Diagnosis Made Easier Diagnosis Made Easier Principles and Techniques for Mental Health Clinicians James Morrison The Guilford Press New York London © 2007 The Guilford Press A Division of Guilford Publications, Inc. 72 Spring Street, New York, NY 10012 www.guilford.com All rights reserved No part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher. Printed in the United States of America This book is printed on acid-free paper. Last digit is print number: 987654321 Library of Congress Cataloging-in-Publication Data Morrison, James R. Diagnosis made easier : principles and techniques for mental health clinicians / James Morrison. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-1-59385-331-0 ISBN-10: 1-59385-331-9 1. Mental illness—Diagnosis. 2. Mental health services. I. Title. [DNLM: 1. Mental Disorders—diagnosis. 2. Interview, Psychological. 3. Physical Examination—methods. WM 141 M879di 2006] RA469.M67 2006 616.89′075—dc22 2006011629 For Chris, who makes everything easier About the Author James Morrison, MD, earned his BA at Reed College in Portland, Ore - gon, and obtained his medical degree and psychiatric training at Washing - ton University in St. Louis. With an extensive work history in both the pri - vate and public sectors, he is currently Professor of Clinical Psychiatry at Oregon Health and Science University in Portland. Dr. Morrison’s other books for professionals include The First Interview, DSM-IV Made Easy, When Psychological Problems Mask Medical Disorders, and Interviewing Children and Adolescents. In 2002 he published a manual for patients and their relatives, Straight Talk about Your Mental Health. vi Contents Introduction ix PART I The Basics of Diagnosis 1 The Road to Diagnosis 3 2 Getting Started with the Roadmap 7 3 The Diagnostic Method 14 4 Putting It Together 23 5 Coping with Uncertainty 42 6 Multiple Diagnoses 56 7 Checking Up 68 PART II The Building Blocks of Diagnosis 8 Understanding the Whole Patient 87 9 Physical Illness and Mental Diagnosis 98 10 Diagnosis and the Mental Status Examination 116 PART III Applying the Diagnostic Techniques 11 Diagnosing Depression and Mania 127 12 Diagnosing Anxiety and Fear 164 13 Diagnosing Psychosis 182 14 Diagnosing Problems of Memory and Thinking 213 15 Diagnosing Substance Misuse and Other Addictions 235 vii 16 Diagnosing Personality and Relationship Problems 248 17 Beyond Diagnosis: Compliance, Suicide, Violence 267 18 Patients, Patients 277 Appendix: Diagnostic Principles 301 References and Suggested Reading 303 Index 309 viii Contents Introduction When I set out to write about the diagnostic process, I envisioned a text that could both complement classroom teaching and provide a guide for in - dependent study. That was before I undertook a completely unscientific survey of practicing health care professionals, to learn how they had learned about mental health diagnosis. What I found surprised me. For most of the practitioners I surveyed, training in the refined art of diagnosis was—well, no training at all. Most of the professional schools at which my interviewees trained presented no formal course material on di- agnosis, and still do not do so. Even in medical schools, students and resi- dents are expected to know the current diagnostic criteria, but they re- ceive little if any exposure to a method for making diagnoses. Almost to a person, my sample endorsed the sentiment “I learned diagnosis through on-the-job training.” Similarly, chapters and books that strive to teach clini- cians how to perform a competent clinical evaluation focus on the product, while largely ignoring information about the process. That process is neither simple nor intuitive, and I’d certainly never describe it as easy. But after decades of experience and months of consid - eration, I believe it can be explained it in a way that is straightforward and comprehensible—in short, to make diagnosis easier. In this book, I present a way of thinking about diagnostic problems. The material doesn’t depend much on the vagaries of the latest diagnostic standards or code numbers. Instead, I focus on the essential characteristics of mental disorder, which have been recognized for decades. What’s imper - ative to learn is the scientific method—yes, and the art—of evaluating pa - tients and arriving at logical diagnoses consistent with the facts. Part I focuses on the process of diagnosis. Learning how to diagnose well involves systematically applying logical, easily understood principles to information of several different types, assembled from a variety of sources. Although real life requires us to confront many diagnostic issues ix at once, for convenience I’ve divided the tasks into chapters. By the end of Part I, you’ll see how seasoned clinicians unite their experience with new information to create a working diagnosis. The three chapters of Part II explore the social and other background data you need to understand each patient’s mental health diagnosis. Of course, this is the stuff you need to have first, so you can make the diagno - sis. But when learning new material, you have to start somewhere, and I have judged that many (probably most) of my readers already have some familiarity with interviewing and information gathering. That’s why I’ve gone ahead and presented the diagnostic method first. Finally, in the chapters of Part III, we’ll sift through a great deal of clin - ical material to see how the Part I methods and the Part II data apply to various clinical disorders. We won’t consider every disorder, or even all the varieties of the main disorders; other manuals (including my own DSM-IV Made Easy) handle that chore. Rather, we’ll concentrate on the issues and illnesses that mental health clinicians confront every day. To illustrate the diagnostic methods, I’ve included over 100 patient histories. Before you read my analysis of each clinical example, I recom- mend that you try working through the decision trees and writing up your own list of relevant diagnostic principles. It has been amply proven that we all learn far more efficiently by actively thinking about the solution to a problem, rather than just passively reading something printed on a page. I think you’ll benefit from the practice of thinking about the histories and de- termining how their clues direct you to the diagnosis. You may wonder why each decision tree endpoint reads “Consid - er . . .” Why not just name the disorder and move on? After much thought about these diagrams, I have decided that the more tentative wording is safer. Without being too prescriptive, I want to encourage you to avoid a trap that any clinician can fall into: rushing headlong into diagnostic closure before you have all the necessary facts. Figure 1.1 of this book (which is also printed on the front endpaper) provides a roadmap that shows the diagnostic process graphically. The Ap - pendix (which is also printed on the back endpaper) lists the diagnostic principles I consider important to apply in making a mental health diagno - sis. In the interest of space and economy, I’ve put quite a lot of information relevant to currently recognized major diagnoses into tables in Chapters 3 and 6. Table 3.2 provides a differential diagnosis for each major diagnosis; Table 6.1 lists the illnesses that are commonly comorbid. If I haven’t covered every question you have about diagnosis and the diagnostic method, I urge you to consult my website (http://mysite. x Introduction [...]... relatives, and other clinicians provide information crucial to my appraisal At the very least, such information adds color and depth to the emerging portrait of a new patient When available, old records can sometimes save hours of digging for background information; at times they’ve saved me from a calamitous misdiagnosis The clinical history usually begins with the problem that was immediately responsible for. .. fine writing and teaching of George Staley And innumerable clinicians and countless patients have, however unwittingly, furthered my own education and helped show me the way PART I The Basics of Diagnosis 1 The Road to Diagnosis Carson Years ago I evaluated Carson, a 29-year-old graduate student in psychology He had always lived in the town where he was born, among numerous relatives and friends Through... will be information that helps you understand how the lives of patients, relatives, and close associates have been affected You’ll also begin to pick up previous mental health history, which includes information about other mental or emotional problems, or earlier episodes of the current problem, which can also be important in determining what’s currently wrong In the movies, in novels, and on the... personal and social history For the same reasons that a play is more compelling when we understand what motivates its characters, this information is not just interesting but often highly relevant, even vital, to diagnosis I consider this information to be so important that Chapter 8 is devoted to discussing childhood background, current living situation, and family history, especially of mental disorder... of a busy office day or frantic emergency room evening Symptoms and Signs In Chapter 3 we’ll discuss the basic plan for making a sound diagnosis But before we get there, we need to define some terms that relate to the raw materials for any health care diagnosis Technically, symptoms are what patients complain of, whereas signs are what clinicians notice The patient with pneumonia described in Chapter... concentrating on his studies, panicky feelings, trouble sleeping, and poor appetite Hallucinations and delusions are symptoms So are “nervousness,” fear of spiders, and ideas of suicide Of course, circumstance and degree play important roles in determining what is and is not a symptom: Many people don’t care for spiders, and doctors normally wash their hands frequently, so as not to spread germs from one patient... signs and symptoms For example, despite his doubt that he felt depressed, Carson’s tearfulness and slumped shoulders told another story Symptoms (and signs) are useful in two ways First, like Carson’s panic attack, they signal that something is wrong In the same way, suicidal thoughts, poor appetite, or hearing voices can indicate the need for a mental health evaluation The second use of signs and symptoms... pneumonia) The virtue of a cause-based diagnosis is that it accurately directs the clinician to the best treatment Unfortunately, we’ve managed to identify very few mental health diagnoses by cause Indeed, current diagnostic schemes remain proudly “atheoretical,” using criteria written so as not to force clinicians to choose among competing hypotheses about how and why mental disorders develop Perhaps this... additional health care insurance, and whether his siblings and children might develop a similar illness Finally, carefully defined syndromes facili- Validity and Reliability Validity and reliability are two words often used to describe findings in all fields of health care They have meanings that are quite distinct and different, yet they are sometimes used interchangeably in everyday speech and writing... inaccurate prognosis, social stigma, and inappropriate placement A safety hierarchy places at the top those conditions that are most urgent to treat, are most likely to respond well to treatment, and have the best outcome For me, a safe diagnosis is one that I’d prefer to have for myself or for a member of my family Such a diagnosis, if it turns out to be correct and treatment is effective, could restore . Diagnosis Made Easier Diagnosis Made Easier Principles and Techniques for Mental Health Clinicians James Morrison The Guilford Press New. James R. Diagnosis made easier : principles and techniques for mental health clinicians / James Morrison. p. ; cm. Includes bibliographical references and index. ISBN-13: