The scope of diagnosis of neurological disorders has been constantly changing, and there was a tendency for the diagnosis to be generalized in the past, but now there is a tendency to abolish it. It is rare in the medical field to see such a wide variation in the classification and diagnostic criteria of the current authoritative editions, and such a wide variation in abolition. In the United States, the Diagnostic and Statistical Manual of Mental Disorders, 3rd and 4th editions, have eliminated the general term neurosis. The 10th edition of the International Classification of Diseases (ICD) has almost completely abandoned the concept of neurosis.
The current situation in China is that although the Chinese Classification of Mental Disorders and Diagnostic Criteria retains the diagnosis of neurosis, it has undergone significant changes from the 1st to the 3rd editions: for example, the CCMD-3 has been compared with the CCMD-2-R, dysthymia and depressive neurosis have been eliminated, and somatoform disorders have been moved in. Moreover, the 6th edition of the 11th Five-Year Plan textbook for general higher education, Psychiatry, has adopted the 10th edition of the International Classification of Diseases (ICD).
Is it because neurosis is going to disappear from the world? Of course not. This only shows that the current level of understanding of the diagnosis and differential diagnosis of neurological disorders is problematic, and the resulting classification and diagnostic criteria are highly dubious and uncertain, and it is inevitable that there are contradictions in the scope of their selection and inappropriate treatment of their retention and abolition. Therefore, if we want to solve the problem of diagnosis and differential diagnosis of neurological disorders, we should not stay in the depth and breadth of the current conventional knowledge, but start from a deeper and broader scope of knowledge before we can review the current authoritative classifications and criteria and reposition neurological disorders. A series of differential diagnostic models for neurological disorders and subtypes will combine consensus and insight to answer such questions in an innovative manner.
1. Differential diagnostic models
1.1 Essential combination of symptom aspects
1.1.1 Essential combination of symptom basis. Neurosis is a general term for a group of mild mental disorders, but there are many mild mental disorders and not all of them are neurosis, so there are many diseases that need to be differentially diagnosed with it. Although the symptoms of neurosis are diverse and seem to be heterogeneous and difficult to unify, they have the same combination pattern and are actually homogeneous, which provides a basis for differential diagnosis. No matter which subtype of neurological disorder, its manifestation contents are obviously different, but they are all the same, constituting the same pattern combination: common core symptoms + subtype-specific symptoms. It is a pity that this pattern is not yet well known.
The main symptoms (clinical phases) of neurosis can be generally broken down into two parts: the first part can be called the common or core symptom part, and the second part can be called the personality part or subtype-specific part, both of which are indispensable. The first part of the symptoms, together, manifests as excessive thinking or with excessive attention. The second part of symptoms manifests as one of the following neurotic syndromes, respectively.
(i) generalized anxiety symptoms ;
(ii) panic attacks;
(iii) Mild to moderate depressive symptoms;
④Phobic symptoms;
⑤ Obsessive-compulsive symptoms;
⑥Neurasthenia symptoms;
⑦Suspicious symptoms;
⑧ other neurotic symptoms or a combination of the above symptoms.
1.1.2 Differential diagnosis based on the necessary combination of symptoms
For neurosis, common core symptoms + subtype-specific symptoms are indispensable, otherwise it cannot be diagnosed as neurosis.
Let’s start with the situation in which a patient lacking the first part of symptoms cannot be diagnosed as a neurological disorder. Post-concussion syndrome usually resembles neurosis, but a careful examination will reveal the lack of hyperthought or hyperconcern (the first part of neurosis) as the core basis, and therefore cannot be diagnosed as neurosis; there are more points of differentiation that can be discussed later. Of course, if the patient has a claim for compensation and is overthinking, the situation is even more complex and the differential diagnosis must be made in conjunction with the knowledge presented later. In the same way, if various neurotic symptoms or a combination of them, caused by certain organic diseases such as infections, intoxication, visceral, endocrine or metabolic and cerebral organic diseases, are found to lack hyperthought or hyperconcern (the first part of neurotic symptoms) as the core basis; then these “various neurotic symptoms or a combination of them” can be called neurotic-like syndrome. can be called neurotic-like syndromes, but not neurosis.
As for patients who lack the second part of symptoms, since they do not have neurotic syndromes, they cannot be diagnosed as neurosis.
1.2 Exclusion of symptoms
1.2.1 Basis for exclusion of symptoms
In addition to the first part of symptoms and the second part of symptoms mentioned above, patients with neurosis should not persistently have the following symptoms: dysthymic dissociative symptoms or conversion symptoms, heavy depressive symptoms, psychotic symptoms, deficits in self-awareness, impaired reality testing ability, etc. What is the rationale for this? On the one hand, such symptoms are beyond the scope of mild mental disorders, and on the other hand, if such symptoms are present, one of the following “etiological basis” and “intrinsic relationship basis” must not be valid and be identified. In case of transient disorder, it can be analyzed with reference to the absence of organic pathology.
1.2.2 Differential diagnosis based on exclusion of symptoms
If the patient has “exclusion symptoms”, it means that his condition is beyond the scope of mild mental disorder, and the pattern of performance is also qualitatively different from neurosis, so he cannot be diagnosed as neurosis, but should be diagnosed under other diagnoses.
1.3 Etiology
1.3.1 Etiological basis. Persistent evil thoughts are the hallmark, and persistent evil thoughts have gradually formed before the neurotic syndrome, and then coexist to the present. Persistent obsessions are centered on excessive thought or attention (i.e., the first part of the neurotic symptoms), intertwined with six factors: thought, emotion, attention, memory, will, and personality.
1.3.2 Differential diagnosis based on etiological basis
For patients with complex conditions, it seems from the surface to have the first part of the symptoms of neurosis and the second part of the symptoms, but if excessive thinking or with excessive attention cannot form the etiology lasting evil, then it is also not diagnosed as neurosis, but should be under other diagnosis. The menopausal syndrome, which often behaves like a neurosis, and can induce a certain amount of hypochondriasis or hyperconcentration. However, a careful examination will reveal that the certain hyperthought or hyperconcern is usually forced to be induced after the primary symptoms of the menopausal syndrome appear, and it will automatically and quickly subside when the primary symptoms of the menopausal syndrome are relieved; therefore, it is not capable of forming an etiologically lasting evil thought, and a diagnosis of neurosis cannot be deduced.
1.4 Intrinsic relationship
1.4.1 Basis of intrinsic relationship
There is an inevitable relationship between persistent evil thoughts (etiology) and clinical phases (evidence). Among the general relationships, the most easily perceived one is the positive proportional extinction relationship triggered by the etiology of neurosis. It shows that the scale of the cause determines the scale of the disease mechanism and symptoms; the more complex and widespread the cause, the more intense the disease mechanism initiated and the more symptoms produced, and vice versa.
1.4.2 Differential diagnosis based on internal relationship
Certain psychological disorders have certain psychological causes, and the manifestations of the disease are also or similar to neurotic syndromes, but if there is no “inevitable connection between persistent evil thoughts (causes) and clinical phases (symptoms), and a positive relationship between causes and symptoms”, then it is best not to classify it as a neurosis. Although the onset of hysteria is often associated with psychological factors, its onset pretensions deny the persistence of evil thoughts as the cause of the disease, and does not recognize the existence of a positive proportional relationship triggered by the cause of the disease, and only after recovery. Therefore the intrinsic relationship of hysteria is yet another characteristic, so it is best to separate it from neurosis, and here support the arrangement of the Chinese Classification Scheme and Diagnostic Criteria of Mental Disorders CCMD-3 for hysteria.
Psychogenic mental disorders, with the many subtypes included and the complexity of the situation, should be treated differently. Although patients often admit that they have certain psychogenic causes, most of them deny that “there is a positive relationship between persistent evil thoughts (etiology) and clinical phases (symptoms) triggered by etiology”, so they cannot be classified as neurosis. However, a very small number of patients with mild symptoms admit that “there is a necessary connection between persistent evil thoughts (etiology) and clinical phases (symptoms), and there is a positive relationship between etiology and growth”, so after the acute reaction period, if the conditions of neurosis or its subtypes are met, the diagnosis of neurosis or its subtypes can be modified.
1.5 Absence of organic lesion underlying aspects
1.5.1 No organic lesion as a basis
There is no organic lesion underlying the neurosis; or, the neurosis does not arise from an organic lesion. Various neurological symptoms or their combinations can be seen in infectious, toxic, visceral, endocrine or metabolic and organic brain diseases, called neurological-like syndromes. These neurological-like syndromes cannot be called neurological disorders.
1.5.2 Differential diagnosis based on the absence of organic lesions
In general, it is relatively easy to make the diagnosis of neurosis in the absence of organic lesions. However, when a neurological syndrome occurs after an organic lesion, how can one determine whether the neurological syndrome is directly caused by the organic lesion or whether the organic lesion itself does not cause the neurological syndrome but rather the neurological disorder is caused by overthinking or excessive concern? The clinical picture is often complex and requires analysis to understand.
The absence of organic lesions as the basis for neurosis only means that neurosis is not a direct result of organic lesions; however, it does not mean that patients with neurosis no longer have organic lesions, nor does it mean that patients who have had organic lesions no longer suffer from neurosis. As the human body grows, ages, and undergoes certain factors, various organic lesions tend to increase day by day. The emergence or cure of organic lesions does not mean that neurosis will automatically die out, so the differential diagnosis of neurosis should be carefully analyzed. In some patients, after the appearance or cure of organic lesions, many new psychiatric problems arise, and the original symptoms of neurosis are no longer distinguishable on the basis of the intrinsic relationship between the cause and the symptoms, so it is no longer appropriate to make a diagnosis of neurosis, but rather a diagnosis of “such and such disease with mental disorder”.
On the contrary, in some patients, after the appearance or cure of organic lesions, the original symptoms of neurosis are still clearly identifiable on the basis of etiological relationships, and there is no direct relationship between organic lesions and neurosis-like symptoms, so it is appropriate to retain the diagnosis of neurosis at this time. The general rule is that the diagnosis of neurosis must be based on the three aspects of “symptoms, etiology, and internal system”: if both exist, neurosis still exists; if one is not, neurosis has been abolished.
1.6 Course of the disease
1.6.1 Basis for the course of the disease
The diagnostic criteria for neurosis generally have a duration of illness, and the various versions have different but similar requirements for the duration of illness. Panic disorder requires at least three panic attacks in a month, or the first typical attack followed by a month of anxiety for fear of further attacks. The CCMD-3 requires a duration of at least two years for depressive neurosis, with depressed mood for most of the duration of the illness; if there are normal intervals, they should not exceed a maximum of two months each. Panic disorder requires at least three panic attacks within a month, or anxiety secondary to fear of reoccurrence for one month after the first attack.
The disease is defined by its nature; the duration is merely cosmetic. If the differential diagnosis model shown in this paper is adopted, the required duration of illness is actually very short because it can be judged by its essence. 1 month is sufficient for the common type, and 6 months is sufficient for depressive neurosis.
1.6.2 Differential diagnosis based on duration of illness
If only the duration of illness is not enough, the diagnosis of neurotic reaction can be tentatively made, and the diagnosis can be revised at that time. However, as the level of differential diagnosis improves, the criteria for the duration of illness will be greatly reduced in the future.
1.7 Severity
1.7.1 Severity basis
Impaired social functioning or inescapable mental distress that prompts active medical seeking.
1.7.2 Severity-based differential diagnosis.
If the person does not reach the severity level, the diagnosis of neurosis or its subtypes will not be made for the time being.
2 .Results and clinical validation
If the neuroses listed in the Chinese Classification of Mental Disorders Scheme and Diagnostic Criteria CCMD-2-R and CCMD-3 are treated according to the above model, the disorders that can actually be classified as neuroses are phobias (phobias), anxiety disorders, obsessive-compulsive disorders, depressive neuroses, neurasthenia, and hypochondria. These neurotic subtypes can generally be treated with neurotic dichotomous discriminatory treatment to achieve radical results, confirming their homogeneity.
Disorders that were once classified as neurological disorders in CCMD-2-R and CCMD-3 and should not actually be classified as neurological disorders after treatment with the above model are: dysthymia, somatoform disorders (except for hypochondria). These two types of disorders are generally not effective when treated with the dual diagnosis of neurosis (but they are effective and efficient when treated with other dual diagnosis), which confirms that they are different from the above subtypes of neurosis. According to Wang, “hysteria can and should be completely separated from neurosis”. According to Zheng [17], “it is not clinically practical to classify hysteria as a diagnostic criterion for neurosis”. .
Disorders that were once removed from the scope of neurological disorders in the CCMD-3 and should actually be reclassified as neurological disorders after processing as in the above model are: depressive neurosis. However, depressive neurosis is now considered to be homogeneous with depressive disorder; however, there are some who see their heterogeneity. Fu et al. believe that depressive neurosis differs significantly from depression in a number of ways, and therefore tend to still place depression in the category of affective mental disorders and depressive neurosis in the larger category of neuroses. As academic research, people ultimately believe in the test of truth and practice, and there is always rational reflection after the fad has passed.
The “other neurological disorders” and “other or to be classified neurological disorders” listed in CCMD-2-R and CCMD-3 have not been exposed to much, so we will not take a position for the time being.
3. Discussion
The diagnostic process for psychiatric disorders is still as follows: “In the diagnostic process, it is important to first determine whether the patient has organic problems before considering ‘functional’ mental disorders based on a hierarchical diagnosis. In the process of diagnosing ‘functional’ mental disorders, it is important to consider whether they are psychotic (with hallucinations, delusions, loss of reality testing ability, etc.) or non-psychotic (neurotic, without the aforementioned severe psychotic features); it is also important to consider the relationship between personality factors and psychological stressors and the disease. ” However, this line of thinking does not allow for further differentiation of “functional” mild mental disorders.
Many disorders, such as menopausal syndrome, post-concussion, somatoform disorders (except hypochondria), and non-organic sleep disorders, often have various neurological symptoms or combinations thereof, but may not have psychotic manifestations, and are currently difficult to confirm by various means to be caused by organic problems (although an organic basis may be inferred), and are therefore often “diagnosed “neurosis”. The diagnosis and differential diagnosis of neurosis are so not easy to grasp that there are different opinions on the existence and abolition of diagnosis and classification, which also indirectly affects the research of neurosis.
The Diagnostic and Statistical Manual of Mental Disorders, 3rd and 4th editions in the United States have both eliminated neurosis as a general diagnostic term, and the International Classification of Diseases, 10th edition, has almost completely abandoned the concept of neurosis; the result is that neurosis has been artificially avoided and ignored and submerged, or has been mutilated and confused with other similar disorders. This can seriously affect the academic research and development of neurological disorders in the regions covered. In contrast, Chinese researchers are fortunate that the CCMD-2-R and CCMD-3, although not perfect, still largely retain the diagnosis of neurological disorders, and physicians are able to continue the diagnosis, treatment, and research of neurological disorders in clinical practice in a legitimate manner.
Of course, academic debate is the inexhaustible impetus for academic development. In terms of neurological classification and diagnostic criteria, whether they are “abolished, discarded, or retained”, they all reflect the mainstream academic level of neurological disorders in the region in which they are located. They are treated differently and are mutually reinforcing; relatively speaking, the CCMD series is a class above. Due to the limitations of the era, we cannot ask our predecessors to agree on neurological disorders, nor can we ask them to perfect the diagnostic criteria and differential diagnosis of neurological disorders. But we would expect progress and refinement of it.
A superior diagnostic criteria and differential diagnosis scheme should facilitate the study of disease categorization and diagnosis and treatment. Looking back at the various classification schemes and diagnostic criteria currently in use, it can be said that there are many areas that should be corrected. Since the rational diagnostic model and differential diagnostic model of neurological disorders under the guidance of the dual diagnosis and treatment system of neurological disorders have incorporated deeper contents such as symptom analysis, etiology determination, and internal relationship confirmation, and the synergy between Chinese and Western medicine, the diagnosis and differential diagnosis of neurological disorders are clearer, which is extremely helpful for treatment plan selection and treatment prognosis. Therefore, I hope to work more with my colleagues in the future to advance the academic development of neurological disorders together.