SIF Differential Diagnosis
5/14/2014
Webinar Objectives Differential diagnosis: Navigating difficult diagnostic dilemmas
Anna Ratzliff, MD, PhD
Diagnostic Assessment Workflow
Interview
Develop a Differential
Additional Assessment
Working Diagnosis
The Diagnostic Interview • Systematic information gathering about the patient’s presenting complaints, symptoms and other relevant history • Will lead to a formulation of the patient’s problems and diagnoses • Essential part of building therapeutic alliance • Best done at the first meeting • Why do we care about the diagnosis? – Guides treatment and clinical decision making!
• Integrate a structured diagnostic work flow into the assessment process. • Use diagnostic screeners to aid in developing a differential diagnosis. • Describe an approach to differentiation of common diagnostic dilemmas. • Apply communication strategies to discuss provisional diagnosis with other team members
Diagnostic Assessment Workflow
Interview
Develop a Differential
Additional Assessment
Working Diagnosis
The Diagnostic Interview – Get Organized! • Give an orientation to the structure of the interview – Introduce the concept of the assessment being an important part of getting them the right help
• Start with open-ended question • Let the patient talk for 3-5 minutes • Keep a checklist in mind of the questions you need to ask, and get focused. – History of Present Illness – Past Psychiatric History – Social History and Functional Assessment
1
SIF Differential Diagnosis Screen Five Major Diagnostic Areas
5/14/2014
HPI – Mood Card
Mood: Depression, Mania/Hypomania
• Mood • • • • •
Anxiety: Generalized anxiety, Panic attacks, PTSD, OCD
– “Has there ever been a period of time in your life that lasted for at least a few days in a row when you felt unusually happy or energized for no particular reason?” – “For how long did you feel that way?” – “How was your sleep during that time?” – “How often does an episode like this occur?” – Inquire about pertinent substance use
Psychosis: Primary, Secondary Substance Use: Alcohol, Illicit, Prescription Organic: Cognitive impairment, Relevant medical history
HPI – Anxiety Card • Generalized anxiety – “Do you find yourself feeling nervous or on edge for no particular reason?” – “Are you a worrier?”
• Panic attacks – Inquire about the presence of unprovoked attacks
• PTSD – “Has there been anything that felt particularly traumatic and still comes back to haunt you?” – Reassure the patient that you don’t have to know the details of the trauma while trying to understand the basic nature of the trauma – Nightmares, flashbacks, hypervigilance, avoidance
• OCD – – – –
Washing/cleaning Checking Ordering/counting Hoarding
HPI – Substance Use Card • Ask about each substance individually and don’t be shy – Alcohol • “How often do you use alcohol?” • “How many drinks do you usually have in a day?” • “When was the last time you had anything to drink?”
– – – –
Marijuana Heroin Cocaine Methamphetamine • “Have you ever used ___ ?” • “For long did you use it on a regular basis?” • “When was the last time you used it?”
– Prescription drugs, such as benzos and opioids
– Duration, trigger
Sleep Appetite Energy level Suicidal ideation Mania/hypomania
HPI – Psychosis Card • Questions may need to be tailored to the specific patient • Be alert to signs of possible psychosis: Thought/behavioral disorganization, vagueness of speech, bizarre mannerism, response to internal stimuli • Common ways to phrase your question: – “Have you ever had strange experiences such as hearing voices when no one is around, or seeing things that aren’t there?” – (When suspecting psychotic depression) “Sometimes when people feel very depressed, they can have strange experiences such as hearing voices when no one is around. Has something like this ever happened to you?”
• Inquire about possible delusions when appropriate: – “Have you ever felt that other people (such as your neighbors, or government organizations) are out there to get you?”
HPI – Organic Card • Be alert to signs of possible cognitive impairment: forgetfulness, word-finding difficulty, difficulty tracking conversation • Pertinent medical history: – – – – – –
Head trauma Seizures Thyroid problems Chronic pain Medications Other neurologic disorders
2
SIF Differential Diagnosis
Past Psychiatric History
5/14/2014
Making a Diagnosis
• Psychiatric hospitalizations • Suicide attempts • Past medication trials
Symptoms
– Which medications? – For how long? – Tolerability? – Efficacy?
Social History and Functional Assessment • Start with the present • Focus on pieces relevant to determining the patient’s functional status – Housing situation – Social support • Lives alone? Married? Family? Friends?
– Education attainment – Employment history – Legal history • This is also relevant to assessing violence risk
Screeners as “Vital Signs”
Disorder Functional Impairment
Functional Assessment: Activities of Daily Living • This is only relevant when you suspect the patient may have difficulty handling common daily tasks • Ask how the patient normally spends his/her day, and his/her ability to: – Bath/dress self – Prepare meals – Perform common household chores, e.g., cleaning, laundry – Manage money
Diagnostic Assessment Workflow
• Screeners are like monitoring blood pressure! – Identify that there is a problem – Need further assessment to understand the cause of the “abnormality” – Help with ongoing monitoring to measure response to treatment
Interview
Develop a Differential
Additional Assessment
Working Diagnosis
3
SIF Differential Diagnosis Additional assessment? Depression
5/14/2014
Unipolar Depression: MDD,Dysthymia,Adjustmentd/o
Historyof manic/hypomania
BipolarDisorder,Depressed/Mixed
PervasiveAnxiety/worry
GeneralizedAnxietyDisorder
Recurrentunprovoked panicattacks
PanicDisorder
ReͲexperiencing traumaticevents
PTSD
Obsessionsor compulsions
OCD
Diagnostic Assessment Workflow
Anxiety
Interview
Psychosis
PrimaryPsychoticDisorders SubstanceͲInducedPsychosis MoodDisorderswithPsychosis
Problematic SubstanceUse
SubstanceAbuse/Dependence
Mood Disorders
Working Diagnosis
PHQ-9 Positive: Don’t assume it is unipolar depression!
Unipolar Depression: MDD,Dysthymia,Adjustmentd/o Historyof manic/hypomania
BipolarDisorder,Depressed/Mixed
PervasiveAnxiety/worry
GeneralizedAnxietyDisorder
Recurrentunprovoked panicattacks
PanicDisorder
ReͲexperiencing traumaticevents
PTSD
Obsessionsor compulsions
OCD
• Distress • Unipolar Depression – Major Depressive Disorder – Adjustment
Anxiety
Psychosis
PrimaryPsychoticDisorders SubstanceͲInducedPsychosis MoodDisorderswithPsychosis
Problematic SubstanceUse
SubstanceAbuse/Dependence
• • • •
Bipolar Disorder: Hypomania/mania Substance abuse/dependence Anxiety Disorder Organic causes
Acute:Delirium Chronic:Dementia,Psychotic Disorders
Organicand Cognitive
Bipolar Disorder Diagnosis
Mood Symptom Summary Symptom Cluster
Additional Assessment
Acute:Delirium Chronic:Dementia,Psychotic Disorders
Organicand Cognitive
Depression
Develop a Differential
Consider
Unipolar Depression:
Only depression
Screeners
PHQ9
Depression BipolarDisorder: Historyof manic/hypomania
CIDI or MDQ
• Diagnosis = Screening Tool (e.g., MDQ, or CIDI-3) + Follow-Up Questions • Follow-Up Questions are key to eliminating false positives (e.g., mood episodes from substance abuse). • May also need observation over time and collateral information (e.g., from family)
4
SIF Differential Diagnosis
5/14/2014
Bipolar Disorder: Follow-up Questions • • • • • •
How long do the hypomanic/manic episodes last? How frequently do the hypomanic/manic episodes occur ? During periods of sobriety have you had hypomanic/manic episodes? Do you have a family history of bipolar disorder or schizophrenia? Have you been previously diagnosed with bipolar disorder, and if so, by whom? Have you previously been treated with antidepressants? How did you respond?
• Describe most recent mood episode – When did it start? – How long did it last? – How was your sleep? – Were you using substances? – How would your friends and family describe your behavior?
University of Washington © 2011
Anxiety Disorders Depression
Still stuck?
Unipolar Depression: MDD,Dysthymia,Adjustmentd/o Historyof manic/hypomania
BipolarDisorder,Depressed/Mixed
PervasiveAnxiety/worry
GeneralizedAnxietyDisorder
Recurrentunprovoked panicattacks
PanicDisorder
ReͲexperiencing traumaticevents
PTSD
Obsessionsor compulsions
OCD
Anxiety Summary GeneralizedAnxiety Disorder:Pervasive Anxiety/worry PanicDisorder: Recurrentunprovoked panicattacks
Anxiety
Anxiety
Psychosis
PrimaryPsychoticDisorders SubstanceͲInducedPsychosis MoodDisorderswithPsychosis
Problematic SubstanceUse
SubstanceAbuse/Dependence
Organicand Cognitive
PTSD:ReͲexperiencing traumaticevents
PCL-C
OCD:Obsessionsor compulsions
Y-BOCS
Acute:Delirium Chronic:Dementia,Psychotic Disorders
GAD-7 Postive: Don’t assume it is anxiety • • • •
GAD-7
Major Depressive Disorder Bipolar Disorder: Hypomania/mania Substance abuse/dependence ADHD
University of Washington © 2011
Psychotic Disorders Depression
Unipolar Depression: MDD,Dysthymia,Adjustmentd/o Historyof manic/hypomania
BipolarDisorder,Depressed/Mixed
PervasiveAnxiety/worry
GeneralizedAnxietyDisorder
Recurrentunprovoked panicattacks
PanicDisorder
ReͲexperiencing traumaticevents
PTSD
Obsessionsor compulsions
OCD
Anxiety
Psychosis
PrimaryPsychoticDisorders SubstanceͲInducedPsychosis MoodDisorderswithPsychosis
Problematic SubstanceUse
SubstanceAbuse/Dependence
Organicand Cognitive
Acute:Delirium Chronic:Dementia,Psychotic Disorders
5
SIF Differential Diagnosis
5/14/2014 Substance Use Disorders
Differential for Psychosis
Depression
Primary Psychotic
Mood Disorder
Schizophrenia
Bipolar Disorder
Substance Induced
Medical Conditions Delirium
Intoxication
Major Depression
Withdrawal
Other
Historyof manic/hypomania
BipolarDisorder,Depressed/Mixed
PervasiveAnxiety/worry
GeneralizedAnxietyDisorder
Recurrentunprovoked panicattacks
PanicDisorder
ReͲexperiencing traumaticevents
PTSD
Obsessionsor compulsions
OCD
Other
Brief Psychotic Disorder
Anxiety
Dementia Schizoaffective disorder
Unipolar Depression: MDD,Dysthymia,Adjustmentd/o
Delusional Disorder
Psychosis
PrimaryPsychoticDisorders SubstanceͲInducedPsychosis MoodDisorderswithPsychosis
Problematic SubstanceUse
SubstanceAbuse/Dependence
Acute:Delirium Chronic:Dementia,Psychotic Disorders
Cognitive Impairment
The great masquerader: Substance use
Diagnostic Assessment Workflow
• Past use? • Drugs of choice? • Treatment? – Relapse prevention?
Interview
Develop a Differential
Additional Assessment
Working Diagnosis
• Signs of use? • Current Use?
“Working Diagnosis”
Working Diagnosis
• Most common disorders are most common
Assessment by CM and PCP
– Mood disorders and anxiety are most common
• Use your diagnosis to guide treatment planning – Ex. Bipolar disorder will need a mood stabilizer
• Diagnoses can change over time as you gather more information and observations
Psychiatric Consultant Case Review or Direct Evaluation
Screeners filled out by patient Working diagnosis and treatment plan
6
SIF Differential Diagnosis
5/14/2014
Assessment and Diagnosis in the Primary Care Clinic Gather information
Provide intervention
Exchange information
Generate a treatment plan
-Diagnosis can require multiple iterations of assessment and intervention -Advantage of population based care is longitudinal observation and objective data -Start with diagnosis that is your ‘best understanding’
Case 1 • The patient is a 35-year-old male presenting to his primary care clinic complaining of depression. Patient reports a history of worsening depression over the 3 months. Patient reports difficulty sleeping, irritability, poor energy, poor appetite, feelings of worthlessness and hopelessness, passive suicidal ideation and depression. • What do you think about when getting ready for his assessment?
Differential Diagnosis Unipolar Depression: MDD,Dysthymia,Adjustmentd/o
Depression
Historyof manic/hypomania
BipolarDisorder,Depressed/Mixed
PervasiveAnxiety/worry
GeneralizedAnxietyDisorder
Recurrentunprovoked panicattacks
PanicDisorder
ReͲexperiencingtraumatic events
PTSD
Obsessionsorcompulsions
OCD
Mood Symptom Summary Symptom Cluster
Consider
Unipolar Depression:
Anxiety
Only depression
Screeners
PHQ9
Depression BipolarDisorder:
Psychosis
PrimaryPsychoticDisorders SubstanceͲInducedPsychosis MoodDisorderswithPsychosis
Problematic SubstanceUse
SubstanceAbuse/Dependence
Organicand cognitive
Acute:Delirium Chronic:Dementia,PsychoticDisorders
HPI – Mood Card • Mood – Duration, trigger
• • • • •
Sleep Appetite Energy level Suicidal ideation Mania/hypomania – “Has there ever been a period of time in your life that lasted for at least a few days in a row when you felt unusually happy or energized for no particular reason?” – Inquire about pertinent substance use
Historyof manic/hypomania
CIDI or MDQ
Case 1 … continued • When the patient is asked about bipolar symptoms, the patient has a positive CIDI screener. • Patient reports a previous history of heavy alcohol use. • How would you ask about his previous episodes of mania?
7
SIF Differential Diagnosis
Bipolar Disorder: Follow-up Questions • • • • • •
How long do the hypomanic/manic episodes last? How frequently do the hypomanic/manic episodes occur ? During periods of sobriety have you had hypomanic/manic episodes? Do you have a family history of bipolar disorder or schizophrenia? Have you been previously diagnosed with bipolar disorder, and if so, by whom? Have you previously been treated with antidepressants? How did you respond?
Case 1… conclusion • Be sure to ask about psychosis and other physical symptoms • Working diagnosis: Bipolar I disorder, current episode depressed • Consider Bipolar I disorder, mixed episode; Substance induced mood disorder and Mood disorder secondary to medical condition • Treatment implications – Helpful if can ask about previous treatment response
Key Elements for Talking to PCP
5/14/2014
Case 1… continued • The patient reports that sometimes he has mood episodes that go up and down over a day. • However, he notes two previous episodes of increased energy after little sleep. During these periods of time, he reported "working on a book", spending money to develop a tour to sell his book, impulsive travel to another state and increased sexual promiscuity. • He notes these happened during a period of sobriety. • The patient also reports periods of approximately one week lasting up to one month of increased irritability, agitation with a depressed mood. What is your working diagnosis? Are there other questions you would ask?
Communication: How and When? • Communication is key to team function! • Consider modality – – – – –
In person Staff (MA or nurse) Phone Fax Email (careful with confidential info) – EMR
• Frequency
– Scheduled – As needed
PCP Core Program
Patient
CM
Other Behavioral Health Clinicians
Substance Treatment, Vocational Rehabilitation, CMHC, Other Community Resources
Psychiatric Consultant
Additional Clinic Resources Outside Resources
PCP Discussion Template
• Understand any concerns they have about the patient • Baseline Clinical measures – e.g., PHQ-9 Score
• Current Symptoms – Symptoms that aren’t improving
• Current treatment(s) and length of time • Problematic side effects • Psychiatric consultant recommendations (if relevant)
8
SIF Differential Diagnosis
5/14/2014
Communicating with Psychiatric Consultant
Model Consultation Hour • Brief check in
Care Manager
Psychiatric Consultant
Each 0.5 FTE care manager = 1 hour/week with consultant
Weekly consultation -review caseload -create recommendations -track outcomes
4-6 patients per hour
Consulting Psychiatrist Review Template • ID • Current symptoms and functional impairment – – – – –
• • • •
Mood Anxiety Psychosis Substance use Organic and Cognitive
Suicidality/Safety Medical problems Behavioral health history Psychosocial factors
– Changes in the clinic – Systems questions
• Identify patients and conduct reviews – – – –
Flagged by CM Not improved w/o note Severity of presentation Disengaged from care
• Wrap up – Confirm next consultation hour – Educational resources discussed
Not Just Meds! • Psychiatric consultant can help: – Clarify diagnosis – Suggest psychotherapeutic interventions – Brainstorm strategies when patient not improving – Provide emotional support to Care Manager
Thank you!
Questions
• Questions?
• Personality Disorders • ADHD • Malingering
– Anna:
[email protected]
9
SIF Differential Diagnosis
• •
•
5/14/2014
Personality Disorders
ADHD
• Often co-exist with other psychiatric disorders • Be sensitive to personality traits/disorders for guiding therapeutic stance • Observation over time is especially important to make these diagnoses • May consider a personality disorder when do not respond to treatment or have significant interpersonal difficulties
• Diagnosis of exclusion • Inattention and difficulty with concentration are common in many mood, anxiety and psychotic disorders • Treat other psychiatric disorders first, then re-assess attention • Obtain additional function impairment history
Factitious Disorder and Malingering
Social Innovation Fund
Factitious disorder — The essential feature of factitious disorder is intentionally faking symptoms in order to assume the sick role, ie, to be a patient Malingering — The essential feature of malingering is intentionally faking or grossly exaggerating symptoms for an obvious, external incentive such as avoiding work, avoiding criminal prosecution, obtaining financial compensation, or obtaining medications Clinicians should suspect malingering when any combination of the following is present: – medical-legal context (eg, patient is referred by an attorney for evaluation) –
marked discrepancy between the patient's claimed distress or disability and the objective findings; pan-positive symptoms across many categories! – noncompliance with diagnostic evaluation or treatment – antisocial personality disorder
– What can’t they do right now because of poor attention? • Educational and work functioning history are informative
• Applying these principles within the eligibility criteria for SIF is the topic for the next care manager call – Wednesday, May 21 – Bring questions about SIF eligibility to that call
University of Washington © 2010
10