Tag Archives: Differential Diagnosis

State of the Mental Health Union


Abstract

 

The first ever surgeon general’s report on the “state of the union” in mental health was issued in 1999.  David Satcher, then the reigning surgeon general, emphasized the importance of adopting a national mental health agenda that acknowledges the effect that mental illness has on public health.  He encouraged the general population to acknowledge that that mental illness is both disabling to the individual and costly to the public health system as a whole.  He advocated for increased use of differential diagnosis by emphasizing the concept that both mental health and mental illness are “points on a continuum.”  David Satcher charged us as a profession with reducing and eliminating the stigma associated with mental illness.  He also highlighted the importance of a solid research base to evaluate the practicality and effectiveness of new approaches and overall accountability to the individuals for whom the interventions are intended.  Satcher’s submission represents a blueprint for change.  It’s been 10 years since this comprehensive report. This essay will attempt to access the following question: “How have we done?”

 

State of the Mental Health Union

 

The first ever surgeon general’s report on the “state of the union” in mental health was issued in 1999.  David Satcher, (now former) Surgeon General of the United States, emphasized the importance of adopting a public health perspective, accepting that mental disorders are disabling, and seeing both mental health and mental illness as points on a continuum.  (U.S. Department of Health and Human Services, 1999)  He highlighted overarching themes of reducing and eliminating the stigma associated with mental illness, the importance of a solid research base to evaluate the practicality and effectiveness of new approaches, and overall accountability to the individuals for whom and intervention is intended.  (Satcher, 2000)  Satcher’s submission represents a blueprint for change.  It’s been 10 years since this comprehensive report. This essay will attempt to access the following question: “How have we done?”

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The foundation of Satcher’s public health perspective was rooted in the concept of preventive interventions.  Since 1999 we have made significant progress in developing family-focused preventative interventions (Redmond, Spoth, Shin, & Lepper, 1999) including mother and mother-child programs for children of divorce (Wolchik et al., 2000).  We have adopted an early intervention strategy and attempted to focus our preventative efforts on the individuals who have the most to gain/lose, children.  Preventative efforts focused on coping with anger and stress, family bereavement, bullying, early conduct disorder, social relations, stress inoculation, and suicide prevention are yielding significant results among school-aged children.  (Greenberg, Domitrovich, & Bumbarger, 2001; Shaw, Dishion, Supplee, Gardner, & Arnds, 2006; Weissberg, Kumpfer, & Seligman, 2003)  The underlying theory of many, if not most, of these research efforts is that “prevention programs enhance children’s socio-emotional competence and prevent the emergence of behavior problems.”  (Webster-Stratton, 2003)

Although research suggests that there are correlates of life satisfaction in those with disabling conditions, much of the work has been focused on physical disabilities as opposed to mental illness.  (Mehnert, Krauss, Nadler, & Boyd, 1990; Schröder et al., 2007)  More work remains to be done regarding overall public awareness of exactly how debilitating mental illness can be.  This is particularly true in the cases where individuals whom are heavily medicated may be more disabled by their medication than by the mental illness itself.  (Waldman, 1999)

If we consider seeing mental health and mental illness as points on a continuum a goal, then we should consider ourselves closer to that goal then we were 10 years ago.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000)  Differential diagnosis is more prominent in the DSM-IV-TR than it was in any previous revision of the DSM, and we have every expectation that we will continue to see movement towards continuum based differential diagnosis in the upcoming DSM-V.    As a profession, we can expect that the differentiation between normal psychological functioning and pathological functioning will continue to be defined, or redefined.  (Widiger & Clark, 2000)  We can expect that diagnostic categories be removed, added, merged, linked, or otherwise cross referenced to reflect the “points on a continuum” perspective.  If I could predict the specific changes we should expect I wouldn’t be here, but I can be fairly certain that we should expect change in general.

Reducing and eliminating the stigma associated with mental illness is a tall order that is constantly in the process of fulfillment.  Despite persistent efforts, anti-stigma campaigns have not yet resulted in the desired changes in public attitudes and perceptions.  (McNulty, 2004)  “Many people who would benefit from mental health services opt not to pursue them or fail to fully participate once they have begun.  One of the reasons for this disconnect is stigma; namely, to avoid the label of mental illness and the harm it brings, people decide not to seek or fully participate in care.”  (Corrigan, 2004, p. 614)  The availability of accurate information, persistent social marketing, and direct contact with the mentally ill can effectively combat the negative stereotypes associated with individuals who suffer from mental illness.  (Kirkwood & Hudnall, 2006)  Nonetheless, there is much work to be done… it is certainly a work in progress.  Furthermore, the DSM has made an effort to reduce stigma by changing verbiage.  For example, people who suffer from alcoholism are no longer referred to as “alcoholics” in an effort to focus on the disease, not the deficiency of the individual.

Nowhere have we made more progress than in the arena of developing a solid research base.  Never before in human history have individual clinicians had access to the depth, breadth, and quality of research that we have today.  This is due, in large part, to technology and the advent of reference-able online material.  Scholars are no longer required to scour books at the library in search of support… we simply find a keyword and plug it into resources like Google, ProQuest, PsycARTICLES, WilsonWeb, ERIC or MEDLINE.  The efficient dissemination of information is critical to our success as a mental health community because it prevents duplicate research efforts.  It also provides instant access to research that can justify both diagnosis and treatment modalities.

We have also made significant progress in the form of accountability.  Federal and state regulatory authorities are constantly reviewing, revising, and reinforcing quality control practices with regard to education and credentialing of mental health professionals.  (Nelson, 2007)  Despite the fact that outcome evaluation programs are becoming more common with regard to child welfare services, they are still lacking in the field of mental health as a whole.  (Wall et al., 2005)  Informed consent is now mandatory in most states, although there is a definitive lack of consistency in terms of what that informed consent document should contain, or how clearly it should be worded.  (Walfish & Ducey, 2007)

There’s more work to be done, so the progress doesn’t stop here.  Our profession is currently being assaulted by rigorous cost control efforts in the form of managed care.  Increasingly, insurance companies are making the decision what is best for clients, not their caregivers… or, if the caregivers do weigh in on the decision, it is with the constraints of a limited number of sessions or available treatments.  Although we have made considerable progress on a number of fronts, including information dissemination, accountability efforts, reducing stigmas, and prevention… all of these avenues of progress will need continued emphasis into the 22nd century in order to have a lasting effect on the profession as a whole.

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Corrigan, P. (2004, Oct). How stigma interferes with mental health care. American Psychologist, 59(7), 614-625. doi: 10.1037/0003-066X.59.7.614

Greenberg, M. T., Domitrovich, C., & Bumbarger, B. (2001, March). The prevention of mental disorders in school-aged children: Current state of the field. Prevention & Treatment, 4(1), [np]. doi: 10.1037/1522-3736.4.1.41a

Kirkwood, A. D., & Hudnall, S. B. (2006, Oct). A social marketing approach to challenging stigma. Professional Psychology, 37(5), 472-476. doi: 10.1037/0735-7028.37.5.472

McNulty, J. P. (2004). mmentary: Mental illness, society, stigma, and research. NIMH, Schizophrenia Bulletin, 30(3), 573-575. Retrieved from http://ft.csa.com.ezproxy.bellevue.edu/ids70/resolver.php?sessid=ruib4jnm5uafkc6aefn5lthuo0&server=csaweb106v.csa.com&check=ab5542fe87c5d81a32140a205b771a50&db=psycarticles-set-c&key=SZB/30/szb_30_3_573&mode=pdf

Mehnert, T., Krauss, H. H., Nadler, R., & Boyd, M. (1990). Correlates of life satisfaction in those with disabling conditions. Rehabilitation Psychology, 35(1), 3-17. doi: 10.1037/h0079046

Nelson, P. D. (2007, Feb). Striving for competence in the assessment of competence: Psychology’s professional education and credentialing journey of public accountability. Training and Education in Professional Psychology, 1(1), 3-12. doi: 10.1037/1931-3918.1.1.3

Redmond, C., Spoth, R., Shin, C., & Lepper, H. S. (1999, Dec). Modeling long-term parent outcomes of two universal family-focused preventive interventions: One-year follow-up results. Journal of Consulting and Clinical Psychology, 67(6), 975-984. doi: 10.1037/0022-006X.67.6.975

Satcher, D. (2000, Feb). Mental health: A report of the Surgeon General–Executive summary. Professional Psychology, 31(1), 5-13. doi: 10.1037/0735-7028.31.1.5

Schröder, C., Johnston, M., Morrison, V., Teunissen, L., Notermans, N., & Van Meeteren, N. (2007, Aug). Health condition, impairment, activity limitations: Relationships with emotions and control cognitions in people with disabling conditions. Rehabilitation Psychology, 52(3), 280-289. doi: 10.1037/0090-5550.52.3.280

Shaw, D. S., Dishion, T. J., Supplee, L., Gardner, F., & Arnds, K. (2006, Feb). Randomized trial of a family-centered approach to the prevention of early conduct problems: 2-year effects of the family check-up in early childhood. Journal of Consulting and Clinical Psychology, 74(1), 1-9. doi: 10.1037/0022-006X.74.1.1

U.S. Department of Health and Human Services. (1999). Mental health: A report of the surgeon general. Retrieved from http://www.surgeongeneral.gov/library/mentalhealth/home.html

Waldman, E. (1999, Dec). Substituting needs for rights in mediation: Therapeutic or disabling?. Psychology, Public Policy, and Law, 5(4), 1103-1122. doi: 10.1037/1076-8971.5.4.1103

Walfish, S., & Ducey, B. B. (2007, April). Readability level of Health Insurance Portability and Accountability Act notices of privacy practices used by psychologists in clinical practice. Professional Psychology, 38(2), 203-207. doi: 10.1037/0735-7028.38.2.203

Wall, J. R., Busch, M., Koch, S. M., Alexander, G., Minnich, H., & Jackson-Walker, S. (2005). Accountability in child welfare services: Developing a statewide outcome evaluation program. Psychological Services, 2(1), 39-53. doi: 10.1037/1541-1559.2.1.39

Webster-Stratton, C. (2003). Aggression in young children services proven to be effective in reducing aggression. Retrieved August 8, 2010, from http://www.child-encyclopedia.com/en-ca/child-aggression/according-to-experts/webster-stratton.html

Weissberg, R. P., Kumpfer, K. L., & Seligman, M. E. (2003, June/July). Prevention that works for children and youth: An introduction. American Psychologist, 58(6-7), 425-432. doi: 10.1037/0003-066X.58.6-7.425

Widiger, T. A., & Clark, L. (2000, Nov). Toward DSM—V and the classification of psychopathology. Psychological Bulletin, 126(6), 946-963. doi: 10.1037/0033-2909.126.6.946

Wolchik, S. A., West, S. G., Sandler, I. N., Twin, J., Coatsworth, D., Lengua, L., … Griffin, W. A. (2000, Oct). An experimental evaluation of theory-based mother and mother–child programs for children of divorce. Journal of Consulting and Clinical Psychology, 68(5), 843-856. doi: 10.1037/0022-006X.68.5.84

 

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

Differential Diagnosis – Dysthymic Disorder vs. Major Depressive Disorder


The differential diagnosis of Dysthymic Disorder (DD, also known as depressive neurosis, minor depression disorder, or neurotic depression) and Major Depressive Disorder (MDD) is made difficult because they share the same symptom constellations.  The word ‘Dysthymic’ is of Greek origin, literally translating into “resembling a bad (or abnormal) spirit.”  (Colman, 2009, p. 234)  “In Major Depressive Disorder (MDD), the depressed mood must be present for most of the day, nearly every day, for a period of at least 2 weeks, whereas Dysthymic Disorder (DD) must be present for more days than not over a period of at least 2 years.”  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 374)  Thus, we can visualize DD as a chronic, yet less severe type of depression that typically persists for many years.  Clients with DD may report that they do not recall being depressed and they may lead fully functional lives… as a result, it may be exceedingly difficult to distinguish DD from the client’s usual functioning or personality type.  The bottom line is that the onset, persistence, and severity of depression episodes are not easily evaluated retrospectively.

The DSM-IV-TR, the diagnostic tool of choice for clinicians, sums up differential diagnosis best.  “If the initial onset of chronic depressive symptoms is of sufficient severity and number to meet the full criteria for a Major Depressive Episode, the diagnosis would be Major Depressive Disorder, Chronic (if the full criteria are still met, or Major Depressive Disorder, In Partial Remission (if the full criteria are no longer met).  The diagnosis of DD can be made following MDD only if the DD was established prior to the first Major Depressive Episode (i.e., no Major Depressive Episodes during the first 2 years of dysthymic symptoms), or if there has been a full remission of the MDD lasting (i.e., lasting at least 2 months) before the onset of the DD.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 379)

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This distinction is further complicated by the diagnoses of mood disorder due to a general medical condition and substance-induced mood disorders, both of which are rather self explanatory.  It is also worth noting that depressive symptoms are frequently associated with chronic Psychotic Disorders like Schizophrenia and Schizoaffective Disorder.  A separate diagnosis of DD is not made of the symptoms occur exclusively during the course of the Psychotic Disorder.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 380)

Beyond the typical differential diagnosis techniques, some have suggested that Axis II personality dimensions (PDs) can be utilized in the differential diagnosis of Axis I Depression disorders.  “Personality dimensions are on the forefront of discussions regarding how to improve diagnostic clarification, and may provide a useful way in which to understand and model the comorbidities among and between Axis I and II conditions.”  (Bagby, Quilty, & Ryder, 2008, expression Conclusions)  Not only can PDs have significant impact on the diagnosis process, but they can dramatically alter the course of treatment.  For example, Bagby and associates (2008) found that neurotic personalities respond better to pharmacotherapy when compared to psychotherapy.  Inevitably, to be effective at diagnosis and treatment, we need to consider more than just the DSM-IV-TR… we need to individualize treatment plans based on a true representation of the individual client.  That representation, in my opinion, must include the underlying PDs that compose the fabric of the human experience.

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Bagby, R. M., Quilty, L. C., & Ryder, A. C. (2008, Jan). Personality and depression. Canadian Journal of Psychiatry, 53(1), 14-26. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1426048691&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Colman, A. M. (2009). Oxford dictionary of psychology (3rd ed.). Oxford, NY: Oxford University Press.