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COPING DURING COVID-19 GENERAL PSYCHIATRY GENERAL PSYCHIATRY

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Six Steps to Better DSM-5

Di erential Diagnosis Stay in the Know
Psychiatry and Behavioral Health
Learning Network
September 20, 2014

ORLANDO—Patients often come for treatment with the presenting symptom

of depression, but the path from symptom to diagnosis is not as SUBSCRIBE
straightforward as it may appear. Many DSM disorders could explain the
symptom of depression.

“Your job as a clinician is to figure out what is the right [disorder] so that you
can start the right treatment,” said Michael B. First, MD, Professor of Clinical POPULAR ARTICLES
Psychiatry at Columbia University, New York in his presentation at the 27th
Annual U.S. Psychiatric and Mental Health Congress. Quiz: World Mental Health Day 2020

“Most patients do not come into our o ices saying ‘I have major depressive
Remembering Dr. Lorna Breen on
disorder, give me duloxetine,’” said Dr. First, who is the author of DSM-5
National Physician Suicide Awareness
Handbook of Di erential Diagnosis. “[Di erential diagnosis] is the bread and
Day
butter of our task as clinicians.”

Patients come into the o ice seeking relief from broad symptoms such as Depression Rate in US Adults Tripled
depressed mood or fatigue, and clinicians must consider which of all the During Pandemic
disorders in DSM could account for those symptoms.

Step 1: Rule Out Malingering and Factitious Disorder Endocrine-Disrupting Chemical Exposure
in Teens Associated With ADHD-Like
Dr. First breaks the diagnostic process into six steps, starting with ruling out
Behaviors
malingering or factitious disorder. This is essential because “our work depends
on good faith collaborative e ort between clinician and patients,” he said. “If
the patient is not being honest with report of symptoms, it is impossible to
make an accurate diagnosis based on symptoms.”

Malingering disorder di ers from factitious disorder based on motivation.

Malingering is driven by achievement of clearly recognizable goals, such as
insurance compensation or avoiding responsibilities, and is not a mental
disorder, while factitious disorder occurs in the absence of obvious external
award. A person with factitious disorder wishes to take on the role of sickness
for psychological reasons.

However, Dr. First cautions against treating patients like a hostile witness in a
courtroom. Suspicion of these disorders should only be raised in certain
settings and situations.

Step 2: Rule Out Substance Etiology

CONTINUING EDUCATION
Next, clinicians should consider whether the patient’s’ symptoms might be due
to substance abuse. “Virtually any psychiatric presentation can be caused
substance use,” said Dr. First.
Insomnia in Psychiatric Patient
To make this determination, clinicians can interview the patients, check with Populations: Updates and Considerations
the patient’s family members, look for signs of substance use such as active for Comprehensive Care
intoxication, and order laboratory tests that screen for recent use. Medication
side e ects should also be considered, Dr. First noted.

If signs of substance abuse are evident, the etiological relationship between Tackling the Great Challenge of
substance and psychiatric symptoms must be considered. Psychiatric Medication Adherence in Schizophrenia
symptoms might result from the direct e ect of the substance on the CNS,
substance use could be a consequence or feature of a primary psychiatric
disorder, or substance use and psychiatric symptoms might be completely
independent and truly comorbid.

“Even if independent, it’s well known that psychiatric symptoms and

substances can make each other worse,” said Dr. First.

Step 3: Rule Out Disorder Due to a General Medical Condition

Clinicians should consider direct medical examination for conditions that

commonly account for psychiatric symptoms, such as depression resulting
from thyroid dysfunction.

“The treatment implications here are potentially profound,” said Dr. First.

If a general medical condition (GMC) may be responsible for psychiatric

symptoms, clinicians encounter several possible etiological relationships.
Medication may be responsible for psychiatric symptoms, the psychiatric
symptoms might cause or adversely a ect the GMC, or the symptoms and
GMC may be coincidental.

In addition, the GMC might cause mental health symptoms through a direct
physiological e ect on the brain, such as through having a stroke, or through a
psychological mechanism, commonly seen when patients experience
depressive symptoms in response to cancer diagnosis. In the case of
depression caused by cancer diagnosis, the patients would be diagnosed with
major depressive disorder or adjustment disorder.

For clues to determining whether a GMC is a factor, clinicians can assess

temporal relationship, such as if the psychiatric symptoms began following the
onset of the GMC, if they vary in severity with the severity of the GMC, and if
they remit when the GMC resolves.

An atypical symptom pattern, age of onset, or course also may warrant a

medical workup. For example, first onset of manic episode in an elderly patient
“is a huge red flag,” said Dr. First, as is a person who has a mild depression
accompanied by severe memory or weight loss.

Step 4: Determining the Specific Primary Disorder

At this point in the process, the clinician should pinpoint the specific primary
disorder.

“Many diagnostic groupings in DSM-5 are organized around common

presenting symptoms,” explained Dr. First. He added that decision trees in his
book can provide guidance on choosing among the primary disorders and that
di erential diagnosis table can help ensure other likely candidates explaining
the patient’s behavior have been considered and ruled out.

Step 5: Di erentiate Adjustment Disorders From Residual Other or

Unspecified Categories

If patients present with subthreshold symptoms that are still severe enough to
cause clinically significant distress or impairment, clinicians need to think
about using Adjustment Disorder versus using Other Specified/Unspecified
Disorder.

“If symptoms are a maladaptive response to a psychosocial stressor, then use

Adjustment Disorder,” said Dr. First. “Otherwise, we give the appropriate
residual category.”

For example, a clinician might use Other Specified to give the reason for not
meeting criteria or use Unspecified to choose to withhold indication of the
reason or if the reason is unknown.

Step 6: Establish Boundary With No Mental Disorder

Finally, clinicians should evaluate whether the patient’s symptoms cause

clinically significant distress or impairment in social, occupational, or other
important areas of functioning.

“This begs the question of what it means to be clinically significant. And that’s
a judgment call. Usually if someone comes to you for help that’s a sign it could
be clinically significant, or the problem could have been picked up in a primary
care setting,” said Dr. First.

He added that the symptoms also must represent an internal biological or

psychological dysfunction in the patient. For example, a patient mourning the
loss of a close family member may experience uncomplicated bereavement,
which causes a great deal of distress but would not qualify as a mental
disorder because the distress is not a psychological dysfunction.

—Lauren LeBano

Reference

1. First MB. [Psych Congress conference presentation]. September 19, 2014.

DSM-5: a practical overview of changes.

Topics
► General Psychiatry

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