What is a Clinical Diagnosis?

Developing a clinical diagnosis is the process of identifying a disease, condition, or injury based on the signs and symptoms a patient is having and the patient’s health history and physical exam. Further testing, such as blood tests, imaging tests, and biopsies, may be done after a clinical diagnosis is made. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/clinical-diagnosis

That is the answer for diseases, syndromes, conditions, or injuries in most areas of medicine.

That is not the answer for the fields of psychology or psychiatry. In the field of psychology or psychiatry the process of developing a clinical diagnosis is completely different than in medicine:

In the field of psychology or psychiatry : Clinical diagnosis is the process of using assessment data [psychological and behavioral assessment data] to determine if the pattern of symptoms the person presents with is consistent with the diagnostic criteria for a specific mental disorder outlined in an established classification system such as the DSM-5 or ICD-10. So a psychiatric or psychological review of systems such as we can see described below:

Psychiatric Review of Systems

Screen for present and past:

  • Major depressive/dysthymic symptoms.
  • Manic or hypomanic symptoms.
  • Psychotic symptoms.
  • Generalized anxiety disorder.
  • Panic disorder.
  • Obsessive-compulsive disorder.
  • Other areas suggested by HPI, for example:
    • Dementias
    • Eating disorders
    • Dissociative disorders
    • PTSD

will refer only to behavioral diagnostic criteria of the kind described in the DSM5.

The psychiatric ROS [review of Systems] has nothing to do with a review of a patients physical presenting complaint, the medical history of the patient [eg. recent flu-like illness, injury, major loss of blood, vitamin deficiency, malnutrition, poor living conditions, et..] that could be relevant to their mental status and mood changes and has nothing to do with a list of questions, arranged by organ system, designed to uncover dysfunction and disease within that area; the organ systems being

The National Institutes of Mental Health has stated outright that the DSM5 lacks VALIDITY as a diagnostic and treatment tool. The simple definition of Validity is : the quality of being logically or factually sound; soundness or cogency. Oxford Language Dictionary. So the NIMH has said publically that the DSM5 is not factually or logically sound, and has no cogency. Cogency means “the quality of being clear, logical, and convincing; lucidity.” Oxford Language Dictionary. So not only is the DSM5 not factual or logical, it is also unclear and unconvincing. [says the NIMH].

Paula and I agree. with the NIMH.

The NIMH is trying to come up with a different system to assess and diagnose mental illness.

Paula and I think that this system already exists in medicine. We think that the physical exam and the physical signs and the symptoms of serious mental illness, such as bipolar illness, have been neglected in favour of its stereotypic spectacular behavioural presentation.

The medical causes of altered mental status [and mood] are many; and can be hard to identify –especially if the patient cannot tell you what is wrong because [1] they do not know and [2] they can no longer communicate or think normally. Just because the doctor recognizes the behavioral syndrome or has difficulty identifying a medical cause does not mean there is no medical cause. It simply means that time needs to be spent figuring it out. And it could take a long time.

Altered mental status (AMS) represents a broad spectrum of disease processes, making treatment modalities equally broad and varied. It is hard to diagnose the cause of sudden and continued altered mental status. The DSM5 should be replaced by what medical professionals already know about the assessment of altered mental status because this is what young or middle aged or elderly adults have; they do not have a “mental illness’., they have the consequences of poor physical health having effects on their brain function and ability to function at their best.

Figuring out all the possible physical causes for altered mental status is a gargantuan task which could take months, even years to figure out. Hence the need for a memory aid such as AEIOU-TIPS :

AEIOU-TIPS is a mnemonicacronym used by some medical professionals to recall the possible causes for altered mental status. Medical literature discusses its utility in determining differential diagnoses in various special populations presenting with altered mental status including infants,[1] children,[2]adolescents,[3] and the elderly.[4] The mnemonic also frequently appears in textbooks and reference books regarding emergency medicine in a variety of settings, from the emergency department[5] and standard emergency medical services[6] to wilderness medicine.[7]

Alcohol/Abuse of substances
Acidosis
Alcohol or drug intoxication[3]
Diabetic ketoacidosis; Respiratory acidosis due to CO2 narcosia hypoventilation due to COPDasthmatic airway obstruction, or neuromuscular disease[2]
EEcstasyEnvironmental
Epilepsy
Electrolytes
Encephalopathy
Endocrine disease
Hypothermiahyperthermia[7]
Epileptic seizure (or seizure for any other reason)[4]
Hyponatremiahypernatremiahypocalcemiahypercalcemia[6]
Wernicke’s encephalopathyChronic traumatic encephalopathy (CTE)[6]
Adrenal insufficiencythyroid disease[2]
IInfectionEncephalitismeningitismeningoencephalitissepsis[1]
OOverdose
Oxygen deficiency
Prescription or non-prescription drug overdose[1][3]
Hypoxia due to pulmonary edema, pulmonary embolism or tension pneumothorax; hypoxic brain injury due to cardiac arrest[4][1]
UUnderdose
Uremia
Insufficient dose of prescription medications
Excess urea in the blood due to kidney failurecongestive heart failure, urinary obstruction[6]
TTrauma
Tumor
Concussiontraumatic brain injuryincreased intracranial pressure due to epidural hemorrhage[7]
Brain tumormetastasis to the brain; paraneoplastic syndrome[5]
IInsulin
Intestinal
Hypoglycemia;[7] hyperosmolar hyperglycemic state[6]
IntussusceptionIntestinal malrotation with volvulus[8]
PPsychogenic
Poisons
Psychosispseudoseizureconversion disorder[5]
Carbon monoxide poisoninglead poisoningiron poisoning[5]
SStroke
Shock
Hemorrhagic stroke due to arteriovenous malformation (AVM)[5]
Neurogenic shock due to spinal cord injurycardiogenic shock due to myocardial infarction[6]

from https://en.wikipedia.org/wiki/AEIOU-TIPS

Treating a person with a continuing attack of altered mental status means first and foremost measuring their respiration rate [carefully-with a stopwatch], looking to see if breathing is laboured [as in checking for active exhaling], getting their tidal volume and obtaining their minute ventilation.

That will tell you if they are breathing adequately – with or without healthy lungs; the control of breathing and response to rising carbon dioxide of the blood is very important to their ability to defend their acid base balance.

If they have normal lung function but show abnormal breathing rate, depth or pattern at rest, then it is necessary to explore their acid base status with an arterial blood gas test. Only an arterial blood gas test will give you their PaCO2 or their pH or even their PaO2 . [pulse oximetry is insufficient and can be misleading. ].

There are so many causes of altered mental status and mood, so many to sift through, and this is what psychiatrists should be spending their time doing-this and only this!

Broken control of breathing and its metabolic consequences are only one cause of stable attacks of bipolar depression and mania.

Paula and I know a number of people who have survived huge injuries from being run over by a bus or car as kids, or from being repeatedly choked or hit or attacked, and then went on to have different developing neurological syndromes later on in their lives [eg Parkinson’s, weird metabolic syndromes, kidney failure, heart failure, etc..] and neither patient nor doctor made the connections that might have helped treat these long term complications of their injuries.

The same is true for the so called mental illnesses. The co-morbidities seen in so called mental illness , [such as cardiovascular disease, COPD, kidney disease, etc.] ..may not necessarily be “more than one disease or condition is present in the same person at the same time” The COPD, Kidney problems, cardiovascular complications may be part and parcel of the syndrome of altered mental status; one and the same disease process, not physical and mental processes that are separate.

People with serious mental health problems are often in poor physical health; because their mental problems are a result of their poor health, it is obvious!

Poor physical health and poor physical condition [accidental malnutrition, blood loss, iron deficiency, thiamine deficiency, dehydration, etc…] lead to altered mental status and need to be treated to restore mental status to baseline; if you do that I assure you normal mood will follow as well.

to be continued…errands beckon I’m afraid …….

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