Differentiating Between Mental Disorders
|← Block C4 - Adolescence and Adulthood|
There are currently two widely established systems for classifying mental disorders: Chapter V of the International Classification of Diseases (ICD-10) produced by the World Health Organization (WHO) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) produced by the American Psychiatric Association (APA). In Indonesia, many doctors use Pedoman Penggolongan Diagnostik Gangguan Jiwa (PPDGJ) and the older DSM-IV TR.
Anxiety disorders, bipolar disorder, depression, eating disorder, psychosis including schizophrenia, and substance abuse all most commonly emerge during adolescence. It is no surprise that the peak age of onset for having any mental health disorder is 14 years. That is why these are taught as part of diseases of adolescence.
Differentiating Between Mental Disorders
When trying to differentiate between the many types of mental disorders, pay attention to the diagnostic criteria, particularly the duration of the symptoms and whether they recur or occur with other symptoms. See the table further below on this page for an overview.
Some questions to ask when trying to diagnose mental disorders:
- Are there psychotic symptoms? Excluding psychosis can help narrow down the DDX quickly.
- Are there manic symptoms? This simple question will help exclude all bipolar disorders.
- When was the onset and how long has the duration been?
- Is this the first episode? If not, how frequent are these episodes?
- How severe are the symptoms? Are the symptoms debilitating and interfering with job/family/etc? Thoughts of suicide?
- Is there a genetic predisposition? Genetics play a major role in mental disorders.
- Is the patient aware that they're suffering from this mental disorder? Useful when differentiating between OCD and OCPD.
- Comorbidities? Many mental disorders are variably comorbid with each other.
Duration of Symptoms
|Minimum duration of symptoms for diagnosis|
|Mental disorder||Minimum duration||Criteria|
|Panic Attack||10 minutes||At least 4 symptoms.|
|Depression||2 weeks||At least 5 symptoms.|
|Manic episode||1 week||Elevated mood or irritability.|
|Hypomania||4 days||Not as severe as mania.|
|Bipolar I||1 week||At least one manic episode, and optionally, depression.|
|Bipolar II||4 days||Depression with hypomania (rather than mania).|
|Bipolar mixed||1 week||Manic and depressive episodes occur daily.|
|Bipolar Rapid-cycling||1 year||At least 4 episodes.|
|PTSD||1 month||Difficulty relaxing, nightmares/flashbacks, avoidance.|
|Schizophreniform||1 month||Similar symptoms with schizophrenia. Often becomes schizophrenia. Max 6 months.|
|Schizophrenia||6 months||Disturbance for at least 6 months, incl. 1 month of symptoms.|
|GAD||6 months||Anxious on most days.|
|Conduct Disorder||6 months||At least 1 characteristic behavior in the last 6 months, or at least 3 in the last 12 months.|
|Dysthymia||2 years||2 or more symptoms. Depressed mood, but not as severe as depression.|
|Cyclothymia||2 years||Cycling between periods of hypomania and mild elation. Milder than but similar to bipolar.|
- Definition of Affective Disorders
- aka. "mood disorders". A psychological disorder characterized by the elevation or lowering of a person's mood, such as depression or bipolar disorder. If you have a mood disorder, your general emotional state or mood is distorted or inconsistent with your circumstances. This is a broad category with many disorders in it. Affective disorders can lead to anxiety disorders, disruptive disorders, and substance abuse - each of these a category in itself.
- Definition of Anxiety Disorders
- unlike the feeling of normal everyday anxiety, the anxiety in anxiety disorders does not go away and can get worse over time. These feelings can interfere with daily activities such as job performance, school work, and relationships. Examples include panic disorder, social anxiety disorder, generalized anxiety disorder, and specific phobias.
Generalised Anxiety Disorder (GAD)
- Definition of GAD
- A person feels anxious on most days, worrying about lots of different things, for a period of six months or more.
Psychological therapy, such as cognitive behavioural therapy (CBT). Antidepressants such as selective serotonin reuptake inhibitors (SSRIs).
Obsessive Compulsive Disorder (OCD)
- Definition of OCD
- A person has ongoing unwanted/intrusive thoughts and fears that cause anxiety. Although the person may acknowledge these thoughts as silly, they often try to relieve their anxiety by carrying out certain behaviours or rituals. For example, a fear of germs and contamination can lead to constant washing of hands and clothes.
Obsessive Compulsive Personality Disorder (OCPD)
- Definition of OCPD
- People with OCD have unwanted thoughts, while people with OCPD believe that their thoughts are correct. In addition, OCD often begins in childhood while OCPD usually starts in the teen years or early 20s.
- Definition of Panic Disorder and Panic Attack
- A person has panic attacks, which are intense, overwhelming and often uncontrollable feelings of anxiety combined with a range of physical symptoms. A person having a panic attack may experience shortness of breath, chest pain, dizziness and excessive perspiration. Sometimes, people experiencing a panic attack think they are having a heart attack or are about to die. If a person has recurrent panic attacks or persistently fears having one for more than a month, the person is said to have panic disorder.
- Definition of Phobias
- a type of anxiety disorder, usually defined as a persistent fear of an object or situation the affected person will go to great lengths to avoid, typically disproportional to the actual danger posed. There are two categories of phobias: social phobias and specific phobias.
Five types of simple phobia:
- Animal – common examples include fear of dogs, snakes or spiders.
- Natural environment – examples include fear of height, water, or thunderstorms.
- Blood injections / injury – common examples are the fear of pain or being beaten.
- Situational – such as fear of flying or elevators.
- Other – phobias which do not specifically fit into another subtype.
Social Phobia / Social Anxiety Disorder (SAD)
- Definition of SAD
- aka Social Phobia. A person has an intense fear of being criticised, embarrassed or humiliated, even in everyday situations, such as speaking publicly, eating in public, being assertive at work or making small talk.
Post-Traumatic Stress Disorder (PTSD)
- Definition of PTSD
- This can happen after a person experiences a traumatic event (e.g. war, assault, accident, disaster). Symptoms can include difficulty relaxing, upsetting dreams or flashbacks of the event, and avoidance of anything related to the event. PTSD is diagnosed when a person has symptoms for at least a month.
- Definition of Unipolar Major Depression
- aka. Major Depressive Disorder (MDD), is diagnosed in patients who have suffered at least one major depressive episode and have no history of mania or hypomania. A major depressive episode is a period lasting at least two weeks, with five or more of the following symptoms: depressed mood, anhedonia, insomnia or hypersomnia, change in appetite or weight, psychomotor retardation or agitation, low energy, poor concentration, thoughts of worthlessness or guilt, and recurrent thoughts about death or suicide. In addition, the symptoms must cause clinically significant distress or impairment in functioning, and the syndrome is not due to the physiologic effects of a substance (eg, drug abuse or medications) or another medical condition (eg, hypothyroidism).
- Definition of Dysthymia
- aka. Persistent Depressive Disorder (in DSM-5). It is a continuous long-term (chronic) form of depression, which is milder than the depression experienced in major depressive disorder. Don't confuse this (Persistent Depressive Disorder) with
Pathogenesis of Depression
Almost every compound that inhibits monoamine reuptake, leading to an increased concentration of monoamines in the synaptic cleft, has been proven to be a clinically effective antidepressant. Inhibiting the enzyme monoamine oxidase, which induces an increased availability of monoamines in presynaptic neurons, also has antidepressant effects. These observations led to the pharmacologically most relevant theory of depression, referred to as the monoamine-deficiency hypothesis.
The monoamine-deficiency theory posits that the underlying pathophysiological basis of depression is a depletion of the neurotransmitters serotonin, norepinephrine or dopamine in the central nervous system. Serotonin is the most extensively studied neurotransmitter in depression. The most direct evidence for an abnormally reduced function of central serotonergic system comes from studies using tryptophan depletion, which reduces central serotonin synthesis.
Central Noradrenergic Dysfunction Theory
Dysfunction of the central noradrenergic system has been hypothesized to play a role in the pathophysiology of MDD, based upon evidence of decreased norepinephrine metabolism, increased activity of tyrosine hydroxylase, and decreased density of norepinephrine transporter in the locus coeruleus in depressed patients. In addition: decreased neuronal counts in the locus coeruleus, increased alpha-2 adrenergic receptor density, and decreased alpha-1 adrenergic receptor density.
Dopamine Reduction Theory
Dopamine reuptake inhibitors (e.g., nomifensine) and dopamine receptor agonists (e.g., pramipexole) had antidepressant effects in placebo-controlled studies of MDD. In the cerebrospinal fluid and jugular vein plasma, levels of dopamine metabolites were consistently reduced in depression, suggesting decreased dopamine turnover. Striatal dopamine transporter binding and dopamine uptake were reduced in MDD, consistent with a reduction in dopamine neurotransmission.
The first depressive episode is usually “reactive”, i.e., triggered by important psychosocial stressors, while subsequent episodes become increasingly “endogenous”, i.e., triggered by minor stressors or occurring spontaneously. There is consistent evidence that the volume loss of the hippocampus and other brain regions is related to the duration of depression, suggesting that untreated depression leads to hippocampal volume loss, possibly resulting in increased stress sensitivity and increased risk of recurrence.
GABA Reduction Theory
A series of magnetic resonance spectroscopy studies consistently showed reductions in total gamma-aminobutyric acid (GABA) concentrations in the prefrontal and occipital cortex in acute depression.
- Definition of Bipolar disorder
- Also sometimes known as "manic-depressive illness". Bipolar disorder is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks.
- Bipolar I disorder involves periods of severe mood episodes from mania to depression.
- Bipolar II disorder is a milder form of mood elevation, involving milder episodes of hypomania that alternate with periods of severe depression.
- Cyclothymic disorder describes periods of hypomania with brief periods of depression that are not as extensive or long-lasting as seen in full depressive episodes. Cyclothymia is a mild form of and can progress to bipolar disorder.
- "Mixed features" refers to the occurrence of simultaneous symptoms of opposite mood polarities during manic, hypomanic or depressive episodes. It's marked by high energy, sleeplessness, and racing thoughts. At the same time, the person may feel hopeless, despairing, irritable, and suicidal.
- Rapid cycling must feature at least four episodes in a 12 month period.
- Mania is the cardinal symptom of bipolar disorder. Without the mania, it would be considered Depressive Disorder (which is also called "unipolar disorder", by the way). However, don't let the "bi" in "bipolar disorder" fool you. Bipolar disorder can exist with just mania (and no depression), although this is very rare.
- There are several types of Bipolar Disorder based upon the specific duration and pattern of manic and depressive episodes.
- People who experience clinically significant episodes of mania and depression but who do not meet criteria for Bipolar Disorder are diagnosed as Bipolar Disorder: Not Otherwise Specified (BP-NOS). Don't confuse this with DMDD.
- Some people with bipolar disorder become psychotic when manic or depressed, hearing things that aren't there.
The most common delusion (haha!) that people have about mania is that it always manifests as a feeling of elation or euphoria. This is not always the case. Mania can manifest as a feeling of extreme irritability as well.
Common signs and symptoms of mania include:
- Feeling unusually "high" and optimistic OR extremely irritable.
- "Unrealistic, grandiose beliefs about one's abilities or powers.
- Sleeping very little, but feeling extremely energetic.
- Talking so rapidly that others can’t keep up.
- Racing thoughts; jumping quickly from one idea to the next.
- Highly distractible, unable to concentrate.
- Impaired judgment and impulsiveness.
- Acting recklessly without thinking about the consequences.
- Delusions and hallucinations (in severe cases).
The depressive episodes in bipolar disorder differ slightly from major depression.
Common symptoms of bipolar depression include:
- Feeling hopeless, sad, or empty.
- Inability to experience pleasure (e.g. not enjoying activities usually enjoyed, such as sex).
- Fatigue or loss of energy.
- Physical and mental sluggishness.
- Appetite or weight changes.
- Sleep problems.
- Concentration and memory problems.
- Feelings of worthlessness or guilt.
- Thoughts of death or suicide.
Hypomania is a less severe form of mania. People in a hypomanic state feel euphoric, energetic, and productive, but they are able to carry on with their day-to-day lives and they never lose touch with reality. To others, it may seem as if people with hypomania are merely in an unusually good mood. However, hypomania can result in bad decisions that harm relationships, careers, and reputations. In addition, hypomania often escalates to full-blown mania or is followed by a major depressive episode.
Mood stabilizers are usually the first choice to treat bipolar disorder, usually lithium. Valproic acid is used to treat mania and it is a popular alternative to lithium. Lamotrigine is used for maintenance treatment of bipolar disorder and is often effective in treating depressive symptoms. Other anticonvulsant medications are also used, including gabapentin, topiramate, and oxcarbazepine.
- Definition of Disruptive Disorder
- aka. "Disruptive Behavior Disorders" (DBD). Disruptive behavior disorders (DBD) are a group of behavioral disorders defined by ongoing patterns of hostile and defiant behaviors that children and adolescents direct towards any type of authority figure. While all children go through periods of testing limits by acting out in negative behaviors, children with DBD participate in these behaviors to such an extreme that it affects their everyday lives, as well as the lives of those around them. The two most common forms of disruptive behavior disorders are oppositional defiant disorder (ODD) and conduct disorder.
- Definition of Conduct Disorder
- characterized by persistent and repetitive behaviors that involve violating the basic rights of other human beings and severely breaking rules set to enforce age-appropriate societal norms.
- Definition of Oppositional Defiant Disorder
- similar to conduct disorder but usually presents itself earlier in a child’s life. ODD is characterized by patterns of hostile, defiant, and disobedient behaviors directed at parents, teachers, and any other type of authority figure.
- Definition of Schizophrenia
- a chronic and severe mental disorder that affects how a person thinks, feels, and behaves. People with schizophrenia may seem like they have lost touch with reality. The symptoms of schizophrenia fall into three categories: positive, negative, and cognitive. When a patient has had psychotic symptoms for at least a month but less than 6 months, it is called schizophreniform. Many people with this disorder go on to have schizophrenia. In other words, schizophreniform is often early schizophrenia.
- Definition of Psychotic Disorders
- are severe mental disorders that cause abnormal thinking and perceptions. The main symptom is psychosis. People with psychoses lose touch with reality.
- Definition of Psychosis
- a temporary loss of contact with reality and is a sign of an underlying mental illness: schizophrenia, Alzheimer's Disease, bipolar disorder, or psychotic depression for example. Psychosis is not a permanent state; it can be treated and the majority of people afflicted can live satisfactory lives. Psychosis is a symptom of mental illness rather than the name of a medical condition itself. Two of the main symptoms of psychosis are delusions and hallucinations.
- Definition of Delusion
- a false belief about something. An example of delusion would be believing that you are under surveillance by the police.
- Definition of Hallucination
- false or distorted sensory experiences that appear to be veridical perceptions. These sensory impressions are generated by the mind rather than by any external stimuli, and may be seen, heard, felt, and even smelled or tasted. An example of an hallucination would be hearing somebody call your name, despite nobody calling it (auditory hallucinations are most common, however hallucinations of any of the senses may occur).
- Differentiate hallucinations from delusions
- delusions are false beliefs while hallucinations are false sensations (via the senses: sight, hearing, smell, taste, touch).
Positive symptoms are psychotic behaviors not generally seen in healthy people. People with positive symptoms may "lose touch" with some aspects of reality. Symptoms include:
- Thought disorders (unusual or dysfunctional ways of thinking).
- Movement disorders (agitated body movements).
To remember these, think "positive" is represented by the plus/addition sign (+). So, these are symptoms that add onto the person's consciousness (e.g. hallucinations). Negative symptoms remove from a person's consciousness and decrease functionality (e.g. poverty of speech).
Positive symptoms increase the risk of violent behavior in schizophrenic patients.
Negative symptoms are associated with disruptions to normal emotions and behaviors. Symptoms include:
- "Flat affect" (reduced expression of emotions via facial expression or voice tone).
- Reduced feelings of pleasure in everyday life.
- Difficulty beginning and sustaining activities.
- Reduced speaking.
For some patients, the cognitive symptoms of schizophrenia are subtle, but for others, they are more severe and patients may notice changes in their memory or other aspects of thinking. Symptoms include:
- Poor "executive functioning" (the ability to understand information and use it to make decisions).
- Trouble focusing or paying attention.
- Problems with "working memory" (the ability to use information immediately after learning it).
- Paranoid schizophrenia: a person feels extremely suspicious, persecuted, or grandiose, or experiences a combination of these emotions.
- Disorganized schizophrenia: a person is often incoherent in speech and thought, but may not have delusions.
- Catatonic schizophrenia: a person is withdrawn, mute, negative and often assumes very unusual body positions.
- Residual schizophrenia: a person is no longer experiencing delusions or hallucinations, but has no motivation or interest in life. Very similar to Post-Schizophrenic Depression.
- Schizoaffective disorder: there are two subtypes: (1) Depressive-type: a person has symptoms of both schizophrenia and a major mood disorder such as depression. (2) Bipolar-type: symptoms of both schizophrenia and bipolar.
Eccentric Personality Disorders: Paranoid, Schizoid, Schizotypal
Individuals with these disorders often appear odd or peculiar.
- Paranoid Personality Disorder
- individual generally tends to interpret the actions of others as threatening; preoccupied with suspiciousness/paranoia. They are stuck between their need for others and their mistrust of others.
- Schizoid Personality Disorder
- individual generally detached from social relationships, and shows a narrow range of emotional expression in various social settings; emotional zombies who stopped feeling due to trauma(s) and/or can't feel due to organic depression
- Schizotypal Personality Disorder
- individual is uncomfortable in close relationships, has thought or perceptual distortions, and peculiarities of behavior; preoccupied with seeing themselves and/or the world as strange/odd
Individuals with these disorders have intense, unstable emotions, distorted self-perception, and/or behavioral impulsiveness.
- Antisocial Personality Disorder
- individual shows a pervasive disregard for, and violation of, the rights of others; Preoccupied with disdain/contempt for others and often a need for control/power over others.
- Borderline Personality Disorder
- individual shows a generalized pattern of instability in interpersonal relationships, self-image, and observable emotions, and significant impulsiveness. Core issue is an inability to regulate emotions.
- Histrionic Personality Disorder
- individual often displays excessive emotionality and attention seeking in various contexts. They tend to overreact to other people, and are often perceived as shallow and self-centered. Core issue is attention addiction.
- Narcissistic Personality Disorder
- individual has a grandiose view of themselves, a need for admiration, and a lack of empathy that begins by early adulthood and is present in various situations. These individuals are very demanding in their relationships. Core issue is entitlement.
Anxious Personality Disorders: Avoidant, Dependent, Obsessive-Compulsive
Individuals with these disorders often appear anxious or fearful.
- Avoidant Personality Disorder
- individual is socially inhibited, feels inadequate, and is oversensitive to criticism. Core issue is an inability to resolve their codependent need for connection with their codependent fear of rejection and/or discomfort/anxiety around others.
- Dependent Personality Disorder
- individual shows an extreme need to be taken care of that leads to fears of separation, and passive and clinging behavior. Core issue is the need to be parented by others (i.e. avoid growing up / becoming self-sufficient).
- Obsessive-Compulsive Personality Disorder
- individual is preoccupied with orderliness, perfectionism, and control at the expense of flexibility, openness, and efficiency. Core issue is mental and behavioral rigidity/inflexibility.