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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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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 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).” 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. 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: 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: 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. 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. 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. 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. 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. 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. 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 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. 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. 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. 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. 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. 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: 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. “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. “ 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: 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 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. 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. 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. 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. 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. 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: 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