Psychiatric disorders, diagnosis

Kranzler HR, Rosenthal RN Dual diagnosis alcoholism and co-morbid psychiatric disorders. Am J Addict 12 (suppl 1) S26—S40, 2003 Kranzler HR, Tinsley JA (eds) Dual Diagnosis Substance Abuse andComorbid Medical and Psychiatric Disorders, 2nd Edition. New York, Marcel Dekker, 2004... 

Comparable findings for lifetime prevalence of psychiatric disorders were obtained in another study of 133 persons, which also found that 47% received a concurrent DSM-III diagnosis of substance abuse or dependence (Khantzian and Treece 1985). The most frequently abused substances were sedative-hypnotics (23%), alcohol (14%), and cannabis (13%). Similar rates of psychiatric disorders were found in other studies of drug abusers (Mirin et al. 1986 Woody et al. 1983). Although such diagnoses do not imply causality, and, in many cases, opioid dependence causes or exacerbates psychiatric problems, some causal link seems likely (Regier et al. 1990). 

Bipolar disorder can be conceptualized as a continuum or spectrum of mood disorders and is not comprised solely of bipolar I disorder.9 They include four subtypes bipolar I (periods of major depressive, manic, and/or mixed episodes) bipolar II (periods of major depression and hypomania) cyclothymic disorder (periods of hypomanic episodes and depressive episodes that do not meet all criteria for diagnosis of a major depressive episode) and bipolar disorder, NOS. The defining feature of bipolar disorders is one or more manic or hypomanic episodes in addition to depressive episodes that are not caused by any medical condition, substance abuse, or other psychiatric disorder.1... 

Bipolar disorder, previously known as manic-depressive illness, is a cyclical, lifelong disorder with recurrent extreme fluctuations in mood, energy, and behavior. Diagnosis requires the occurrence, during the course of the illness, of a manic, hypomanic, or mixed episode (not caused by any other medical condition, substance, or psychiatric disorder). 

Most treatment-resistant depressed patients have received inadequate therapy. Issues to be considered in patients who have not responded to treatment include the following (1) Is the diagnosis correct (2) Does the patient have a psychotic depression (3) Has the patient received an adequate dose and duration of treatment (4) Do adverse effects preclude adequate dosing (5) Has the patient been compliant with the prescribed regimen (6) Was treatment outcome measured adequately (7) Is there a coexisting or preexisting medical or psychiatric disorder (8) Was a stepwise approach to treatment used (9) Are there other factors that interfere with treatment ... 

For example, epigenetics and enviromnental factors may play important roles in major psychiatric disorders. Detailed methods for studying these factors are given to provide a prototype model system for better diagnosis and management of... 

The differential diagnosis of depression is organized along both symptomatic and causative lines. Symptomatically, major depression is differentiated from other disorders by its clinical presentation or its long-term history. This is, of course, the primary means of distinguishing psychiatric disorders in DSM-1V. The symptomatic differential of major depression includes other mood disorders such as dysthymic disorder and bipolar disorder, other disorders that frequently manifest depressed mood including schizoaffective disorder, schizophrenia, dementia, adjustment disorder, and post-traumatic stress disorder, and, finally, other nonpsychiatric conditions that resemble depression such as bereavement and medical illnesses like cancer or AIDS. 

Primary care physicians are critical to the successful identification of GAD. Characterized by often-vague physical complaints, GAD must be distinguished from medical illnesses and other psychiatric disorders, though the high rate of comorbidity requires that a thorough evaluation for GAD be completed even when another disorder has been identified. GAD warrants particular consideration for those patients with nonspecific physical complaints who nevertheless have an urgent need for relief that has resulted in repeated office visits. The differential diagnosis for GAD includes other anxiety disorders, depression, and a variety of medical conditions and substance-induced syndromes. 

It is also important to know about comorbid psychiatric disorders. If these are overlooked, treating the substance use disorder becomes significantly more difficult. Recognizing this, most treatment centers have developed dual diagnosis programs to treat those patients who have another major psychiatric illness in addition to a substance use disorder. It may be virtually impossible to discern at first, but the other psychiatric illnesses might either contribute to or be a result of substance use. The social toll of alcoholism alone can trigger a severe clinical depression. However,... 

Psychiatric medications do not currently play a prominent role in the treatment of cocaine-dependent patients (see Table 6.4). Although researchers have labored to find medications to treat cocaine addiction, there have not been any notable breakthroughs. As with other substance use disorders, the presence of a psychiatric disorder for which medication is indicated (i.e., depression, anxiety disorders, bipolar affective disorder, or schizophrenia) should prompt appropriate treatment. Similar to the presence of alcohol intoxication, deferring a diagnosis for a day or two in a new patient with no past history is often the more prudent course. 

Appropriate management of AN also requires the early detection and treatment of any comorbid psychiatric disorders. The most common comorbid conditions associated with AN are major depressive disorder (MDD), obsessive-compulsive disorder (OCD), and substance use disorders. At the time of presentation, over 50% of AN patients also fulfill criteria for MDD however, accurate diagnosis of depression in these patients is complicated by the fact that prolonged starvation often produces a mood disturbance and neurovegetative symptoms identical to MDD. If MDD appears to be comorbid with AN at the time of presentation, there is debate as to whether it is more prudent to withhold treatment of the depression until weight restoration has been initiated. If the depression persists despite refeeding, then treatment of the depression is likely warranted. 

In a 1994 study Teplin evaluated 728 male jail detainees, and found that nearly two-thirds of this population had a psychiatric disorder with antisocial personality disorder (ASP), the most common diagnosis at 50%. However, 35% of the population had a current diagnosis other than ASP, and two-thirds had previously been given a lifetime diagnosis other than ASP. Substance abuse was common, with a 62% lifetime prevalence. More than one out of three detainees had a severe mental disorder (schizophrenia, bipolar affective disorder, or major depression). In another study, 693 homicide offenders were evaluated and elevated rates of schizophrenia and ASP were found (Eronen et al., 1996). Earlier studies found schizophrenia in 29%-75% and affective disorders in 4%-35% of prisoners. 

Like most psychiatric disorders, diagnostic criteria for ADHD are based on history and behavioral assessment. There are no pathognomonic laboratory or radiologic tests to confirm the diagnosis. 

Pediatric PTSD is a psychiatric disorder that is prone to both under- and overdiagnosis, especially when assessments are superficially or inexpertly conducted. For example, a traumatic exposure history in combination with current externalizing behavioral symptoms does not necessarily imply a diagnosis of PTSD. Conversely, children who present with an externalizing behavioral disorder in conjunction with anxiety symptoms and aggression are often not fully evaluated for PTSD. 

Simeon et al. (1995) mailed questionnaires to 135 child psychiatrists in 43 countries to obtain more precise information on the views and approaches to the diagnosis and treatment of childhood psychiatric disorders. Of 43 questionnaires returned, data from 38 respondents representing 24 different countries were included. The study indicated that child psychiatrists in Europe and elsewhere outside the United States would use methylphenidate to treat 58% of ADHD patients, with their second choice being imipramine (18%), and 11% would not use medication. The investigators reported that one of the controversies that remained was the diagnosis and treatment of ADHD, as the prescription rates varied extremely from one country to another. In Italy, for example, the diagnosis of ADHD was rarely made and psychostimulants were rarely used. The authors concluded that the choice of medication was frequently restricted by lack of availability as well as by political or social attitudes (Simeon et al., 1995). 

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