Mastering Differential Diagnosis: Avoiding the Framing Bias

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@allceus.com Counselortoolbox you I'd like to welcome everybody to today's presentation on differential diagnosis. Exploring the Framing bias We're going to start out by defining the framing bias and learn about medical diagnoses and symptoms of substance intoxication or withdrawal, which also mimic mood disorders. So the framing bias is the tendency to react to a particular set of symptoms in different ways depending on how or where it's presented. So for example, medical practitioners, when you go into their office and you're describing that you've got lack of pleasure, no motivation, sleep changes, appetite changes, fatigue and difficulty concentrating, they may lean towards depression or they may start running some blood work to see if there's a physical thing going on. But a lot of medical practitioners automatically, or yeah, automatically think substance use or addictive behaviors. And it may not be a substance. It may be something like gambling or Internet porn that is not only flooding the brain with dopamine and causing some neurochemical imbalances, but it's also keeping people from getting sufficient sleep. So, but if those same symptoms are presented in a mental health clinic, a mental health clinician is going to obviously start saying, oh, that sounds like depression. So we're going to look for a mental health diagnosis and or normal reactions to psychosocial stressors. So if somebody just lost a job or lost a significant other and they're depressed, we might look at it and go, yeah, I can totally get that. So we're looking at what's going on and why is this important? Well, let me not get ahead of myself. We may miss medical or substance use issues. I know when I went through training we really weren't provided a lot of education about substance use or medical disorders, disorders that could present similarly. And I know back in the DSM it says, you know, cannot be better explained by a medical disorder or substance use, but we kind of skimmed over that in our diagnosis class and even my practicum supervisor kind of skimmed over that a little bit. And you know, thankfully my internship supervisor was co occurring and he was like, you know, we need to look a little bit more biopsychosocially at what's going on. Because if the issue is an organic mood disorder that may need some sort of psychotropic medication or something, that's one thing. But if it's caused, you know, if the neurotransmitter Imbalances are caused by something else, like, you know, losing your house, getting a divorce, living in a very chaotic, stressful environment, then maybe psychotropic medications aren't going to, you know, address everything. And we can talk about depression, but we also need to address those psychosocial stressors for the person to really get a complete recovery. And substance abuse clinicians, when people come in, we're looking for substance use issues and addiction issues, and also normal reactions to those psychosocial stressors. But a lot of times, substance abuse clinicians, for a variety of reasons, not only just their setting, but also based on training, may miss mental health and medical issues. So again, we really want to look at, based on the setting, we anticipate somebody presenting with a certain type of diagnosis. If you go to your medical doctor, they're not as likely to screen for substance use, use, et cetera. And if you go to a mental health clinician, a lot of mental health clinicians, again, aren't as likely to screen for substance use or addictive behaviors as a contributing factor to whatever the mood issue is that they're presenting with. So if it's caused by medical or psychosocial issues, psychotropics will probably not help much. So if it's a hormone imbalance or hypothyroid or something like that, an SSRI is probably not going to help very much. If it's caused by psychosocial issues, you know, stress at home, you hate your job, yada yada. Again, a pill may give a little bit of hope, but likely it's not going to provide the type of recovery that the person's looking for. If the symptoms are caused by substances, psychotropics can help kind of bridge the gap. So what we're looking at is, you know, we've talked about how in addictive behaviors, the neurochemicals in the brain get monkeyed up because the brain is protecting the body from being overstimulated so much. You're not supposed to be that happy or that stimulated or that whatever all the time. So the receptors become less sensitive. So when the person is in early recovery, what would normally help them feel happy? What would normally help them feel okay, as they define it for them, doesn't do it for them. So they're in this persistent state of gray blah. Think Eeyore. And psychotropics can help bridge the gap. One of my clients referred to it as helping him see color because when he was in early recovery, his neurotransmitters were so out of whack. And probably depleted the dopamine and glutamate and stuff because he'd been abusing stimulants, cocaine and crack that, you know, for a couple of months after he would get clean, he just still couldn't see colors. So he would start looking for things to help him feel better, help him feel happy or see color, as he put it. And with this particular client, it was always relationships. So he felt crappy, he would stick it out for a while, then eventually he would find a relationship. So he'd feel the butterflies in his stomach and he'd start to feel something again. But these relationships inevitably were dysfunctional and then they would break up and he would relapse. So, you know, we can look at psychotropics for some things and they can be helpful. I don't want you to think that because they're not helpful for the majority doesn't mean they're not helpful in certain specific circumstances. If symptoms are caused by a mental health issue which exists independently of substance abuse or addiction, recovery needs to address both. Recovery needs to look at any addictive behaviors that may be going on. So what I mean by that is if somebody had a pre existing major depressive disorder and then, you know, in their teens or twenties, suddenly they start developing an addictive disorder, so they're presenting with both of them. But the mental health issue we know has been going on since they were knee high to a grasshopper. You know, we need to address both of those. And even if they present with both issues and the substance abuse is caused by the mental health, or the mental health is caused by the substance abuse or vice versa, we have to treat them both. That's what co occurring is all about. Because if somebody has a mental health issue and you know they stop using, then you're going to have somebody who's depressed, for example, clean, they're probably not going to stay clean very long. If you go the other way and you address the mental health issue and they're still using, the substance use or the addiction is going to keep their neurotransmitters kind of mucked up. So we need to address them both in order to help the person achieve sustained recovery. We need to find or look for, regardless of the setting where the person presents the cause of the symptoms. So think about it this way. The cause of low water pressure, and we've all had that occasionally at our house, I think. And so you're thinking to yourself, you get in the shower and can't hardly wash your hair, so you got to Wonder what's going on. Well, it could be caused because the water pressure coming into the house is fine, but doesn't make it where it needs to be. There's dripping, faucets, running toilet, poor fittings or a crack in the line somewhere, you know, so coming into the house doing just fine but not getting to your shower. Or it could be a pressure reducing valve malfunction which is out at the road. So it's actually not even getting into the house. You know, you don't have enough water coming in, period. Same sort of thing with neurotransmitters. The amount of neurotransmitters may be fine, you might have enough in your brain, but they don't make it to where they need to be because you're bleeding them off through lack of coping skills. So you're having these extreme dysphoric moods and you're just using a ton of energy, getting upset, getting stressed, resentments, you know, those things that take a lot of energy to kind of hold and contain, especially if people are stuffing them. Psycho, psychosocial stressors that may be going on. A person is going to, if they have X amount of neurotransmitters, they're going to feel okay normally. But if they've got a lot of stressors going on in their life, that's going to deplete the amount of neurotransmitters available. And substances, you know, if somebody's using substances that's going to alter how quickly certain neurotransmitters are used and mess up the function. So the amount, if left to their own devices, the brain is producing enough, but something's happening that's keeping the person from being able to feel happy or, you know, the pressure reducing valve could be malfunctioning. That is, the brain can't even under the best circumstances produce enough of a neurotransmitter. And this is generally either, you know, from birth, it's a genetic predisposition or from brain damage of some sort that can cause the brain to not be able to actually produce the neurotransmitters or something genetic that keeps the body from being able to make certain neurotransmitters. But the last one is something that the person's going to have a history of depression, anxiety, et cetera, you know, dating back quite a ways if it's an organic issue. Otherwise we want to look at what's causing the leaks, what is making it. So this, what would normally be an adequate amount of neurotransmitters what is making it so this person is not feeling happy and start ruling out from there. So going over generalized anxiety, at least six months of excessive anxiety and worry about a variety of things. The presence for most days of feeling wound up, tense or restless, becoming fatigued or worn out, concentration problems, irritability, significant muscle tension, and difficulty with sleep. So when you start thinking about this, this is generalized anxiety, but it also overlaps with substance use, intoxication, if we're talking about feeling wound up, and concentration problems, difficulty with sleep, if somebody's abusing stimulants. And this can even be, you know, over the counter stimulants, caffeine, pre workout supplements, et cetera. But they can start experiencing symptoms of generalized anxiety. So we want to ask, you know, not just about illicit drugs that people are taking, but over the counter meds that they're taking. And we want to look at what else is going on. The other thing to remember is it's kind of a teeter totter. What goes up must come down. So if somebody's abusing stimulants, then when they're withdrawing, when the stimulant, stimulants are leaving their system, they're going to start having depressive type symptoms. So they may become fatigued or worn out really easily. A lot of the patients that I've worked with who are in recovery, especially from crack and cocaine addiction, find that, that first few months, you know, long after they discharge from the facility, they get worn out easier and they need more sleep. And you know, it feels, some days just feel a lot harder. And there can be some irritability on when they're using and when they're detoxing. In panic disorder, palpitations, pounding heart or accelerated heart rate. Now that's something that's common to stimulants as well as certain strains. And I want to emphasize this, not all strains of cannabis produce the same symptoms. They, they genetically kind of breed it. And certain strains will produce feelings of calm, certain will produce euphoria. Spice tends to produce the palpitations, pounding heart, accelerated heart rate. I've had clients that have used when they were, when I was at the residential facility, they were out on, at work and they would come back to the facility. And since spice is technically legal and back then we couldn't test in urine screens for it, of course they were going to try to use it. And there were two instances where the clients came back and their heart rate was almost 200 beats a minute and they just felt like they couldn't move they were sweating, trembling, shaking, feelings of shortness of breath. When your heart's pounding that fast, you're going to have a feeling of shortness of breath, nausea or abdominal distress. This is common with substance use, substance misuse, as well as detoxing. Think about opiates. When people have been taking opiates and then they start to detox, they have a lot of flu like symptoms. Feeling dizzy, unsteady, lightheaded or faint. This can be anxiety. It can also be physical problems such as. And some of these other things that deal with the heart can be due to heart problems. So we want to make sure that people are getting a physical to rule out some of this stuff. And we're going to talk about the physical issues in a few minutes. I'm going to spend less time on the mood stuff because we all know what these symptoms are. Symptoms of derealization, feelings of unreality or depersonalization. Now, this is really common in, even in among cannabis users. So we want to rule out what's going on. Fear of losing control or going crazy or dying. Numbness or tingling sensations and chills or hot flushes. Just being aware and making sure we communicate with our clients. What's going on. Major depression, depressed mood most of the day. Diminished interest or pleasure in all or almost all activities. Well, if somebody's using at a certain point when their use gets to be significant, they're probably going to really only focus on using. And a lot of times they're using just to feel okay. They're not even getting all that high anymore. They're not getting the same rush, which is evidence of the tolerance. But the depressed mood, the apathy, the lack of pleasure in most things. Well, if they've already, you know, mucked up that whole dopamine system, yeah, it's going to be hard to feel pleasure. So we want to look at what's causing the depression, what's causing the lack of pleasure. Is it nutritional, is it biological, is it addictive? Significant changes in eating patterns, sleeping patterns, psychomotor agitation or retardation. And that's where other people can also see it, where they, somebody seems like either wound up like crazy or they just are moving at a snail's pace. Fatigue or loss of energy and feelings of worthlessness or excessive or inappropriate guilt. We'll also see this in addiction. Fatigue or loss of energy. We'll see in a lot of different medical disorders, from lupus to chronic fatigue syndrome to fibromyalgia. And you're going to be surprised probably at how Common some of these things are diminished ability to think or concentrate and recurrent thoughts of death. Not just fear of dying with mania or hypomania. And I put them both together because you know, we're not diagnosing right now. What we're looking at is what else could cause these type of symptoms. But that sense of inflated self esteem or grandiosity is not uncommon among people who are, who are drinking. It's also not uncommon among people who are using stimulants. Decreased need for sleep common among stimulant abusers, more talkative than usual or pressure to keep talking. Stimulants, flight of ideas or subjective experience that their thoughts are racing again, stimulants, distractibility, an increase in goal directed activity either socially or at work or at school and excessive involvement in pleasurable activities that have a high potential for negative consequences. So people are starting to use poor judgment. Well, when we talk about substances and the diagnosis for a substance use disorder as it's called in the DSM 5, one of the key factors is is this person using and continuing to use despite it causing negative problems and, or are they using in risky situations? So we want to look and say are these symptoms caused by substance use or something else? And the other thing we really want to consider and make sure that our clients are educated about is the fact that there are some over the counter medications and supplements, including certain types of ginseng and workout supplements that can cause anxiety or manic like symptoms. Bipolar is when the person experiences both manic and depressive symptoms. You know, we know this symptoms can alternate co occur or be present to a greater or lesser degree. Now think about somebody using a stimulant for example, and they are wired and then they crash and they have this depressive period. And the, it's not just mood wise, it's their body going wow, you know, I haven't slept for three days. So they may feel depressed, their neurotransmitters are not adjusting as well as they need to be. So somebody who's using may seem, especially if they're abusing stimulants may seem like they've got bipolar or cyclothymic disorder. When we're looking at cyclothymic disorder, we see for at least two years the presence of these hypomanic episodes and numerous periods of depressive symptoms that don't meet the criteria for major depressive episode. And the person hasn't been without symptoms for more than two months. Now I put this one here because a lot of us it's been my experience that cyclothymic disorder almost never gets diagnosed. So we want to take a look at that and say, you know, what is, what's going on? Cyclothymic disorder or, or substances. Because people may attribute it to substance use or psychosocial stressors when there actually might be cyclothymic disorder and an organic brain issue going on. So you know, again, going over to the other side going, instead of blaming substances or just stress, let's look and see how long has this been going on and you know, is there a period, period of remission and what else might be contributing to it. So those are our mental health issues and those are the things that we're generally looking for and those are the diagnoses that we generally label. But it's important to remember that physical conditions can mimic intoxication or withdrawal and can worsen during use or withdrawal. And people often self medicate physical and emotional conditions, pardon me, with substances. Effective treatment involves addressing physical and emotional conditions and your psychosocial stressors and treatment side effects which are unpleasant. So if somebody starts taking, you know, a psychotropic medication and it is making them too tired. I had one client who was taking atypical antipsychotic and she would take it at 6 o' clock at night and she couldn't wake up, you know, really like start functioning until after 11 the next morning. So she worked with her doctor and switched the schedule so she actually started taking instead of taking it at night, she would take it at lunchtime and it wouldn't, you know, get in her system enough to inhibit her during the afternoon, but it would be out of her system enough by the time she had to get up and go to work the next morning that she was able to go to work. So we want to help people work with some of the side effects that might be going on. So depressive like symptoms can be caused by diabetes, hypothyroid. That means not enough high thyroid hormone, fibromyalgia, chronic fatigue hormone issues including polycystic ovarian syndrome and menopause, lupus and adrenal issues, manic like symptoms. That's a smaller group and we're really looking at hyperthyroid, too much thyroid hormone, lupus. And I put substance toxicity and poisoning here because these are not your recreational drugs. These are, you know, exposure to things like thallium or whatever that are causing poisoning to your system. But they weren't, they're not actually mood altering drugs. By their very nature. Anxiety symptoms can be caused by hyperthyroid Too much thyroid hormone. Hormone imbalances. Sex hormone imbalances. Blood sugar issues. When your blood sugar gets low, your body perceives that as a threat, releases cortisol, which tells your body to release glucose into, into the, into the system. So when your blood sugar gets low, that's why some people start to get shaky and may feel like they're having panic attacks. Making sure to moderate that heart problems, including supraventricular tachycardia, which often happens when somebody goes upstairs or something and all of a sudden their heart starts pounding really, really fast. Lack of oxygenation. If their heart is not functioning properly or it's beating too slowly, then there might not be enough oxygen getting throughout the system. So the person can feel confused, disoriented, tired, dizzy, and an irregular heartbeat. And most people experience occasional irregular heartbeats, the kind of flutter feeling. But if it's regularly irregular, the person needs to be evaluated for it because again, that's something. When your heart goes flippity flop, it will cause a stress reaction. It will cause your body to go, oh, this is bad. And serotonin syndrome. And serotonin syndrome is when you have too much serotonin and you start having increased heart rate, increased blood pressure, etc. We're going to talk about that one. Chronic fatigue. Now, a lot of people are diagnosed with chronic fatigue. So what does it look like? Fatigue, chronic. Obviously you get fatigued easier than normal. You do normal things like getting up and doing the laundry and then you need a nap. And that's not somebody being lazy. For people with chronic fatigue syndrome, that's them feeling, you know, oh my gosh, I am exhausted. And this can also start causing depression. If they're normally, they normally did a lot of stuff, then chronic fatigue sets in. They can't do half the stuff they used to without getting completely wiped out. It'll have some mood effects. Chronic fatigue also has sore throat memory problems. So again, overlapping with depression here, enlarged lymph nodes in the neck. Muscle pain that's unexplained. Joint pain that can move from joint to joint. Now remember, if serotonin goes down, our pain perception can will go down. Our pain tolerance will go down. So someone with depression may feel pain in joints or in muscles. So differential diagnosis, and this is where the physician comes in. I'm not saying that we do this, but I do want to make sure that we effectively look at it and make sure that we've ruled out any physical causes. Headaches and exhaustion, pain in the abdominal region, allergies and sensitivities, chest pain. Think back to anxiety and panic attacks. Bloating and diarrhea that also can be common with anxiety. Dry mouth, dizziness when standing up or having problems with balance. Not totally uncommon with anxiety, also not totally uncommon in the middle of a panic attack. Irregular heartbeats, morning stiffness, jaw pain. Now with morning stiffness, thinking about it, you know, a lot of us do things occasionally and we wake up in the morning, we're like, oh, I did that wrong. If we've got somebody who has a lot of anxiety and they are tense and they're grinding their teeth all night long and they just carry tension in their muscles, they may still wake up, have morning, morning stiffness. They may not have chronic fatigue. It may be generalized anxiety or something. So we want to kind of look at how many of these symptoms are present and again, refer for a medical eval. Nausea, night sweats and chills, depression, anxiety and panic are common. Co occurring with chronic fatigue, being short of breath, just like with a panic attack, tingling sensations in your extremities like with a panic attack, and vision blurring, eye pain, sensitivity to light or dry eyes, and changes in weight. So when clients come in and if they start presenting with new symptoms, we want to take those into consideration and go, oh, does this change the clinical picture? If somebody has diabetes and they'll start talking about urinating a lot more frequently, being unusually thirsty, having extreme hunger, unusual weight loss, extreme fatigue and irritability, and some anxiety. And the weight loss, the fatigue and irritability can be common to anxiety or depression. They're also common in substance use or withdrawal from substances. If somebody's using a lot of stimulants, they're going to lose weight faster. And some substances are also appetite suppressants. So when people are using them, they're not going to be as hungry. So they may not really notice or think about where the weight loss is coming from. Hypoglycemia, which is low blood sugar, about 200,000 people per year are diagnosed with hypoglycemia when their blood sugar gets low. Like I said earlier, people may experience nervousness. A lot of times it feels kind of like a panic attack, maybe a mild panic attack, but they start feeling nervous, sweating, having intense hunger, not always trembling, weakness, heart palpitations, trouble speaking or word slurring, and difficulty concentrating. And I ask you to think back to a time when your blood sugar has gotten really low. Maybe you got to work in the morning and you worked through lunch and you're driving home in the evening, and you haven't had anything to eat all day except for maybe a diet soda and a couple of cups of black coffee or something. So your blood sugar is low. How much more difficult is it to concentrate? And do you ever find that you have trouble speaking or slurring your words because your blood sugar is low? You know, not because you've been drinking alcohol or whatever, but, you know, these are symptoms that can be really frightening to clients. And a lot of times, if they don't understand where they're coming from, if they have undiagnosed hypoglycemia, they may feel these and actually trigger a panic attack. So we want to, you know, make sure we're identifying what's going on. Fibromyalgia. Now I said hypoglycemia is about over 200,000 cases a year. Fibromyalgia is diagnosed with over 3 million cases a year. So fibromyalgia is probably a diagnosis that some of your patients have because there's also a higher rate of people with depression and anxiety. Among people with depression, fibromyalgia. Fibromyalgia, chronic muscle pain, muscle spasms, tightness or weakness, moderate or severe fatigue and decreased energy. So it kind of overlaps some with chronic fatigue, but it also overlaps with depression, insomnia, or waking up feeling just as tired as when you went to sleep. Again, this is overlapping with both depression and anxiety symptoms. Difficulty remembering and concentrating. Overlapping with chronic fatigue and mood disorders. Irritable bowel syndrome, you know, upset belly. Since we know that, again, a bunch of the serotonin is in our gut. If serotonin levels are wonky because of depression or anxiety or because of food allergies or something else, you know, there's a bunch of other things. People may experience. Irritable bowel tension or migraine headaches, not uncommon in people with anxiety who hold a lot of their stress in their neck and maybe squint a lot. Jaw and facial tenderness could be fibromyalgia. Could be somebody who grinds their teeth every night, so their face is actually sore in the morning. I'm one of those people that grinds my teeth at night, and. And I've actually cracked the enamel on several of my teeth. And that's with the splint that I get to wear at night. And it's one of those things. I just wake up in the morning and I'm like, okay, do I have an earache? Or. No, no, I was probably grinding my teeth last night. So I Can recognize that, and I can sort of differentially diagnose for myself. But it's important to, you know, understand that these things can be common for mood disorders. But there also may be an underlying medical sensitivity to odors. Noise, lights, medications, food and cold. Some people may naturally be sensitive to medications. I know I am. I can take one Benadryl, and I'm just, like, passed out. And I'm also really sensitive to odors, especially when my estrogen is high. When I was pregnant, I couldn't be around anything. So this may be a normal condition for somebody, or it may be an indication that there's something physical going on. Feeling anxious or depressed. Just like with chronic fatigue syndrome, you're going to see these symptoms, or you can see these symptoms concurrently with fibromyalgia. And it may be part of the fibromyalgia. It may be a result of having fibromyalgia part, or it may have triggered the fibromyalgia. So either way, we need to address it. But understanding, you know, if we hear a client reporting anxiety and or depression symptoms, we do want to poke around a little bit to see if there's something else going on that requires a medical referral. Numbness or tingling in the face, arms, hands, legs, and feet. Now, remember, and I can never remember which arm it is, but if people have shooting pains down their arm or they have numbness in their arm, probably want to refer them to a medical evaluation because that can be a sign of an impending heart attack or stroke. But it could also be fibromyalgia. Sleeping wrong. Especially, you know, if you sleep wrong on your shoulder, your hand may go to sleep. So encouraging clients not to get freaked out. But that might be something that warrants taking a look at reduced tolerance for exercise. Just like chronic fatigue syndrome with fibromyalgia, people, you know, they go out and they exercise, and you can use that term pretty loosely. They may go out and walk the dog and come home and they're just, like, completely wiped out. A feeling of swelling in hands and feet without actually having swelling. And dizziness. So dizziness keeps coming up, too. You see, again, just like yesterday when we were talking about the neurotransmitters, a lot of these disorders and conditions overlap. Not only the medical conditions, but the mental health stuff. Hypertension, severe headache, fatigue or confusion, vision problems, chest pain, difficulty breathing, irregular heartbeat, blood in the urine. Now, that doesn't overlap with mental health, thank goodness. And pounding in your chest, neck, or ears. So we're also looking. You do have people who have generalized anxiety and concurrent hypertension that those two don't surprise you to see them together. So if you've got somebody with anxiety, we want to also ask them about any of these symptoms to see or, and, or if they've been to the doctor recently to see where their blood pressure is. If they're experiencing acute chest pain, again, refer out because we don't want people to have a heart attack or stroke. Heart issues in general, and like I said, there's a whole bunch of different heart issues. Shortness of breath, palpitations, a faster heartbeat, weakness or dizziness, nausea and sweating. These are all similar to a panic attack. But these are all also sort of anxiety symptoms. So if somebody's experiencing anxiety and likely there's some cognitive behavioral stuff going on too, no doubt. But if they're struggling to make the gains that they're hoping for, or if they're still struggling with weakness and dizziness or it's pronounced, we want to refer them to be evaluated by their physician to make sure that there's not some sort of heart issue going on. And most of the heart issues can be corrected quite easily. So I don't want people to get freaked out. But if they are feeling, especially if they're feeling easily tired, sweating, nausea, or their heart is beating faster or slower than usual, I really want them to go get evaluated to rule out anything else that might be causing it. Lupus, and you know, you may be going, well, what is lupus? Lupus is actually a pretty common autoimmune diagnosis with over 200,000 people again getting diagnosed each year. Painful, swollen joints, unexplained fever, red rashes most commonly on the face. Chest pain upon deep breathing, unusual loss of hair, which you also see in polycystic ovarian syndrome. Pale or purple fingers or toes from cold or stress. So if, you know, if their fingertips start turning really pale or purple, something to take a look at if they're sensitive to the sun, if they have actual swelling in the legs or around their eyes, mouth ulcers, swollen glands. And then here's where we get to the overlap. Fatigue, confusion, dizziness, depression and extreme excitability in certain types of lupus. So you can have some manic type symptoms here too. And this might be something that you want to look at considering adjusting your intake packet. So there's a check sheet for people to go through and check off any symptoms that they may be having, because you probably don't have the time or the desire to go through each one of these with each client each day. But if they can do a check sheet, then you can get a more global picture of what's going on and it will facilitate a warm referral to their physician. So, you know, with release of information, you can let their fax over this information or send over this information to their physician. Polycystic ovarian syndrome. Again, really common, 200,000 cases a year. So you're asking, what is it? People with polycystic ovarian syndrome are females. They typically have increased hair on their face, chest, torso, thumbs and toes and tend to have a lot of weight gain around the middle and male pattern baldness and or very thin hair. So if somebody is exhibiting those signs, they may want to go get evaluated by their doctor or endocrinologist. They also have infrequent, absent or irregular menstrual periods, cysts on the ovaries, acne, oily skin and dandruff. Patches of skin on the neck, arms, breasts or thighs that are thick and dark brown or black skin tags the excess flaps of skin in the armpits or neck areas. And, you know, I think everybody gets the occasional skin tag here and there. But if they're getting a lot of them, you know, something to consider. They have pelvic pain, anxiety or depression and sleep apnea. And a lot of the sleep apnea they've attributed to the middle weight, weight gain, causing problems with breathing during sleep. But think about this. If people are having sleep apnea, we know that with polycystic ovarian syndrome, their hormones are not in whack, for lack of a better term. And because of the physical symptoms of it, with the really thin hair, inability to lose weight, heavy weight gain, and potentially obesity, our society is not overly welcoming of those kinds of physical characteristics and can be highly critical. So there may be some other psychosocial stuff and anxiety, depression that is being caused by this. So, you know, let's make sure we try to get this addressed as well as we can. And obviously there are medications that can help. Thyroid issues, another 200,000 plus a year. Some hyperthyroid, some hypothyroid. Now think hyperthyroid. Hyper. There's too much thyroid hormone, so it's going to be more manic anxiety like symptoms. With hypothyroid, you've got more fatigue, weakness and weight gain, coarse, dry hair, dry, rough, pale skin, cold intolerance, muscle cramps, constipation, depression, irritability, memory loss, abnormal menstrual cycles and decreased libido. When does this happen? You know, is it something you've always had? No, not necessarily. Thyroid issues can happen at any point in your life. Women who have recently had a child are at an increased risk for having some thyroid changes. So, you know, if you've got a client who just had a child and starts exhibiting some of these symptoms, might be worth having it checked out. A lot of times when people go to their doctor and complain of depression like symptoms, doctors will do a basic blood panel to look at thyroid hormones. But sometimes it's a little bit more difficult to pick out. So more intensive thyroid or different types of thyroid tests need to be run. And if somebody suspects they've got thyroid problems, they can go on and look at, look up those tests and advocate for themselves. The big take home is the fact that thyroid problems, especially hypothyroid, are really not uncommon. And there's medication that can treat it, so it's not a big deal. But they can also. A lot of times, hypothyroid really strongly mimics depression. And, you know, you may feel you're going to feel depressed, but once the thyroid levels are leveled out and at the right place, people often start feeling a lot better. Now, they may still have some frustration or grief or whatever that they need to deal with resulting from whatever happened during the period before they were diagnosed. But with hypothyroid, a lot of times, if we get the thyroid levels correct, people start feeling significantly better. And the nice thing is it's quickly. So serotonin syndrome. I promised you we'd go over this again. Agitation or restlessness, confusion, rapid heart rate and high blood pressure, dilated pupils, loss of muscle coordination or twitching muscles or muscle rigidity. So, you know, heavy sweating, diarrhea, headache, shivering or goosebumps, high fever or seizures. Serotonin syndrome happens when the person, the level of serotonin in the person's system goes up above what is okay for them. Since we can't measure neurotransmitter levels accurately, we can't say if it goes above so much per nanoliter of blood. What we're looking at is, you know, when it goes above what's normal for them. And it's important to recognize that you don't have to have somebody who is in a medical crisis with serotonin syndrome for them to have serotonin syndrome. There's like pre diagnostic or pre. What's the word I'm looking for before it meets the criteria for diagnoses? You know, we want to treat it then. We don't want to let it get to the point where it's a life threatening crisis. So patients need to be aware of what's going on. Over the counter medications, including cough syrups and diphenhydramine supplements, including five HTP and same types of ginseng in addition to SSRIs. But clients do not need, do not need to be on an SSRI to be on a prescription serotonin drug in order to experience serotonin syndrome. It can happen with over the counter medications that are used. You know, sometimes they're used in combination, but they're used like as they're supposed to be on according to the bottle. But when you put the two of them together or three of them together, it ends up causing too much serotonin in the system. So like if you combine same with 5 HTP, don't do it. Even if you're taking both of them as prescribed, the two of them together can overload your system. So let's talk briefly about substances. Substances that can cause depression symptoms include opiates. You know, opiates are a system depressant. Some opiates make people feel like they're uber selves, especially Vicodin. I found a lot of people experience almost more energy and sort of a giddy attitude on that as opposed to some of your other opiate drugs. But opiates can produce depression symptoms. When used above normal amounts, it can suppress respiration and heart rate. Anti anxiety medications, your benzodiazepines are also possibly going to produce symptoms of depression depressants. Your barbiturates, your sleep aids can produce depressive symptoms, inhalants. And this includes paint. And I put that there because, you know, if you've ever been in a situation like you're painting the inside of your house and it's not well ventilated, you can start feeling symptoms of depression. And some people are really sensitive to paint fumes. They don't have to be, you don't have to be huffing paint to experience some of the neurological effects of it. So being aware that that's true. Interestingly, there are a couple of types of paint out right now that are mineral based and they don't have the formaldehyde and all the other stuff that people tend to react poorly to in the VOCs. So if you're having your facility painted, consider looking into one of the green paints that is supposed to be odor free. GHB is a depressant and it will produce depression effects. Alcohol initially is a system depressant. It monkeys with serotonin levels and can produce, not only when somebody's taking it, it will have that depressant disinhibitory effect. But when they are detoxing from it after the anxiety period, they can have sort of enduring depression from what happened kind of while they were, while it was in their system. When people drink alcohol the first hour or two after they drink it, they're going to have those depressant effects. And then as it starts to leave their system, the g, the I did that yesterday too. The GABA system can't keep up with how fast it's leaving their system. So a lot of people start feeling excessive anxiety and they'll medicate that by having another drink. People experience depression from withdrawal or recovery from stimulant intoxication or use. So if you've just used cocaine or crack or something else and you're coming down off of it, yeah, you're going to feel tired, you're going to kind of bottom out. But people who've been using for a while, you know, it's kind of like sitting in the driveway with your foot on the gas and just revving that engine, and revving that engine. It takes a while for the engine to cool down after you do that for a period of time. The body requires time after it's been revved for a couple of days or a week, binge or something, the person is going to feel depressive type symptoms, most likely for a week or two afterwards. And cannabis intoxication. And this is more true of heavy users. But cannabis can produce symptoms of lack of motivation, apathy, lack of pleasure in most things. And again, it's certain strains especially that people use that are higher in certain chemicals. The key takeaway point is to recognize that cannabis can have some weird effects. Spice definitely can have some long standing effects including psychosis, mania. Manic symptoms can be triggered by ecstasy, mdma, methamphetamine. Neither one of those really probably surprises you. Cocaine, not a surprise. Steroids can trigger manic like symptoms and hypomanic like symptoms. So if you've got somebody who may not be using recreationally for mood issues but is using steroids as a bodybuilder, they may experience some manic type symptoms and potentially some aggressive symptoms. Caffeine, you know, yeah, even a pot of coffee is probably not going to produce mania. But if somebody is abusing supplements that have caffeine in them and there's actually an upper tolerable limit of caffeine that's safe, you can actually overdose on caffeine enough to cause yourself to end up in the hospital. But caffeine can cause manic and anxiety type symptoms. Ginseng, overuse energy drinks and pre workout supplements. And one of the things that I see with this, especially with the energy drinks, is people look at the caffeine on the energy drink and they're like, there's not that much caffeine in that compared, comparatively speaking, compared to Starbucks or something. So, you know, I can drink six of these, no big deal. What they're not taking into account is all of the other stuff that's in those energy drinks, including ginseng in many cases that contribute to the energy that it's giving you. So making sure that people understand that energy drinks, while they may not have much caffeine, as some other things, have a lot of stimulant substances in them and can trigger manic or anxiety episodes. And when you're coming off of them, can trigger depression or lethargy, a rare ish side effect. When somebody who has bipolar disorder is given an ssri, it can trigger a manic episode. So if you've got a client, they start on an ssri, they have a manic episode. You might think, oh well, let's back up here. There's more to the clinical picture. Anxiety symptoms can be caused by caffeine. And this is even lower amounts of caffeine if somebody is particularly sensitive or and especially if it's taken in a short period of time. 300 milligrams of caffeine, for example, over the course of the day, not as likely to produce anxiety symptoms as getting a large coffee at Starbucks. And you know it has like 300 milligrams of caffeine in it and drinking it in an hour and then your body's just flooded and you're like wired decongestants. People don't think about these. So if you've got a client who is coming in and they're complaining of anxiety symptoms, and especially sudden onset anxiety symptoms, you've been treating them for a while for whatever, and either their anxiety symptoms get worse or they've had depression and all of a sudden they've got anxiety, we want to look at it and go, hmm, what changed? And for some of these clients, maybe they started taking decongestants because they're fighting off a cold. Important for them to understand if they are more sensitive to it because decongestants are stimulants. Pseudoephedrine is one of the ingredients they use to make methamphetamine. So again, pre workout supplements and Energy drinks can cause anxiety in a lot of people. Alcohol, especially in early withdrawal. And this is, like I said, whether it's one drink and it's getting out of your system and people start feeling an anxiety response and their blood pressure goes up a little bit, or if they're withdrawing from significant alcohol use, alcohol and benzodiazepines. But alcohol is one of the few drugs that the detox is life threatening. So if somebody has been doing a fifth a day or something, has been a chronic drinker and they want to detox, strongly encourage them to go under a medically managed detoxification and they can do it. A lot of places will do outpatient, but it's important that they be medically monitored because they can. Their blood pressure can go too high and they can have a stroke, seizure, all kinds of nasty stuff. But before they get to that point, there's significant anxiety symptoms. Cannabis and spice intoxication can produce high levels of anxiety medication side effects, including SSRIs. If you've ever read the side of the bottle for medications or the insert that the pharmacist gives you, a lot of medications and interestingly, including ssri, serotonin reuptake inhibitors can cause anxiety in certain people. Sometimes it's a short thing while their body gets used to it. Sometimes it's perpetual and they may need to change medications or something. But antidepressants can cause anxiety symptoms in some people, making sure clients understand this and that it is something that's treatable. It's not like, oh my gosh, I have another symptom coming on. We want to say again, what changed that prompted these symptoms coming on? And if it's a medication than having them work with their doctor to figure out what to do about it. Mood and physical symptoms can all be caused by physical conditions, substances including withdrawal or intoxication, and what I call rebalancing that period of, you know, one day to a month where the brain is going or even somewhat longer where the brain is trying to get the neurotransmitters back in balance with not having the substance there. They can be caused by mood issues. Depression can cause physical symptoms as well as mood issues. And psychosocial stressors can cause both mood and physical symptoms. So maybe somebody doesn't have long standing depressive disorder, they've just got an adjustment disorder going on or however you want to diagnose it because of an acute psychosocial stressor. Unless we address the psychosocial stressor, they're going to have difficulty achieving Full recovery, full and effective recovery requires identifying and addressing both the presenting symptoms to provide proximal relief. So if they come in complaining of anxiety, you know, they're looking for help, they're looking for hope. So we want to give them tools to start addressing that and help them feel like they're getting traction. But we also need to look at the underlying cause of the presenting symptoms. Remember the leak? What is keeping you from feeling happy? Because we need to address that. If you, if all you do is, you know, turn up the water pressure when you don't have enough water pressure in your house, well, what you could end up doing is making that crack worse if there's a leak in the system. So it's important to look at the underlying causes, the vulnerabilities that may be contributing to or causing the presenting symptoms, including physical issues as well as psychosocial stressors. So there are some brief texts that you can look at that talk about different drugs if you're not familiar with some of the different drugs of abuse. And you can find them in Spanish as well. Are there any questions? Alrighty, everybody. I know that was another one of those that was really academic, but I think it's good to periodically remind ourselves other things that we need to look for in our assessment process in order to make sure clients achieve the best possible and longest lasting recovery. Have an amazing weekend and I'll see you all on Tuesday. 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.