Steps in making differential diagnosis

Step 1: Rule out Malingering & fastidious disorder

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.

Step 2: Rule out substance etiology

Virtually any psychiatric presentation can be caused substance use. If signs of substance abuse are
evident, the etiological relationship between substance and psychiatric symptoms must be considered.
Psychiatric symptoms might result from the direct effect 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

Step 3: Rule out disorder due to general medical condition

Step 4: Determining specific primary disorder

Step 5: Differentiate Adjustment Disorders From Residual Other or Unspecified Categories

HOPI

Mood Anxiety Psychosis Substance abuse Organic

• Depression • Generalized • Primary • Alcohol • Cognitive
• Mania/ anxiety • Secondary • Illicit drug use function
Hypomania • Panic attacks • Prescribe drug • Relevant
• PTSD medical history
• OCD

Mood
• Mood – Duration & trigger
• Sleep – Sleep disturbance ?
• Appetite
• Energy level
• Suicidal ideation
• Mania/ Hypomania
» Has there any period of time in your life that lasted for at least few days in a row, when you felt
unusually happy or energized for no particular reason ?
» For how long did you feel that way ?
» How was your sleep during that time ?
» How often does this episode occur
» Substance use ?

Anxiety
• Generalized anxiety
» Do you find yourself feeling nervous for no particular reason ?
» Are you a worrier ?
• Panic attacks
» Any presence of unprovoked panic attacks ?
• PTSD
» Has there been anything that felt particularly traumatic & still comes back to haunt you ?
» Understand basic nature of trauma – nightmares, flashback, hypervigilance, avoidance
• OCD
» Washing, cleaning
» Checking
» Ordering, counting
» Hoarding

Psychosis
• Signs of possible psychosis
» Thought/ Behavioral disorganization
» Vagueness of speech
» Bizarre mannerism
» Response to internal stimuli
• Questions
» Have you ever had strange experiences of hearing voices when no one is around or seeing things that
aren’t there ?
» [When suspect psychotic depression] “Sometimes, when people feel very depressed, they can have
strange experience such as hearing voices when no one is around. Has something like this ever
happened to you ?”
» [Inquire about delusion] “Have you ever felt that other people are out there to get you ?”

Substance use
• Alcohol
» How often drink alcohol ?
» How many drink alcohol per day ?
» When was the last time drink alcohol?
• Marijuana
• Heroine
• Cocaine
• Methamphetamine (“Pil kuda”)
» For how long use ?
» When was the last time use ?
• Prescription drugs – ex benzos, opiods

Organic

Past psychiatric history

• Psychiatric hospitalization
• Suicide attempts
• Past medication trial
» What medications
» Duration
» Adverse effect
» Efficacy

Social history & functional assessment

• House situation
• Social support
• Education attainment
• Employment history
• Legal history
Functional assessment
• Bath/ dress self
• Prepare meals
• Perform common household chores
• Manage money
 Making differential diagnosis

Mood Anxiety Psychosis Substance use Organic

• Depression • Generalized • Primary • Alcohol • Cognitive
• Mania/ anxiety • Secondary • Illicit drug use function
Hypomania • Panic attacks • Prescribe drug • Relevant
• PTSD medical history
• OCD

Class Subclass Criteria & history Psychiatric disorder Screening

Mood Depression Only depression • Unipolar depression – Major depressive PHQ-9
disorder (MDD), Dysthymia, Adjustment d/o
Mania/ History of manic/ • Bipolar disorder CIDI or MDQ
Hypomania hypomania • Mixed depression (Unipolar + bipolar
depression)
Anxiety Anxiety Pervasive anxiety/ • Generalized anxiety disorder GAD-7
worry
Recurrent • Panic disorder
unprovoked panic
attacks
Re-experiencing • PTSD PCL-C
traumatic events
Obsession or • OCD Y-BOCS
compulsion
Psychosis Psychosis Differential diagnosis
Primary psychotic • Schizophrenia
disorder • Schizoaffective disorder
Mood disorder with • MDD
psychosis • Bipolar disorder
Substance induce • Intoxication
psychosis • Disorder
Medical conditions • Delirium
• Dementia
Others • Brief psychotic disorder
• Delusional disorder
Substance Substance use • Substance abuse/ dependence – alcohol,
use illicit drug, prescribe drug
Organic Cognitive • Acute: Delirium
impairment • Chronic: Dementia
• Psychotic disorder
Medical
conditions a/w
psychiatric
symptoms
 Medical conditions associated with psychiatric symptoms

Medical conditions Psychiatric symptoms or history to suspect

Cancer
CVD (Endocarditis, Hypertension, Obesity,
Dyslipidemia)
Diabetes mellitus, Metabolic syndrome
Chronic pain condition, Skeletal connective tissue
disease
Dementia & Parkinson’ disease
Delirium
Dental disorder
GIT – GERD
Intellectual, developmental disabilities
Respiratory (Pneumonia, TB, COPD)
Skin infection (Sepsis, Poor wound healing)
Infectious disease (HIV, Syphilis, fever, rash, seizure)
Pancreatitis
Liver disease (Hepatitis, Cirrhosis)
Multiple sclerosis (MS)
Traumatic injury, falls, fracture
• Depression, Comorbid anxiety
• Depression
Heart healthy = Brain healthy
• Depression, Sleep & memory disturbance
• Depression, Anxiety, PTSD, Substance use
disorder (SUD)
• Depression, Anxiety, Personality changes,
 Motivation, Sleep disruption, Memory/
attention problem, Hypersexuality
• Confusion, Combativeness, Sleep-wake
disruption, hallucinations
• CVD association, Substance use disorder (SUD)
• SUD, EDS
• Depression, anxiety, personality issues
• Depression, anxiety
• IV drug user
• IV drug user
• Alcohol, Alcohol withdrawal syndrome (AWS)
• Fatigue, depression, SUD
• Anxiety, depression, sleep, memory
• Anxiety, depression, PTSD, SUID, Sleep &
memory disruptions

Unipolar depression
• Don’t just assume, must rule out – Bipolar disorder, Substance abuse, Anxiety disorder, Organic cause

Bipolar disorder diagnosis

• Diagnosis – Screening tool (MDQ or CIDI-3) + Follow up questions
• Follow up questions importance: To rule out false positive (mood episode from substance abuses)
» How long do hypomanic/ manic episode last ?
» How frequently do hypomanic/ manic episode occur ?
» During period of sobriety (stable), do you have hypomanic/ manic episode ?
» Do you have family history of bipolar disorder or schizophrenia ?
» Have you been previously diagnosed with bipolar disorder, if so, by whom ?
» Have you previously been treated with antidepressant, if so, how did you respond ?

Generalized anxiety disorder – GAD-7 Positive

• Don’t assume it its GAD, must rule out – MDD, Bipolar disorder, Substance use, ADHD

Working diagnosis
• Most common disorder are most common ! – Mood disorder & anxiety
• Use your diagnosis to guide treatment planning – Bipolar disorder need mood stabilizer