10 Common Errors in the Diagnosis of PTSD & Mood Issues

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@Allce.com Counselortoolbox all right, now I'd like to welcome everybody to Today's presentation on 10 Common Errors in effective differential diagnosis of mood disorders and ptsd. As we go through, we're going to talk about them. I will summarize them at the end. Please remember there's also a copy of this presentation, a PDF in the classroom if you want to follow along. So we're going to go through your basic mood disorders, but a couple of things we're going to include. In addition to bipolar cyclothymic depressed anxiety disorders, we're also going to look at premenstrual dysphoric disorder, circadian rhythm sleep disorder, and we're going to touch briefly on agoraphobia since that was separated. If you remember, when the DSM 5 came out was separated from panic disorder. So depressive disorders. A couple of things that we need to remember, especially if you see children, is that a lot of times bipolar and ADHD were getting overly diagnosed in children, so they added something called disruptive mood dysregulation disorder. We are going to cover that particular diagnosis in the developmental disorders because I was targeting kids in that one. But do be aware we're going to talk about that a little bit. And basically it's for children that have irritability and frequent episodes of excess, extreme behavioral discontrol throwing things, throwing temper tantrums, just being kind of challenging to the extreme. We're also going to talk about persistent depressive disorder, which instead of being dysthymia, which I always kind of described, kind of like Eeyore, it actually includes chronic major depressive disorder and the previous dysthymic disorder. And then premenstrual dysphoric disorder is now a distinct diagnosis. So that's important because when we get to looking at the direction of symptoms, the duration of symptoms for PMDD is not long enough to qualify for major depression or persistent depressive disorder. So we needed or it helps that we have this thing in here that can kind of validate. And when we're talking about diagnoses, a couple of the reasons that we want to make accurate diagnoses, number one, is to ensure that the person gets adequate and accurate treatment. Treating bipolar is different than treating depression, especially pharmaceutically. But we also want to make sure that we're not giving somebody multiple different diagnoses. We're just kind of spitting in the wind. Because in the event we go back to having insurance companies be able to deny pre existing conditions, if somebody's already been diagnosed with bipolar, depression and anxiety disorder, then, and you know they only have one of those, it was just presenting differently or diagnosed differently, then we're kind of setting them up. Now if they had one of them and that's what they still have, then they're still precluded from seeing that or being treated for that and getting reimbursed. But so we want to make sure that that's there and as well. So major depressive disorder, if you remember it requires five or more of the characteristics, two or more for persistent depressive disorder. So we're not looking at necessarily lesser intensity symptoms, we're just looking at fewer symptoms. With major depressive disorder it only has to occur for two weeks. With persistent depressive disorder or we're looking at two years without a remission of more than two months. So it doesn't have to be two solid years with no remissions ever, but definitely without a two month remission in there. And this is representing a change in functioning for the individual. So if the person has always kind of been a little bit slow going sloth, like some people are like that, that doesn't necessarily mean they're experiencing a major depressive disorder. I might look at some other diagnoses, but definitely it's a change in previous functioning. So we're looking at depressed mood, sleep is in, sleep is decreased, their interest is decreased in activities, guilt or worthlessness is expressed. So this is spells out digi caps, energy is decreased, concentration difficulties, appetite disturbance or weight loss, psychomotor retardation or agitation and suicidal thoughts. Okay, so that really didn't change. One thing that did change, and we're going to talk about that, is there's no bereavement exclusion anymore. So if somebody is presenting and they've experienced a loss recently and they're in that bereavement period, you know, before technically we couldn't diagnose them with major depressive disorder. Now that's not the case. Now if they present with major depressive disorder symptoms and meet criteria, we can diagnose that even if they're in the bereavement period, which is helpful for reimbursement. The person can't meet the criteria for a mixed episode and has to cause clinically significant distress. Okay, we know that not due to the direct physiological effects of a substance. So let's stop there. Major depressive disorder, a slowing of everything. We're having energy that's decreased concentration difficulties, changes in appetite. We can see this in detox from opiates. We can see this in intoxication from opiates. We can see this in withdrawal from alcohol. We can see this in withdrawal from stimulants. So we want to make sure that the person hasn't recently started taking a medication or using recreational drugs or that they're not detoxing. We also want to rule out general medical conditions. And if you were at one of the differential diagnosis presentations I did a few weeks ago, we really talked a lot about medical disorders that have symptoms that are symptomatic, similar to mood disorders. And what I'm thinking about here is hypothyroidism, chronic fatigue, fibromyalgia, lupus. There are a lot of issues, physiological issues, menopause, hormone imbalances, sex hormone imbalances, low testosterone. So those are things that a doctor obviously is going to have to assess and rule out. But we definitely want to. Before we slap a diagnosis of major depressive disorder on and start with cognitive stuff, although that will probably be helpful, we want to make sure to rule out the direct physiological effects of something else going on that did. In order for our treatment to be maximally effective, we also want to consider the individual's history. Like I said, have they always kind of been flat and like this? If so, we may want to look at a different diagnosis and cultural norms for the expression of distress. And as I mentioned earlier, premenstrual dysphoric disorder, obviously that's only for females, but you know, if somebody is only meeting that criteria for about six days out of the month, and then they are asymptomatic the rest of the month and it recurs, this isn't recurrent major depressive disorder. This could be pmdd, but we'll get there. Persistent depressive disorder, which used to be called dysthymia, and recurrent major depressive disorder, is a depressed mood that occurs for most of the day for more days than not for at least two years. So we're talking a long period of time. Major depression may precede or occur during a persistent depressive episode. So thinking back to the DSM 4, if somebody had what we used to call dysthymia, and then they have intermittent episodes of major depressive disorder, it's not, you're still looking at what's now persistent depressive disorder, but it's also important to look at those, the course of the illness. And if there are episodes of major depressive disorder, Intertwined with a lower grade, the, the dysthymia, what used to be dysthymia, you can diagnose both persistent depressive disorder as well as major depressive disorder. And this will have a different effect as far as treatment is concerned. When we're looking at what do we do for prevention, what do we do, you know, what triggers those major depressive episodes. I guess I should go down instead of up with my, with my little graph. But when their mood starts to really bottom out and they start getting that major depression, what triggers that as opposed to what maintains the dysthymia type things that are going on. And for persistent depressive disorder, there can be no hypomanic episodes in the first two years. So, you know, when we get to bipolar, we'll start talking about hypomanic. And the course mania is a distinct period. And this is really, really important for differential diagnosis to differentiate it from generalized anxiety, adhd, those types of things. It's a distinct period. It's not something that's ongoing, abnormally and persistently elevated, expansive or irritable mood. And in adults, it can be irritable too. It doesn't have to just be happy, go lucky and on top of the world. And it lasts at least one week. Now with adults especially, well, that's not true with children too. If the person wants something, you know, they have this intense goal driven activity during the manic episode and they're denied their wishes, they can get quite irritable during a manic episode. So again, not assuming that the person is going to be just fanciful and all that kind of stuff, high mood ability is possible. So they can go from being really on top of the world to really ticked off on the turn of a dime. In children, happiness, silliness, that's inappropriate to context and developmental age is kind of what we're looking for because, you know, most kids aren't going to walk around 10 foot tall and bulletproof. But you know, if somebody is just over the top, happy and silly and gregarious, consider it. And the depressive symptoms can also occur during a manic episode. And these depressive symptoms can last hours or a couple of days. And I've seen instances where clinicians have not diagnosed the bipolar disorder because the person did have depressive symptoms that occurred sporadically throughout. So the mnemonic that we're looking at here is dig fast. During the period of the mood disturbance and increased energy or activity, person has at least three of the following symptoms. Distractibility, and so think adhd, anxiety Even depression. People have difficulty concentrating, so they may be more easily distractible. So we want to rule out, you know, what are we talking about here? They can report a heightened sense of smell, hearing or vision. And interestingly, people with premenstrual dysphoric disorder also sometimes report heightened senses, especially smell. But sometimes hearing or vision are also reported, but it's usually smell. So that's important to again look at to see what we're diagnosing. Indiscretion or excessive involvement in activities that have a high potential for painful consequences. Unrestrained buying sprees, those are so easy now that you can buy online. I mean, people can get on the Internet and spend tens of thousands of dollars at the drop of a hat. Sexual indiscretions and foolish investments. So people are usually taking high risks, hopefully for high rewards. But you start seeing more of this and poor judgment at this point in children development, development, mentally inappropriate sexual preoccupations, or taking on many tasks simultaneously. And you may see this in adults who have a more severe, you know, moderate to severe fetal alcohol spectrum disorder, because remember, their developmental and their chronological age can be quite different. So these are things that we kind of want to pay attention to. Grandiosity, that inflated self esteem, uncritical self confidence, despite no prior experience. Somebody may decide they're going to write a novel or open a church or start a business or you know, all of a sudden they just kind of go off with a wild hair. And you know, some of us tend to be a little impulsive like that, but most of the time, you know, it's an idea. We'll talk about it, but we won't like quit our job and sell everything and go do it. Now. Just because somebody does this again doesn't mean that they are in a manic episode. Some people have that epiphany moment where they're just like, you know what? This is not where I want to be 10 years from now, so I'm going to change it. So remembering to take everything into consideration, delusions of grandeur are possible. Thinking that you are the smartest, you are the brightest. We see this a lot in children who overestimate their abilities. Thinking that they're better than they are, thinking that they should be the star quarterback, thinking that they can do anything. Thinking that they don't need to study for tests because they're too smart to fail. When we start seeing some of that flight of ideas, what's normative for the person? You know, some people are kind of all over the place and this Would be more so than normal. Their activity is increased either socially, at work or at school, or sexually. Or they may display psychomotor agitation. So purposeless, non goal directed activity like pacing around in a circle, Some perseverative movements like shaking their, shaking their leg or doing something like that can also that agitation that you see where you're just like, just be still for half a second, please. There's often a marked increase in sociability, including talking to strangers, making friends with people, just walking up to people in the street during a manic episode. So being prepared if this isn't somebody's normal modus operandi. I've worked with people who are business developers and in sales and they've never met a person that they couldn't strike up a conversation with. Me, on the other hand, I'm just kind of like, hi, how you doing there? So that would be a change for me. Dress may become markedly more seductive or flamboyant in order to attract that attention that they're seeking. And people may become aggressive or hostile. So being aware that again, you're not necessarily just dealing with somebody who is happy all the time, especially if they are thwarted from getting what they want, you may see them become somewhat aggressive or hostile. Now this is a nice one. For some people, their need for sleep is decreased. They feel rested after only three hours. It's not that they have insomnia. It's not that they go to sleep. They sleep for three hours and they wake up and you know, they may be good for a while, but then they get sleepy again. This is somebody who sleeps for three hours, gets up and they're raring to go and they can go, go, go, go, go. And talkativeness. So people in a manic episode can be more talkative. They can have somewhat pressured speech, kind of like what I'm demonstrating right now. But what we want to look for is what is their normal rate of speech. One of my daughter's best friends, bless her heart, I don't think she takes a breath, but she just has so much to say and she's always just wanting to share. And she's often in a, in a really good mood. She's not manic, she's just a really talkative, happy young woman. So for the manic episode, it has to cause marked impairment in social or occupational functioning or necessitate hospitalization. So even if it doesn't cause problems in your social life or your job, if you start doing things that require hospitalization to prevent self harm, or if there are psychotic features, then you've got a manic episode not attributable to the effects of a substance. Caffeine, you know, and that, that would be a short thing. Caffeine is not going to last for the duration that we're looking for of one week. So you're, you're going to want to remember that if somebody is displaying these symptoms, you're probably looking at either a substance of abuse, whether they're abusing stimulants. Well, that would probably be what we would be looking for. Or you might also want to look at medications and other treatments, other drugs that they may abuse that are stimulants. You would look for ADHD medications that they may be taking and just kind of see what's in their system. Hyperthyroid every once in a while can be severe enough to present with pseudomonic symptoms. We also want to look at substances, medications such as steroids, l dopa, antidepressants and stimulants. So I wouldn't have thought of steroids until I did this presentation. So steroids can put somebody seemingly into a manic episode and think about sort of an irritable manic episode with the rages that you sometimes see with roid rage. Stimulants include ADHD meds, weight loss medications, even over the counter ones, especially herbal medications. Because people tend to take way more than, you know, probably they should energy drinks. If they're drinking them and they're just kind of pounding them back, you want to rule that out. You want to be able to get a period where they don't have that caffeine or guarana or whatever else it is their system. And that can be really difficult. I have a friend of mine, I think he mainlines and I use that term sort of jokingly, monster drinks. I think he does like drinks like eight a day. And I'm just like, oh my gosh, if I drink half of one, I would probably have a coronary. So you need to make sure that. And remember, caffeine has a 12 hour life in your system. So you want to make sure that the person hasn't had any caffeine for at least 12 hours before you even start getting a good idea. But even after that 12 hours, if they've been doing that for that long, they're probably going to have withdrawal effects that you're going to have to get through again before you can get a clear diagnosis of what in the world is going on with this person. Light therapy can actually trigger a manic episode in Some people, I just learned that electroconvulsive therapy can trigger a manic episode. So once the treatments are removed and the effects of the treatment are expected to have worn off, then you can assess again and decide, is this person demonstrating mania or was it the side effects of those medications? Multiple sclerosis, stroke, lupus, aids, and encephalitis can also present symptoms similar to mania. And since we're mentioning encephalitis right now, I'll tell you, my ferrier's wife just got encephalitis and she was in the hospital for like 10 days and she's still trying to recover now. She presented more on the depressed, almost comatose state and she was really, really ill by the time they figured out what was wrong with her. But encephalitis still exists. So if somebody is presenting with a sudden change again, it's important to have things like this ruled out. Hypomania is a distinct period which is elevated and expansive and irritable for at least four consecutive days. You're not looking for the full week, you're not looking for an extended period. So that gives you a little bit more wiggle room. The episode is not severe enough to cause marked impairment in social or occupational functioning. A lot of people who have hypomania aren't going to complain about it at all. And when we get down to bipolar 2, we're going to talk about the fact that a lot of people who have bipolar two, when they experience their depressive episodes, those are pretty debilitating. When they have their hypomania episodes, those feel so liberating. That's not something they're going to complain about. And they may not know what normal or midline is, so they may not realize that they're bouncing to another extreme. Don't confuse hypomania with euthymia, though, which is an elevated mood that occurs for a couple days following the remission of major depression. Another diagnostic issue, because sometimes people will say, oh, went straight into a hypomanic episode that lasted for four days. And that's not necessarily true. So if it was preceded by a major depressive episode, you want to diagnose with caution bipolar, because you may just be looking at major depressive disorder. So let's hit the highlights of bipolar. Many children and some adolescents may experience bipolar like phenomena, especially short duration hypomania that don't meet the criteria for bipolar disorder. Think about when you were an adolescent. I mean, those hormones are raging. You're going through all these changes Stuff happens at school, whatever, it can trigger a whole lot of excitement, can trigger a whole lot of anxiety, it can trigger hypomanic like symptoms. But is it a distinct episode? Is it something that meets the Criteria for bipolar 2? A third of persons with bipolar disorder may attempt suicide, which is another reason it's important for us to differentiate between, you know, what we're looking at, whether we're looking at unipolar depression or bipolar issues or whatever. There's a six fold increase in suicide risk among first degree relatives of someone with bipolar bipolar disorder. So if Jim Bob comes into your office and you find out that his mom had bipolar disorder, he said a six fold increase for suicide risk even though he may not have bipolar disorder. So from a risk management perspective, important to know 14% of those with bipolar have at least one eating disorder, especially binge eating. And so we're going to talk about that when we get to eating disorders. But, but definitely something to pay attention to when we're looking at diagnoses and when we're looking at making sure that treatment is comprehensive and biopsychosocial anxiety and eating disorders are commonly associated with depressive episodes. So when somebody's in their depressive episode of the bipolar disorder, anxiety and eating disorders often go up when they are in the manic episode. Substance use disorders and other addictive behaviors such as gambling and sex are more often present. So when you're looking for any co occurring issues, it's definitely worth considering whether it alters with which type of episode they're in, which it probably will because your relapse prevention planning for those people is going to, or long term recovery planning, whatever you want to call it, is probably going to reflect, you know, the differences based on whether they're in a depressive episode, a manic episode or a remission episode. 75% of people with bipolar have anxiety disorders. So we want to make sure not to miss that as a co occurring issue because anxiety and stress can intensify or even trigger a bipolar mood episode. So we want to make sure we're dealing with that. ADHD and other impulse control disorders, including intermittent explosive disorder are common in 50% of people with bipolar. Substance use in 50% of people with bipolar. So bipolar plus alcohol use disorder produces a greatly increased risk for suicide. Just be aware of that. Metabolic syndrome is also very common with bipolar and this can help a little bit with differential diagnosis. If you have somebody that's carrying a lot of weight around their middle, they report high blood pressure, problems with their blood sugar and Abnormal cholesterol levels that often corresponds with bipolar. If you have a client with bipolar disorder, make sure they're getting evaluated by their physician regularly for metabolic syndrome. And people with bipolar often have a high incidence of migraines. Interesting to know. But that's also going to probably affect, especially during the depressive episodes, their prognosis for that episode if they're struggling with chronic pain from the migraines. Criterion A for manic and hypomanic episodes now includes an emphasis on change in activity and energy as well as mood. So you know that's just a change in the DSM 5. The diagnosis of bipolar 1 disorder, mixed episode that requires simultaneously meeting full criteria for both mania and major depressive disorder has been removed. So that's something to remember. If you're like me and you hate change and you're still struggling to transfer to the DSM 5 even though it's been there for like three years now, that's changed. And there's a specifier for anxious distress intended to identify patients with anxiety symptoms that are not part of the bipolar diagnostic criteria. They don't meet criteria for generalized anxiety, but there is some anxious distress there. You see that a lot with people with bipolar too. Neither psychosis nor major depression is required for bipolar 1. What you have to have is one full blown manic episode. It can be preceded or followed by hypomanic or depressive episodes. You just need that one full blown manic episode. Bipolar 1 is equally common in males and females, but women are more likely to be rapid cycling. So paying attention to that and have which is four or more episodes in a year and have multiple comorbidities, including higher rates of eating disorders and alcohol use disorder. And remember, bipolar plus alcohol use disorder, greater risk for suicide. Prevalence rates for both bipolar 1 and 2 is about 3%, based on the CDC and National Institute of Mental Health estimates. So three out of every hundred people. The mean age of onset is 18 for bipolar 1 and mid 20s for bipolar 2. Right around the same age, we're looking at late adolescence. That's also about the same time we start seeing the onset of personality disorders, which just complicates the picture trying to figure out what you're dealing with. 20% of adolescents with major depression develop bipolar disorder within five years of the onset of depression. This may be important for you to remember when it comes time to take your quiz. 20% of adolescents with major depression develop bipolar disorder within five years of the onset of their depression. So if you work with adolescents that have major depression you want to be on the lookout for it to move on to bipolar later in life. Or if you're working with somebody who is a younger person and comes in saying, I've been having major depression all my life, but seems to be meeting criteria for bipolar, that's not an unexpected transition. Onset of manic symptoms in mid or late life should prompt consideration of neurocognitive disorders or substance use. So if you see somebody in their 40s coming in and they're just having an onset of symptoms, we really want to have them evaluated for some, for strokes, for other neurocognitive issues and you know, see if we can get a good feel on substance use, including herbs and over the counter. 60% of manic episodes occur before a major depressive episode. So that's not a really important statistic to remember, but it is just one of those things I'm going to throw out. The only really important statistic is that 20% of adolescents with major depression go on to develop bipolar. Bipolar 2 often begins with a major depressive episode and is much more complicated chronic than bipolar one. So you're going to have potentially more episodes. It requires a lifetime experience of one episode of major depressive disorder. So instead of bipolar one, which requires one episode of manic, bipolar two requires one episode of major depression, much easier to differentiate than in the DSM iv, at least one hypomanic episode and no manic episodes. So once you have a full blown manic episode, you're up to bipolar one. But for bipolar two, you have to have the major depression. It's not better explained by any of your schizoaffective schizophrenia, schizophreniform or other psychotic disorders. Now when you think about psychotic disorders, think about your flattening of affect. Think about some of those things that might, might go along with a disorder. Diagnosis of a psychotic disorder. And when we're talking about major depression, you can have people that have very flat affect and a lot of difficulty concentrating. So you know, you can see where there might be some differentiating to be done. Symptoms of depression or unpredictability of alterations between depression and hypomania cause clinically significant distress because they tend to be more chronic. The person may have a lot of difficulty and it may be very frustrating to them because they don't know when they're going to wake up and when they're be Dr. Jekyll or Mr. Hyde, so to speak. So they may go to bed and wake up and be in a hypomanic episode and they're feeling great and they're able to tackle projects at work and get a lot of stuff done, but they don't know when they're going to hit the wall and then run into a depressive episode. So it can be very frustrating. They also don't know, don't necessarily go straight from hypomanic to depressive. They may be on top of the world, and this is where they like to be, and they're really productive. And then they hit that remission period and they still feel, you know, blue. They still feel kind of low compared to the hypomania, and they miss that period. So they miss that. That's frustrating. And they're not able to get as much done. So people at work might be going, well, you were doing great two weeks ago, and now I can't get you to get your work done. What in the world is going on? So we need to help people advocate for themselves and be aware of their own ebbs and flows and figure out how to work with those in interpersonal relationships, like doing chores around the house and going out with friends and that kind of stuff, as well as at work. Intervals between episodes decrease with age, so the older you get, the shorter the remission periods, basically. And depressive episodes are more enduring with time. So the shorter the episodes and the longer the depression lasts. Oh, that really sucks. So we really want to help people find. Figure out how they can prevent their vulnerabilities as much as possible and maximize their remission periods. And another reason we may see depression periods increase with age isn't just because of the progression of the disorder, but look at what's going on in that person's life. As a person's life gets more complicated as they go through their midlife crisis, as they go through generativity versus stagnation and all those other Ericksonian stages. There's a lot of stuff they've got to deal with. And so they may have some psychosocial issues we can help them work on and coping skills and other things that we can help them address that can reduce the length and severity of some of their depressive episodes. Depression plus hypomania may present as irritable depression or depression with increased energy. So just because somebody has some energy doesn't mean that they're not depressed. And this is another big oopsie that I see a lot of times in diagnosis because people will say, well, you know, the person didn't have that fatigue and lethargy and, you know, psychomotor slowing. Well, it's psychomotor slowing or agitation that we're looking at. So remember that you can have these co occurring now, according to the dsm, and I didn't experience this, don't know anybody who did. But right after childbirth, evidently there's supposed to be a surge of energy anyhow in people, in women, right after they give birth, they may trigger a hypomanic episode that is not that normal surge of energy that happens right after childbirth, which can foreshadow impending depression. So childbirth can actually trigger some of the hormone changes that may trigger a bipolar episode. People who are separated, divorced or widowed have a higher risk than those who are married or who have never been married. And family history is one of the strongest predictors. The degree of kinship increases the magnitude of risk. So if your parent has bipolar and then you're at a much greater risk for developing it. If it's your grandparent, then you've got a little bit more wiggle room. If it's your great grandparent or your cousin, then you're looking at, you know, even less of a risk of developing bipolar. And remember, people can have bipolar and potential but never develop it. If you believe that whole nature nurture thing, which obviously I do. Once an individual experiences psychotic features, further episodes are likely going to include psychosis, preparing a client for that, preparing their family for that, and writing the treatment plan to make sure that it's, you know, indicative of that. The suicide risk for people with bipolar is 15 times higher than the general population. So again, if you've got somebody with bipolar 2, for example, and they're not complaining about that hypomania, but they have major depressive episodes and you miss it and they've got unipolar depression, then what you're looking at is potentially missing the fact that they are at increased risk even over people with unipolar depression for suicide. Now, interestingly, past history of suicide attempt and the percent of days depressed during the past year are most predictive of suicide attempts. And ideation. It makes sense. And when somebody is coming out of a depressive episode is one of the times. It's not the only time, but there is an even increased risk during that period. When they're coming out of that depressive episode, they've got enough energy to actually follow through on planning or concentration to make a plan is when they're at a super high risk for suicide. From a clinical perspective, functional recovery lags behind symptom recovery. So even though they may be displaying mood stabilization vocationally, interpersonally and Cognitively, they still may be struggling quite a bit to get their thoughts in order to get back into a routine, to kind of get into the groove of remission, if you will, their interpersonal life. You know, the people in their life don't really know what to expect. So family education is really helpful. For people with bipolar and same thing vocationally, you know, if they were in a depressive episode, they may be way behind. If they were in a manic episode, they may have 17 projects that they undertook and now they're going, oh my gosh, what do I do? So we need to help with time management and setting realistic goals and that sort of thing, as well as trying to set boundaries and identify warning signs before going into a manic episode so you don't take on 17 projects that you're then saddled with. So bipolar one, at least one manic episode. Bipolar two, at least one major depressive episode. No mania, cyclothymia, new one two years with numerous periods with hypomanic and depressive symptoms that don't meet criteria for hypomanic or depressive episodes. So cyclothymia can be something that we look at now. Remember, teenagers aren't going to have this experience for two years where they have the hypomanic symptoms and the depressive symptoms that don't meet criteria for diagnosis. It's going to be a lot shorter period of time. So they won't meet criteria for cyclothymia. But if you've got somebody who seems to be cycling but not quite meet criteria, cyclothymia is definitely something to consider because it seems to go under diagnosed. And finally, remember that major depressive disorder may also have some hypomanic symptoms that are fewer and shorter in duration than required for bipolar. So you may have occasional bursts of energy or increases in goal directed activity and irritability can be present in both depression and bipolar disorder. Want to rule out anxiety disorders which can be comorbid, but you don't want to mistake one for the other. Separate anxious ruminations about, you know, I'm worried that we're not going to pay our house, we're not going to make our bills, that I'm going to die, that this is going to happen from racing thoughts about a variety of things. So you really want to look at is it an anxious rumination or is the person just kind of all over the place and not necessarily the theme is not necessarily always anxious and differentiate from efforts to minimize anxiety from impulsive behavior. So some things people may do to minimize their Anxiety can seem somewhat impulsive, substance use, for example. But we want to rule that out and figure out were they trying to self medicate their anxiety or was it impulsive, goal directed with high probability or high likelihood of harm. ADHD is especially common to misdiagnose in children and adolescents. I've seen a lot of people, a lot of children who are diagnosed with ADHD when it could have been or might should have been bipolar disorder. So you want to clarify if the symptoms are of a distinct episode, which would be bipolar or they're ongoing. So are we looking at, you know, a couple of weeks to a month, or is this something that's been going on for two years? Borderline also has impulsivity and mood lability issues. So rule it out. The personality disorder is a little easier. Symptoms again, must represent a distinct episode. And if the person has a personality disorder or has bipolar disorder, then a personality disorder shouldn't be diagnosed until the bipolar symptoms are stabilized. So you really want to. And this is true with addiction too. We want to get the person clean and sober and get the substances out of their system before we look and say, were these behaviors due to the bipolar or the addiction or are they due to a personality disorder? And disruptive mood dysregulation disorder can be diagnosed in lieu of bipolar if the mood is irritable, persistent and severe. And again, we'll do more talking about that in a couple classes. Pmdd, Premenstrual dysphoric disorder, mood swings, sadness, increased sensitivity to rejection, anger, irritability, increased interpersonal conflict, problems concentrating, having a depressed mood, negative critical thoughts about the self or sense of hopelessness, tension, anxiety, being on edge, appetite changes, overeating, including binging or specific food cravings, sleeping too much or just not being able to sleep, feeling overwhelmed and out of control, tender breasts, pain, bloating, swelling, weight, increase fatigue, lethargy, lack of energy and reduced interest in usual activ. Okay, did that just sound like a pharmaceutical advertisement? These are all the different symptoms that somebody with premenstrual dysphoric disorder may present with. That's not a surprise to anybody who has ever, you know, experienced. Occurs in between 3 and 8% of women and symptoms last on average for six days. So not the two weeks that we're looking for for major depression. They tend to be most intense just before the start of the menstrual flow and absent in the post menstrual week. So this is what we're really looking for for differential diagnosis duration and the absence. So it repeats pretty Predictably not due to any other mental illness causes significant distress, it can cause increases in sensitivity in one or more senses. The current consensus is that normal hormone fluctuations trigger pain, anxiety and depressive symptoms through interaction with the serotonin symptom system, gaba, adrenaline and opioid pathways. So they're really not sure exactly which pathway or how many of them, or maybe it's a combination. They also know that premenstrual dysphoric disorder commonly co occurs with depression and anxiety disorders. So again, you may have persistent depressive disorder with interspersed premenstrual dysphoric disorder. You can have them both or you may just have pmdd. Circadian rhythm sleep disorder is not a mood disorder, obviously, but I threw it in here because we know that people who are not getting enough sleep, people who are getting inadequate quality sleep, can present with symptoms to that seem similar to depression. And they may be self medicating their tiredness with stimulants which can make them present seemingly manic or hypomanic. So you know, just being aware. Circadian rhythm sleep disorder is a persistent or recurrent pattern of sleep disruption leading to excessive sleepiness or insomnia that's due to a mismatch between the sleep wake cycle required by a person's environment. So you know, for example, when, when my husband was on midnight shift he went into work at 7, he got off work at 7am and then would repeat. But his regular life, if you will, when he wasn't on duty we were 7am to 7pm and when he was working he was 7pm to 7am so there was a 12 hour shift. So his body never knew when it was supposed to sleep, when he was supposed to eat. Some people may exhibit a variable sleep pattern where they're taking multiple naps throughout the day leading to similar sleepiness or trouble concentrating. So what we're looking at is a mismatch for the person because we want their circadian rhythms in sync with when they're supposed to be awake and when they're supposed to be asleep, even if they're working overnight shift. Recommended that when on their days off, they keep the overnight shift hours if at all possible. The disturbance does not occur exclusively during the course of another sleep disorder or other mental disorder such as depression, anxiety or bipolar. Because remember in depression sometimes there's frequent fatigue, sometimes insomnia. Same thing with anxiety disturbance is not due to the direct physiological effects of a substance or general medical condition. Fibromyalgia, chronic fatigue, Lyme disease, any of those pain things that are going to keep people from sleeping could make them feel sleepy and disrupt their circadian rhythms. Just because the circadian rhythms are disrupted doesn't mean they meet this criteria. It has to be a standalone and not due. The sleep disruption has to be not due to other factors like pain or sickness or something else. Mood disorder. Four to six people will experience generalized anxiety disorder. Seven will experience social anxiety Two times as frequent in women as men. The age of onset for generalized anxiety is actually 45 to 59 years old. I learned that. And social anxiety is 8 to 15 years old. Oh, breaks my little heart. So the acronym we use for generalized anxiety, we want to look at symptoms lasting at least six months so we can have adjustment disorder. We can have issues that persist for a month or two. Wouldn't meet the criteria for generalized anxiety. It has to last at least six months. Worry anxiety, tension in the muscles, concentration difficulties, hyperarousal or irritability, energy loss, restlessness and sleep disturbance. Many individuals with generalized anxiety also experience symptoms such as sweating, nausea and diarrhea. Not part of a panic attack. You know, panic attacks are much more intense than that. The anxiety, worry or associated symptoms can cause difficulty in functioning and is unrelated to other medical conditions, including prescription medication, alcohol or recreational drugs such as stimulants or alcohol use, and is not better explained by a different mental disorder. And remember, when people are detoxing from depressants, A lot of times they have rebound anxiety, Especially when they're getting off of benzodiazepines. So we want to consider substances. Social anxiety is fear or anxiety specific to social settings in which the person feels noticed, observed, and scrutinized. In children, it needs to occur with their peers, not in adult interactions. A lot of kids are going to have anxiety around adults. The individual fears that they're going to display their anxiety and experience rejection. And these social interactions constantly provoke distress. The fear and anxiety is grossly disproportionate to the actual situation, and it persists again for six months or longer. It's not just this one. You know, getting married is causing social anxiety or going on a job interview. It's six months of anxiety related to particular social situations. It can't be attributed to a medical disorder, substance use, adverse medication effects. But we do want to rule out shyness. Some people, it's not that they're anxious so much, but they're shy. And it's a gray area. Introverts tend to get exhausted when they're around a lot of other people and may not want to Be in large groups of people. So we want to make sure we don't pathologize. Introversion. Introverts tend to do well in small groups and think and like quiet time each day. Doesn't mean they're socially anxious necessarily. Agoraphobia, you need to have fear of being out in public places or in crowds. Generalized anxiety disorder. The anxiety is going to be more than just about social situations Now. Body dysmorphic disorder is another one where there's often hiccups because people are afraid that someone is seeing this perceived flaw in their physical presentation. So they're afraid to go out and interact with people and they have a high level of anxiety. In social situations, Body dysmorphic disorder and social anxiety can co occur. An avoidant personality disorder is another one that you want to rule out. Social anxiety can lead to depression due to loneliness, isolation and inability to make social contact. But it can be addressed with cognitive behavioral therapy, exposure therapy, and in some instances SSRIs. Agoraphobia is now an independent diagnosis, not a modifier of panic disorder. But the person has to have fear or anxiety in a minimum of two situations, including being out in public open spaces and in crowds. And they need to avoid those places. Not just be afraid of them and grit them through it, but they need to actually avoid them, which is going to cause the problems in functioning. Acute stress disorder and PTSD have changed in stressor criterion being explicit as to whether the traumatic event was experienced directly or indirectly or witnessed. The criterion for subjective reaction of horror and helplessness is eliminated. They found out that had no clinical utility. The diagnostic thresholds for children and adolescents was lowered and there's a separate criteria for children under the age of 6. The diagnostic clusters were reorganized to form a total of four from intrusions, avoidance, negative cognitions and alterations, and arousal or reactivity. Now overall your diagnosis is basically the same, but there are four categories instead of three. So one of the things that I see mistaken is in a diagnosis of PTSD is the person didn't have to directly experience it. They could have witnessed the event as it occurred or heard about the event occurring to a significant other. Now this does not apply to natural death. Even if somebody dies suddenly, it has to be like a traumatic accident or some sort of person traumatic event. But you can get it through hearsay and repeated extreme exposure to aversive details of the events can also trigger it. But it does not apply to exposure through electronic media, television, movies or pictures unless the exposure is work related, which I found to be a little Odd, but go figure. Intrusive or distressing memories, nightmares, whether the content or affect of the dream are related to the events or unrecognizable in children. Flashbacks and dissociative reactions and intense or prolonged psychological or physiological distress. Avoidance of the distressing memories and reminders of the memories. Negative mood is the new category, but it's still covering a lot of the same stuff. Persistent inability to experience positive emotions, negative thoughts, distorted sense of blame, being stuck in severe emotions related to the trauma such as horror, survivor guilt, shame, sadness, reduced interest in pre trauma activities and feeling detached, isolated or disconnected as far as arousal, sleep disturbance, irritable behavior, hypervigilance, really strong startle response, problems with concentration. Those are all common symptoms that you're looking for. The duration is from three days to a month for acute stress disorder. If it persists longer than a month, then we move on to post traumatic stress disorder. So our criteria are really the same except for your duration. Symptoms typically are going to begin immediately after the trauma. The disturbance causes clinically significant impairment and is not due to a substance, medical condition or brief psychotic disorder. So what are the 10 errors? Missed diagnoses of bipolar 1, 2 or cyclothymia, premenstrual dysphoric disorder and disruptive mood dysregulation disorder in children. So we want to make sure that we're getting those diagnoses where they are. Failure to rule out medical conditions including fibromyalgia and chronic fatigue. No, we can't test for those, but we need to make sure that a medical professional is helping us complete the biopsychosocial evaluation. Sleep issues and addictive behaviors can also cause symptoms like some of these conditions. But when sleep or the addiction are handled, those symptoms disappear. Misdiagnosis of ADHD for bipolar 2 or. Disruptive mood disorder in children, ineffective. Differentiation between social anxiety, body dysmorphic disorder and premenstrual dysphoric disorder and avoidant personality disorder and you're going, huh? But if you look at the criteria, there's a fair amount of overlap in irritability and avoidance and social anxiety, you know, fear of being judged and things like that in all of those. So make sure that we differentially diagnose there over diagnosis of social anxiety in persons who are shy or introverted. Failure to diagnose depression during the bereavement period, we can bill for that and help people during that period where some insurance, a lot of insurance, won't cover treatment for bereavement and failure to diagnose acute stress in persons who did not directly experience the event. So we want to make sure that we diagnose acute stress disorder when it exists so we can provide early intervention services and prevent PTSD when possible. Anxiety, depression, mania and acute stress all have overlapping symptoms, so we need to really listen to what's going on. Effective treatment requires effective diagnosis of all conditions, mental health and addictive, ruling out of substance and medication effects and evaluation of medical issues including pain, hormones, stroke, fibromyalgia, chronic fatigue and autoimmune disorders including lupus, multiple sclerosis and rheumatoid arthritis, which all have depressive or manic like symptoms associated with them. All right, as far as the childbirth issue, you know, I'm not sure where that spurt of energy is supposed to come from or the, you know, onset of hypomania is kind of comes from, but it specifically referring to the mother who is experiencing the hormone changes. And they figure that the hormone changes are responsible for that mood shift and may not necessarily be indicative of a. Of the onset of a bipolar disorder. There may just be some hypomanic symptoms that go away. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceus.com counselortoolbox this episode has been brought to you in part by allce.com, providing 24. 7 multimedia continuing education and pre certification training to counselors, therapists and nurses since 2006. Use coupon code counselortoolbox to get a 20% discount off your order this month. So for Thursday's class I've changed the format a little bit so there's not quite as much information for you to try to be digesting. Please feel free to email me@drperiodsnipeslce.com should you have any questions because I know I powered through this. If you have any questions, please feel free to stick around and share them or email me and otherwise I will see you tomorrow when we talk about 10 ways to use patient placement criteria to improve your treatment program effectiveness and efficiency. See? Try saying that a bunch of times. Let's see. Okay, I think I have it set now so you can unmute yourself should you want to ask a question. But otherwise have an amazing afternoon. Okay everybody, have a great day. See you tomorrow.