Originally titled,
A Misdiagnosis of Schizophrenia: based on errors of attribution, lack of professional judgement and ethical integrity
Schizophrenia is a diagnosis of exclusion, however many people do not have the necessary physical or neurological exams to discover if there is a physical or neurological cause for the symptoms they have before a diagnosis is applied, and drugs to treat it are prescribed. Some will, sooner or later, be Court Ordered to take the drugs to treat a diagnosis of schizophrenia, without ever having the requisite medical exams needed to exclude the medical conditions that could be the potential cause for their symptoms.
Then there are situations like what happened to my eldest son who was diagnosed with schizophrenia at the age of eighteen at the local community health clinic, Central Washington Comprehensive Mental Health. The diagnosis was based on the intake staff misunderstanding and misinterpreting what my son said; belief in the bio-medical disease paradigm; and an assumption that he must have a genetic defect. First, he was lied to about the diagnosis he was given, then he was lied to about why the drugs were prescribed.
He was depressed and eighteen and went to the walk-in mental health clinic for help. He saw an individual who did an evaluation and intake. When he came home with a prescription for a neuroleptic drug that he'd been told was to help him sleep; I was alarmed---scratch that---I was pissed off. I told him that he had been lied to, and that I believed that he had been diagnosed with Schizophrenia. Being eighteen, he thought mom was overreacting---and overly suspicious, if not "paranoid." He basically believed I was wrong.
The drug prescribed had negative effects which he could not tolerate, so he went back to the mental health clinic and was prescribed another neuroleptic; again he was told it was to "help him sleep." I convinced him that he needed to go look at his medical record, as he had a legal right to do. He went down to the clinic with a printout of the section of the law that states he has the right to examine his chart.
He discovered that he had indeed been given a diagnosis of schizophrenia. This psychiatric diagnosis was based on three things:
1. His brother had a diagnosis of schizophrenia
2. He told the person who did the intake and assessment that he was working at Earthlink, an internet service provider that provides technical assistance to it's customers over the phone. This was recorded in his chart as "He thinks he is an "earthling" in training."
3. At the time, he was interested in studying Neuro-Linguistic programming, (NL P™) is defined as the study of the structure of subjective experience and what can be calculated from that and is predicated upon the belief that all behavior has structure. The mental health professional had never heard of "Neuro-Linguistic Programming" and did not think it was an actual field of study; and assumed that my son had made it up. This interest in an actual field of study was labeled an "entrenched delusion."
Don't forget this diagnosis was given to my elder son based on an intake appointment by a clinician who saw him ONE time--he had no history of hallucinations, or delusions. He was depressed, he was eighteen and he was worried about his brother. Nathan has always felt that it was his job to fix what was wrong, and overly-responsible for taking care of his brother and myself.---This is common for adolescent males raised by single mothers. He was depressed in part because he felt as if he had failed.
He needed support to deal with a great deal of grief, loss and trauma. He needed help figuring out what he is and is not responsible for. He needed support in order to figure out it was never his responsibility to fix any of what had happened to his brother. He needed help to learn how to deal with the emotional trauma he had experienced; and to learn that it is, and never was his fault. He needed to be assured that none of what had happened and what was happening was his fault. He needed to know it was never his responsibility to take care of his mother and his brother--he was a kid and he had not failed anyone at all.
via The Wall Street Journal:
Confusing Medical Ailments With Mental Illness
An elderly woman's sudden depression turns out to be a side effect of her high blood-pressure medication.
A new mother's exhaustion and disinterest in her baby seem like postpartum depression—but actually signal a postpartum thyroid imbalance that medication can correct.
A middle-aged manager has angry outbursts at work and frequently feels "ready to explode." A brain scan reveals temporal-lobe seizures, a type of epilepsy that can be treated with surgery or medication.
More than 100 medical disorders can masquerade as psychological conditions, according to Harvard psychiatrist Barbara Schildkrout, who cited these examples among others in "Unmasking Psychological Symptoms," a book aimed at helping therapists broaden their diagnostic skills.
Studies have suggested that medical conditions may cause mental-health issues in as many as 25% of psychiatric patients and contribute to them in more than 75%. read here.
Confusing Medical Ailments With Mental Illness
An elderly woman's sudden depression turns out to be a side effect of her high blood-pressure medication.
A new mother's exhaustion and disinterest in her baby seem like postpartum depression—but actually signal a postpartum thyroid imbalance that medication can correct.
A middle-aged manager has angry outbursts at work and frequently feels "ready to explode." A brain scan reveals temporal-lobe seizures, a type of epilepsy that can be treated with surgery or medication.
More than 100 medical disorders can masquerade as psychological conditions, according to Harvard psychiatrist Barbara Schildkrout, who cited these examples among others in "Unmasking Psychological Symptoms," a book aimed at helping therapists broaden their diagnostic skills.
Studies have suggested that medical conditions may cause mental-health issues in as many as 25% of psychiatric patients and contribute to them in more than 75%. read here.
via Cold Spring Harbor Laboratory:
ID 899
DSM-IV Criteria for Schizophrenia
Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) diagnostic criteria for schizophrenia and associated disorders.
Transcript:
DSM-IV-TR: Diagnostic criteria for schizophrenia: A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): (1) delusions (2) hallucinations (3) disorganized speech (e.g., frequent derailment or incoherence (4) grossly disorganized or catatonic behaviour (5) negative symptoms, i.e., affective flattening, alogia (poverty of speech), or avolition (lack of motivation) Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other. B. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement). C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal (symptomatic of the onset) or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive Episode, Manic Episode, or Mixed Episode have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated). Subtypes Schizophrenia Subtypes: The subtypes of schizophrenia are defined by the predominant symptomatology at the time of evaluation. Because of the limited value of the schizophrenia subtypes in clinical and research settings (e.g. prediction of course, treatment response, correlates of illness), alternative subtypes are being actively investigates. Subtypes include 1. Paranoid Type 2. Disorganized Type 3. Catatonic Type 4. Undifferentiated Type 5. Residual Type Schizophreniform disorder, schizoaffective disorder, and delusional disorder are closely related to schizophrenia and their symptoms are also listed below. In addition symptoms are listed for the following related disorders: brief psychotic disorder, shared psychotic disorder, psychotic disorder due to a general medical condition, substance-induced psychotic disorder, and psychotic disorder not otherwise specified. 1. Paranoid Type A type of Schizophrenia in which the following criteria are met: A. Preoccupation with one or more delusions or frequent auditory hallucinations. B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect. 2. Disorganized Type A type of Schizophrenia in which the following criteria are met: A. All of the following are prominent: (1) disorganized speech (2) disorganized behaviour (3) flat or inappropriate affect B. The criteria are not met for Catatonic Type. 3. Catatonic Type A type of Schizophrenia in which the clinical picture is dominated by at least two of the following: (1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor (2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli) (3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism (4) peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures) (5) stereotyped movements, prominent mannerisms, or prominent grimacing (6) echolalia (word repetition) or echopraxia (repetitive imitation) 4. Undifferentiated Type A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type. 5. Residual Type A type of Schizophrenia in which the following criteria are met: A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior. B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). Diagnostic criteria for Schizophreniform Disorder: A. Criteria A, D, and E of Schizophrenia are met. B. An episode of the disorder (including prodromal, active, and residual phases) lasts at least 1 month but less than 6 months. (When the diagnosis must be made without waiting for recovery, it should be qualified as "Provisional.") Specify if: Without Good Prognostic Features With Good Prognostic Features: as evidenced by two (or more) of the following: (1) onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning (2) confusion or perplexity at the height of the psychotic episode (3) good premorbid social and occupational functioning (4) absence of blunted or flat affect Diagnostic criteria for Schizoaffective Disorder: A. An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia. Note: The Major Depressive Episode must include Criterion A1: depressed mood. B. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms. C. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness. D. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Specify type: Bipolar Type: if the disturbance includes a Manic or a Mixed Episode (or a Manic or a Mixed Episode and Major Depressive Episodes) Depressive Type: if the disturbance only includes Major Depressive Episodes Diagnostic criteria for Delusional Disorder: A. Nonbizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month's duration. B. Criterion A for Schizophrenia has never been met. Note: Tactile and olfactory hallucinations may be present in Delusional Disorder if they are related to the delusional theme. C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre. D. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods. E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Specify type (the following types are assigned based on the predominant delusional theme): Erotomanic Type: delusions that another person, usually of higher status, is in love with the individual Grandiose Type: delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person Jealous Type: delusions that the individual's sexual partner is unfaithful Persecutory Type: delusions that the person (or someone to whom the person is close) is being malevolently treated in some way Somatic Type: delusions that the person has some physical defect or general medical condition Mixed Type: delusions characteristic of more than one of the above types but no one theme predominates Unspecified Type Diagnostic criteria for Brief Psychotic Disorder: A. Presence of one (or more) of the following symptoms: (1) delusions (2) hallucinations (3) disorganized speech (e.g., frequent derailment or incoherence) (4) grossly disorganized or catatonic behavior Note: Do not include a symptom if it is a culturally sanctioned response pattern. B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning. C. The disturbance is not better accounted for by a Mood Disorder With Psychotic Features, Schizoaffective Disorder, or Schizophrenia and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Specify if: With Marked Stressor(s) (brief reactive psychosis): if symptoms occur shortly after and apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture Without Marked Stressor(s): if psychotic symptoms do not occur shortly after, or are not apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture With Postpartum Onset: if onset within 4 weeks postpartum Diagnostic criteria for Shared Psychotic Disorder (Folie à Deux): A. A delusion develops in an individual in the context of a close relationship with another person(s), who has an already-established delusion. B. The delusion is similar in content to that of the person who already has the established delusion. C. The disturbance is not better accounted for by another Psychotic Disorder (e.g., Schizophrenia) or a Mood Disorder With Psychotic Features and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Diagnostic criteria for Psychotic Disorder Due to a General Medical Condition: A. Prominent hallucinations or delusions. B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. C. The disturbance is not better accounted for by another mental disorder. D. The disturbance does not occur exclusively during the course of a Delirium. Code based on predominant symptom: - With Delusions: if delusions are the predominant symptom - With Hallucinations: if hallucinations are the predominant symptom Diagnostic criteria for Substance-Induced Psychotic Disorder: A. Prominent hallucinations or delusions. Note: Do not include hallucinations if the person has insight that they are substance induced. B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2): (1) the symptoms in Criterion A developed during, or within a month of, Substance Intoxication or Withdrawal (2) medication use is etiologically related to the disturbance C. The disturbance is not better accounted for by a Psychotic Disorder that is not substance induced. Evidence that the symptoms are better accounted for by a Psychotic Disorder that is not substance induced might include the following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication, or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non-substance-induced Psychotic Disorder (e.g., a history of recurrent non-substance-related episodes). D. The disturbance does not occur exclusively during the course of a delirium. Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention. Diagnostic Criteria for Psychotic Disorder Not Otherwise Specified: This category includes psychotic symptomatology (i.e., delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior) about which there is inadequate information to make a specific diagnosis or about which there is contradictory information, or disorders with psychotic symptoms that do not meet the criteria for any specific Psychotic Disorder. Examples include: 1. Postpartum psychosis that does not meet criteria for Mood Disorder With Psychotic Features, Brief Psychotic Disorder, Psychotic Disorder Due to a General Medical Condition, or Substance-Induced Psychotic Disorder 2. Psychotic symptoms that have lasted for less than 1 month but that have not yet remitted, so that the criteria for Brief Psychotic Disorder are not met 3. Persistent auditory hallucinations in the absence of any other features 4. Persistent nonbizarre delusions with periods of overlapping mood episodes that have been present for a substantial portion of the delusional disturbance 5. Situations in which the clinician has concluded that some type of psychotic disorder may be present, but is unable to determine whether it is primary, due to a general medical condition, or substance induced.
Keywords:
dsm, schizophrenia, schizoaffective, diagnosis, diagnostic, delusions, hallucinations, paranoid, paranoia, disorganize, catatonic, catatonia, undifferentiated, residual, schizophreniform, delusional, delusion, psychosis, psychotic
Keywords:
dsm, schizophrenia, schizoaffective, diagnosis, diagnostic, delusions, hallucinations, paranoid, paranoia, disorganize, catatonic, catatonia, undifferentiated, residual, schizophreniform, delusional, delusion, psychosis, psychotic
A link from Pat Risser: Medical Problems Related to Psychiatric Symptoms
Portions of this blog post were originally published with the title:
"Making a diagnosis without a complete neurological and physical examination can lead to misdiagnosis" on 8-21-2011
photo from fisher price
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