OBJECTIVE: To explore the standardized method of differential diagnosis of neurological disorders and to improve the accuracy.
METHODS: A total of seven aspects of essential combination of symptoms, etiology, intrinsic relationship, severity, duration, exclusion of symptoms and non-organic pathological basis were used as elements of the differential diagnosis model of neurasthenia, which was clinically validated using the dual identification and treatment of neurosis. Results Neurological disorders have significant differences compared with other diseases with neurological symptoms. Among them, the necessary combination of symptoms, etiology and intrinsic relationship is the core of differential diagnosis; exclusion of symptoms, non-organic pathological basis, is also important, but whether it becomes the basis of differential diagnosis in some specific cases depends on the situation; severity and duration of disease have some significance.
Conclusion: The differential diagnosis model of neurological disorders has the advantage of being more meticulous and standardized and accurate.
Differential diagnosis model of neurasthenia
1 .Introduction
Neurosis is a common subtype of neurosis. The diagnosis of neurasthenia has gone through the extreme process of generalization and abandonment as much as possible. This is due to the lack of understanding of its nature. In fact, the diagnosis and differential diagnosis of neurasthenia can be fundamentally clarified and rationalized; however, this requires new theory and practice. Now, based on the theory and practice of dual diagnosis and treatment of neurosis, the differential diagnosis model of neurasthenia is elaborated by combining the relevant contents of the Chinese Classification and Diagnosis of Mental Disorders CCMD-2-R and Chinese Classification and Diagnosis of Mental Disorders CCMD-3. It also belongs to the differential diagnosis model system of neurosis.
2.Differential diagnosis model
2.1 Essential combination of symptoms
2.1.1 Essential combination of symptom basis. The main symptoms of neurosis (clinical phase) can be broken down into two parts, the first part can be called the common symptoms or core symptoms of neurosis, manifested as excessive thinking or with excessive attention; the second part can be called the personality part or subtype characteristics part, manifested as the commonly considered symptoms of neurosis; one cannot be without the other. Expressed mathematically: the necessary combination of symptoms of neurosis = common core symptoms of neurosis + symptoms of neurosis.
The symptoms of neurosis, as expressed in CCMD-3, are “predominantly symptoms of brain and somatic weakness, characterized by persistent and distressing mental fatigue (e.g., feeling unrefreshed, feeling sluggish, inattentive or unsustainable, poor memory, decreased thinking efficiency) and physical fatigue, which cannot be recovered by rest or recreation, and at least two of the following.
①Emotional symptoms, such as worry, mood tension, irritability, etc., often related to various conflicts in real life, feeling difficult to cope with. There may be anxiety or depression, but it does not dominate;
② excitement symptoms, such as feeling mentally excitable (e.g., increased recall and association, mainly struggling with directed thinking, while non-directed thinking is active, painful and unpleasant because it is difficult to control), but no increased verbal movement. Sometimes there is sensitivity to sound and light;
③ Muscle tension pain (e.g. tension headache, limb muscle aches) or dizziness;
④Sleep disorders, such as difficulty in falling asleep, excessive dreaming, feeling uncomfortable after waking up, loss of sleep sensation, and disturbance of sleep-wake rhythm;
⑤ Other psychophysiological disorders, such as dizziness, tinnitus, heartburn, chest tightness, abdominal distension, indigestion, frequent urination, excessive sweating, impotence, premature ejaculation, or menstrual disorders, etc.” In particular, if analyzed according to the theory of dual diagnosis and treatment of neurosis, the “excitement symptom” should be refined as the core symptom of neurasthenia and not as an alternative symptom.
2.1.2 Differential diagnosis based on the necessary combination of symptoms
For neurasthenia, common core symptoms + neurasthenia symptoms are indispensable, otherwise it cannot be diagnosed as neurasthenia. Patients who lack the first part of symptoms as the core basis cannot be called neurasthenia; their neurasthenia symptoms can only be called neurasthenia-like syndrome associated with a certain disease, which can exist in many diseases such as: post-concussion syndrome, cerebral arteriosclerosis, hyperthyroidism, menopausal syndrome, somatic forms of autonomic dysfunction, somatization disorder, psychoactive substance-induced psychosis, depression, schizophrenia, etc. depression, schizophrenia, etc.
As for patients who lack the second part of symptoms, since they do not have neurasthenia-like syndrome, they naturally cannot be diagnosed as neurasthenia.
2.2 Etiological aspects
2.2.1 Etiological basis. Persistent evil thoughts are the hallmark, and persistent evil thoughts have gradually formed before the neurasthenia symptoms, and then coexist to the present. Persistent evil thoughts with excessive thinking or excessive attention as the core, intertwined with thinking, emotion, attention, memory, will and personality six factors.
2.2.2 Differential diagnosis by etiological basis
For patients with complex conditions, it seems from the surface that they have the first part of the symptoms of neurasthenia and the second part of the symptoms, but if excessive thinking or excessive attention with excessive attention cannot form the etiology of persistent evil thoughts, then it cannot be diagnosed as neurasthenia either, and other diagnoses should be made.
Example analysis. In a patient with menopausal syndrome, a combination of symptoms similar to neurasthenia may occur when there is a certain amount of hypochondriasis or hyperconcentration: neurasthenia + hypochondriasis or hyperconcentration. The difference between these two disorders is not apparent from the appearance of the symptom combination alone, but it is clear from the etiology of neurasthenia. In neurasthenia, excessive thinking or excessive concern first forms the etiological cause of the persistent evil thoughts before triggering neurasthenia symptoms; in menopausal syndrome, a certain amount of excessive thinking or excessive concern appears or dies with neurasthenia symptoms and is not etiological in nature.
2.3 Intrinsic relationship aspects
2.3.1 Intrinsic relationship basis
There is an inevitable relationship between the persistent evil thoughts of neurasthenia (etiology) and the clinical phase (symptoms). Among the general relationships, the most easily perceptible one is the positive proportional relationship between the etiology triggered by the etiology and the growth. It is expressed that the scale of the cause determines the scale of the disease mechanism and symptoms; the more complex and extensive the cause, the more intense the disease mechanism initiated, and the more symptoms produced, and vice versa.
2.3.2 Differential diagnosis based on internal relationship
Some psychological disorders have certain psychological causes, and the manifestations of the disease are also similar to neurasthenia, but if there is no “inevitable connection between the persistent evil thoughts (causes) and the clinical phase (symptoms), and the positive relationship between the causes and the symptoms”, then it cannot be diagnosed as neurasthenia.
Example analysis. Many psychogenic disorders, some schizophrenia, hysteria, depression, etc., often have or coincide with a history of mental stimulation in the earliest period of the disease, and are considered to have a certain “psychogenic” cause. Some of them also have certain symptoms of neurosis. However, a careful study will reveal that these patients do not have “an inevitable connection between the persistent evil thoughts (cause) and the clinical phase (symptoms), and a positive relationship between the cause and the duration”, so they cannot be diagnosed as neurasthenia. However, a very small number of psychogenic disorders with mild symptoms admit that “there is an inevitable connection between persistent evil thoughts (etiology) and clinical phases (symptoms), and a positive proportional relationship between the etiology and the duration”, therefore, after the acute reaction period, the diagnosis of neurasthenia can be modified if the conditions of neurasthenia are reached.
2.4 Disease course aspects
2.4.1 Basis of disease course
The diagnostic criteria for neurasthenia generally have a disease duration requirement, and the various versions have different but similar requirements for disease duration. both CCMD-2-R and CCMD-3 require that the disease duration criteria meet the symptom criteria for at least 3 months.
The disease is defined by its nature and the duration is merely cosmetic. If the differential diagnosis model shown in this paper is used, the required duration of disease is actually very short, 1 month, because it can be determined by its nature.
2.4.2 Differential diagnosis based on duration of disease
If only the duration of the disease is not enough, the diagnosis of neurasthenic 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 the disease will be greatly reduced in the future.
2.5 Severity
2.5.1 Severity basis
Impaired social functioning or inescapable mental distress that prompts active medical seeking.
2.5.2 Severity-based differential diagnosis.
If the severity is not reached, the diagnosis of neurasthenia will not be made for the time being.
2.6 Exclusion of symptoms
2.6.1 Exclusion of symptoms
In addition to the first part of symptoms and the second part of symptoms mentioned above, patients with neurosis should not have the following symptoms persistently: hysterical dissociative symptoms or conversion symptoms, manic symptoms, heavy depressive symptoms, psychotic symptoms, deficits in self-knowledge, impaired reality testing ability, etc. What is the rationale? On the one hand, such symptoms are beyond the scope of mild mental disorders such as neurasthenia, and on the other hand, if such symptoms are present, one of the following “etiological basis” and “internal 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.
2.6.2 Differential diagnosis based on exclusion of symptoms
If the patient has persistent “exclusion symptoms”, it indicates that his condition is beyond the scope of mild mental disorders such as neurasthenia, and the pattern of performance is also qualitatively different from neurosis, so he cannot be diagnosed as neurasthenia, and other diagnoses should be made.
2.7 No organic lesion basis
2.7.1 No organic lesion as the basis
There is no organic lesion as the basis for neurasthenia; or rather, neurasthenia is not due to organic lesion. Various neurological symptoms or their combinations can be seen in infectious, toxic, visceral, endocrine or metabolic and organic brain diseases, which are called neurological-like syndromes; similarly, if they are manifested as neurasthenia-like symptoms, they are called neurasthenia-like syndromes and cannot be called neurasthenia.
2.7.2 Differential diagnosis based on the absence of organic lesions
Generally speaking, in the absence of organic lesions, it is relatively easy to make the diagnosis of neurasthenia. However, when neurasthenia-like syndrome is found after an organic lesion, how to determine whether the neurasthenia-like syndrome is directly caused by the organic lesion, or whether the organic lesion itself does not cause neurasthenia-like syndrome but rather the neurasthenia is caused by excessive thinking or excessive attention? The clinical situation is often complex and requires analysis to understand.
The fact that neurasthenia is not based on organic lesions only means that neurasthenia is not directly caused by organic lesions; however, it does not mean that neurasthenia patients no longer have organic lesions, nor does it mean that patients who have had organic lesions no longer suffer from neurasthenia. As the human body grows, ages and undergoes certain factors, various organic lesions tend to increase with each passing day. The emergence or cure of organic lesions does not mean that neurasthenia must automatically die out, so the differential diagnosis of neurasthenia should be treated differently and analyzed carefully. In some patients, after the appearance or cure of organic lesions, many new psychiatric problems arise, and the original symptoms of neurasthenia can no longer be distinguished on the basis of the internal relationship between the causes of neurasthenia, so it is no longer appropriate to make a diagnosis of neurasthenia, but to diagnose “a certain disease with neurasthenia-like syndrome or a certain disease with mental disorder”.
On the contrary, in some patients, after the appearance or cure of organic lesions, the original symptoms of neurasthenia are still clearly identifiable on the basis of the internal relationship between the cause and the organic lesions and neurasthenia-like symptoms are not directly related, so it is appropriate to keep the diagnosis of neurasthenia at this time. The general trick is that the diagnosis of neurasthenia must be based on the three aspects of “symptoms, etiology and internal system”: if both exist, neurasthenia still exists; if one is abolished, neurasthenia has been abolished.
3, Discussion
3.1 Reflection on exclusion criteria
According to the relevant contents of CCMD-2-R and CCMD-3, the diseases that need to be excluded in neurasthenia are dealt with in two steps, the first step is to exclude other diseases with neurotic-like symptoms, and the second step is to exclude other neurotic subtypes.
The first step is to exclude organic mental disorders, psychoactive and non-addictive substance-induced mental disorders, various psychotic disorders such as schizophrenia, paranoid psychosis, and mood disorders, as described in the CCMD-3 exclusion criteria.
The second step as CCMD-3 exclusion criteria.
(1) Exclude any of the above neurological subtypes;
(2) Exclude schizophrenia and depression.
Description.
(1) If neurasthenia symptoms are seen in other subtypes of neurosis, only other corresponding types of neurosis are diagnosed;
(2) neurasthenia symptoms are commonly seen in various organic brain diseases and other somatic diseases, and in this case the diagnosis should be neurasthenia syndrome of these diseases.”
Although this is the authoritative “exclusion criteria”, it is only partially reasonable. The following is a review of the theory of dual diagnosis and treatment of neurosis.
In terms of “exclusion of organic mental disorders”.
(1) Patients with hyperthyroidism who have neurological symptoms are generally no longer diagnosed as neurological disorders. This is because these patients do not have the above-mentioned “necessary combination of symptoms, etiology, and internal relationship”, and often have “manic symptoms, heavy depressive symptoms, psychotic symptoms, lack of self-awareness, impaired reality testing ability, etc.”, which are clearly organic It is a disease based on clear organic lesions. Neurological disorders with dual diagnosis and treatment have no effect on their neurological symptoms, while their neurological symptoms can be controlled or eliminated by treating hyperthyroidism.
② Hypertension, coronary heart disease, etc., if neurasthenia symptoms are present, the diagnostic situation should be treated differently. In these patients, if they have the above-mentioned “necessary combination of symptoms, etiology, and internal relationship”, then neurasthenia can be diagnosed in parallel, and in this case, the use of dual diagnosis and treatment of neurological disorders is good for the presence of neurasthenia symptoms. In such patients, if they do not have the above-mentioned “necessary combination of symptoms, etiology, and internal relationship”, only “hypertension, coronary heart disease, etc.” with neurasthenia can be diagnosed, and neurasthenia cannot be diagnosed in parallel. In this case, the use of neurological dichotomy is not useful for the presence of neurological symptoms.
”In the case of mental disorders caused by psychoactive and non-addictive substances: withdrawal reactions to euphoric drug overdose, hypnotic and sedative drugs, anxiolytic drugs, etc., if neurological symptoms are present, the diagnosis should be treated differently. Generally speaking, if the withdrawal reaction period has passed and the neurological symptoms have disappeared automatically, the diagnosis is no longer made; if the withdrawal reaction period has passed and the neurological symptoms are still present, the neurological disorder may exist, but further analysis is needed, and the above-mentioned “necessary combination of symptoms, etiology, and internal relationship” becomes the criterion for differential diagnosis. The reasons for this analysis are described above.
For “various psychotic disorders”: such as schizophrenia, paranoid psychosis, and mood disorders such as mania, depression, schizophrenia, etc., if symptoms of neurasthenia are present, the diagnosis of neurasthenia is generally no longer concurrent. See above for specific analysis reasons.
If anxiety disorders, obsessive-compulsive disorders, phobias, hypochondria, etc. are present, the diagnosis of neurosis can be made concurrently because they are of the same level of illness. They are mixed neuroses. In this case, the use of dual diagnosis and treatment of neurosis has a good effect on the coexisting symptoms.
3.2 Reflection on the treatment of survival
True neurosis exists, and it will not be increased by people’s proliferation of diagnoses, nor will it be decreased by people’s abandonment of diagnoses; what it needs is people’s accurate diagnosis and efficient treatment or even eradication.
In the recent century, the concept of neurasthenia has undergone a series of changes. With the change of doctors’ understanding of neurasthenia and the differentiation of various special syndromes and subtypes, this diagnosis is no longer made in the United States and Western Europe, and the field tests of the CCMD-3 working group have proved that the diagnosis of neurasthenia has also been significantly reduced in China. There is a tendency for neurasthenia to lean toward the diagnosis of depressive disorders and anxiety disorders, which is related to the effect of antidepressant and anxiolytic drugs on it. However, the diagnosis ultimately has to reflect the nature and characteristics of the disease. The efficacy of drugs can only be used as a reference for diagnosis, not to mention that there are many therapies and drugs that have some effect on neurasthenia, and the current antidepressant and anxiolytic drugs are only effective but far from a cure for neurasthenia.
Not to explore the essence of neurasthenia, but easily follow the trend of drug response and artificially flood the diagnosis of neurasthenia, or easily change the name of the disease and artificially flood the diagnosis of neurasthenia, are very impetuous academic style and risky behavior.
Of course, academic debate is the inexhaustible power and necessary process of academic development. The CCMD series is relatively prudent and higher, but it is far from perfect. The rational diagnosis and differential diagnosis of neurasthenia under the guidance of the dual diagnosis and treatment system of neurological disorders has added deeper contents such as symptom analysis, determination of etiology, and proof of internal relationship, and the synergy between Chinese and Western medicine, so the diagnosis and differential diagnosis of neurasthenia are clearer, which is extremely helpful to the selection of treatment plan and treatment prognosis. Therefore, I hope to work more with my colleagues in the future to promote the academic development of neurasthenia together.