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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: 9 8 7 6 5 4 3 2 1 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, Oregon, and obtained his medical degree and psychiatric training at Washington University in St. Louis. With an extensive work history in both the private 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 PART I ix 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 235 and Other Addictions vii viii Contents 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 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 independent 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 diagnosis, and still do not do so. Even in medical schools, students and residents are expected to know the current diagnostic criteria, but they receive 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 clinicians 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 consideration, 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 imperative to learn is the scientific method—yes, and the art—of evaluating patients 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 x Introduction 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 diagnosis. 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 clinical 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 recommend 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 determining how their clues direct you to the diagnosis. You may wonder why each decision tree endpoint reads “Consider . . .” 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 Appendix (which is also printed on the back endpaper) lists the diagnostic principles I consider important to apply in making a mental health diagnosis. 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.