work related.

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SOMATIC SYMPTOM AND RELATED DISORDERS This is a new section of the DSM and the disorders represent significant revisions over DSM-IV. The principles behind the changes are crucial in understanding these diagnoses. In DSM-IV there was a great deal of overlap across the somatoform disorders and a lack of clarity about the boundaries of diagnoses. The previous criteria over-emphasised the centrality of medically unexplained symptoms. The reliability of determining that a somatic symptom is medically unexplained is limited and grounding a diagnosis on the absence of an explanation problematic. It is not appropriate to give an individual a mental disorder diagnosis solely because a medical cause cannot be demonstrated. The new classification defines the major diagnosis, somatic symptom disorder, based on positive symptoms (distressing somatic symptoms plus abnormal thoughts, feelings and behaviours in response to these symptoms). A distinctive characteristic of many individuals with Somatic Symptom Disorder is not the somatic symptoms per se, but the way they present and interpret them. Incorporating affective, cognitive and behavioural components into the criteria for Somatic Symptom Disorder provides a more comprehensive and accurate reflection of the true clinical picture than can be achieved by assessing the somatic complaints alone. Somatic Symptom Disorders can accompany diagnosed medical disorders. Somatic Symptom Disorder (which may be with predominant pain, previously referred to as Pain Disorder)

Individuals typically have multiple, current, somatic symptoms that are distressing or result in significant disruption of daily life. Sometimes only one severe symptom, most commonly pain, is present. The symptoms may be specific or relatively non-specific. They represent normal bodily sensations or discomfort that does not generally signify serious disease. Somatic symptoms without an evident medical explanation are insufficient to make this diagnosis. The individual’s suffering is authentic, irrespective of whether it is medically explained. Individuals have one of:

• Disproportionate thoughts about the seriousness of one’s symptoms.

• Persistently high levels of anxiety about health or symptoms.

• Excessive time and energy devoted to these symptoms or health concerns. which have lasted longer than six months. Conversion Disorder (Functional Neurological Symptom Disorder) Many clinicians use the alternative names of ‘Functional’ (referring to abnormal central nervous system function) or ‘Psychogenic’ (referring to an assumed aetiology) to describe the symptoms of Conversion Disorder. In this disorder there may be one or more symptoms of various types. Motor symptoms include weakness or paralysis; abnormal movements, such as tremor or dystonic movements; gait abnormalities; and abnormal limb posturing. Sensory symptoms include altered, reduced, or absent skin sensation, vision, or hearing. Episodes of abnormal generalised limb shaking with apparent impaired or loss of consciousness may resemble Epileptic Seizures (also called Psychogenic or Non-Epileptic

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Seizures). There may be episodes of unresponsiveness resembling syncope or coma. Other symptoms include reduced or absent speech volume (Dysphonia/Aphonia) altered articulation (Dysarthria), a sensation of a lump in the throat (Globus), and Diplopia. There must be clinical findings that show clear evidence of incompatibility with neurological disease. Internal inconsistency at examination is one way to demonstrate incompatibility. Examples of such examination findings include:

• Hoover’s Sign.

• Marked weakness of ankle plantar-flexion when tested on the bed in an individual who can walk on tip-toes.

• Positive findings on the Tremor Entrainment test.

• Epileptic attacks with a normal simultaneous EEG or resistance to the opening of closed eyes.

• Tunnel vision. The diagnosis should be based on the overall clinical picture and not on a single clinical finding. The symptoms or deficit cause clinically significant distress or impairment.

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SUBSTANCE-RELATED AND ADDICTIVE DISORDERS Encompasses ten separate classes of drugs: alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; sedatives; hypnotics and anxiolytics; stimulants; tobacco; and other substances. All drugs that are taken in excess have in common direct activation of the brain rewards system, which is involved in the reinforcement of behaviours and the production of memories. They produce such an intense activation of the rewards system that normal activities may be neglected. Instead of achieving rewards system activation through adaptive behaviours, drugs of abuse directly activate the reward pathways. Pharmacological mechanisms by which each class of drugs produces rewards are different, but the drugs typically activate the system and produce feelings of pleasure, often referred to as a ‘high’. Furthermore, individuals with lower levels of self-control, which may reflect impairments of brain inhibitory mechanisms, may be particularly predisposed to develop substance abuse disorders, suggesting that the roots of substance abuse disorders for some people can be seen in behaviours long before the onset of actual substance use itself. The essential features of a Substance Use Disorder are a cluster of cognitive, behavioural and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems. An important characteristic of Substance Use Disorders is an underlying change in brain circuits that may persist beyond detoxification, particularly in individuals with severe disorders. The behavioural effects of these brain changes may be exhibited in the repeated relapses and intense drug craving when the individuals are exposed to drug-related stimuli. A diagnosis of a Substance Use Disorder is based on a pathological pattern of behaviours related to use of the substance. These include: 1. impaired control (criterion 1-4) 2. social impairment (criterion 5-7) 3. risky use (criterion 8-9) and 4. pharmacological criteria (criterion 10-11)

• Criterion 1: The individual may take the substance in larger amounts for over a longer period than was originally intended.

• Criterion 2: The individual may express a persistent desire to cut down or regulate the substance use and may report multiple unsuccessful attempts to decrease or discontinue the use.

• Criterion 3: The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects. In severe cases most of the individual’s daily activities revolve around the substance.

• Criterion 4: Craving.

• Criterion 5: Failure to fulfill major obligations at work, school or home.

• Criterion 6: Continued substance use despite persistent or recurrent social or interpersonal problems.

• Criterion 7: Important social, occupational or recreational activities may be given up or reduced.

• Criterion 8: Recurrent substance use in situations in which it is physically hazardous.

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• Criterion 9: Continued use despite knowledge of having a persistent or recurrent physical or psychological problem likely to have been caused or exacerbated by the substance.

• Criterion 10: Tolerance.

• Criterion 11: Withdrawal. Tolerance is signaled by requiring a markedly increased dose of the substance to achieve the desired effect or a markedly reduced effect when the usual dose is consumed. Withdrawal is a syndrome that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance. After developing withdrawal symptoms, the individual is likely to consume the substance to relieve the symptoms. Neither tolerance, nor withdrawal is necessary for a diagnosis of a Substance Use Disorder. However, for most classes of substances, a history of withdrawal is associated with a more severe clinical course. Symptoms of tolerance and withdrawal occurring during appropriate medical treatment with prescribed medications are specifically not counted when diagnosing a Substance Use Disorder. The appearance of normal, expected pharmacological tolerance and withdrawal during medical treatment has been known to lead to an erroneous diagnosis of ‘addiction’ even when these were the only symptoms present. Individuals whose only symptoms are those that occur because of medical treatment should not receive a diagnosis solely on the basis of these symptoms. However, prescription medications can be used inappropriately, and a Substance Use Disorder can be correctly diagnosed when there are other symptoms of compulsive, drug-seeking behaviour. The word addiction is not used as a diagnostic term in DSM-5, although it is in common usage in many countries to describe severe problems related to compulsive and habitual use of substances. The more neutral term Substance Use Disorder is used to describe the wide range of the disorder, from a mild form, to a severe state of chronically relapsing, compulsive drug taking. Some clinicians will choose to use the word ‘addiction’ to describe more extreme presentations, but the word is omitted from the official DSM-5 Substance Use Disorder diagnostic terminology because of its uncertain definition and its potentially negative connotation.

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TRAUMATIC BRAIN INJURY (TBI)

A TBI occurs when a blow to the head causes death of brain cells, or rupture of nerves or brain axons (Oppenheimer 1968). Significant TBI causes loss of consciousness, confusion, amnesia or neurological signs. These can be used as indicators of severity. It is associated with a wide range of potential neuropsychiatric outcomes. This ranges from death or profound impairment to full and fast recovery (Wortzel & Granacher 2015). Post Traumatic Amnesia (PTA - the period for which the brain is incapable of forming new memories, or of establishing a continuous pattern of memory after the accident) is the most sensitive marker of damage (Jennett & Teasdale 1981). It is often measured by using the Westmead Post Traumatic Amnesia Scale

Length of PTA Likely Outcome

1 day or less Expect quick and full recovery. A few may show persistent disability

Greater than 1 day but less than 1 week

Recovery period more prolonged – weeks or months. Full recovery possible for most.

1-2 Weeks Recovery a matter of many months. Many have residual problems. Functional recovery likely.

2-4 Weeks Recovery is prolonged, > 1 year not unusual. Permanent deficits are likely

More than 4 Weeks Significant permanent disability now certain. A matter of long term retraining and management

Behavioural disorder following TBI is typically associated with frontal systems impairment. Frontal systems are the seat of personality. Impairment alters the capacity to think through reactions leading to personality change. Close observers of the brain injured person have difficulty predicting their response. Poor judgement and instinctive responses lead to anger. This is often over trivial issues (Darby & Walsh 2005). Disordered function may be physical, cognitive, or behavioural. Sometimes, extensive structural damage on scans, causes no functional problems, while severe functional problems are associated with normal scans (Rosenthal et al 1991). Behavioural change because of frontal lobe dysfunction (executive function), is difficult to test for. It relies heavily on the reports of observers (Darby & Walsh 2005). Minimal Traumatic Brain Injury (mTBI)/Concussion mTBI (previously called concussion) accounts for more than 80% of TBI events. It is generally associated with an excellent prognosis. Concussion is a term commonly used in the sports world and mTBI in the trauma literature. Concussion refers to an immediate and transient loss of consciousness after a blow to the head. This is accompanied by a brief period of amnesia. This event is common, particularly on the sports field. Among the most widely

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accepted definitions is that offered by the American Congress of Rehabilitation Medicine (Kay et al 1993). There must be at least one of the following:

Indicator For mTBI

Loss of Consciousness < 30 mins

Confusion < 24 hrs

Glasgow Coma Score (GCS) 13 + by 30 mins

If any of these parameters are exceeded the injury breaks into the moderate to severe range. If there is day of trauma radiological evidence of acute neurotrauma (so called complicated mTBI) the outcome may be more akin to a moderate TBI. Symptoms

Common Acute Symptoms of mTBI

Loss of Consciousness Tinnitus

Headache Bad taste in the mouth

Lightheadedness or dizziness Fatigue or lethargy*

Blurred vision or tired eyes Sleep pattern changes*

Confusion Mood or behavioural changes*

Problems with memory, concentration, attention or thinking*

* Confounded with symptoms of other psychiatric disorders

The International Collaboration on mTBI Prognosis The ICMTBIP has updated our understanding of the effects of mTBI. Full and fast recovery is the norm for most people (Carroll et al 2014). In the first 48hrs to two weeks after injury, mTBI is associated with cognitive deficits. The nature and size of these varies across studies. Recovery often occurs during the first month after injury. Certain cognitive deficits may last longer than 3 months. These may be of questionable clinical significance. There is some evidence that complete recovery may take up to a year for some. There is no quality medical evidence to support the occurrence of long-standing severe neurocognitive impairment after a single uncomplicated mTBI. There are “consistent findings that having negative expectations about head injuries is associated with poorer cognitive test performance”. After motor vehicle accidents (the leading cause of mTBI) the median time to recovery is 100 days, although 23% had not recovered by 1 year (Cassidy et al 2014). Countries in which litigation after accidents is infrequent have low rates of post-concussive disability. The problem is almost unknown in young children. Nonetheless, difficulty concentrating can

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occur in the absence of complicating features. This can be demonstrated with neuropsychological tests, in some cases for months after concussion. There are few quality studies on return to work after mTBI. The majority suggest that most workers return within 6 months. Five to twenty per cent face problems 1 to 2 years’ post injury (Doctor et al 2005, Stulemeijer et al 2008, Kristman et al 2010). mTBI does not appear to be a significant risk factor for long-term work disability (Cancelliere 2014).

DSM 5 for Neurocognitive Disorders due to TBI This has departed significantly from its predecessors. The major distinction is between Mild or Major Neurocognitive Disorder. Mild Neurocognitive Disorders are associated with modest cognitive decline. This does not interfere with the capacity for independent living. There is evidence of a traumatic brain injury - that is, an impact to the head or other mechanisms of rapid movement or displacement of the brain within the skull, with one or more of the following:

• Loss of consciousness

• PTA

• Disorientation or confusion

• Neurological signs Problems present immediately or are obvious after recovery of consciousness. They persist past the acute post-injury period. Symptoms must not be due to delirium. They are not better explained by another mental disorder. Providers are cautioned to be mindful of possible somatic factitious symptoms. This is especially when symptoms appear to be incompatible with the initial injury severity. DSM notes “other symptoms that may potentially co-occur with neurological symptoms (eg depression, irritability, fatigue, headache, photosensitivity, sleep disturbance) also tend to resolve in the weeks following mTBI. Substantial subsequent deterioration in these areas should trigger consideration of additional diagnoses”. The Workcover WA Guides (2016) To diagnose a brain injury post injury disturbance should be associated with at least one of; abnormal GCS; significant PTA; or radiological evidence of intracranial pathology. Assessment of Brain Injury involves Neurologists, Rehabilitation Physicians and Psychiatrists (amongst others). Relevant sections of the WA Guides are chapter 5 for neurologists (as psychiatric features may be a primary consequence of neurological disorders), and chapter 11 for psychiatrists (for psychiatric manifestations and impairment that are not directly related to neurological impairment).

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REFERENCES

Andras, P. & Charlton, B. G. (2002). Commentary on Sweeney & Kernick (2002), Clinical Evaluation: Constructing a New Model for Post-normal Medicine. Journal of Evaluation and Clinical Practice. 8, 131 – 138. Copolov, D.L., Rubin, R.T., Mander, A.J. et al. (1986). DSM-III Melancholia: Do the criteria accurately and reliably distinguish endogenous pattern depression? Journal of Affective Disorders, 10, 191-202. Croskerry, P. (2009). A Universal Model of Diagnostic Reasoning. Academic Medicine. 84, 1022 – 1028. Llewelyn, H., Ang, H. A., Lewis, K. et al. (2009). Oxford Handbook of Clinical Diagnosis. Oxford: Oxford University Press. Sweeney, K. & Kernick, D. (2002). Clinical Evaluation: Constructing a New Model for Post-normal Medicine. Journal of Evaluation and Clinical Practice. 8, 131 – 138. Zimmerman, B., Lindberg, C. & Plsek, P. (2001). Edgeware: Insights from Complexity Science for Health Care Leaders. Texas: VHA Inc.