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CIDS Clinical Interviewing and diagnostic skills interim exam 1 summary
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- Universiteit Van Amsterdam (UvA)
CIDS Clinical Interviewing and diagnostic skills interim exam 1 summary
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Clinical Interviewing and Diagnostic SkillsSummary
Week 1
Chapter 1. Differential Diagnosis Step by Step
Step 1: Rule Out Malingering and Factitious Disorder
This relies on the honesty of the patient. Malingering occurs in the case where the goal is to
obtain external rewards. Factitious Disorder contains no external gains or rewards. the clinician’s
index of suspicion should be raised
- when there are clear external incentives to the patient’s being diagnosed with a
psychiatric condition
- when the patient presents with a cluster of psychiatric symptoms that conforms more to a
lay perception of mental illness rather than to a recognized clinical entity
- when the nature of the symptoms shifts radically from one clinical encounter to another
- when the patient has a presentation that mimics that of a role model
- when the patient is characteristically manipulative or suggestible
Step 2: Rule Out Substance Etiology (Including Drugs of Abuse, Medications)
This is a crucial point not to miss out. Virtually any presentation encountered in a mental health
setting can be caused by substance use. First, determine whether the person has been under the
influence of a substance. Once substance use has been established, the next task is to determine
whether there is an etiological relationship between it and the psychiatric symptomatology. There
are three possibilities:
- the psychiatric symptoms result from the direct effects of the substance on the CNS
Determine the temporal relationship between the use of substance and symptoms. Re-evaluate
after a period of abstinence to determine whether the psychopathology is primary and not due to
substance use. In determining the likelihood that the pattern of substance/medication use can
account for the symptoms, you must also consider whether the nature, amount, and duration of
,substance/medication use are consistent with the development of the observed psychiatric
symptoms. You should also consider other factors in the presentation that suggest that the
presentation is not caused by a substance or medication.
- substance use is a consequence of having a primary psychiatric disorder
Substance use could be a form of self-medication. Patients of different disorders prefer different
types of medication (stimulants vs CNS depressants). The tricky part is that the clinician must
rely on the retrospective reporting of the patient in terms of the temporal relationships. It may be
useful to confer with informants close to the patient.
- the psychiatric symptoms and the substance use are independent
Even though the two disorders can be independent, they could cross-contaminate each other.
After deciding that a presentation is due to the direct effects of a substance or medication, you
must then determine which DSM-5 Substance-Induced Disorder best describes the presentation.
Step 3: Rule Out a Disorder Due to a General Medical Condition
It is important because many individuals with general medical conditions have resulting
psychiatric symptoms as a complication of the general medical condition and because many
individuals with psychiatric symptoms have an underlying general medical condition.
This differential diagnosis can be difficult for four reasons:
- symptoms of some psychiatric disorders and of many general medical conditions can be
identical
- sometimes the first presenting symptoms of a general medical condition are psychiatric
- the relationship between the general medical condition and the psychiatric symptoms
may be complicated
- patients are often seen in settings primarily geared for the identification and treatment of
mental disorders in which there may be a lower expectation for, and familiarity with, the
diagnosis of medical conditions
Virtually any psychiatric presentation can be caused by the direct physiological effects of a
general medical condition, and these are diagnosed in DSM-5 as one of the Mental Disorders
Due to Another Medical Condition. Once a general medical condition is established, the next
task is to determine its etiological relationship, if any, to the psychiatric symptoms. There are
five possibilities:
, - the general medical condition causes the psychiatric symptoms through a direct
physiological effect on the brain
- the general medical condition causes the psychiatric symptoms through a psychological
mechanism
- medication taken for the general medical condition causes the psychiatric symptoms, in
which case the diagnosis is a Medication-Induced Mental Disorder
- the psychiatric symptoms cause or adversely affect the general medical condition
- the psychiatric symptoms and the general medical condition are coincidental
There are two clues suggesting that psychopathology is caused by the direct physiological effect
of a general medical condition. Firstly, the nature of the temporal relationship between the
psychiatric symptoms and the general medical condition should be investigated. Sometimes the
temporal relationship is not the best informant. The second clue that a general medical condition
should be considered in the differential diagnosis is if the psychiatric presentation is atypical in
symptom pattern, age at onset, or course. Finally, if you have determined that a general medical
condition is responsible for the psychiatric symptoms, you must determine which of the DSM-5
Mental Disorders Due to Another Medical Condition best describes the presentation.
Step 4: Determine the Specific Primary Disorder(s)
Determine which group of disorders are most likely based on the symptomatology.
Step 5: Differentiate Adjustment Disorders From the Residual Other Specified or
Unspecified Disorders
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, with the choice of the
appropriate residual category depending on which DSM-5 diagnostic grouping best covers the
symptomatic presentation. DSM-5 offers two versions of residual categories: Other Specified
Disorder and Unspecified Disorder. As the names suggest, the differentiation between the two
depends on whether the clinician chooses to specify the reason that the symptomatic presentation
does not meet the criteria for any specific category in that diagnostic grouping.
Step 6: Establish the Boundary With No Mental Disorder
, This is done after consulting the decision trees and the differential diagnosis tables. 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 prevent over-diagnoses, the criteria “The disturbance causes clinically significant
distress or impairment in social, occupational, or other important areas of functioning.” exists.
There is no absolute definition of clinical significance unfortunately. This is decided by the
cultural norms, the patient and the clinicians initiative, among other factors. Mostly clinical
significance is not an issue since its logical to expect that people will consult professionals if
they feel like their problem is serious.
Differential Diagnosis and Comorbidity
Differential diagnosis is 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. Sometimes multiple decision trees must be consulted because
patients could come with a diverse range of symptoms. A naïve and mistaken view of
comorbidity might assume that a patient assigned more than one descriptive diagnosis actually
has multiple independent conditions. This is certainly not the only possible relationship. In fact,
there are six different ways in which two so-called comorbid conditions may be related to one
another:
- condition A may cause or predispose to condition B
- condition B may cause or predispose to condition A
- an underlying condition C may cause or predispose to both conditions A and B
- onditions A and B may, in fact, be part of a more complex unified syndrome that has
been artificially split in the diagnostic system
- the relationship between conditions A and B may be artifactually enhanced by
definitional overlap
- the comorbidity is the result of a chance co-occurrence that may be particularly likely for
those conditions that have high base rates
DSM-5 Psychotic Disorders
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