Differential Diagnosis

Ken Denman ARNP, PhDc, MS, BSN, RN. Psychiatry Armor Correctional Medical Services

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The Diagnostic Problem

DSM Diagnosis = a somewhat paradigmatic symptoms cluster at the syndromal level of abstraction However, individuals usually present clinicians with a single symptom/small set of symptoms: That they find most distressing That they are most comfortable discussing Getting from a single or small number of related symptom to a diagnosis useful for treatment is what differential diagnosis is all about.

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Step #1 Is the presenting symptom for real?

This does not imply that one should always mistrust what the patient says. However there are diagnoses in which conscious feigning of symptoms is usual (Malingering and Fictitious Disorder) and one in which unconscious feigning of symptoms is usual (Conversion Disorder).

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Step #1 (corollaries)
1. Is this a situation in which feigning of symptoms is more typical: ER, forensic evaluation, prison, inpatient unit? 2. Does the presentation of symptoms conform more to a popular view of a disorder than to an actual clinical entity? 3. Do the symptoms shift significantly from one clinical encounter to the next? 4. Do the symptoms mimic the presentation of a role model like a parent or another patient? 5. Is the patient unusually manipulative or suggestible?
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Step #2 Rule out substance etiology (drugs of abuse, medications, toxin exposure).
1. Does the individual use any substances? This includes dependence, abuse, recreational use, medical use, and environmental exposure. This will involve a thorough history and evaluation, laboratory tests, and toxicology.

In an aging population with less cautious use of pharmacotherapy, medication use is an increasing concern.

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Step #2
2. What is the etiologic relationship between substance use and psychiatric symptoms? a) The symptoms are a direct result of the effects of the substance use. b) The substance use is secondary to the psychiatric symptoms. c) The psychiatric symptoms and substance use are independent of each other.
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Step #2
Temporal sequence is a helpful, but not infallible, guide. If the onset of psychiatric symptoms clearly precedes the onset of substance use, it is probably a primary psychiatric disorder. If the onset of substance use clearly precedes the psychiatric symptoms than the symptoms are more likely to be substance induced. If the psychiatric symptoms abate in about 4 weeks after substance intoxication or withdrawal, the symptoms are more clearly substance induced. Excepting Substance Induced Persisting Dementia or Amnesiac Disorder.
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Step #2 Caveats
Often individuals suffering from substance use and psychiatric symptoms are not the best historians of their own experience. Substance misuse and psychiatric disorders often have their onset in late adolescence without any causative link. If psychiatric symptoms are severe and pose a risk to self or others, waiting 4 weeks to determine etiology raises serious questions.
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Step #2
3. Is the pattern of substance use or withdrawal sufficient to account for the symptoms? Is the nature, amount, and duration of substance use consistent with the observed symptoms? Not all substances nor all dose levels of specific substances produce specific symptoms.

4. Is the pattern of substance use consistent with an attempt to relieve the symptoms?
5. Are there other factors like heavy genetic loading for a specific psychiatric problem that point to a nonsubstance induced etiology? 6. In the absence of persuasive evidence in either direction, could the two disorders simply be comorbid?
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Step #3 Rule out a disorder due to a general medical condition?

The clinical implication of this step are profound. Differential diagnosis is complicated: Symptoms of some psychiatric conditions and many general medical conditions can be identical. Sometimes the first presenting symptom of a general medical condition is psychiatric. The relationship between medical conditions and psychiatric conditions can be complicated Patients are often seen in mental health setting where there is low expectation of and little familiarity with general medical conditions.
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Step #3
- Just as with substance use, virtually any psychiatric presentation can be caused by the direct physiologic effects of a general medical condition (e.g. Mood Disorder due to Hypothyroidism). - A good diagnostic evaluation should contain a thorough history and physical as well as tests for those medical conditions most likely to cause the presenting symptoms ( thyroid function tests for depression, brain imaging for lateonset psychosis) In counseling work practice, involvement of a physician with good diagnostic skills, like an Internist, in the evaluation process is very important.

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Step #3
If a general medical condition is present, its etiologic relationship, if any, to the psychiatric symptoms must be established. 1. The medical condition causes the psychiatric symptom by direct action on the CNS. 2. The general medical condition causes the psychiatric symptoms through a indirect or psychological mechanism. 3. Medication taken for the medical condition causes the psychiatric symptoms. 4. The psychiatric symptoms adversely effect the medical condition. 5. The psychiatric symptoms and the medical condition are purely coincidental,

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Step #3
There are some clues that are helpful, but not infallible, in making the clinical judgment mentioned earlier. Temporality: do psychiatric symptoms follow the onset of the medical condition, vary in intensity with it, and disappear when it is resolved? Remember that psychiatric symptoms can precede, by some time, the onset of some medical problems or not occur until late stages of others.
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Step #3
Atypicality: are the psychiatric symptoms atypical in pattern, age of onset, or course. e.g. significant weight loss and severe fatigue with mildly depressed mood, first onset of Manic Episode in an elderly individual, severe disorientation accompanying psychotic symptoms.

Remember, manifestation of psychiatric disorders is very heterogeneous and atypical presentations are not unknown.
If you determine that a medical condition is causing the psychiatric symptoms, determine which DSMIVTR diagnosis of Mental Disorders Due to a General Medical Condition best describes the presentation. A decision tree or algorithm is very helpful.

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Step #4
Determine the specific primary disorder(s). The arrangement of disorders g in the DSMIVTR into broad categories of disorders is done to somewhat facilitate this process: Disorders First Diagnosed in Infancy, Childhood, or Adolescence; Delirium, Dementia, Amnestic, and other Cognitive Disorders; SubstanceRelated Disorders; Schizophrenia and other Psychotic Disorders; Mood Disorders; Anxiety Disorders; Somatoform Disorders; Factitious Disorders; Dissociative Disorders; Sexual and Gender Identity Disorders; Eating Disorders; Sleep Disorders; ImpulseControl Disorders; Adjustment disorders; Personality Disorders

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The problem is that many disorders share common symptoms: Insomnia

Acute Stress Disorder Cyclothymic Disorder Delirium Dysthymic Disorder GAD Hypomanic Episode Major Depressive Disorder Manic Episode Mixed Episode

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Weight Loss
Anorexia Nervosa Dysthymic Disorder Hypomanic Episode Major Depressive Disorder Manic Episode Mixed Episode Substance Intoxication

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Irritability
Acute Stress Disorder ASPD Attentional Deficit/Hyperactivity Disorder BPD Conduct Disorder Cyclothymic Disorder Delusional Disorder Dysthymic Disorder GAD Nightmare Disorder PTSD Schizoaffective Disorder Schizophreniform Disorder

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Continued Schizophrenia Substance Use/Withdrawal Hypomanic Episode Major Depressive Disorder Manic Episode Mixed Episode PTSD Schizoaffective Disorder Schizophreniform Disorder Schizophrenia Substance Use/Withdrawal

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Step #4 Dysthymic Disorder must be differentiated from . . . In contrast to Dysthymic Disorder, the other condition . .

Major Depressive Disorder is characterized by one or more major depressive episodes; both can be diagnosed if the MDE occurs after the first 2 yrs. of Dysthymic Disorder

Depressive symptoms associated with chronic Psychotic Disorder occurs exclusively during the psychotic disturbance
Cyclothymic Disorder is characterized by hypomanic periods as well as depressive periods.

Nonpathological periods of sadness is characterized by short duration, few symptoms, an no significant impairment or distress

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Step #5
If the symptom pattern or the severity of impairment or distress does not meet criteria for a specific diagnosis, differentiate adjustment disorder from not otherwise specified. If the clinical judgment is made that the symptoms developed from a maladaptive response to a psychosocial stressor, then adjustment disorder appropriate.

If the judgment is that the stressor is not responsible for the development of the symptoms, than the relevant Not Otherwise Specified category can be diagnosed. Given the ubiquity of stressors, the point is not whether a stressor is present or not but whether it is the etiology of the symptoms.
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Step # 6
Establish the boundary with no mental disorder This is an obvious but not always an easy step to take. Many symptoms are so ubiquitous that they occur at least briefly in the lives of most people.

At some time most individuals will experience symptoms of anxiety, depression, difficulty sleeping, or sexual dysfunction.
It is important not to pathologize what is really the human condition.

The disturbance must cause clinically significant impairment or distress in social, occupational, or other important areas of functioning.

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Step # 6
The diagnosis of Hypoactive Sexual Desire Disorder should not be made in someone with low sexual desire, who is not in a current intimate relationship with anyone, and who is not particularly bothered by it. The problem is that what is clinically significant is greatly influenced by cultural context, the setting in which the individual is seen, clinician bias, client bias, and availability of resources. Unfortunately there is little solid research and no hard and fast rules that can guide this decision.
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Comorbidity Although it is best to follow the principle of parsimony, it is also important to remember that most diagnoses are not mutually exclusive.
In an individual with delusions, hallucinations, and mood symptoms a decision must be made among Schizophrenia, Schizoaffective Disorder, and Mood Disorder with Psychotic Features.
In an individual with multiple unexpected panic attacks, significant depression, and a maladaptive perfectionistic and rigid personality style the diagnoses of Major Depressive Disorder, Panic Disorder, and Obsessive Compulsive Personality Disorder may all apply.
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Comorbidity
Using multiple diagnoses is neither good nor bad so long as the implications are understood. Do not hold the mistaken view that multiple descriptive diagnoses are actually independent:

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Comorbidity
Having more than one DSMIVTR diagnosis does not mean that there is more than one underlying pathophysiological process. The diagnoses are not entities but descriptive building blocks, useful for communicating diagnostic information and guiding therapeutic choices.
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Practice
Consider the case of a 38 year old married male who is referred for evaluation after a second DUI. He readily admits that he is a regular and heavy drinker, that he has tried to stop drinking several times but without any sustained success, and that he often drinks more than he intends. He also complains of feelings of intense sadness, difficulty sleeping, weight loss, constant sense of fatigue, feelings of guilt and worthlessness, and occasional thoughts of suicide.
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Practice
This is not an atypical presentation and poses a serious differential challenge. Although this is a kind of forensic evaluation, let us assume that there is no reason to believe that the individual is not being perfectly honest about his symptoms.

Let us further assume that a recent history and physical reveals no apparent medical problem which might explain the symptoms.
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PRACTICE
The diagnostic question then is: Is this an individual whose Major Depressive Disorder is secondary to his Alcohol Dependence, or whose Alcohol Dependence is secondary to his Major Depressive Disorder, or who has both Major Depressive Disorder and Alcohol Dependence as comorbid conditions.

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Diagnostic tree Practice

Consider the case of a 28 year old, unmarried woman, who seeks help because of panic attacks. She was perfectly fine until she was in her last year of graduate studies in molecular biology and was attacked and carjacked guy in the library parking lot late one night. Her attacker forced her to dive, at knife point, to a deserted area where he raped, beat, and left her. She was so shaken by the experience that she dropped out of school without finishing her degree. She still has nightmares about the attack and takes benzodiazepines, off and on, to help her sleep. She eventually got a job as a technician in a medical lab and was doing better until the lab started running a late shift. When she works late, the thought of having to go to her car in a dark and deserted parking lot makes her feel like she is smothering. When she can convince someone to go with her to her car, she feels better. But several times she could not find anyone and her heart beat so fast and hard she was convinced she was about to die. She doesnt want to loose her job but she also doesnt want to continue to live as she has for the past several months.

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Practice
The presenting symptom is panic attacks. The diagnostic question is whether this symptom is the result of the after effects of benzodiazepine use, a developing anxiety disorder, or trauma

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