Download DIFFERENTIAL DIAGNOSIS

Paula Halcomb, M.S.
Certified Psychologist with
Autonomous Functioning
American Psychiatric Association: Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric
Association, 2013.
All content from this presentation is not meant for publication. It
is being presented at a WSH intern seminar for introductory
purposes. The DSM 5 is published by the American Psychiatric
Association (APA). APA is not affiliated with this training nor do
they endorse the material. The DSM 5 is copyrighted so no
portion of this presentation should be replicated, and this
presentation is not connected to any publication or for-profit
use. All DSM 5 material in this presentation is either direct
content or paraphrased material of the DSM 5. The above
reference reflects the appropriate bibliography reference for all
DSM-5 content that is included in this presentation.
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A systematic method utilized to identify the
condition, syndrome, or disorder which causes
an individual’s signs, symptoms, and behavior.
This method was first suggested for use in the
diagnosis of mental disorders by Emil
Kraepelin. It is considered to be more
systematic than the old fashioned method of
diagnosis by impression.
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Differential diagnosis often involves first
making a list of possible diagnoses, then
attempting to remove diagnoses from the list
until one diagnosis remains.
The diagnosis appears to be the most
comparable to reflect the individual’s
symptoms, behavior, presentation, and current
functioning after the process of elimination has
occurred that progressively weeds out the
impossible and/or less probable diagnoses.
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The differential diagnosis in mental health treatment is
utilized to distinguish between separate psychiatric
conditions that initially appear to look similar to each
other.
Mental health symptoms occur on a continuum that
ranges from barely noticeable symptomatology to
clinical profiles that are easily diagnosed. The difficulty
of diagnosing occurs when an individual’s symptoms
do not fit cleanly into a specific diagnostic category.
The differential diagnosis determines the plan of and
recommendations for treatment.
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Diagnosing mental health conditions can be
quite complicated as the same symptoms can
occur in very different disorders. As a result,
mental health professionals use clinical
interviews, assessment, psychological testing,
observations, and past history to formulate the
differential diagnosis.
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Identifying an accurate diagnosis is partially
based on discriminating between mood,
anxiety, and thought disorders. An example
would be sleep disturbance which can be a
symptom typical for those with Major
Depressive Disorder, Bipolar Disorder,
Generalized Anxiety Disorder, Schizoaffective
Disorder, Substance Use Disorder, etc.
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Discriminating between the effects of drug use,
substance abuse, or an organic (either medical
or psychiatric) condition requires the use of
differential diagnosis. A mental health
diagnosis should not be determined while the
individual is currently under the influence of
drugs or alcohol.
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Psychiatric symptoms can surface as a result of
a medical condition. It is a misconception that
mental health is a separate entity from physical
health. There is a brain/body connection to
consider when attempting to discriminate
between differential diagnoses.
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Some people are relieved to get a diagnosis as it
provides them an explanation for how they had
been feeling and what they had been experiencing.
It gives them hope as treatment can begin, and
they can then access appropriate services and
support.
However, others have shared that being assigned a
diagnosis is like being labeled which determines
how they may be treated by mental health
professionals, friends, family, etc. Others may
only see the label and not the person. Giving a
diagnosis typically leads to some type of treatment
that the individual may or may not want.
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Research suggests that applying a diagnosis can
affect how people feel about themselves especially
since many mental health diagnoses have negative
connotations in today’s society. Once a diagnosis
is given, individuals often begin to experience
stigma and even discrimination.
Giving a diagnosis can be frightening to the
individual because the psychiatrist or other mental
health professional has not taken the time to
explain the diagnosis, exactly what it means, or the
implications of the disorder and treatment.
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1. REIMBURSEMENT - ICD 10 CODES HAVE
TO BE SUBMITTED TO INSURANCE CO.
2. PROVIDES GUIDELINES FOR
TREATMENT
3. PROVIDES UNDERSTANDING OF THE
CLIENT
4. STIMULATES RESEARCH
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In an inpatient setting, when one or more diagnosis is
given, the prinicipal diagnosis is the condition
determined to be chiefly responsible for the admission
of the individual.
In an outpatient setting, when one or more diagnosis is
given, the reason for visit is the condition that is chiefly
responsible for services received during the visit.
In the majority of cases, the prinicipal diagnosis or the
reason for visit is the main focus of attention or
treatment.
The prinicipal diagnosis is listed first, and any other
disorders are listed in order of focus of attention and
treatment. The disorder listed as prinicipal diagnosis or
the reason for visit is followed by the qualifying phrase
“(prinicipal diagnosis)” or “(reason for visit).”
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Research suggests that people with a
combination of substance abuse (use) [alcohol
or drugs or both] and mental health disorder
struggle more than those with just substance
abuse (use) or mental health disorder.
The combination of a substance abuse (use)
and a mental health disorder such as
depression, bipolar, anxiety, or schizophrenic
disorders, etc. is a dual diagnosis.
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Approximately 50% of individuals with severe
mental disorders are also affected by substance
abuse.
Approximately 37% of alcohol abusers (users) and
53% of drug abusers (users) have at least one
severe mental illness.
Per report, of all individuals diagnosed as
mentally ill, 29% abuse (use) either alcohol or
drugs.
According to the National Institute of Drug Abuse,
those with a dual diagnosis present more severe
symptoms than those caused by either condition
alone.
An appropriate diagnosis is necessary and crucial
for the formulation of an adequate treatment plan
and aftercare plan in one’s recovery from a dual
diagnosis.
A number of disorders show a substantial comorbidity with
substance use including:
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Antisocial Personality Disorder – 83.6%
Schizophrenia – 47%
Anxiety Disorder – 24%
Bipolar Disorder – 61%
Major Depressive Disorder – 37%
Persistent Depressive Disorder – 31%
Therefore, when evaluating a client with an identified substance use
problem, without any additional information, you can assume there is a
50% chance that a comorbid psychiatric diagnosis will also exist.
After obtaining a good history, assessing the
following issues can help clarify the diagnosis:
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Time of onset – If the psychiatric symptoms began prior to
the substance use, then it is likely that a psychiatric disorder
exists.
Substance use patterns – A psychiatric disorder likely exists
if the psychiatric symptoms persist during significant
periods of abstinence from substance use (3 months or
longer).
Consistency of symptoms – If the nature and magnitude of
the client’s symptoms and problems are qualitatively
different or beyond what one would expect given the
amount and type of substance used, then a psychiatric
disorder likely exists.
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Family history – Many psychiatric conditions have a strong
hereditary component, and a family history of mental illness can
support the suspicion that a particular client has a mental illness.
Response to substance use treatment – Clients with both
psychiatric and substance use disorders often have significant
difficulty complying with traditional substance use treatment
programs and relapse during or shortly after treatment.
Client’s stated reason for substance use – Individuals with a
primary psychiatric diagnosis and secondary substance use
disorders will often say that they “self medicate.” They say that
they use alcohol to quiet AH, they use stimulants to counter the
effects of depression, they use alcohol or another depressant to
take the edge off anxiety or soothe mania. Substance use will
likely exacerbate psychotic conditions, but this does not mean that
the condition is substance-induced.
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Alcohol use is prone to promote depression,
delirium, or anxiety. Clients are susceptible to
suicide, self-harm, psychosis, cirrhosis of liver,
stomach ailments, malnutrition, chronic fatigue,
and oversensitivity.
Opioid use can cause delirium, anxiety,
hallucinations, and manic-type reactions. They
may also suffer from cardiovascular issues. Those
who abuse opioids may experience mood swings,
depression, tension, insecurity, inadequacy,
problematic relationships, or impulsiveness.
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Stimulant use (cocaine and amphetamines) can
lead to dramatic behavioral changes, chaotic
behavior, social isolation, aggressive behavior, and
sexual dysfunction. Those in acute intoxication
may present with rambling speech, transient ideas
of reference, paranoid ideation, auditory/tactile
hallucinations, and threatening/aggressive
behavior. Depression, SI, irritability, anhedonia,
emotional lability, and attention/concentration
issues may occur during withdrawal.
Marijuana users are liable to suffer from short-term
memory impairment, mood swings, paranoia,
anxiety, hallucinations, delusions, or depression.
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Co-occurring mental, neurodevelopmental,
medical, and physical conditions are noted
frequently in those with intellectual disability.
Rates of some conditions such as mental
disorders, cerebral palsy, and epilepsy are 3 to
4 times higher than in the general population.
The prognosis and resulting outcomes of such
co-occurring diagnoses may be influenced by
the presence of ID.
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The most common co-existing mental and
neurodevelopmental disorders are ADHD,
depressive and bipolar disorders, anxiety
disorders, autism spectrum disorder,
stereotypic movement disorder (with and
without self-injurious behavior), impulse
control disorders, and major neurocognitive
disorders. Major depression may occur
throughout the range of severity of intellectual
disability. Aggression and disruptive
behaviors including harm of others or property
destruction may also be prevalent.
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Increased likelihood of suicide
More severe mental health problems
Homelessness or unstable housing
Increased risk of violence
Increased risk of victimization
More involvement with the criminal justice system
Family problems
History of childhood trauma/abuse (sexual/physical)
Noncompliance with medication and other forms of treatment
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These guidelines are meant to assist the
clinician deal with the uncertainty of “real
world” problems. There are no hard and fast
rules in making these judgments. The goal is to
collect as much information as possible, weigh
the data, consider all the diagnostic
alternatives, make the best possible clinical
judgment using the information available at the
time, and clearly communicate your findings,
including your level of certainty in your
documentation.
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Anxiety disorders have one of the longest
differential diagnosis lists of all psychiatric
disorders. Anxiety is a nonspecific syndrome and
can be due to a variety of medical or psychiatric
syndromes. A variety of anxiety symptoms, such
as panic, worry, rumination, and obsessions, can
present in a variety of psychiatric illnesses,
including depressive disorders, bipolar disorders,
psychotic disorders, personality disorders,
somatoform disorders, and cognitive impairment
disorders (delirium). Anxiety can also be observed
as part of substance withdrawal or intoxication
effects.
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Other important causes in the differential
diagnosis include medication-induced anxiety
such as epinephrine, theophylline or other
neurostimulant bronchodilators, analgesics
containing caffeine, corticosteroids, antivirals,
etc. Anxiety is also common in those with
migraines, seizure disorders, or other CNSbased disorders, sleep disorders such as
restless leg syndrome, and sleep apnea, and
periodic limb movement. Heroin use should
also be considered in the differentials.
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In Bipolar I and II Disorders, Cyclothymic
Disorders, Major Depressive Disorders, and
Persistent Depressive Disorders, one can use
the specifier of “With anxious distress.”
High levels of anxiety have been associated
with higher suicide risk, longer duration of
illness, and greater likelihood of treatment
nonresponse.
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Patients with anxiety disorders are at higher
risk for developing comorbid depression. In
such patients, it is important to identify the
anxiety disorder because affected individuals
often require specific treatment approaches.
Commonly encountered anxiety disorders
include: GAD, OCD, Panic Disorder, Phobic
Disorders, and PTSD.
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Differential diagnosis for depression includes a variety of
medical disorders:
Central nervous system diseases (Parkinson disease,
Neurocognitive disorders, stroke, Huntington disease,
multiple sclerosis, etc.)
Endocrine disorders (hyper or hypo- thyroidism, Addison
disease, Cushing Syndrome, etc.)
Drug related conditions (substance use, HTN meds,
smoking cessation aids [Chantix], steroids, sex hormones,
sedatives, muscle relaxants, H2 blockers [Zantac, Tagamet],
appetite suppressants, chemotherapy agents, etc.)
Infectious diseases (mononucleosis, Lyme’s Disease, HIV,
syphilis, encephalopathy, etc. )
Sleep-related disorders (obstructive sleep apnea)
Distinguishing Depression from other Disorders:
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It cannot be established that an organic factor initiated and
maintained the disturbance.
The disturbance is not a normal reaction to the death of a
loved one (bereavement is a psychosocial stressor that can
precipitate depression).
At no time during the disturbance has there been delusions
or hallucinations occurring for as long as 2 weeks in the
absence of prominent mood symptoms (before the mood
symptoms developed or after they have remitted).
It is not superimposed on Schizophrenia Spectrum and
Other Psychotic Disorders.
It must be determined that there has not been a manic or
hypomanic episode.
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Major Depressive Disorder must be differentiated
from Persistent Depressive Disorder. For a
diagnosis of Persistent Depressive Disorder,
patients present with depressed mood for most of
the day, for more days than not for at least two
years in adults. PPD represents a consolidation of
DSM IV defined chronic MDD and Dysthymic
Disorder. Major depression may precede PDD,
and major depressive episodes may occur during
PDD. Individuals whose symptoms meet MDD
criteria for 2 years should be given a diagnosis of
PPD as well as MDD.
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Misdiagnosis of Bipolar Disorder as recurrent
unipolar depression may occur if the clinician
does not identify the presence of hypomania
between depressive episodes. This leads to
inadequate treatment and theoretically, could
lead to a precipitation of a hypomanic, manic,
or mixed episode.
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Patients with certain personality disorders
(borderline personality disorder) may present
with mood changes as a prominent symptom.
Remember that the presence of a personality
disorder can be difficult to determine in the
setting of active affective symptoms. Many
depressed patients who appear labile,
demanding, or pathologically dependent look
dramatically different once the depressive
episode has been treated adequately.
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Major depressive disorder does not cause focal
neurologic signs. Such findings should prompt an
evaluation for other organic syndromes.
A broad range of physiologic and structural CNS
processes can produce changes in mood and
behavior. Note that major depressive disorder can
produce measurable cognitive deficits or a
worsening of preexisting neurocognitive disorder
(dementia). This decline in cognitive functioning,
which on formal testing appears to arise from
impaired concentration or motivation used to be
referred to as “pseudodementia or dementia of
depression” and should remit with successful
treatment of the depressive episode.
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Alzheimer’s Disease and other degenerative
and vascular neurocognitive disorders can be
associated with affective symptoms, especially
in the initial phases of the neurocognitive
disorder.
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Pharmacologic agents can produce changes in mood.
Among antihypertensive agents, beta blockers have a
reputation for being strongly associated with
depression. However, research has been somewhat
contradictory, but suggests at most a minor role in this
regard. One study found no significant increased risk
of depressive symptoms with beta-blockers although
there was a small but significant risk of fatigue and
sexual dysfunction. Risk appears to vary with different
beta-blockers. One study in elderly patients found that
highly lipid-soluble beta-blockers (mostly Propranolol)
were associated with depressive symptoms during the
first 3 months of use. In contrast, pindolol may
accelerate or enhance the effects of antidepressant
drugs.
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Substance use can cause significant mood
symptoms. This is especially true of alcohol,
cocaine, amphetamines, cannabis,
sedatives/hypnotics, and narcotics. Inhalant
use should also be considered, particularly
among young male patients. Also, several
drugs can cause side effects that resemble
depression symptoms, such as alcohol,
barbiturates, cardiac drugs, steroids and
hormones, beta blockers, hypnotics, and
stimulants.
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Distinguishing schizoaffective disorder from
schizophrenia and from depressive and bipolar
disorders with psychotic features is often difficult.
Criterion C (Symptoms that meet criteria for a
major mood episode are present for the majority of
the total duration of the active and residual
portions of the illness) is designed to separate
schizoaffective disorder from schizophrenia.
Criterion B (Delusions or hallucinations for 2 or
more weeks in the absence of a major mood
episode [depressive or manic] during the lifetime
duration of the illness) is designed to distinguish
schizoaffective disorder from a depressive or
bipolar disorder with psychotic features.
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Schizoaffective disorder can be distinguished
from a depressive or bipolar disorder with
psychotic features based on the presence of
prominent delusions and/or hallucinations for
at least 2 weeks in the absence of a major mood
episode. In contrast, in depressive or bipolar
disorder with psychotic features, the psychotic
features primarily occur during the mood
episodes(s). Because the relative proportion of
mood to psychotic symptoms may change over
time, the appropriate diagnosis may change
from and to schizoaffective disorder.
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For example, a diagnosis of schizoaffective
disorder for a severe and prominent major
depressive episode lasting 3 months during the
first 6 months of a chronic psychotic illness
would be changed to schizophrenia if active
psychotic or prominent residual symptoms
persist over several years without a recurrence
of another mood episode. Many individuals
diagnosed with schizoaffective disorder are
also diagnosed with other mental disorders,
especially substance use disorders and anxiety
disorders.
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Adjustment disorders can accompany most mental disorders and any
medical disorder. Adjustment disorders can be diagnosed in addition to
another mental disorder only if the latter does not explain the particular
symptoms that occur in reaction to the stressor. For example, an
individual may develop an adjustment disorder, with depressed mood,
after losing a job and at the same time have a diagnosis of OCD. An
individual may have a depressive disorder or bipolar disorder and an
adjustment disorder as long as the criteria for both are met.
The required symptom profile for PTSD and acute stress disorder
differentiates them from the adjustment disorders. An adjustment
disorder should also be diagnosed for individuals who have not been
exposed to a traumatic event but who otherwise exhibit the full symptom
profile of either acute stress disorder or PTSD.
In the presence of a personality disorder, if the symptom criteria for an
adjustment disorder are met, and the stress-related disturbance exceeds
what may be attributable to maladaptive personality disorder symptoms,
then the diagnosis of an adjustment disorder should be made.
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Substance/Medication-Induced Mental Disorder VS
Depressive Disorders or Bipolar and Related Disorders
Schizophenia Spectrum and Other Psychotic Disorders
VS Substance Use
Borderline Personality Disorder VS Bipolar and
Related Disorders
Major Depressive Disorder VS Adjustment Disorders
Major Depressive Disorder VS Persistent Depressive
Disorder (Dysthymia)
Major Depressive Disorder VS Medical Condition
Schizoaffective Disorder VS Major Depressive Disorder
or Bipolar and Related Disorder with Psychotic
Features
Culture provides the clinician with interpretive
frameworks that influence one’s experiences and
presentation of symptoms, cues, and behaviors
that fulfill criteria for diagnosis. “It is
transmitted, revised, and recreated within the
family and other social systems and institutions.”
Therefore, when assessing one in order to
diagnosis, you must consider if one’s presentation
differs from their sociocultural norms and leads to
difficulties in their adaptation in their respective
culture and in social and family contexts.
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“Culture, race, and ethnicity are related to
economic inequities, racism, and
discrimination that result in health disparities.
Cultural, ethnic and racial identities can be
sources of strength and group support that
enhance resilience, but they may also lead to
psychological, interpersonal, and
intergenerational conflict or difficulties in
adaptation that require diagnostic assessment.
“Understanding the cultural context of illness experience
is essential for effective diagnostic assessment and clinical
management. Culture refers to systems of knowledge,
concepts, rules, and practices that are learned and
transmitted across generations. Culture includes
language, religion and spirituality, family structures, lifecycle stages, ceremonial rituals, and customs, as well as
moral and legal systems. Cultures undergo continuous
change over time. In the present world, most individuals
and groups are exposed to multiple cultures, which are
used to fashion their own identities and make sense of
experience. These features of culture make it crucial not to
overgeneralize cultural information or stereotype groups
in terms of fixed cultural traits. “
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The Outline for Cultural Formulation introduced in the
DSM-IV provided a framework for assessing
information about cultural features of an individual’s
mental health problem and how it relates to a social
and cultural context and history. The DSM-5 not only
includes an updated version of the Outline but also
presents an approach to assessment, using the Cultural
Formulation Interview (CFI) which has been fieldtested for diagnostic usefulness among clinicians and
for acceptability among patients.
The revised Outline for Cultural Formulation calls for
systematic assessment of the following categories:
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Cultural identity of the individual
Cultural conceptualizations of distress
Psychosocial stressors and cultural
features of vulnerability and resilience
Cultural features of the relationship
between the individual and the clinician
Overall cultural assessment
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Describe the individual’s racial, ethnic, or cultural
reference groups that may influence his or her
relationships with others, access to resources, and
developmental and current challenges, conflicts, or
predicaments. Language abilities, preferences, and
patterns of use are relevant for identifying
difficulties with access to care, social integration,
and the need for an interpreter. Other clinically
relevant aspects of identity may include religious
affiliation, socioeconomic background, personal
and family places of birth and growing up,
migrant status, and sexual orientation.
Describe the cultural constructs that influence
how the individual experiences, understands, and
communicates his or her symptoms or problems
to others. These constructs may include cultural
syndromes, idioms of distress, and explanatory
models or perceived causes. The level of severity
and meaning of the distressing experiences
should be assessed in relation to the norms of the
individual’s cultural reference groups.
Identify key stressors and supports in the
individual’s social environment and the role of
religion, family, and other social networks
(friends, neighbors, coworkers) in providing
emotional, instrumental, and informational
support. Social stressors and social supports vary
with cultural interpretations of events, family
structure, developmental tasks, and social
context.
Identify differences in culture, language, and
social status between an individual and clinician
that may cause difficulties in communication and
may influence diagnosis and treatment.
Experiences of racism and discrimination in the
larger society may impede establishing trust and
safety in the clinical diagnostic encounter. Effects
may include problems eliciting symptoms,
misunderstanding of the cultural and clinical
significance of symptoms and behaviors, and
difficulty establishing or maintaining the rapport
needed for an effective clinical alliance.
Summarize the implications of the components of
the cultural formulation identified in earlier
sections of the Outline for diagnosis and other
clinically relevant issues or problems as well as
appropriate management and treatment
intervention.
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The CFI is a set of 16 questions that clinicians may
utilize to attempt to understand how the
individual’s cultural views may influence care.
Culture is basically defined by values, orientations,
knowledge, and practices which are part of an
individual’s participation in diverse social groups.
Attention is paid to the individual’s
perspective/experience of the problems and the
social contextual relation of the problem.
This interview’s purpose is not intended to detect
pathologies but perspectives.
This interview most likely will be the most useful
when the initial assessment is completed.
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The CFI may be used in its entirety, or components may be
incorporated into a clinical evaluation as needed. The CFI may be
especially helpful when there is:
Difficulty in diagnostic assessment owing to significant
differences in the cultural, religious, or socioeconomic
backgrounds of clinician and the individual .
Uncertainty about the fit between culturally distinctive
symptoms and diagnostic criteria.
Difficulty in judging illness severity or impairment.
Disagreement between the individual and clinician on
the course of care.
Limited engagement in and adherence to treatment by
the individual.
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1) Cultural Definition of the Problem: This is the
individual’s view of the presenting factors that
influenced the current distress and/or symptoms.
2) Cultural Perceptions of Cause, Context, and
Support: This is what the individual believes has
caused the problem.
3) Cultural Factors Affecting Self Coping & Past
Help Seeking : This is what the individual has
done in the past to modify the situation.
4) Cultural Factors Affecting Current Help
Seeking: This is to clarify the individual’s
perception of the treatment relationship.
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Cultural concepts of distress refers to ways that
cultural groups experience, understand, and
communicate suffering, behavioral problems,
or troubling thoughts and emotions.
Three main types of cultural concepts may be
distinguished.
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1) CULTURAL SYNDROME - a group or clusters of cooccurring symptoms in a specific cultural group,
community, or context. It may or may not be recognized as
an illness within one’s culture but such patterns of distress
and signs of illness may be recognized by an outside
observer.
2) CULTURAL IDIOM OF DISTRESS - a linguistic term,
phrase, or way of communicating regarding the suffering of
those of a specific cultural group which refers to shared
concepts of pathology and ways of voicing prominent
characteristics of distress.
3) CULTURAL EXPLANATION OR PERCEIVED CAUSES
– labels, attributions, or features of an explanatory model
that indicate culturally recognized meaning or etiology or
cause for symptoms, illness, or distress.
Cultural concepts are important in making a
psychiatric diagnosis for the following reasons:
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To avoid misdiagnosis
To obtain useful clinical information
To improve clinical rapport and engagement
To improve therapeutic efficacy
To guide clinical research
to clarify the cultural epidemiology