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Chapter 10

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University of Toronto St. George
Michael Inzlicht

Chapter 10: Differential Diagnosis *REMEMBER YOU HAVEN’T DONE CH. 9 YET Case/Intro • Lori, had been in therapy bc multiple issues in life • Was referred bc also CNS difficulties (epilepsy, borderline intellec fxn. She was in special edu, though her placement in this may have been done w/o testing) • She would misuse support services at times • Has had multiple therapists, a social worker, psy’ist, neuro’ist, etc. and county employees helping her w/ life skills, of both genders, and still had difficulty w/ all of them • Her siblings are fine though, Lori is the only one who is having so much trouble • Partial care: a program designed to help ppl transfer from a hospital-based program to living on one’s own or in a group setting (classes, life skills, therapy, etc.) • Then began living on her own but still w/ some services as part of aftercare plan: provides a person w/ community-based services as one transitions to living on their own (i.e. help w/ transport, meal planning, budgeting, financial assistance) • Vulnerable adult: defin varies by state, but usually implies someone who for physical or mental health reasons may be an easy victim of unscrupulous individuals, or may have difficulty living on one’s own in the community (i.e. Lori was incompetent to manage her own affairs) • has had poor relationship in jobs she has managed to get and with men • makes very poor choices about whom to trust. Has been sexually assaulted. • Has let people borrow money from her even when she knows the money won’t be returned • Nervous, trouble sleeping, anxious • When she’s under stress, has alcohol (not to excess, but bc of epilepsy she should have none) • Extant records = i.e. medical, school, etc. records • Lori was administered the HRTB over 2 days to prevent fatigue • She was given a 5 axis diagnosis (1: Dystymic, PTSD (?), alcohol abuse (?) 2: Borderline IQ, Borderline PD, 3: Epilepsy, 4: Poor social, finance, employment, family, 5: GAF = 50) Difficulties in Differential Diagnosis • Lezak: one of the most common issues a clin npsy’ist faces is that brain disease may manifest in an emotional or personality disturbance. Or conversely that behv/cog things might actually have a psy rather than neuro basis o However new tech and research has shown that CNS would still be involved regardless • Diff diag needs to be done to prioritize issues (and, on a related note, to determine the causal pattern so that the issue that may be causing other issues is dealt with first) • It is also important to determine pre-existing difficulties/circumstances before the CNS difficulty o These premorbid factors may help or hinder any form of treatment or rehab Dev of the Diagnostic Sys • Diagnostic label = term applied to a group of symptoms which tend to occur together (the group of symptoms can be called a syndrome) • DSM, published by APA, considered a medical text, patterned after the ICD, published by WHO o Includes symptoms, incidence, prevalence, sex ratio, familial pattern, diff diag info o Everything other than symptoms is only in the DSM but not in the ICD o Uses the same code numbers as the ICD for medical record-keeping purposes • Primary use of DSM is for the professional to apply the appropriate term to the client’s symptoms in order to ensure appropriate treatment (also helpful for communication among professionals, research, insurance  most insurance is only eligible if diagnostic label is given) • The original reasoning for dev’ing a diagnostic schema in the US though, came from a need to collect statistical info (to determine amount of money fed gov should allocate for services for people w/ certain difficulties) o The 1840 census was the first time that a psychiatric category was included and was termed idiocy/insanity o By 1880 census, 7 categories of mental illness: mania, melancholia, monomania, paresis, dementia, dipsomania, epilepsy o 1917: Comm on Stats of APA + Nat’l Comm on Mental Hygiene formed a plan that was adopted by Census Bureau for gathering uniform stats across mental hospitals • Subsequently, APA + NYC Academy of Med collab’d to dev a nationally acceptable psych nomenclature. Was incorporated in first edition of American Med Assoc’s Standard Classified Nomenclature of Disease (used primarily to diag pts w/ severe psych or neuro) • Later, a broader nomenclature was dev’d by US Army and modified by Veterans Admin to incorporate outpatient presentations of WWII veterans o At this point, ICD-6 which included mental disorders for the first time (10 categories for psychosis, 9 for psychoneurosis, 7 for character, behv, intelligence disorders) o First DSM in 1952, patterned after the ICD-6 • DSM-I = glossary of descriptions of diag categories. Was 1 official manual of disorders to focus on clinical utility. “reaction” was used throughout, reflecting Meyer’s (one of the original authors) psychobio view that mental disorders are rxns of personality to psych, soc, bio • DSM-II in 1968 was similar to original DSM except w/o “reaction” o At the same time, there was widespread nonacceptance of ICD-6 and 7 (which both were thought to lack specific diag criteria) o So, WHO sponsored a review of diag by Stengel who said we needed more explicit def’ns for reliable diag (however, his conclusions were not included in DSM-II) • DSM-III in 1980 which was coord’d w/ ICD-9 (1975) was quite diff bc included explicit diag criteria, multiaxial sys, descriptive approach, that attempted to be neutral about etiology) • But still unclear criteria at times, so DSM-III-R 1987 which included PTSD, excluded homosecuality (except in case of ego-dystonic circumstances = person doesn’t want to be gay) • DSM-IV 1994: benefited from lit reviews and field trials that were done even before DSM-III • Goal = to provide comprehensive, unbiased info to ensure it was best clinical + research lit • Ethnic considerations were also considered in diagnosis more around the time of DSM- IV • Also women (bc most clin npsy’ists = men) • ~ = included 3 types of info w/ regards to culture o 1-Discussion of cultural variation in clinical presentation of various disorders o 2-Descriptions of culture-bound syndromes (in Appendix I) o 3-Outline for cultural formulations to assist cnpsy’ist in eval’ing and reporting the input of the client’s culture) • DSM-IV-TR (= Text Revision) 2000 was an intermediary step btwn IV and V o Same info as IV, but corrected factual errors to keep it up-to-date and reflect new info o Made changes to increase its edu value, updating ICD-9-CM codes. o But no new subtypes, disorders, appendices!!!! • ICD-10 is the current version, 1992. Though a clinical modification in 2004 o All versions list symptoms with an overarching term used to describe the syndrome o Includes all known medical and mental difficulties Axes of the Diagnostic and Statistical Manual of Mental Disorders • Axis = one of 5 areas in which info is placed, to give professional a clearer picture of client. Each axis contains diff info and is supposed to aid in treatment planning and to predict outcome • It is common for professionals who are just starting in the field and learning nomenclature to overdiagnose. So, it is very important that all required symptoms be present before label • Nosology = classification sys (made up of nomenclature) • Categories 2, 3, and 4 in Axis-I are listed in that order bc in DSM-III-R, they were all under the same category called organic mental syndromes and disorders (i.e. it was thought that all of these had a bio basis and the other disorders did not, but ofc current research says no) • However, for ex in terms of diff diag, it is imp to rule out substance-abuse as a cause for depression before diag’ing Major Depression • Mental Disorders due to Med Condition and Substance-Related Disorders which are listed in the Axis-I sections but the text and criteria for them is placed in diag sections w/ the disorders w/ which they share phenomenology (the remaining sections also group by phenomenology) Axis I • Includes clinical syndromes: set of symptoms that through research have been determined to coexist on a regular basis and hence have been given a label (i.e. Schizophrenia) • An individual does not have to have any Axis I diagnosis and if this is the case, they receive V 71.09 as their V code. • If, their ~ diag is deferred: 799.9. this might happen if diag is provisional, time limited until other info is gathered (i.e. they are not completely sure if condition exists currently) • And also includes V codes: which are issues that need to be addressed in rehab, treatment, therapy but tend not to be viewed as mental disorders and are technically referred to as “other conditions that may be a focus of clin attn) o Ex. academic problems, malingering, religious/spiritual problems • The syndromes and V codes are listed on this axis in order of imp for treatment • 16 classes of disorders Disorders Usually First Evident in Infancy Childhood or Adolescence • The disorders in this category may not be apparent till adulthood though and thus they might not be diagnosed till then (i.e. ADHD). And vice versa for disorders in other categories (certain ones can still potentially appear in childhood, i.e. depression, schizophrenia) • Covers a broad array of behvs. Typically, the behvs that cause a diag are: o exacerbation of normal behv (i.e. excess movement of ADHD) o Absence of expected behvs (i.e. selective mutism) o Behv that does not occur in a normal child (i.e. hand flapping of autism) • Mental retardation is kinda in this category but excluded bc this is on Axis-II • Learning Disorders are difficulties w/ academic fxn in which person performs below what would be expected for their age, edu, and measured intelligence o Different from normal variations in academic ability o Not due to lack of opportunity, poor teaching, cultural difficulties o Not synonymous w/ low IQ, but many of these ppl are scored w/ low IQ when tested o Needs to be separated from vision, auditory difficulties, and from mental retardation (when doing diff diag, bc learning disorders are not any of those things) • 4 types: Reading Disorder, Math Disorder, Disorder of Written Expression, Learning Disorder NOS (Not otherwise Specified). And they tend to occur together • New approach = response to intervention = screens kids who do not respond well to proven intervention strategies at an early age before the Learning Disorder causes sig difficulties • ~ may be diag’d in conjunction w/ Pervasive Dev Disorders (PDD) only when person’s performance is below what is expected for a given intelec fxn and schooling • Ppl w/ Communication Disorders may also have ~’s (but it will be very difficult to assess this) • Motor Skills Disorder comprises Dev Coord Disorder = motor coord that is substantially lower than would be expected for age and measured intelligence o Must be separated from coord problems due to neuro disorders, mental retardation o This diag is not appropriate if criteria for PDD is met (children who have ADHD are often climbing, falling, or knocking things over, but this is usually bc distractability, impulsivity) • Communication Disorders include difficulties w/ speech or language. 4 types: o 1- Expressive Lang Disorder, 2- Mixed Receptive Expressive Lang Disorder, 3- Phonological Disorder, Stuttering. 4- NOS • Shouldn’t be diag’d if criteria for PDD though • Communication difficulties could be because of mental retardation, hearing or other sensory deficit, severe enviro deprivation • Selective mutism may also be considered ~, but should not be diag’d if they are able to communicate in any setting • ~ may also be related to a general med condition, but only if it continues beyond the usual recovery period • PDD = severe difficulties that include deficits in reciprocal social interaction, impairment in communication, and the presence of stereotypical behv interests + activity • Autistic Disorder is the most commonly diag’d ~ o The exact figures are controversial, but btwn 2-20/10,000 to 1/500 • Autism includes symptoms of: o Qualitative imp in social interaction (at least 2 of:  Imp in use of multiple nonverbal  Failure to dev peer relationships at appropriate dev lvl  Lack of sharing of interests  Lack of social or emotional reciprocity o Imp in Communication (at least 1 of:  Delay or lack of spoken speech  Inability to sustain conversation  Stereotyped/repetitive lang  Lack of make-believe play o Restrictive and/or repetitive pattern of behv (at least 1 of:  Preoccupation w/ stereotypic interests  Inflexible routines  Stereotyped and repetitive motor mannerisms  Preoccupation w/ objects • Onset is typically <3 y.o and more often in boys • Rett’s Disorder, = more common in girls • for the first 5 months, normal prenatal and postnatal dev, normal psychomotor dev, normal head circumference. Then after: deceleration of head growth, loss of previously acquired hand movmenets, loss of social engagement, poor coord, severely impaired expressive + receptive lang dev • Childhood Disintegrative Disorder = more common in boys • Normal dev for first 2 yrs , but before 10ys, there is a loss of previously acquired skills • at least two of: o expressive/receptive lang o social skills/adaptive behv o bower or bladder control/play and motor skills • also, abnormalities in fxn in at least two of: o interaction, communication, restricted/repetitive/stereotyped behv • Asperger’s Disorder has been difficult to separate from Autistic Disorder however, kids w/ ~ often fxn much better in their enviro • Symptoms include: imp in social interaction and restrictive, repetitive or stereotyped behv • No delay in lang or in cog dev and IQ is avg typically • Diag categories that need to be separated from PDD: o Schizophrenia w/ Childhood Onset o Selective Mutism o Lang Disorders o Mental Retardation o Stereotypic Movement Disorders o ADHD • Attention Deficit and Disruptive Behv Disorders = include difficulties that often include behvs that are not socially acceptable, violate social rules and norms, or may be -ve, hostile, and/or threatening. This grouping includes 6 types: o ADHD, including problems w/ inattention o Hyperactivity-Impulsivity or both o Conduct disorder o Oppositional Defiant Disorder o ADHD NOS o Disruptive Behv Disorder NOS o Comorbidity is possible with these 6 types • The symptoms of ~ need to be separated from: o Mental Retardation, Stereotypic Movement Disorders, Mood/Anxiety, PDD, Psychotic, Substance-Related Disorders • Feeding/eating disorders of infancy/early childhood includes: Pica, Rumination Disorder, NOS • Anorexia and bulimia are not included here • Mouthing or eating of non-nutritive substances is relatively common at a very young age and may not indicate presence of a disorder o Pica is separated from other EDs bc: inappropriate consumption of things like paint, feces • Need to be careful to diff diag from PDD, Schizophrenia, and neuro or other med difficulties • Tic Disorders = vocal, motor tics. Includes 4 types: Tourette’s, Chronic Motor/Vocal Tic Disorder, Transient Tic Disorder, and ~ NOS o These must be separated from other types of abnormal movements that accompany med conditions like Huntington’s, stroke, or if related to substances • Elimination Disorders includes Encopresis = passage of feces at inappropriate times, places o Must be careful to separate from general med conditions • Other Disorders of Infancy, Childhood, or Adolescence = a catchall category • Separation Anxiety Disorder = excessive anxiety concerning separation from home or those to whom the child is attached, with inappropriate lvls of concern for their age (child fears something will happen to primary caretaker or to themself. This fear can mean they can’t sleep alone, get nightmares, physical symptoms, and anxiety) o Need diff diag to separate from PDD, Schizophrenia, other psychotic, other anxiety • Selective Mutism = refusal to speak in social sit’ns despite speaking in other sit’ns o Diff diag must separate from Comm Disorders, PDD, Schizophrenia, Mental Retardation • Reactive Attachment Disorders: characterized by disturbed and developmentally inappropriate social interactions usually caused by severely deficient parenting o Thought to occur due to insecure/ambivalent attachment o Diff diag must separate from Mental Retardation, PDD, Social Phobia, ADHD • Stereotypic Movement Disorder: pattern of repetitive, appearing to be driven, nonfxn’l motor behv that interferes w/ normal activity o Need to diff diag from Mental Retardation, PDD • OCD and Tic Disorders may also appear similar • Lastly, any movement or self-injury that may be caused by meds needs to be ruled out • There is also an NOS category for coding disorders that have apparently early onset of symptoms but do not clearly fit any of the above Delirium, Dementia, and Amnestic and Other Cog Disorders • Each disorder in this section = sig deficit in cog that is quite diff from their premorbid lvl of fxn • Etiology = general med condition, substance, or a combo of these factors • In DSM-III-R, these were referred to as organic mental syndromes and disorders • Delirium = dev’s over a short period of time and includes: o Disturbance of consciousness = lack of awareness of enviro, inability to focus, sustain, or shift attn o Cog disturbances = mem imp, disorientation, lang disturbances o Also can include delusions, hallucinations, agitation • 4 types: Delirium bc Med Cond, Sustance-Induced, Multiple Etiologies, NOS • ~ must not be better characterized by dementia (both involve mem deficits) in diff diag (though it is possible that both may coexist o Delirium = shorter, rapid onset vs. Dementia = gradual onset, over time • Must also be separated from Brief Psychotic Disorder, Schizophrenia, Schizophreniform, other psychotic, mood w/ psychotic features • Most prevalent in elderly, ppl undergoing med procedures, cancer pt’s, ppl w/ AIDS • Dementia: characterized by dev of multiple cog diffs including mem imp and at least one of: aphasia, apraxia, agnosia, or disturbance in exec fxn. Caused by direct physio effect of a med cond, substance, or multiple etiology. Types: o Alzheimer’s D, Vascular D, D due to HIV, D due to Head Trauma, D due to Parkinson’s, D due to Huntington’s, due to Pick’s, due to Creutzfeldt-Jakob, due to Med Cond, Substance-induced Persisting D, and due to Multiple Etiologies • Stages in deterioration of cog fxn: o Early: aware of his/her cog decline, may be some emotional change (depression, agitation, aggression, apathy) too(apart from E bc of knowing that one’s cog is declining) o Social and occupational fxning may already be affected at this stage • Diff diag also needs to separate: • Amnestic Disorders: also involves serious mem deficits, but w/o other cog difficulties • Mental Retardatio: has as a symptom subavg general intellec fxn but no sig mem imp • Schizophrenia, Depression, may also involve mem difficulties (especially in elderly it is very hard to separate mood disorder from dementia) • Amnestic Disorders: primary symptom = mem disturbance due to physio of med cond, or substance. Types: Due to Med Cond, Substance-Induced Persisting, NOS • Diff diag needs to happen to separate from dementia, delirium (if they had mem loss as a symptom at the beginning). Also need to diff diag from dissociative disorders (like dissociative amnesia, which does not have deficits in learning but more often forgetting bc trauma) and from mem imp bc intoxication or withdrawal from a substance • Cognitive Disorer NOS: a catchall diag for cog dyfxn symptoms bc of direct physio from med, that does not fit the aforementioned. May be a mix of symptoms of attn, concn, mem, exec fxn, etc. and ppl w/ this diag may be very diff o DSM-V will break up this category a bit into postconcussion syndrome, mild neurocog Mental Disorders Due to Medical Condition • Mental symptoms which are a direct physio consequence of a med cond • If this is the diag, a med cond must also be coded on Axis III • Includes, delirium, dementia, amnestic, psychotic, mood, anxiety, sexual dysfxn, sleep • 2 criteria must be present for the diag of ~ to be made: o Must be etiologically related to a me cond through a physio mech o And the condition must not be better accounted for by another mental disorder • Diff diag must separate from: primary mental disorder, substance, or combined of these two • Catatonic disorder due to med cond has any of the following symptoms: motor immobility, excessive motor activity, extreme negativism or mutism, peculiarities of voluntary movement, echolalia (repetition of something spoken by another person), echopraxia (same for movement) • Perosnality Change due to... = persistent P disturbance from their premorbid pattern o Coded on Axis I not Axis II • Subtypes: labile (if affective lability = predominant feature), disinhibited (if impulse control=main feature), aggressive, apathetic, paranoid, other type, combined type • Mental Disorders NOS: residual category Subtance-Related and Substance-Induced Disorders • Drug abuse, side effects of meds, and/or toxin exposure • 11 classes of substance abuse contained in DSM-IV-TR: alcohol, amphetamine (or similar pathomimetics), caffeine, cannabis, cocaine, hallucinogens, inhalants, nicotine, opiods, PCP (or similar arylcyclohexamines), sedatives, hypnotics, anxiolytics • Substance-related is divided into: o 1) Substance-Use (abuse and dependence) o 2) Substance-Induced (intoxication, delirium, withdrawal) • Imp cog/mood are the most common symptoms o But sometimes anxiety, hallucinations, delusions, seizures • Dependence: pattern of repeated use that can lead to tolerance, withdrawal, and compulsive drug-taking behv (may be applied to every substance except caffeine). Defined as 3+ symptoms of the following, within a 12 month period: o Tolerance (higher doses or over a longer period than intended) o Withdrawal (psych or physio) o Desire or unsuccessful efforts to control use o Time spent to obtain or recover from the substance o Activities given up for the substance (social, occu, rec) o Continued use even if physical/psych problems occur • There are many specifiers: w/ physio dep, w/o physio dep. And after 1 month of no dependence: early full remission, early partial remission, sustained full, sustained partial, agonist therapy, controlled enviro • Abuse: defined as having 1+ of the following within the past 12 months: o Failure to fulfill major role objectives o Repeated substance use in a sit’n that could be dangerous o Repeated legal problems o Use despite persistent/recurrent social/interpersonal problems • These symptoms do not meet the criteria for dependence • Intoxication: maladaptive behv/psych changes assoc’d w/ direct physio effects o Not caused by a med cond and not better accounted for by another mental disorder • Withdrawal: often but not necessarily assoc’d w/ dependence. i.e. can be diag’d on its own o Usually there are social, occu, or other difficulties • Diff Diag is difficult bc each class of substance has its own symptoms • Multiple diagnoses of the aforementioned are possible if all criteria is met for each diag and termed polydrug abuse • The main diag issues are between dependence vs abuse, and intox vs withdrawl • Most treatment programs are abstinence-based but some controversial controlled use therapies for alcohol. These programs may not be good for ppl w/ CNS difficulties Schizophrenia and Other Psychotic Disorders • ~ termed “thought disorders” bc the primary symptoms are about how the person thinks/conceptualizaes info that they receive from outside world through senses • ~ occur in ppl who had a period of “normal fxn” first • Prodrome: occurs as behv tends to dev bc of stress o Up to 85% who later dev schizophrenia go through a prodromal phase • Schizophrenia = group of +ve, -ve symptoms present most of the time over 1 month. 2+ of: • +ve = symptoms beyond normal emotions. o Hallucinations, disorganized speech, disorg’d/catatonic (rigid/malleable motor behv often called waxy flexibility) behv • -ve = absence of normal expressions or feelings o Affective flattening, alogia (lack of logical thought or speech), avolition (lack of motivation). And one or more areas of fxning (work, school, etc.) must have declined prior to symptom onset, i.e. downward course of fxning • Some signs must persist for at least 6 months to be considered symptoms • Subtypes: Catatonic Type, Disorganized (disorg speech, behv or flat and inappropriate affect), Paranoid, Undifferentiated, Residual (evidence of a disturbance but criteria for active phase is no longer met) • Med conds w/ psychosis elements need to be separated in diff diag, as well as substance-induced delirium/dementia, mood disorder w/ psychotic features (this last is very diff to differentiate bc mood disturbances occur during prodromal, active, and residual phases. But if psychotic features only occur during course of mood disturbance, then it’s mood) • PDD also shares symptoms of lang, affective, interpersonal difficulties, but is usually only <3y.o • And early or childhood onset Schizophrenia is rare. And must also be separated from the disorganized speech of a communication disorder or ADHD • Also have to diff diag from PDs (Paranoid, Schizoid, Schizotypic), though these may precede • Schizophreniform Disorder = same symptoms but duration of prodromal, active, residual is 1-6months and w/o the individual needing to exhibit difficulties in social, occu fxn. o Specifiers = w/ good prognostic features (i.e. good premorbid social and occu fxn), or w/o. Also, similar diff diag difficulties as the ones listed for schizophrenia • Schizoaffective Disorder = symptoms of Schizophrenia + Major Depression, Mania or both at the same time. + min 2 weeks of delusions, hallucinations w/o mood disturbance o Similar diff diag to schizophrenia but alos have to diff from mood disorders w/ psychotic and schizophrenic episode w/o mood • Delusional Disorder = presence of 1+ nonbizarre delusions (=false beliefs even when evidence to the contrary for at least 1 month). Subtypes: o Erotomanic: delusion that someone is in love w/ them o Grandiose: great talent, insight, power, etc. o Jealous: that their lover is unfaithful o Persecutory: being conspired against, obstructed in their pursuit of goals, harmed, cheated, spied, etc. o Somatic: bodily fxns or sensations o Mixed (1+ of the aforementioned themes) o Unspecified (main theme cannot be determined) • Similar diff diag issues to Schizophrenia • Brief Psychotic Episode = sudden onset of at least one of the +ve symptoms of Schizophrenia o 1 day-1month. Again similar diff diag. • Shared Psychotic Disorder (folie a deux) = appearance of all or part of a delusion within an individual who is closely involved w/ another individual who has a psychotic disorder w/ prominent delusions (usually spouse or living w/ them for a long period in isolation. May occur w/more than one person. Usually not difficult to diag) • Psychotic Disorder due to Med Cond = diag not given if symptoms occur during delirium o But, may be an additional diag w/ dementia o Need to rule out Substance-Induced Psychosis, Primary Psychosis, or Primary Mood • Substance-Induced Psychosis: needs to be diff’d from intox, withdrawal. Also, excessive use of amphetamines can present like schizophrenia) Mood Disorders • ~ = Mood or Affective Disorders. Predominant symptom = fluctuations in mood from what is considered normal state for the person • Referred to as the “common cold” of mental health bc ~ are the most common reason ppl come in for therapy. Though, at present anxiety > mood in terms of prevalence at clinics • And often combo of mood and anxiety so a Mixed Anxiety Depressive Disorder category is recommended for DSM-V • Major Depression: 1+ depressive episodes, w/o a history of mania, mixed, or hypomanic eps • 5+ of the following for min 2 weeks: o Weight gain/loss, insomnia/hypersomnia, psychomotor agitation/retardation, fatigue, feelings of worthlessness/guilt, difficulty in concn, recurrent thoughts of death • AND must also have depressed mood or loss of interest/pleasure • Specifiers = mild, mod, severe w/o psychotic, severe w/ psychotic, chronic w/ catatonic, w/ melancholia (a distinct type of depression that is worse in the morning, early morning awakenings, psychomotor retardation/agitation, anorexia, excessive/inappropriate guilt), w/ atypical, w/ post-partum onset (within 4 weeks of giving birth) • Diff diag from mood disorders caused by substances, med conds • ADHD has symptoms of distractibility and low frustration tolerance so both may be diag’d • Dysthymic Disorder: chronic depressed mood for most of the day for more days than not fo
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