Download File

Differential diagnoses 1
Running head: DIFFERENTIAL DIAGNOSES
Differential Diagnoses
Sarah Brick
Advanced Psychopathology
Professor Herkelrath
Northwest University
Differential diagnoses 2
Introduction
Accurate and early diagnosis of mental disorders is vital to ensure that patients
receive the proper treatment and care needed to manage one’s mental health. However,
diagnosing is often challenging as many symptoms overlap with multiple disorders. The
Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision, American
Psychiatric Association, 2000) is considered the most reliable and accurate resource that
provides information pertaining to diagnoses, etiology, and research on mental illness.
The trained professional carefully reviews DSM IV criteria when making a diagnosis.
The purpose of this paper is to familiarize the reader with differential diagnostic
considerations according to the DSM IV and supporting literature. The author has
provided a differential diagnostic discussion on each of the following DSM IV
classifications including (a) psychotic disorder, (b) mood disorder, (c) anxiety disorders,
(d) somatoform disorder, (e) substance induced disorders, and (f) mental disorder due to a
general medical condition. A specific disorder will be discussed within each category.
For example, schizoaffective disorder will be addressed under the psychotic disorder
classification. Additionally, a brief clinical description of each disorder is provided. The
provided diagnostic criteria should not be used to diagnose, as the descriptions are
summarized and lacking in detail. Please refer to the DSM IV for additional information.
Differential diagnoses 3
Differential Diagnoses
Schizophrenia and Other Psychotic Disorders
Schizoaffective Disorder. To meet the requirements of schizoaffective disorder,
the DSM IV has identified four criteria. First, during an uninterrupted period of time a
major depressive episode, manic episode, or a mixed episode must occur simultaneously
with symptoms that meet Criterion A for schizophrenia. Secondly, delusions or
hallucinations are present during same period of illness and lasts two weeks void of
prominent mood symptoms. Thirdly, symptoms are present for a significant amount of
the total duration of the active and residual periods of the illness. Lastly, the disturbance
is not better accounted for by substance use or a general medical condition.
If criteria
are met, specify if bipolar or depressive type.
In their book, Miller and Schultz (2002) state that schizophreniform disorder,
affective disorders, depression in schizophrenia, delusional disorder, brief reactive
psychosis, and psychosis not otherwise specified (NOS) must be distinguished from
schizoaffective disorder before a diagnosis is made.
The DSM IV has identified differential diagnosis considerations. Substanceinduced psychotic disorder and substance induced delirium are differentiated from
schizoaffective disorder based on the etiology of the substance use and symptoms. If
there is evidence from a complete history evaluation, physical examination, or laboratory
tests indicating a general medical condition, a psychotic disorder due to a general medical
condition, a delirium, or a dementia is diagnosed.
Schizoaffective disorder has received considerable controversy in terms of
definition and classification (Averill, Reas, Shack, Shah, Cowan, Krajewski, Kopecky
and Guynn, 2004). According to Averill et al. (2004), the boundaries between
Differential diagnoses 4
schizoaffective, schizophrenia, and bipolar disorder are unclear. In their research, Chen,
Swann, and Johnson (1998) state that schizoaffective disorder is an unstable diagnosis
that often times resolves into either schizophrenia or bipolar disorder. Additionally, Maj,
Pirozzi, Formicola, (2000) researched the reliability and validity of the DSM IV
diagnostic category of schizoaffective disorder. The study indicates that the diagnosis of
schizoaffective disorder depends more on the definition of schizophrenia than on the
different symptomatological patterns of the two conditions.
References
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental
Disorder, (4th ed.), Text Revision. Washington, DC: Author.
Averill, P., Reas, D., Shack, A., Shah, N., Cowan, K., Krajewski, K., Kopecky, C.,
Guynn, R., (2004). Is schizoaffective disorder a stable diagnostic category: a
retrospective examination. Psychiatric Quarterly, 75, 215-227.
Chen Y., Shann, A., Johnson, B., (1998). Stability in bipolar disorder. Journal of
Nervous and Mental Diseases 186, 17-23.
Miller, D., & Schultz, S., (2002). Differential diagnosis in schizophrenia. Schizophrenia:
A new guide for clinicians. Csernansky, J. (Ed). New York: New York: Marcel
Dekker.
Maj, M., Pirozzi, R., Formicola, A., (2000). Reliability and validity of the DSM IV
diagnostic category of schizoaffective disorder: Preliminary data. Journal of
Affective Disorders, 57, 95-98.
Differential diagnoses 5
Mood Disorder
Major Depressive disorder. According to the DSM IV the essential diagnostic
feature of major depressive disorder is the presence of a major depressive episode. Once
a major depressive episode has been confirmed, specify if single or recurrent. All the
diagnostic criteria are the same for both single and recurrent with the exception of
frequency. To meet the criteria for a major depressive disorder, single episode there must
be indication of a single major episode. For a major depressive disorder, recurrent two or
more major depressive episodes have occurred. Additionally, the episode(s) is not better
accounted for by a schizoaffective disorder, and there has never been a manic episode,
mixed episode or a hypomanic episode. If the full criteria are met specify the current
clinical status or features. If the full criteria are not currently met, specify the current
clinical status or features of the most recent episode. Lastly, to make a sound diagnosis
specify the pattern of the episode(s) and the presence of interepisode symptoms.
The DSM IV supplies much information about differential diagnosis of major
depressive disorder and major depressive episode. If the mood disturbance is caused by a
medical condition, the appropriate diagnosis would be mood disorder due to a general
medical condition.
Depression and attention deficit hyperactivity disorder (ADHD) are sometimes
misdiagnosed in adolescents (Poissant, & Montgomery, 2003). According to Pine,
Cohen, Cohen & Brook (1999), adolescents can present with irritability and agitation, as
opposed to outward feelings of worthlessness and hopelessness, for example.
Additionally, In both ADHD and in a major depressive episode, distractibility and low
frustration tolerance can occur which can complicate differential diagnosis.
Differential diagnoses 6
In elderly persons, dementia must be considered when assessing for a major
depressive episode, according to the DSM IV. There is often a premorbid history of
declining cognitive function in the individual with dementia. The person without
dementia is more likely to have a somewhat normal premorbid state and abrupt cognitive
decline associated with depression.
Casey, Maracy, Kelly, Lehtinen, Ayuso-Mateos, Dalgard, and Dowrick, (2006)
examined variables that might distinguish an adjustment disorder from a depressive
episode. The study failed to identify any variables that independently differentiate
adjustment disorder from a depressive episode. It is noteworthy to mention however, that
the study had multiple limitations which may have skewed the data.
References
Casey, P., Maracy, M., Kelly, B., Lehtinen, V., Ayuso-Mateos, J., Dalgard, O., &
Dowrick, C. (2006). Can adjustment disorder and depressive episode be
distinguished? Resutls from ODIN. Journal of Affective Disorder, 92, 291-297.
Pine, D., Cohen, e., Cohen, P., Brook, J., (1999). Adolescent depressive symptoms as
predictors of adult depression: Moodiness or mood disorder? American Journal
of Psychiatry, 156, 133-135.
Poissant, H., & Montgomery, C., (2003). Attention deficit and hyperactivy Disorder
(ADHD) and Depression in children and adolescents: Implications for
parishioners and educators. Journal of Cognitive Educations and Psychology, 3,
323-341.
Differential diagnoses 7
Anxiety Disorder
Posttraumatic Stress Disorder. The development of characteristic symptoms
following exposure to an extreme traumatic stressor is the essential feature of
posttraumatic stress disorder (PTSD). According to the DSM IV, a diagnosis of PTSD
requires the following, (a) exposure to a traumatic event, (b) persistent reexperiencing of
traumatic event, (c) persistent avoidance of stimuli associated with the trauma, (d)
persistent increased arousal, (e) disturbance last more than one month, and (f) disturbance
causes clinically significant distress. If criteria is met, specify if condition is acute or
chronic and with delayed onset.
It is important to distinguish the symptoms of PTSD from different disorders (Lee
& Young, 2001). Hill (1994) identifies that the stressor in adjustment disorder can be of
any severity. The stressor may be a single event or there may be multiple stressors. In
PTSD the stressor is terrifying and horrific; as opposed to adjustment disorder the
stressor does not meet this level of intensity.
Acute stress disorder is differentiated from PTSD because the symptom pattern
must occur within four weeks of the traumatic event and be resolved within that four
week period. The diagnosis is changed from Acute stress disorder to PTSD if the
symptoms persist for more than one month and meet criteria for posttraumatic stress
disorder (Lee & Young, 2001).
PTSD must be distinguished from general anxiety disorder (Keane, Taylor, &
Penk, 1997). Anxiety is present in PTSD. If the anxiety occurs exclusively during the
course of PTSD, then generalized anxiety disorder is not diagnosed.
According to the DSM IV, obsessive compulsive disorder must be distinguished
from PTSD. In obsessive compulsive disorder, the individual experiences the intrusive
Differential diagnoses 8
thoughts as inappropriate and have no connection to a traumatic event. In PTSD
intrusive thoughts or flashbacks are related to a traumatic event. Furthermore, flashbacks
must be distinguished from delusions and hallucinations that may occur in a
schizophrenia or other psychotic disorders.
Lee and Young (2001) cautions the forensic psychologist against malingering. In
this situation, the individual fake’s illness in order to gain financially from litigations, be
eligible for benefits, or used as mitigating circumstances in a forensic context.
References
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental
Disorder, (4th ed.), Text Revision. Washington, DC: Author.
Hill, P. (1994). Adjustment disorder. Child and Adolescent Psychiatry, 3, 375-391.
Keane, T., Taylor, K., & Penk, W. (1997). Differentiating post-traumatic stress disorder
(PTSD) from major depression (MDD) and generalized anxiety disorder (GAD).
Journal of Anxiety Disorder, 11, 317-328.
Lee, D., & Young, K., (2001). Post-traumatic stress disorder: diagnostic issues and
epidemiology in adult survivors of traumatic events. International Review of
Psychiatry, 13, 150-158.
Differential diagnoses 9
Somatoform Disorder
Hypochondriasis. A preoccupation with fears of having, or the idea that one has,
a serious illness based on misinterpretation of one or more bodily signs or symptoms is
the essential feature of hypochoncriasis. Additional criterions include a persistent
preoccupation despite appropriate medical evaluation and reassurance. The belief is not
of delusional intensity and is not restricted to concern about appearance. Additionally, the
disturbance causes clinically significant amount of distress and last at least six months. If
criteria are met specify if individual has poor insight. Interestingly enough, Allen and
Hollander (2004) in their research identify three subtypes of hypochondriasis. These
three subtypes have been described as obsessive compulsive hypochondria, phobic
hypochondria, and depressive hypochondria.
An underlying general medical condition is the most important differential
diagnostic consideration in hypochondriasis according to the DSM IV. A few of the
main medical conditions that may appears like hypochondriasis includes the early stages
of neurological conditions, endocrine conditions, disease that affect multiple body
systems, and occult malignancies. Children often present with somatic symptoms like
abdominal pain. These children should not be diagnosed with hypochondriasis unless the
child has a prolonged preoccupation with having a serious illness. In the elderly, bodily
preoccupations and fears may be a response to increasing debility.
Concerns about health or illness characterizes a number of different disorders.
According to the DSM IV however, hypocondriasis is not diagnosed if the individual’s
health concerns are better accounted for by an anxiety disorder, or a major depressive
episode.
Differential diagnoses 10
According to the DSM IV, intrusive thoughts about having a disease and
associated compulsive behaviors may occur in individuals with hypochondriasis. When
the obsessions or compulsions are not restricted to concerns about illness, a separate
diagnosis of obsessive compulsive disorder is given.
Atmaca, Kuloglu, Tezcan, and Unal, (2002) report on monosymptomatic
hypochondriacl psychosis (MHP) and hypocondriasis. They state that because MHP is
rare it tends to be neglected in differential diagnosis. MHP is a syndrome classified in
DSM IV as a subtype of paranoia (delusional disorder somatic subtype). Interestingly,
Munro (1988) reports that while hypochondriac patients want to be diagnosed, patients
with MHP want to be treated for the disease they actually believe they have.
References
Allen, A., & Hollander, E., (2004). Similarities and differences between body
dysmorphic disorder and other disorders. Psychiatric Annals, 34, 927-933.
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental
Disorder, (4th ed.), Text Revision. Washington, DC: Author.
Atmaca, M., Kuloglu, M., Tezcan, E., Unal, A., (2002). The detergent is circulating in
my blood: a case report. International Journal of Psychiatry in Clinical Practice,
6, 117-119.
Munro, A. (1988). Monosymptomatic hypochondriacal psychosis. British Journal of
Psychiatry, 153, 117-119.
Differential diagnoses 11
Substance Induced disorders
Substance Induced Psychotic Disorder. The DSM IV describes substance
induced psychotic disorder as having prominent hallucinations or delusions that are
judged to be due to the direct physiological effects of a substance. Hallucinations should
not be included if the person has insight that they are substance induced. Through
laboratory findings , physical examination and a full history intake, there is evidences to
support that either (a) the symptoms developed during, or within a month of substance
intoxication or withdrawal, or (b) medication use is etiologically related to the
disturbance. Additionally, the disturbance is not better accounted for by a psychotic
disorder that is not substance induced. Specify with onset during intoxication or with
onset during withdrawal.
Substance intoxication or substance withdrawal needs to be distinguished from
substance induced psychotic disorder. When the psychotic symptoms are judged to be in
excess of those usually associated with intoxication or withdrawal, a substance induced
psychotic disorder should be made. A diagnosis of substance intoxication or withdrawal,
with perceptual disturbances is made when an individual is intoxicated with stimulants,
cannabis, opioid, phencyclidine, or those withdrawing from alcohol, but is able to realize
that the perception is substance induced. Hallucinogen persisting perception disorder is
diagnosed when flashback’s occur long after the use of hallucinogens has stopped.
A primary psychotic disorder is distinguished form a substance induced psychotic
disorder by the fact that a substance is judged to be etiologically related to the symptoms
(DSM IV; Cimpean, Torry, & Green, 2005; Kosten & Ziedonis, 1997).
Differential diagnoses 12
References
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental
Disorder, (4th ed.), Text Revision. Washington, DC: Author.
Cimpean, D., Torrey, W., Green, A., (2005). Schizophrenia and co-occuring general
medical illness. Psychiatric Annals, 35, 71-81.
Kosten, T., & Ziedonis, D., ( 1997). Substance abuse and schizophrenia: Editor’s
introductions. Schizophrenia Bulletin, 23, 181-186.
Differential diagnoses 13
Mental Disorder Due to a General Medical Condition
Personality change due to a…[Indicate the general medical condition]. A
persistent personality disturbance that is judged to be due to the direct
physiological effects of a general medical condition describes the essential feature of a
personality change due to a general medical condition. To meet DSM IV criteria
additional considerations must be made. The personality change is not better accounted
for by another mental disorder. The disturbance does not occur during the course of
delirium, and it must cause clinically significant distress or impairment. If disturbance
meets criteria, specify type.
Changes in personality can be associated with a chronic general medical condition
as they are painful and debilitating. However, personality change due to a general
medical condition is distinguished from a chronic general medical condition only if a
direct pathophysiological mechanism can be established (Tueth, 1995).
According to Tueth (1995) personality change due to a general medical condition,
and dementia is the too most commonly seen mental disorder in the elderly. Tueth
(1995) stresses the importance of differentiating the two. If the personality occurs
exclusively during the course of delirium or dementia, then personality change due to a
general medical condition is not made. However, if the personality change is a
significant part of the clinical presentation, then a personality change due to a general
medical condition may be given in addition to a diagnosis dementia.
Mood disorder, schizophrenia, delusional disorder, and panic disorder, for
example cause considerable personality changes and need to be differentiated from a
personality change due to a general medical condition diagnosis (Tueth, 1995). These
Differential diagnoses 14
disorders can be distinguishable if a clinically significant change from baseline
personality functioning is marked by a specific etiological general medical condition.
References
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental
Disorder, (4th ed.), Text Revision. Washington, DC: Author.
Tueth, M. (1995). DSM-IV disorder most commonly seen in the elderly. Clinical
Gerontolotist, 16, 74-76.
Weiner, M., (1996). Diagnosis of dementia. American Psychiatric Association, 23, 1-41