Differential Diagnosis Flashcards
Why was the definition of mental health developed?
The definition of mental disorder was developed for clinical, public health, and research purposes
How does the DSM define a mental disorder?
The DSM defines a mental disorder is “a syndrome characterized by clinically significant disturbance
in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the
psychological, biological, or developmental processes underlying mental functioning”
A diagnosis of a mental disorder must have clinical utility and it should help clinicians determine?
- Need for treatment
- Potential treatment options
- Potential treatment outcomes
- Prognosis (most likely course, recovery, etc.)
Is the diagnosis of a mental disorder equivalent to a need for treatment?
NO
The diagnosis of a mental disorder is NOT equivalent to a need for treatment.
What is the definition of differential diagnosis?
“the process of determining which of two or more diseases or disorders with overlapping
symptoms a particular patient has”
(APA Dictionary of Psychology)
“a systematic process used to identify the
proper diagnosis from a set of possible
competing diagnoses”
(Cook & Décary, 2020)
What does errors in mental health diagnoses have implications for?
- Costs related to treatment
- Resources available to researchers studying disorders
- Pharmaceutical interest in treating the disorders
- Patient outcomes!
- Efficacy of treatment
- Disruptions to long-term quality of life (QOL)
- Associated Stigma
How does the DSM-5 differential diagnosis work?
Generally based on the notion that the clinician is choosing a single
diagnosis from among a group of competing, mutually exclusive diagnoses
to best explain a given symptom presentation
- I.e., a person who presents with delusions, hallucinations, and manic symptoms.
The question is whether the best diagnosis is:
- Schizophrenia
- Schizoaffective Disorder
- Bipolar Disorder With Psychotic Features
Only one of these can be given
However, not all DSM-5 diagnoses are mutually exclusive
- Assignment of more than one DSM-5 diagnosis to a given person is both allowed and necessary to adequately describe the presenting symptoms (I.e. Schizophrenia
Spectrum Disorder and Other Specified Depressive Disorder)
How is the DSM-5 differential diagnosis broken down into 6 steps?
Broken down into six basic steps:
1) Ruling out Malingering and Factitious Disorder
2) Ruling out a substance etiology
3) Ruling out an etiological medical condition
4) Determining the specific primary disorder(s)
5) Differentiating Adjustment Disorder from the residual Other
Specified and Unspecified conditions
6) Establishing the boundary with no mental disorder
What is step 1: ruling out malingering and factitious disorder? What is malingering and factitious?
Some patients may elect to deceive the clinician by producing or
feigning the presenting symptoms
Two conditions in DSM-5 are characterized by feigning:
- Malingering - When the motivation is the achievement of a clearly
recognizable goal (e.g., insurance compensation, avoiding legal or military
responsibilities, obtaining drugs)
- Factitious Disorder - When the deceptive behavior is present even in the absence of obvious external rewards (I.e., Munchausen syndrome)
What is step 5: differentiating adjustment disorder from the residual other specified and unspecified conditions?
If the clinical judgment is made that the symptoms have developed as
a maladaptive response to a psychosocial stressor, the diagnosis would be an Adjustment Disorder
If it is judged that a stressor is not responsible for the development of
the clinically significant symptoms, then the relevant Other Specified
or Unspecified category may be diagnosed
How do you do step 4: determining the specific primary disorder(s)?
- A process of elimination
- Decision trees
What is step 6: establishing the boundary with no mental disorder?
“Taken individually, many of the symptoms included in DSM-5 are
fairly ubiquitous and are not by themselves indicative of the
presence of a mental disorder. During the course of their lives, most
people may experience periods of anxiety, depression, sleeplessness,
sexual dysfunction, etc., that may be considered as no more than an
expected part of the human condition…”
How do you do the process of elimination?
First, making a diagnosis requires that you have a good picture of the
course of illness including:
- Current symptoms
- Past symptoms (if any)
- Psychosocial history
- Medical History
Then, if a person is exhibiting psychotic symptoms then it’s just a
matter of following the diagnostic criteria for the symptom that is the
most severe…
What does the DSM-5 decision tree help you do?
The DSM-5 handbook for Differential Diagnosis provides decision
trees for making a diagnosis based on the presence of either:
- Hallucinations
- Delusions
These decision trees allow you to eliminate diagnoses that don’t fit
and find the one that does..
True or False: Start with the worst component of the symptom presentation
True
What is the most common medical cause of acute psychosis?
Substance-Induced Psychosis
Frequently diagnosed in psychiatric emergency service settings
Psychotic symptoms may occur during intoxication or withdrawal
Psychosis typically subsides when sober or within a month of stopping substance use.
What is step 2: ruling out a substance etiology?
You need to determine if the presenting symptoms arise from a substance that is exerting a direct effect on the central nervous system (CNS)
- Virtually any presentation encountered in a mental health setting can be caused by substance use!
- Missing a substance etiology is probably the single most common diagnostic error made in clinical practice.!
If they ARE using a substance, you have to determine if there is an etiological relationship between it and the psychiatric symptomatology
This requires that you answer 3 questions…
What are the 3 questions required for ruling out a substance etiology?
- Do the psychiatric symptoms result from the direct effects of the substance?
- You need to figure out if they used the substance and then the symptoms emerged, or if they had symptoms prior to the substance - Is the substance use a consequence of having a primary psychiatric disorder (e.g., self-medication)?
- ifs the substance us a direct effect of the illness - Do the psychiatric symptoms ever occur independently from the substance use?
These are not always easy to answer…
What is step 3: ruling out an etiological medical condition?
One of the most important and difficult distinctions in psychiatric diagnosis!
- Many individuals with general medical conditions have resulting psychiatric symptoms as a complication of the general medical condition
- Many individuals with psychiatric symptoms have an underlying general medical condition
Treatment implications of this differential diagnostic step are profound!
What are personality disorders?
A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the norms and expectations of the individual’s culture, is pervasive and inflexible, is stable over time, and leads to distress or impairment
What personalities are in cluster A?
The odd, eccentric cluster
- Paranoid Personality disorder
- Schizoid personality disorder
- Schizotypal personality disorder
What personalities are in cluster B?
The dramatic, unpredictable cluster
- Antisocial personality disorder
- Borderline personality disorder
- Histrionic personality disorder
- Narcissistic personality disorder
What personalities are in cluster C?
The anxious, fearful cluster
- Avoidant personality disorder
- Dependent personality disorder
- Obsessive-compuslive personality disorder
What is the relationship between psychosis and personality disorders?
Unlike schizophrenia, PDs do not include persistent psychotic symptoms
Symptoms of psychosis are transient and are directly related to the characteristic symptoms of the PD
This is not only about Cluster A Personality Disorders (I.e., Paranoid, Schizoid, and Schizotypal personality disorders)…!!!
