Psychotherapy
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DSM-5 Handbook of differential diagnosis
Chapter 1
Differential diagnosis step by step
If the patient is not being honest regarding the nature or severity of his or her symptoms, all bets are off regarding the clinician’s ability of arrive at an accurate psychiatric diagnosis.
Most psychiatric work depends on a good-faith collaborative effort between the clinician and the patient to uncover the nature and cause of the presenting symptoms.
Two conditions in DSM-5 are characterized by feigning
These two are differentiated based on the motivation for the deception.
The clinician’s index of suspicion should be raised when
It is useful for clinicians to become mindful of tendencies they might have toward being either excessively sceptical or excessively gullible.
Whether the presenting symptoms arise from a substance that is exerting a direct effect on the central nervous system.
Virtually any presentation encountered in a mental health setting can be caused by substance use.
The determination of whether psychopathology is due to substance use often can be difficult because although substance use is fairly ubiquitous and a wide variety of different symptoms can be caused by substances, the fact that substance use and psychopathology occur together does not necessarily imply a cause-and-effect relationship between them.
The first task is to determine whether the person has been using a substance
This entails history taking and physical examinations for signs of substance intoxication or substance withdrawal.
It is usually wise to consult with family members and obtain laboratory analysis of body fluids to ascertain recent usage of particular substances.
Patients who use or are exposed to any of a variety of substances can and often do present with psychiatric symptoms.
Once substance use has been established, the next task is to determine whether there is an etiological relationship between it and the psychiatric symptomatology
This requires distinguishing among three possible relationships between the substance use and the psychopathology
In diagnosing a substance-induced disorder, there are three considerations in determining whether there is a causal relationship between the substance use and the psychiatric symptomatology
In some cases, the substance use can be the consequence or an associated feature (rather than cause) of psychiatric symptomatology
The substance-taking behaviour can be considered a form of self-medication for the psychiatric condition.
Individuals with particular psychiatric disorders often preferentially chose certain classes of substances.
The hallmark of a primary psychiatric disorder with secondary substance use is that the primary psychiatric disorder occurs first and/or exist at times during the person’s lifetime when he or she is not using any substance.
In other cases, both the psychiatric disorder and the substance use can be initially unrelated and relatively independent of each other
There are high prevalence rates of both psychiatric disorders and substance use disorders.
Even if initially independent, the two disorders may interact to exacerbate each other and complicate the overall treatment.
This independent relationship is essentially a diagnosis made by exclusion.
A lack of a causal relationship in either direction is more likely if there are periods when the psychiatric symptoms occur in the absence of substance use and if the substance use occurs at times unrelated to the psychiatric symptomatology.
After deciding that a presentation is due to the indirect effect of a substance or medication, you must then determine which DSM-5 substance-induced disorder best describes the presentation.
Determine whether the psychiatric symptoms are due to the direct effects of a general medical condition.
This differential diagnosis can be difficult for four reasons
Virtually any psychiatric presentation can be caused by the direct physiological effects of a general medication condition, and these are diagnosed in DSM-5 as one of the mental disorders due to another medical condition
You should direct the history, physical examination, and laboratory tests toward the diagnosis of those general medical conditions that re most commonly encountered and most likely to account for the presenting psychiatric symptoms.
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 possible relationships
There are two clues suggesting that psychopathology is caused by the direct physiological effect of general medical condition
Neither of these is infallible.
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.
Determine which among the primary DSM-5 mental disorders best accounts for the presenting symptomatology.
Many clinical presentations do not conform to the particular symptom patterns, or they fall below the established severity or duration thresholds to qualify for one of the specific DSM-5 diagnoses.
In such situations, if the symptomatic presentations is severe enough to cause clinically significant impairment or distress and represents a biological or psychological dysfunction in the individual, a diagnosis of a mental disorder is still warranted and the differential outcomes down to either an Adjustment disorder or one of the residual Other specified or Unspecified categories.
Establish the boundary between a disorder and no mental disorder.
Generally, the rule of thumb, if the comorbid psychiatric presentation warrants clinical attention and treatment, it is considered to be clinically significant.
Differential diagnosis is generally based on the notion that the clinician is choosing a single diagnosis from among a group of competing, mutually exclusive diagnosis to best explain a given symptom presentation.
Very often, DSM-5 diagnoses are not mutually exclusive, and the assignment of more than one DSM-5 diagnosis to a given patient is both allowed and necessary to adequately describe the presenting symptoms.
The use of multiple diagnoses is in itself neither good or bad as long as the implications are understood.
There are sex different ways in which two so-called comorbid conditions may be related to one other
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This is a bundle about the ussage and efficacy of psychotherapy. This bundle contains the literature used in the course 'DSM-5 and psychotherapy' at the third year of psychology at the University of Amsterdam.
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