Tag Archives: Diagnosis

Can Symptoms Be False?


Having a person come into a clinician’s office and presenting with symptoms of one or more disorders can be a tricky process for the clinician to try to diagnose, even without the presence of factitious symptoms.  The presence of factitious symptoms can make the diagnosis very complicated because the clinician would need to have the patient go through their history, which would be a normal step, but then if the clinician suspects any kind of factitious disorder, generally a more thorough history would be required.  Because the person feels a need to continue to be sick they would be complaining of the same symptoms over and over again, or possibly complaining of the symptoms getting worse.  The problem would be that there isn’t anything real to back it up.  A misdiagnosis would come into play, probably several times. It could be possible that factitious disorders are responsible for the averages given when it comes to the length of time it takes to diagnose.

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People who suffer from factitious disorder don’t have an ulterior motive, people who malinger do.  Malingering is when someone gives factitious symptoms in order to gain something.  Malingering generally causes a person to choose not to follow a Doctor’s reference for psychiatric care.  In rare cases when someone who is malingering does choose to seek psychiatric help, the sessions don’t offer any kind of help to further the person’s treatment.  There are various things that motivate a person to malinger.  These could include trying to gain material items such as a car or jewelry or to win a lawsuit for monetary value.  It could also be something as simple as to gain someone’s attention.

Between having patients come in with factitious symptoms either controlled or uncontrolled and people who are malingering, it is easy to see how a clinician would need to be extremely cautious when it comes to giving a diagnosis.

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References: Malingering. Psychnet-uk.com.;  The Unexplained. Bellevue.edu

Major Depression Disorder (MDD)


There are some significant differences between diagnosing a child with MDD and diagnosing an adult.  First and foremost, symptom duration must be at least 1 year (as opposed to 2 for adults).  Secondly, the presentation is likely to be different… with children exhibiting somatic complaints, irritability, and social withdrawal much more often their adult counterparts.  In both cases, one symptom must be depressed or irritable mood and/or inability to experience pleasurable emotions from normally pleasurable life events such as eating or social interaction (anhedonia).

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The likelihood that comorbid conditions will appear increases with the severity of the depression.  (Netherton, Holmes, & Walker, 1999, p. 266)  Often MDD is comorbid with anxiety disorders, ADHD, behavior disorders, eating disorders, and/or substance abuse.  There does appear to be a distinct lack of a “developmental perspective” in the DSM-IV-TR, but that is not exclusive to this particular category or disorder…  I suspect that’s just an effort to remain “atheoretical.”

I am not at all surprised that rates of depressive disorders increase with age, since frequency, duration, and severity of previous episodes seem to be an indicator of risk.  Also, for lack of a better explanation, the longer you live, the more likely you are to have to endure a negative life event.  I was surprised to see that by age 15, females are twice as likely as males to receive a depressive disorder diagnosis.

Theoretically speaking, I came to favor the interpersonal/cognitive/behavioral models of development for depression.  There was a continued lack of a developmental model, however, for all the theories.  On the whole, I got the impression that we were really selling the childhood cohort short due to lack of research (or, perhaps that’s just the Netherton text working, not sure which… will definitely check this out when I get knee deep into the journal reading).

Attachment theory rears its ugly head again, condemning insecure parental attachment as being significant in the etiology of depression related cognitive processes.  (Netherton et al., 1999, p. 269)  The text suggests that this leads to a more depressive perspective on self, world, and future… culminating in a sense of helplessness and hopelessness.  It would appear that depression is a possible marker for RAD?  I would like to see some comorbity rates.

I understand that self assessment has to be a key component for assessment, but I wouldn’t bet the house on those results alone.  I really like the idea of a multi-trait, multi-method, multi-informant approach to increase diagnostic reliability and validity.  I really believe that you need to take a big picture approach to the complete child, accessing cognitive, affective, interpersonal, adaptive, genetic, and environmental effects to be able to diagnose this disorder effectively.  In addition to a full batter of testing and semi-structured interviews, if able we should dig into a medical history and eliminate underlying organic causes… paying special attention to drug history since many anticonvulsants and some antibiotics are associated with depressive symptoms.

Although I will give treatment only cursory coverage, at this early stage I am very much in favor of cognitive restructuring and development of more adaptive cognitions.  Although the text didn’t really address it, I would also take a “top down” approach and see if I couldn’t convert this to a family intervention.  I am increasingly aware that families are systems and that children tend to play a specific role in that system.

Depression is one area where I am a proponent of pharmacological intervention, despite the fact that I have come out against the pharmacological means to the end on some other diagnosis.  It would appear to me that SSRI’s were made specifically for depression, success rates are relatively high, and side effects are minimal.  I’m not sure I could consider TCAs and MAOIs unless SSRI+CBT failed.  ECT is our last resort… but the degree of impairment would have to be pretty serious for me to suggest it.

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Reference

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Response to: Growing up bipolar: ‘Nobody was on my side’ (CNN)


CNN published an insightful piece on Bipolar Disorder today (see link below) that hit a few significant points that have been under expressed here of late…  I have to credit the author (Elizabeth Landau) because she acknowledged that the spike in bipolar disorder diagnosis rates could be attributed to our collective focus on the disorder.

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I would also like to demonstrate support for the ‘mind over meds’ concept that is purveyed when the author suggests “as a first line of defense, family support and therapy would be given to the child and problematic environments — be it home or school — would be improved, and then medication would be given as needed.”  Medication should be a last resort, especially when it comes to psychotropic drugs.  It is widely acknowledged that there is no psychotropic drug that comes without significant potential for side effects.  Regardless of our theoretical perspective… Cognitive Behavioral – Dialectical Behavioral – Gestalt – Group – Psychoanalytic – Talk… or the other variations of therapy… I would submit that the best case scenario for medication is as an adjunct treatment… adjunct to traditional therapy services.  What’s not to like about no side effects?

Last, but certainly not lest, CNN provides another voice to the growing crowd of providers who are frustrated by a general lack of access when it comes to individuals without insurance.  All men are created equal. Those five words used to mean something.  Unfortunately, those of us who are wading through the fragmented mess we call a mental health system in the United States know… it’s exactly what the author of the article purports it to be…

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Link to the original article:

http://www.cnn.com/2010/HEALTH/08/30/bipolar.kids/index.html?hpt=C2

Roles of Cross Cultural Influences in Diagnosis


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Before we can begin exploring deviations from the norm as it relates to a specific culture, it is extremely important that we define exactly what is meant by the word culture.  Culture is defined as the customary beliefs, social forms, and material traits of a racial, religious, or social group.  It could also be defined as the set of shared attitudes, values, goals, and practices that characterizes an institution or organization. (culture, 2010)

As with any definition, it comes with limitations.    Given the changing nature of our social world and given the efforts of individuals to adapt to such changes, culture can best be viewed as an ongoing process, a system or set of systems in flux. (Lopez & Guarnaccia, 2000, p. 574)  Constant change is the rule with and within any given subset or group of people.  Any generalization regarding a population should come with a specific guideline as to whom it would apply, and more specifically, over what period of time the cultural generalization encompasses.   Attempts to freeze culture into a set of generalized value orientations or behaviors will continually misrepresent what culture is. (Lopez & Guarnaccia, 2000, p. 574)  While the representation may prove valid for a period of time, it is inevitable that the research will date itself; thereby propagating the perpetual need for new and innovative research.

A related limitation of the values-based definition of culture is that it depicts people as recipients of culture from a generalized “society” with little recognition of the individual’s role in negotiating their cultural worlds.  A viable definition of culture acknowledges the agency of individuals in establishing their social worlds. (Lopez & Guarnaccia, 2000, p. 574)  Simply because I am a white male from Omaha doesn’t necessarily mean that I have assumed all the traits that could be used to label or otherwise describe that general population.  Exceptions are abundant in every generalization about a specific populace.

An important component of this perspective is the examination of intra-cultural diversity.  In particular, social class, poverty, and gender continue to affect different levels of mental health both within and across cultural groups. (Lopez & Guarnaccia, 2000, p. 575)  In order to be truly inclusive of all the various aspects a culture has to offer, we would have to adopt a multi-layered approach to our cultural studies.  We all wear many hats, and it is a disservice to not examine all of them.  Similarly, it is unfair to assume that those intra-cultural differences affect different cultural populations the same.

Culture is linked to the way emotions, mental distress, social problems, and physical illness are perceived, experienced, and expressed.  Beliefs about what constitutes illness and what can be done about it vary considerably across cultures.  (Bhui & Dinos, 2008, p. 411)  We have established that in some cases a diagnosis has the potential to become a self-fulfilling prophecy.  Even a correct diagnosis may have a negative impact on a specific client.  The cultural connotations associated with a specific diagnosis can play a role in the effect it has on your individual client.  Before we diagnose, need to consider the socio-cultural context of the illness.  For example, a mental health diagnosis may have real implications for a member of the US Armed Forces.

As immigration into the United States continues to accelerate, we must ready ourselves for the influx of clients from the underdeveloped, or the developing world.  Mental health diagnostic constructs and subsequent treatment practices designed in developed countries are often used in the provision of care in the developing world and in care practices for ethnic minorities, asylum seekers, and refugees.  However, there are concerns about the limitations of using mono-cultural outcome measures in these culturally diverse contexts. (Bhui & Dinos, 2008, p. 411)  Our interview process is currently dependant on interviewing and subsequently interpreting the responses from our clients.  Given the complexities of our global community, it is suitably difficult to make underlying cultural assumptions.

In closing, while there are definitive benefits to the standardization of diagnosis techniques, we need to understand and appreciate that those standard one size fits all solutions may not always been the most appropriate way to proceed with accessing the mental state of a culturally diverse client.

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References

Bhui, K., & Dinos, S. (2008, Dec). Health beliefs and culture: Essential considerations for outcome measurement. Disease Management & Health Outcomes, 16(6), 411-419. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=36400847&site=ehost-live

Lopez, S. R., & Guarnaccia, P. J. (2000). Cultural psychopathology: Uncovering the social world of mental illness. Annual Review of Psychology, 51(1), 571-598. Retrieved from http://web.ebscohost.com.ezproxy.bellevue.edu/ehost/pdf?vid=6&hid=113&sid=f275d2f9-b3c8-458b-9968-29981a5cf4c1@sessionmgr114

culture. (2010). In Merriam-Webster Online Dictionary.  Retrieved March 16, 2010, from http://www.merriam-webster.com/dictionary/culture

Ooops! …on the potential for malpractice when serving diverse populations.


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If there is anything that keeps a therapist up at night, it’s the potential for a malpractice suit… misdiagnosis, diagnostic errors, and/or delayed diagnosis are at the forefront of our concerns.  “What if I get it wrong?”

Braun & Cox (2005) suggest some measures that can be implemented to reduce likelihood of getting into this legal or ethical dilemma.  Informed consent can help clients understand benefits, and allow the clinician to properly set expectations around the services that are covered… especially with regard to termination since additional sessions are likely to be expensive in some cases.  Furthermore, clients need to be aware that counselors can no longer ensure privacy of disclosure because managed care organizations (MCOs) may require sensitive information.  The release of this information may precipitate changes in treatment and outcome due to the fact that MCOs typically determine the type of treatment that should be employed and/or would be covered.  We would also need to familiarize ourselves with “brief therapy models” in order to be competent at providing services through MCOs.  (Braun & Cox, 2005, p. 426)  If we intend to work with this specific client population we need to be well versed in all of the above considerations before we even consider taking a client that intends to utilize them as a 3rd party payer.

Although I do not consider it to be a personal deficit, historically, there is a general mistrust and underutilization of the medical and mental health communities as it relates specifically to people of color.  Adequately addressing this climate of mistrust demands that we engage in an “honest and thorough self-examination of conscious and unconscious attitudes about race and the legacy of racism in the United States.”  (Suite, La Bril, Primm, & Harrison-Ross, 2007, p. 883)  Furthermore, Suite and associates (2007) suggest we “keep at arm’s length assumptions of cultural homogeneity and offer contextually based mental healthcare.”  They define contextually based mental healthcare as “extensive and critical interpretation of the historical, cultural, spiritual, political, social and philosophical underpinnings of racism in medicine and draw connections on how these factors impact the self-identities of communities and individuals therein.”  In my opinion, it is absolutely imperative that we attempt to understand how individual people of color perceive mental healthcare as an institution, as well as rebuild trust in the institution as a whole by delivering culturally sensitive options at every step of the therapeutic process.

References

Braun, S. A., & Cox, J. A. (2005, Fall). Managed mental health care: Intentional misdiagnosis of mental disorders. Journal of Counseling and Development : JCD, 83(4), 425-433. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=916199881&sid=10&Fmt=3&clientId=4683&RQT=309&VName=PQD

Suite, D. H., La Bril, R., Primm, A., & Harrison-Ross, P. (2007, Aug). Beyond misdiagnosis, misunderstanding and mistrust: Relevance of the historical perspective in the medical and mental health treatment of people of color. Journal of the National Medical Association, 99(8), 879-885. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1319356711&sid=10&Fmt=3&clientId=4683&RQT=309&VName=PQD

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