Differential diagnosis practice Flashcards
What is the first step?
Rule Out Malingering and Factitious Disorder
Look at the case in picture 1. How would we consider this case in terms of step 1 and what are possible answers?
Sufficient answer for this case: ‘‘There are reasons to carefully consider the veracity of the reporting by this patient. There may certainly be a motive for this given the circumstances for asking diagnostic consultation. Furthermore, the history gives example of the patient giving false documentation.’’
Possible answer in a different case: ‘‘There is no information suggesting malingering or factitious disorder.’’
What is step 2?
Rule Out Substance Etiology (Including Drugs of Abuse, Medications)
What are the tasks in step 2?
- Obviously, the first task is to determine whether the person has been using a substance.
- Once substance use has been established, the next task is to determine whether there is an etiological relationship with the psychiatric symptomatology.
- After deciding that a presentation is due to the direct effects of a substance or medication, determine which DSM-5-TR Substance/Medication-Induced Mental Disorder best describes the presentation.
What are the three possible relationships between the substance use and psychopathology?
- the psychiatric symptoms result from the direct effects of the substance on the CNS (resulting in a diagnosis of Substance/Medication-Induced Mental Disorder in DSM-5-TR)
- the substance use is a consequence (or associated feature) of having a primary psychiatric disorder (e.g., self- medication)
- the psychiatric symptoms and the substance use are independent
In diagnosing a Substance/Medication-Induced Mental Disorder, what are the three considerations in determining whether there is a causal relationship between the substance use and the psychiatric symptomatology?
- Consider whether a temporal relationship exists between the substance/medication use and the onset or maintenance of the psychopathology.
- In determining the likelihood that the pattern of substance/medication use can account for the symptoms, consider whether the nature, amount, and duration of substance/medication use are consistent with the development of the observed psychiatric symptoms.
- Consider other factors in the presentation that suggest causes other than a substance or medication.
Look at the case in picture 2. How would we consider this case in terms of step 2 and what are possible answers?
- Using lot of pain medication
- The relationship between use of substance and symptoms is important substance follows the symptoms (somatic symptoms) or symptoms follow the substance (substance-induced disorder - diagnose in step 4)
- Also check whether the severity of symptoms matches the dose of the substance
Possible answer (fitting with this case): ‘‘There is quite some use of [substance] and this all started before the onset of [symptoms]. The use of [substance] may have caused the symptoms presented and their severity is consistent with this.’’
Other possible answers (not fitting this case): ‘‘There is no information on use of drugs. This should certainly be informed about before making any final diagnostic decisions.’’
‘‘This patient doesn’t use drugs or medication.’’
What is step 3?
Rule Out a Disorder Due to Another Medical Condition
What are the four reasons why can differential diagnosis in step 3 be difficult?
- symptoms of some psychiatric disorders and of many nonpsychiatric medical conditions can be identical (e.g., symptoms of weight loss and fatigue can be attributable to a Depressive or Anxiety Disorder or to a nonpsychiatric medical condition);
- sometimes the first presenting symptoms of a medical condition are psychiatric (e.g., depression preceding other symptoms in pancreatic cancer or a brain tumor);
- the relationship between the nonpsychiatric medical condition and the psychiatric symptoms may be complicated (e.g., depression or anxiety as a psychological reaction to having the nonpsychiatric medical condition vs. the medical condition being a cause of the depression or anxiety via its direct physiological effect on the CNS);
- psychiatric patients are often seen in settings primarily geared toward the identification and treatment of mental disorders in which there may be a lower expectation for, and familiarity with, the diagnosis of medical conditions.
What are other important parts of step 3?
- Virtually any psychiatric presentation can be caused by the direct physiological effects of a nonpsychiatric medical condition, and these presentations are diagnosed in DSM-5-TR as one of the Mental Disorders Due to Another Medical Condition (e.g., Depressive Disorder Due to Hypothyroidism).
- Once a nonpsychiatric medical condition is established, the next task is to determine its etiological relationship, if any, to the psychiatric symptoms.
- There are two clues suggesting that psychopathology is caused by the direct physiological effect of a nonpsychiatric medical condition.
- Finally, if the clinician concludes that a nonpsychiatric medical condition is responsible for the psychiatric symptoms, they must determine which of the DSM-5-TR Mental Disorders Due to Another Medical Condition best describes the presentation.
What are two clues suggesting that psychopathology is caused by the direct physiological effect of a nonpsychiatric medical condition?
- The first clue involves the nature of the temporal relationship and requires consideration of whether the psychiatric symptoms a) begin following the onset of the nonpsychiatric medical condition, b) vary in severity with the severity of the medical condition, and c) remit when the medical condition resolves.
- The second clue that a nonpsychiatric medical condition should be considered in the differential diagnosis is whether the psychiatric presentation is atypical in symptom pattern, age at onset, or course.
Look at the case in picture 3. How would we consider this case in terms of step 3 and what are possible answers?
After ruling out a substance/medication-induced etiology, the clinician next determines whether the psychiatric symptoms are due to the direct effects of a general medical condition.
- As a psychologist you cannot do this on your own but you always need to be aware of it and ask help from a physician or psychiatrist in case of possible somatic causes
- For the exam, it’s sufficient to show awarness of the possiblities as described in the chapter
Answer for this case: ‘‘There seems to be a complex interaction between somatic illness (CF) related to respirations and emotions, cognitions and behaviours of the patient (e.g. refusing a device that may release the symptoms). The anxiety of the patient may certainly be cause and/or excerbated by the illness, but also the other way around. Careful consultation with a medical professional is needed before any definitive diagnosis.’’
Possible other answers:
‘‘There is no information on medical condition. This should certainly be informed about before making any final diagnostic decision.’’
‘‘There are some medical issues, but these are very unlikely to be related to the psychological problems.’’
‘‘This person doesn’t have medical issues.’’
What is step 4 and other info
Once substance use and nonpsychiatric medical conditions have been ruled out as etiologies, the next step is to determine which among the independent DSM-5-TR mental disorders best accounts for the presenting symptomatology
- Chapter 2 and 3 of the handbook gives many decision-trees. You don’t need to learn them by heart, but they can be very useful in understanding how to differentiate between syndromes
Look at the case in picture 4. How would we consider this case in terms of step 4 and what are possible disorders?
+ exam info
- Dissociative amnesia
- MDD
- PTSD
- Borderline PS
Start by thinking what are the most likely disorders. He will ask us to name 3 or 4 disorders and there will be a couple that he wants us to say but there might be differences between students on the remaining 2 disorders - not necessarily wrong if we can argue for it! Quality of the arguments is what matters.
What are arguments for and against MDD in case in picture 4?
For:
- Experiencing persistently depressed mood
- insomnia
- fatigue
- feelings of worthlessness, suicidality
- (Note: the fact that in the case it is mentioned that she had ‘‘chronic, severe depression’’ is insufficient, you have to judge yourself)
- Using the words from the case is important - the better you connect the actual case description to how they are described with dsm, the better it is (e.g. when feelings of worthlessness - ‘‘in many cases the patient is feeling lost in life and that she doesn’t matter’’)
Against:
- The episodic nature of the symptoms and their duration (minimum 14 days) is not clearly established
- Persistent depressive syndrome cannot be ruled out
- We don’t have sufficient info to determine that symptoms are present nearly every day
- (Note: Ruling out persistent depressive syndrome is necessary, because it cannot be comorbid. This is not true for many other disorders!)
- !!!! ALWAYS spell out arguments against the diagnoses, we can always find something
So what is the conclusion of MDD diagnosis in this case?
- '’Likely’’, ‘‘possible’’ both okay
- '’unlikely’’, ‘‘certain’’ not okay
- We need to explain the choice!!
- '’Although the case is suggestive of the presence of at least 5 symptoms of MDD, we need more info on duration of these symptoms and their continous presence.’’
- Note: !!!! Indicating that more info is needed is good, but always be specific regarding what info you need!!!!
What is step 5?
Differentiate Adjustment Disorders From the Residual Other Specified or Unspecified Mental Disorders
Look at the case in picture 5. How would we consider this case in terms of step 5 and what are possible answers?
Many clinical presentations of mental disorders (particularly in outpatient and primary care settings) do not conform to the particular symptom patterns in DSM-5-TR diagnostic criteria, or they fall below the established severity or duration thresholds to qualify for one of the specific DSM-5-TR diagnoses. In such situations, if the symptomatic presentation is severe enough to cause clinically significant impairment or distress and reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning in the individual (part of the DSM-5-TR definition of a mental disorder, p. 14), a diagnosis of a mental disorder is still warranted, and the differential comes down to either an Adjustment Disorder or one of the residual Other Specified or Unspecified categories.
- Four possible residual categories but the differences between them are not important for the exams: other specified mental disorder due to another medical condition, unspecified mental disorder due to another medical condition, other specified mental disorder, unspecified mental disorder
Possible answer for this case:
‘‘In step 4 none of the disorders applied. Yet, mr. Sims seems to be affected quite negatively and may certainly need some psychological care. He does seem to fit the profiel of the adjustment syndrome as he has recently had some difficult life experiences and is now suffering from emotional, cognitive and behavioural consequences.’’
Other possible answer:
‘‘In step 4 it became quite likely that … syndrome applies. This would rule out adjustment syndrome. Furthermore, I do not see indications for the need for an otherwise or not-otherwise specified syndrome.’’
What is step 6?
Generally, the last step in each of the decision trees is to establish the boundary between a disorder and no mental disorder. This decision is by no means the least important or easiest to make. Taken individually, many of the symptoms included in DSM-5-TR 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, or sexual dysfunction that may be considered as no more than an expected part of the human condition. To be explicit that not every such individual qualifies for a diagnosis of a mental disorder, DSM-5-TR includes with most criteria sets a criterion that is usually worded more or less as follows: “The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.”
Look at the case in picture 6. How would we consider this case in terms of step 6 and what are possible answers?
Answer for this case:
‘‘Bethany Pinsky has certainly experienced negative emotional consequences from the traumatic experience, but her emotions and functioning are not so much affected that a DSM-5 diagnoses is warranted.’’
‘‘As discussed in step 4, Mr. Quigly likely applied for acute stress syndrome. The consequences are clinically significant as indicated by his emotional suffering weeks after the trauma.’’
- Argue why the symptoms are severe enough in terms of functioning
- Say specifically, it’s problematic in this and this way
