Is it a quirk or a mental illness?

Jay Fawver, MD, psychiatrist, Medical Director, PPG – Mind-Body Medicine, explains the key criteria used to diagnose common mental health conditions.

Consider the following scenarios:

  • An 18-year-old young man who is “moody” and isolates himself to his bedroom
  • A 34-year-old woman who has a controlled obsession to shove people to the ground
  • A 43-year-old woman who twirls her hair and bites her nails
  • A 62-year-old man who exclusively eats the foods on his plate in a clockwise direction
  • A 75-year-old man who is experiencing daytime sleepiness and a decline in motivation

Do any or all of these individuals have a need for psychiatric treatment?

How is a psychiatric condition determined?

All of us have quirks, peculiar mannerisms, personal habits and comfortable routines that are shaped by our past experiences, coping skills and interpersonal relationships. These characteristics mold us to be unique individuals rather than unfeeling and predictable robots.  Based upon our life circumstances, we experience various degrees of sadness, anxiety, joy, anger and apathy as normal ebbs and flows (vicissitudes) of our daily emotional experiences.   With these factors in mind, how do we determine the presence of a psychiatric condition that warrants mental health treatment?

At Parkview Physicians Group – Mind-Body Medicine, our clinicians consider the following factors to determine the need for treatment of symptoms described by a patient or loved one:

  • Symptom clusters defining psychiatric diagnoses
  • Duration and persistence of symptoms
  • Functional impairment caused by the symptoms
Symptom clusters

Symptom clusters have been defined by the Diagnostic and Statistical Manual, version 5 (DSM-5) for several psychiatric conditions, including mood disorders, anxiety disorder, psychotic disorders, attention deficit disorder and memory disturbances. As with any diagnostic assessment, treatment is directed to address these symptoms. Similar to assessing an individual’s diabetes control with a hemoglobin A1C, symptom clusters for various conditions can be screened, measured and tracked by patient-rated outcome metrics (PROMs), including:

  • Patient Health Questionaire-9 (major depression)
  • Mood Disorder Questionnaire (screening for bipolar spectrum conditions)
  • GAD-7 (generalized anxiety disorder)
  • Liebowitz Social Anxiety Scale (social anxiety disorder)
  • Adult ADHD Self-Report Scale Symptom Checklist (screening for ADD/ADHD)
  • PTSD-Checklist-Specific Scale (PTSD)
  • Epworth Sleepiness Scale (hypersomnia, possibly related to sleep apnea)

If symptom clusters are identified, further evaluation is warranted, including identification of pertinent family history of similar conditions, the use of alcohol or other substances as a means of self-medication, past medication treatment effects, past life experiences that contributed to the symptoms, coping abilities, impact of past counseling and associated medical conditions that may contribute to the symptomatology. Such medical conditions masquerading as psychiatric problems may include:

  • Thyroid conditions
  • Diabetes mellitus type II
  • Sleep apnea
  • Migraine headaches
  • Tension headaches
  • Irritable bowel syndrome
  • Fibromyalgia
  • Restless legs syndrome

One might ask If determining a diagnosis is really necessary. Many people are reluctant to be “labeled” with such a condition. 

Imagine if you saw your primary care clinician complaining of a “nagging cough.” Obviously, treatment would be entirely different based upon the diagnosis of either lung cancer, seasonal allergies, pneumonia, gastric reflux, heart failure or a side effect to Lisinopril, all of which can cause the symptom of a “nagging cough.” In a similar manner, if you experience “poor motivation, fatigue and impaired concentration,” we need to determine the precise diagnosis prior to choosing treatment options, as these “psychiatric” symptoms may be actually due to sleep apnea, anemia, heart or kidney failure and/or hypothyroidism. If those conditions are determined to not be present, psychiatric conditions such as major depression, bipolar disorder or attention deficit disorder may be considered. In all cases, the diagnosis directs proper treatment.

Duration and persistence of symptoms

Not only do symptom clusters need to be simultaneously present, they need to persist for defined durations to meet diagnostic criteria to warrant treatment for a psychiatric condition. For instance, such durations include:

  • 4-7 days for bipolar disorder
  • 2 weeks for major depression
  • 1 month for post-traumatic stress disorder (PTSD)
  • 6 months for schizophrenia

Experiencing shorter durations of symptom clusters could be considered diagnostic “traits” rather than disorders and would possibly warrant a “watchful waiting” approach or more conservative management.

Functional impairment

A psychiatric “vital sign” is the ability to work, attend school or proceed with your usual daily activities. Functional activities include social, marital, work or school functioning and can be measured by such outcome metrics as the Work and Social Adjustment Scale (WSAS), which is a 5-item scale addressing these activities that can predict future likelihood of relapse with conditions such as major depression.  

Functional impairment is significantly impacted by an individual’s concentration, memory and reasoning. For instance, if you can’t think, you can’t work; If you can’t think, it’s difficult to interact with others. Difficulty with concentration can be assessed using a Perceived Deficit Questionnaire (PDQ-20) or more formalized and extensive neuropsychological testing.

The ultimate goal of psychiatric treatment is complete recovery, which means a restoration to your best functioning, allowing you to reach your full potential and satisfaction with relationships, physical health and productive activity, while establishing meaning to your life.

Key takeaways

Consider these factors if you’re wondering whether you merely have a peculiar behavior or an established psychiatric illness. You should embrace your individual personality and unique behavioral mannerisms unless they meet criteria for a psychiatric condition that hinders your quality of life. A psychiatric diagnosis is based upon defined symptom clusters persisting for specified durations while also causing impairment in your daily functioning.

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