OBJECTIVE: To explore the standardized method of differential diagnosis of phobias 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 lesion basis were used as elements of the differential diagnosis model of phobias, and clinical validation was performed using the dual dialectical treatment of neurosis.
RESULTS: There are significant differences between phobias compared to other disorders with phobic symptoms. The necessary combination of symptoms, etiology, and intrinsic relationships is central to the differential diagnosis; the exclusion of symptoms, the basis of nonorganic pathology, is also important, but whether it becomes the basis for differential diagnosis in some specific cases depends on the situation; the severity and duration of the disease have some significance. Conclusion The differential diagnosis model for phobias has the advantage of being more meticulously standardized and accurate.
Differential diagnosis model for phobias
1 , Introduction
Phobia, also known as phobia, is a common subtype of neurosis. It also has certain suspected diseases. Now, based on the theory and practice of dual dialectical treatment of neurological disorders, the differential diagnosis model of phobia is elaborated by combining the relevant contents of the Chinese Classification and Diagnostic Standard of Mental Disorders CCMD-2-R and the Chinese Classification and Diagnostic Standard of Mental Disorders CCMD-3. This 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 phobia (clinical phase) can be broken down into two parts, the first part can be called the neurological common symptoms or core symptoms part, manifested as excessive thinking or with excessive attention; the second part can be called the personality part or subtype characteristics part, manifested as commonly considered phobic symptoms; one cannot be without the other. Expressed mathematically: essential combination of phobic symptoms = neurotic common core symptoms + phobic symptoms.
There are several groups of phobic symptoms, and the general expression of CCMD-3 is “a neurotic disorder characterized by an excessive and irrational fear of external objects or situations. The patient knows that the fear is unnecessary, but is unable to prevent the onset of the fear, which is often accompanied by significant anxiety and autonomic symptoms. The patient desperately avoids the feared object or situation, or endures it with awe.
Diagnostic criteria.
(1) Meet the diagnostic criteria for neurosis;
(2) Fear is predominant.
The following 4 items need to be met.
(1) Intense fear of some object or situation, with a degree of fear disproportionate to the actual danger;
(2) Anxiety and autonomic symptoms during the attack;
(3) Repeated or persistent avoidance behavior;
(4) Know that the fear is excessive, unreasonable, or unnecessary, but cannot be controlled;
(3) Avoidance of fearful situations and things must be or have been a prominent symptom;
(4) Exclude anxiety, schizophrenia, and hypochondria”. Then further subtype, place phobia.
Diagnostic criteria.
(1) Meet the diagnostic criteria of phobia ;
(2) Fear of certain specific environments, such as squares, closed rooms, dark places, crowded places, transportation (such as crowded ship cabins, train cars), etc. One of the key clinical features is excessive fear of being in the above situations when there is no immediately available exit;
(3) Exclusion of other fear disorders”; social phobia (social anxiety phobia).
Diagnostic criteria.
(1) Meet the diagnostic criteria for phobias;
(2) Fear of objects mainly for social situations (such as eating or talking in public, parties, meetings, or fear of making some embarrassing behavior, etc.) and interpersonal contact (such as contact with people in public, fear of eye contact with others, or fear of being scrutinized in relation to the crowd, etc.);
(3) Often accompanied by low self-esteem and fear of criticism;
(4) Exclusion of other fear disorders”;
Specific phobias.
(1) Meets the diagnostic criteria for phobias;
(2) The object of fear is a specific object or situation not included in place fear and social fear, such as animals (e.g., insects, rats, snakes, etc.), heights, darkness, lightning, blood, trauma, injections, surgery, or sharp objects;
(3) to exclude other fear barriers”.
2.1.2 Differential diagnosis based on the necessary combination of symptoms
For phobias, common core symptoms + phobic symptoms, are indispensable, otherwise the phobia cannot be diagnosed. Patients who lack the first part of the symptoms as the core basis cannot be called phobic; their phobic symptoms can only be called a phobia-like syndrome associated with a certain disease, which can exist in many diseases such as psychoactive substance-induced psychosis, schizophrenia, anxiety (avoidance) personality disorder, etc.
As for patients who lack the second part of the symptoms, since there is no phobia-like syndrome, naturally they cannot be diagnosed as phobic.
2.2 Etiological aspects
2.2.1 Etiological basis. Persistent evil thoughts are the hallmark, and persistent evil thoughts have gradually formed before the phobic symptoms, and then coexist to the present. Persistent evil thoughts are centered on excessive thinking or excessive attention, intertwined with six factors: thinking, emotion, attention, memory, will, and personality.
2.2.2 Differential diagnosis by etiological basis
For patients with complex conditions, it seems from the surface to have the first part of the symptoms of phobia and the second part of the symptoms, but if excessive thinking or excessive attention with excessive attention does not form the etiology of persistent evil thoughts, then it is also not diagnosed as phobia, but should be under other diagnoses.
Example analysis. In patients with anxiety (avoidance) personality disorder, a combination of symptoms similar to phobias occurs when there are certain thoughts or associated concerns: phobic symptoms + (certain) thoughts or associated concerns. 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 the phobia. In phobias, excessive thoughts or concerns first form the etiology of persistent evil thoughts before triggering phobic symptoms; in anxiety (avoidance) personality disorders, (certain) thoughts or concerns appear or disappear with anxiety (avoidance) personality disorder symptoms such as nervousness and sweating, and do not have an etiological nature.
2.3 Intrinsic relationship aspects
2.3.1 Intrinsic relationship basis
There is an inevitable relationship between the persistent evil thoughts of phobia (etiology) and the clinical phase (symptoms). Among the general relationships, the most easily perceived one is the positive proportional extinction relationship triggered by the etiology. 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 a certain cause, and the manifestation of the condition is also or similar to phobias, but if there is no “inevitable connection between the persistent evil thoughts (cause) and the clinical phase (symptoms), the cause of the disease triggered by the positive relationship between growth and decline”, then it can not be diagnosed as a phobia.
Example analysis. Some schizophrenic disorders often have or coincide with a history of psychological stimulation during the earliest stages of the disease, and are considered to have a certain “psychogenic” cause. Some of them also have certain phobic symptoms such as fear of meeting people and going out. However, a careful study will reveal that these patients do not have “an inevitable link between persistent evil thoughts (etiology) and clinical phases (symptoms), a positive relationship between etiology and growth”, and therefore cannot be diagnosed as phobias.
However, a very small number of psychogenic disorders with milder symptoms admit that “there is a necessary connection between persistent evil thoughts (etiology) and clinical phases (symptoms), and a positive proportional relationship between etiology-induced and gradual”, so after the acute reaction period, the diagnosis of phobia can be modified if the conditions of phobia are met.
2.4 Disease course aspects
2.4.1 Basis of disease course
The diagnostic criteria for phobias generally have a disease duration requirement, and 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 determined by its nature and the duration is only 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 phobic reaction can be tentatively made and the diagnosis can be revised at a later time. However, as the level of differential diagnosis improves, the criteria for the duration of illness 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 phobia 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 the symptoms and the second part of the symptoms mentioned above, phobic patients should not have the following symptoms on a lasting basis: hysterical dissociative symptoms or conversion symptoms, manic 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 such as phobias, 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.
2.6.2 Differential diagnosis based on exclusion of symptoms
If the patient has persistent “exclusion symptoms”, it means that his condition is beyond the scope of mild mental disorders such as phobias, and the pattern of performance is also qualitatively different from neurosis, so he cannot be diagnosed as a phobia, 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 pathology underlying the phobia; or rather, the phobia is not due to organic pathology. Various neurotic symptoms or their combination can be seen in infectious, toxic, visceral, endocrine or metabolic and organic brain diseases, called neurotic-like syndrome; similarly, if it is manifested as phobic-like symptoms is called phobic-like syndrome, can not be called phobia.
2.7.2 Differential diagnosis based on the absence of organic lesions
Generally speaking, it is relatively easy to make a diagnosis of phobia in the absence of organic lesions. However, when a phobic syndrome is found after an organic lesion, how can one determine whether the phobic syndrome is directly caused by the organic lesion or whether the organic lesion itself does not cause the phobic syndrome but rather the phobia is caused by excessive thoughts or concerns? The clinical picture is often intricate and requires analysis to understand.
The absence of organic lesions as a basis for phobias simply means that phobias are not directly caused by organic lesions; however, it does not mean that phobic patients no longer have organic lesions, nor does it mean that patients who have had organic lesions no longer suffer from phobias. As the body grows, ages, and undergoes certain factors, various organic lesions tend to increase with each passing day. After the appearance or cure of organic lesions does not mean that phobias must automatically die out, since the differential diagnosis of phobias should be treated differently and carefully analyzed.
In some patients, after the appearance or cure of organic lesions, there are many new psychiatric problems, and the original symptoms of phobias are no longer distinguishable on the basis of the intrinsic relationship between the cause, it is no longer appropriate to make a diagnosis of phobia, but can be diagnosed as “a certain disease with phobia-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 phobias are still clearly identifiable on the basis of etiological relationships, and organic lesions are not directly related to phobic symptoms, it is appropriate to retain the diagnosis of phobias at this time. The overall trick is that the phobia must be judged by the “symptom-etiology and intrinsic system”: if both exist, the phobia still exists; if one is abolished, the phobia has been abolished.