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Mental Health Nursing · Chapter 11

Diagnosed by What Is Present

These disorders used to be defined by absence — symptoms without an explanation — which taught a generation to diagnose by exclusion and to say “we could not find anything”. Current classification defines them by what is there. Place seven people, and the panel on the right builds the three axes that actually separate them. Then take three chart entries that would close the record to the next clinician and replace them with something usable.

Seven people

In six of these seven the bodily suffering is entirely genuine. In the seventh the question is not psychiatric at all. Choose, and the panel tells you which feature carried the diagnosis.

The three axes

Place a person and their three axes appear here: is the symptom intentionally produced, what is the motivation, and what does nursing actually do about it.
Positive signs — findings, not accusations Functional neurological symptom disorder is diagnosed by what the examination shows, not by what the scan fails to show:
  • Hoover’s sign. The person cannot voluntarily press the weak leg down, yet the same leg extends normally against your hand when the opposite hip is flexed against resistance. Automatic movement is preserved; voluntary movement is not.
  • Tremor entrainment. A functional tremor takes up the rhythm of, or stops during, a beat tapped by the other hand.
  • Non-epileptic seizures. Longer duration, closed eyes with resistance to opening, side-to-side head movement, a waxing and waning course, no post-ictal confusion, and a normal serum lactate.
None of this means the person is producing the symptom on purpose. The nervous system’s access to voluntary control is genuinely disrupted.
Watch the middle axis. Only two of these seven categories involve intentional production, and in both of those the point of care is safety and protection rather than confrontation. Everywhere else, intentionality is not the question you are asking.

Recognise and replace

Each entry below is a real phrase that has been written in real notes. Every one is stigmatising, and every one tells the next clinician to stop looking — which is precisely how a person with a long somatic history dies of an aortic dissection. Choose the replacement that would survive both a court and the next shift.