Tag Archives: Schizophrenia

Comorbidity: Substance Abuse Disorders (SUDs)


Comorbid, or comorbidity, is literally defined as “recurring together.”  (Shiel, Jr. & Stoppler, 2008, p. 94)  For our purposes, comorbidity will refer to cases where two or more psychiatric conditions coexist, and where one of the conditions is a substance abuse disorder (SUD).  “There are 11 groups of substances specifically discussed in the DSM-IV: alcohol; amphetamines and related sympathomimetics; caffeine; cannabis; cocaine; hallucinogens; inhalants; nicotine; opiates; phencyclidine and related drugs (PCP); and sedatives, hypnotics, and anxiolytics.”  (Colman, 2009, p. 741)  Any one of the above substances, or combination of the above substances, can contribute to and be related this discussion of comorbidity with SUDs.

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Although this list is by no means exhaustive, “long-term substance use is related to psychiatric conditions such as suicide and depression, affective disorders, eating disorders (ED), and personality disorders (PD).”  (Netherton, Holmes, & Walker, 1999, p. 248)  Increased risk of mood disorders has been documented across all substance categories and across all mood related diagnoses.  (Blaney & Millon, 2009, p. 287)  Substance-Related Disorders are commonly comorbid with many mental disorders, including Conduct Disorder in adolescents; Antisocial and Borderline Personality Disorders, Schizophrenia, Bipolar Disorder.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 204)   Schneier et al. (2010) also concluded that alcohol use disorders and social anxiety disorder (SAD) is a prevalent dual diagnosis, associated with substantial rates of additional co-morbidity.

ADHD represents a risk factor for substance abuse.  ADHD patients with a high degree of nicotine consumption may be consuming large quantities as a form of self-medication.  Nicotine and alcohol, when combined, pose a markedly greater risk for the development of other addictions.  (Ohlmeier et al., 2007, p. 542)  There is “high comorbidity between heavy drinking and heavy smoking.”  (Blaney & Millon, 2009, p. 266)  These admissions seem to support the premise that alcohol and nicotine continue to serve as “gateway drugs” for people whom suffer from ADHD.

“In terms of clinical presentation, a concurrent Personality Disorder (PD) diagnosis is associated with an earlier age of onset of alcohol-related problems, increased addiction severity, more secondary drug use, more psychological distress, and greater impairment in social functioning.  As for course in addiction treatment, a concurrent PD diagnosis has been associated with premature discontinuation of treatment, earlier relapse, poorer treatment response, and worse long-term outcome.”  (Zikos, Gill, & Charney, 2010, p. 66)  Cluster B (Antisocial, Borderline, Histrionic, and Narcissistic) Personality Disorders (PDs) appear to be particularly prevalent, perhaps because the link between substance dependency and antisocial behavior can be found genetically.  (Blaney & Millon, 2009, p. 263)

“Among individuals with schizophrenia, between 40% and 50% also meet criteria for one or more substance use disorders.”  (Blaney & Millon, 2009, p. 288)  Comorbid substance use complicates adherence to sometimes complex schizophrenia treatment regimens.  Poor adherence to treatment results in worsening of schizophrenia symptoms, relapse, worsening of overall condition, increased utilization of health care facilities, re-hospitalization, reduced quality of life, social alienation, increased substance abuse, unemployment, violence, high rates of victimization, incarceration, and death.  (Hardeman, Harding, & Narasimhan, 2010, p. 405-406)  The compounding effect of substance abuse on the quality of life for individuals with schizophrenia can’t be understated.  Substance abuse is particularly common and also worsens the course of schizophrenia.  (Buckley, Miller, Lehrer, & Castle, 2009, p. 396)

Differential diagnosis and treatment can sometimes be a troublesome proposition.  Comorbidity complicates the diagnosis, treatment, and clinical course of Substance Abuse Disorders (SUDs).  (Blaney & Millon, 2009, p. 287)  “If symptoms precede the onset of substance use or persist during extended periods of abstinence from the substance, it is likely that the symptoms are not substance induced.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 210)  Carbaugh and Sias (2010) concluded that successful outcomes can be increased through proper diagnosis and early intervention, at least in the case of comorbid Bulimia Nervosa and substance abuse.  Prevention of substance use disorders can help alleviate or decrease much impairment in psychiatric patients in particular.  (Powers, 2007, p. 357)  Furthermore, a review of treatments for patients with severe mental illness and comorbid substance use disorders concluded that mental health treatment combined with substance abuse treatment is more effective than treatment occurring alone for either disorder or occurring concurrently without articulation between treatments.  (Hoblyn, Balt, Woodard, & Brooks, 2009, p. 54)

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References

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

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Buckley, P. F., Miller, B. J., Lehrer, D. S., & Castle, D. J. (2009, Mar). Psychiatric comorbidities and schizophrenia. Schizophrenia Bulletin, 35(2), 383-402. doi: 10.1093/schbul/sbn135

Carbaugh, R. J., & Sias, S. M. (2010, Apr). Comorbidity of bulimia nervosa and substance abuse: Etiologies, treatment issues, and treatment approaches. Journal of Mental Health Counseling, 32(2), 125-138. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2026599321&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD

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

Hardeman, S. M., Harding, R. K., & Narasimhan, M. (2010, Apr). Simplifying adherence in schizophrenia. Psychiatric Services, 61(4), 405-408. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2006767471&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Hoblyn, J. C., Balt, S. L., Woodard, S. A., & Brooks, J. O. (2009, Jan). Substance use disorders as risk factors for psychiatric hospitalization in bipolar disorder. Psychiatric Services, 60(1), 50-55. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1654365811&sid=6&Fmt=3&clientId=4683&RQT=309&VName=PQD

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

Ohlmeier, M. D., Peters, K., Kordon, A., Seifert, J., Wildt, B. T., Weise, B., … Schneider, U. (2007, Aug). Nicotine and alcohol dependence in patients with comorbid attention-deficit/hyperactivity disorder (ADHD). Alcohol and Alcoholism : International Journal of the Medical Council on Alcoholism, 42(6), 539-543. doi: 10.1093/alcalc/agm069

Powers, R. A. (2007, May). Alcohol and drug abuse prevention. Psychiatric Annals, 37(5), 349-358. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1275282831&sid=5&Fmt=3&clientId=4683&RQT=309&VName=PQD

Schneier, F. R., Foose, T. E., Hasin, D. S., & Heimberg, R. G. (2010, Jun). Social anxiety disorder and alcohol use disorder co-morbidity in the National Epidemiologic Survey on Alcohol and Related Conditions. Psychological Medicine, 40(6), 977-988. doi: 10.1017/S0033291709991231

Shiel, W. C., Jr., & Stoppler, M. C. (Eds.). (2008). Webster’s new world  medical dictionary (3rd ed.). Hoboken, NJ: Wiley Publishing.

Zikos, E., Gill, K. J., & Charney, D. A. (2010, Feb). Personality disorders among alcoholic outpatients: Prevalence and course in treatment. Canadian Journal of Psychiatry, 55(2), 65-73. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1986429431&sid=1&Fmt=3&clientId=4683&RQT=309&VName=PQD

Paranoid Schizophrenia vs Delusional Disorder


Analysis of the common psychopathological features in the various psychotic disorders suggest that symptoms can be clustered into five main categories: (Os & Kapur, 2009, p. 635)

1)      Psychosis, encompassing positive symptoms of delusions and hallucinations.

2)      Alterations in drive and volition, encompassing negative symptoms including lack of motivation, reduction in spontaneous speech, and social withdrawal.

3)      Alterations in neurocognition, encompassing cognitive symptoms including difficulties in memory, attention, and executive functioning.

4)      Affective dysregulation giving rise to depressive symptoms or 5) manic (bipolar) symptoms.

The term schizophrenia is typically applied to a syndrome that is characterized by a long duration, bizarre delusions, negative symptoms, and few affective symptoms (non-affective psychosis).  (Os & Kapur, 2009)  Formerly called dementia praecox, some of its associated features include inappropriate affect, anhedonia, dysphoric mood, lack of insight, depersonalization, and delrealization.  (Colman, 2009, p. 674)  Schizophrenia affects approximately 0.7% of the world’s population, with prevalence greater in men throughout adulthood, but equal by the end of the risk period.  Schizophrenia is highly heritable, with onset being rare before adolescence or after middle age (although men become ill earlier in life than women).  (MacDonald & Schulz, 2009, p. 495)  Schizophrenia subtypes include paranoid, disorganized, catatonic, undifferentiated, and residual types.  This article will focus on paranoid schizophrenia, which tends to be the least severe subtype of schizophrenia.

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“The essential feature of the Paranoid Type of Schizophrenia is the presence of prominent delusions or auditory hallucinations” where no disorganized speech, disorganized or catatonic behaviors, or flat or inappropriate affect is present.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 313)  Differential diagnosis is an exclusionary process since of all the other subtypes must be eliminated before diagnosing the paranoid subtype.  Paranoid schizophrenia sufferers typically have delusions that are persecutory and/or grandiose; they also typically have a recurrent theme.  Hallucinations are usually related to the same content theme as the delusions, and may include the associate features of anxiety, anger, aloofness, and/or argumentativeness.  Onset tends to be later in life when compared with other subtypes of schizophrenia, and the distinguishing characteristics are often more stable over time.  The prognosis is considerably better when compared with other schizophrenia subtypes, especially regarding occupational functioning and independent living.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 314)

“The essential feature of Delusional Disorder is the presence of one or more non-bizarre delusions that persist for at least 1 month.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 323)  Bizarreness is mostly subjective since it is contingent on socio-cultural norms and expectations.  Bizarre delusions (as in schizophrenia) are “clearly implausible, not understandable, and not derived from ordinary life experiences.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 324)  In contrast, non-bizarre delusions (as in delusional disorder) involve situations that could conceivably happen in real life… like being followed, poisoned, etc.  Subtypes of delusional disorder are categorized based on the content of the delusions or the theme thereof.  They include erotomanic, grandiose, jealous, persecutory, somatic, mixed, and unspecified types.  This essay will focus on persecutory delusions, although persecutory delusions often coexist with and are comorbid with other delusion types (particularly grandiose, in mixed presentation).

A determination of persecutory delusions is complicated by the fact that the incidence of persecutory thoughts is relatively common among the general population.  (Brown, 2008, p. 165)  “The criteria used to distinguish between these different categories of psychotic disorder are based on duration, dysfunction, associated substance use, bizarreness of delusions, and presence of depression or mania.”  (Os & Kapur, 2009, p. 635)  In delusional disorders, distortions of reality coexist with realms of rational, realistic thinking.  (Blaney & Millon, 2009, p. 361)  Delusional disorders are distinguished from schizophrenia by the absence of active phase symptoms of schizophrenia (e.g. prominent auditory or visual hallucinations, bizarre delusions, disorganized speech, grossly disorganized or catatonic behavior, and/or negative symptoms).  “Compared with schizophrenia, delusional disorder usually produces less impairment in occupational and social functioning.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 327)

“The assessment of bizarreness is generally absent among lists of delusion dimensions, notwithstanding its key role in the distinction between DD and PS.”  (Blaney & Millon, 2009, p. 365)  To improve decision-making and reduce the chance of misdiagnosis, Brown (2008) suggests we ascertain, to the extent available, base rates of the specific persecutory beliefs (e.g. discrimination and harassment, mental illness stigma, criminal victimization, relationship infidelities, conspiracies, stalking, surveillance, poisoning, etc) in our area.  Secondly, he suggests we consider alternative hypotheses, especially in decisions that have a very low base rate.  While actively searching for disconfirming information, we should postpone decisions until further information is collected.  I agree with his suggestion that we should rely more on information, and less on intuition, when it comes to confirming or disconfirming persecutory beliefs.  (Brown, 2008, p. 172)

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References

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

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Brown, S. A. (2008). The reality of persecutory beliefs: Base rate information for clinicians. Ethical Human Psychology and Psychiatry, 10(3), 163-179. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1646112241&sid=7&Fmt=3&clientId=4683&RQT=309&VName=PQD

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

MacDonald, A. W., & Schulz, S. C. (2009, May ). What we know: Findings that every theory of schizophrenia should explain. Schizophrenia Bulletin, 35(3), 493-508. doi: 10.1093/schbul/sbp017

Os, J. V., & Kapur, S. (2009, Aug 22-Aug 28). Schizophrenia. The Lancet, 374(9690), 635-645. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1843730411&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Schizophrenia, Downward Social Drift, and Interpersonal Adjustment


Everyday social encounters present people with schizophrenia a considerable amount of difficulty.  They show significant impairment in both “instrumental relationships” and social-emotional relationships.  This impairment is demonstrated by “downward social drift” and, perhaps more importantly, the fact that the majority of people with schizophrenia never marry.  Of note is that interpersonal adjustment issues are much more prevalent in the male portion of the schizophrenia population that in the female portion.

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Social competence is a global or “macro” measurement of social role performance.  Global social competence issues continue to be a marker not only for people who have schizophrenia, but for people who are considered “high risk.”  I still don’t quite understand the etiology of these social deficits however… which came first, the social deficits or the disorder?

Social skills are less global and more molecular, thereby representing skills that enable a person to competently perform a social task.  They include “specific verbal, non-verbal and paralinguistic (e.g., voice tone) behavioral components that together form the basis for effective communication.”  (Blaney & Millon, 2009, p. 335)  To my own personal delight, I really enjoy any opportunity to utilize role-play… and this is one of them.  Typically, people with schizophrenia will show weaker verbal and nonverbal skill development, they tend to be less assertive, and they tend to deny making errors or lie as opposed to apologize or explain.  I am really looking forward to utilizing role-play with this population, I believe it to be one of my strong suits (and one of the pieces I really enjoy).

People with schizophrenia can have remarkably impaired ability to solve social problems.  This might manifest in difficulty recognizing interpersonal problems, formulating solutions to that problem, or perhaps most importantly implementing a solution that has a probably degree of success.  They are generally less able to recognize poor problem solutions (e.g., solutions that are unlikely to work).

Gender is an often neglected variable when studying schizophrenia.  Female patients typically have later onset, shorter and less frequent psychotic episodes, and show better response to treatment when compared to make counterparts.  They are more likely to be marked, to live independently, and to be employed (despite having similar symptoms to men).  Women often require less antipsychotic medication to stabilize them.  This leads some authors to speculate about the neuroprotective properties of estrogen… interesting concept to say the least.  This might be off-base, but could this possibly explain the late life crisis that women often experience around menopause?

Positive and negative symptoms should not be viewed in the context of “good and bad.”  Positive symptoms are “added,” like delusions or hallucinations for example.  Negative symptoms are typically features that are removed, reduced, or blunted.  This typically manifests as emotional withdrawal or anhedonia.  Negative effects have been shown to predict both unemployment and reduced social network size.  In total, positive symptoms, negative symptoms, and “disorders of relating” represent three distinct dimensions of schizophrenia.  (Blaney & Millon, 2009, p. 340)

Of particular interest to me is the discussion on interpersonal stress, relapse, and the apparent foundation of the above in family systems theory.  Specifically, “the social environment into which schizophrenia patients were discharged after they left the hospital was significantly associated with how well patients fared psychiatrically over the next several months.”  (Blaney & Millon, 2009, p. 349)  Expressed emotion (EE) reflects the extent to which the relatives of a psychiatric patient talk about that patient in a critical, hostile, or emotionally over-involved way.  EE has been found to be a reliable predictor of relapse, and as a result, family therapy focused on dealing with living with a schizophrenic patient is definitely in order.  This can assist family members in overcoming their apparent difficulty in accepting, and understanding, the disorder.

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Reference

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Schizophrenia Information Grab-bag


“Schizophrenia is the most crippling of the psychiatric disorders.”  (Blaney & Millon, 2009, p. 298)  That’s a bold first statement.  I was curious as to the reason why typical onset times are younger (sooner) for males as compared to females.  The developmental perception I am accustomed to generally indicate that females “grow up” sooner than males… I am the slightest bit curious what could cause this phenomenon to flip-flop.  Any insight there readers?

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Although I was alive during the 1980’s, I was so young that I was wholly unaware of the de-institutionalization that took place during that era.  The statement that prisons have become the de factor health care provider reaffirms my belief that working with that population is absolutely critical to our success as a society.

Typical schizophrenia characteristics include hallucinations, delusions, disorganized speech, grossly disorganized or catatonic behavior, and/or negative affective symptoms.  The text states that the most common types of hallucination consist of hearing voices, one or several, typically making commentaries about the individual or conversing with each other.  One word… WOW.  Persecutory, grandiose, or somatic delusions are most common.  The first person accounts depict individuals who are very disturbed to say the least.  In particular, an individual who believed that they were controlled by someone (the “controller”) and the persistent belief that other people have external controllers was beyond comprehension.

Regarding the etiology of the disorder, it is increasingly evident that there is some kind of genetic link involved in schizophrenia.  The diathesis-stress theory of illness is the predominant theory, suggesting that a predisposition may not be sufficient in itself to cause schizophrenia, but probably requires some kind of “trigger” such as exposure to prenatal insults.  (Blaney & Millon, 2009, p. 302)

This is my first exposure to “genotype” and “phenotype.”  Genotype represents the underlying genetic constitution of the individual (genetic predisposition?).  Phenotype refers to the observable traits, characteristics, or behaviors of an individual.  It is entirely possible to have a genotype that suggests a predisposition to a disorder like schizophrenia, but the disorder will not be expressed behaviorally by the phenotype.  “In other words, what the individual inherits is a liability or predisposition for developing the disease, not the disease itself.”  (Blaney & Millon, 2009, p. 305)

With regard to prenatal and perinatal insult, the critical period of exposure appears to be the 2nd trimester (4th-6th month of pregnancy).  Examples might include toxemia, preeclampsia, or labor delivery complications.  Fetal hypoxia (oxygen deprivation) was strongly linked with later schizophrenia.  Prenatal stress, inclining losing a spouse or being exposed to a military invasion, has been implicated in the predisposition of schizophrenia.  Maternal viral infection, including influenza, was also implicated.  Unlike influenza studies, increased risk for offspring exposed to prenatal nutritional deficiencies was primarily attributed to growth and development during the 1st trimester, not the second.

Cognitive impairments are considered to be central, or primary, in schizophrenia.  Typically, they predate the more typical outward signs of the illness (hallucinations, delusions, etc.).  The cognitive impairments can occur in the absence of the other clinical symptoms.  “It is estimated that 90% of patients have clinically meaningful deficits in at least one cognitive domain and that 75% have deficits in at least two.”  (Blaney & Millon, 2009, p. 309)

Neurocognitive assessment is used in contemporary practices to quantify the severity of impairment in clinically relevant domains of cognitive functioning.  Relevant domains are speed of processing, attention/vigilance, working memory, verbal learning, visual learning, reasoning and problem solving, and social cognition.  Typically, a patient with schizophrenia will struggle with verbal learning and vigilance, and have lesser impairments in visual organization and vocabulary.

A neuro-developmental view of schizophrenia is the foundation of high-risk research.  “The majority of individuals who succumb to schizophrenia and other psychotic disorders manifest prodromal signs of behavioral disturbance” in adolescence, and they get progressively worse as they approach young adulthood.  (Blaney & Millon, 2009, p. 321)  The prodromal period represents a clinically significant opportunity for intervention, with high potential to shed light on the etiological origins of schizophrenia.

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Reference

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

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.