Differential Diagnosis – Part 2

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Differential Diagnosis:
 What is it?

— and why would I care?

by Madelyn Griffith-Haynie, CTP, CMC, ACT, MCC, SCAC
Part Two of the Differential Dx article
in the Comorbities Series

To answer the first part of the question, click HERE to read the first part of this article.  (Click the link at the end of THAT article to come back here to read why you really need to care.)

The answer to the second part?

In a nutshell: as with everything else in life,
“The Name of the Game™ determines the rules!”

If you don’t have the correct diagnosis, there is NO WAY you will be addressing your problems in a manner that will be successful.

Pretend you are a former college marathon runner in his late 30’s.  Lately you’re having problems completing your morning run.  You can barely breathe after about ten minutes of what used to be an easy warm-up.

Obviously, you’d be headed for trouble if you were treated with asthma medication and the source of your shortness of breath turned out to be a problem with your heart.

Since you aren’t sure what’s going on, you’d want to feel confident that your doctor knows enough about “shortness of breath” conditions to make a referral to the correct specialist, even if your particular doctor specializes in sports medicine, right?

When you’re dealing with a differential diagnosis that has few quantifiable measures to identify it, it becomes all the more important to work with a doctor who has the depth of knowledge it may take to distinguish between a daunting number of possibilities with similar presentations — yet very different treatments.

How will they find what they don’t know to look for?

Doctors are finally becoming more widely aware that ADD affect looks different from person to person, but it is also important for them to understand that it looks different in the same person at different points through life.

Although, thanks to the web as well as medical journals, most physicians have been exposed to the “changing through the years” concept,  there is far too much room for interpretation in the terminology used in physician resources.  Words can only do so much.

If your doctor has insufficient depth of experience with living, breathing illustrations of diagnostic terminology, how will he or she be able to have confidence that the diagnosis is accurate?  More to the point, how will YOU be able to have confidence that the diagnosis is accurate?

As an example,
what does a seemingly straightforward term like hyperactivity really MEAN?

• We would get a great deal of agreement that the behavior of a little boy who rarely sleeps and can’t sit still for a single moment in the doctor’s office would be a good example.
• But what about the well-behaved teen wearing headphones, bouncing subtly to the music of her iPod ?

Does it help to note that her nails are bitten to the quick and that her foot has been jiggling triple-time, non-stop from the time she sat down?

By the way, the kids are siblings, their mother struggles with treatment-resistant depression, and a cousin is currently doing well on Adderall.

Many doctors wouldn’t have the experience to interpret those elements as evidence of a high probability of ADD with fine-motor hyperactivity in the sister.  Yet even if they did (and the identification were on the money), we still can’t say the girl has ADD.  Or the little boy either, for that matter.  All we can say is that it makes sense to strongly consider ADD.

The examples above are based on an actual family, by the way.  

It was only after the girl was warned that she was probably going to have to repeat her sophomore year of high school, initiating her slide into depression (and her threats of suicide), that her mother begin the relentless advocacy necessary for the poor kid to be properly diagnosed with ADD.

With proper medication, a summer school catch-up program that including many sessions with a tutor, and regular sessions with both an ADD-knowledgable therapist and an ADD Coach, for the remainder of high school she did not bring home a grade below a B (with straight As in many of her classes).

What a crime she had to go through the first two years of high school feeling stupid and inadequate!  Not to mention the negative effect it had on her education.

The very same doctor who sent the girl home to “try harder” accurately diagnosed her little brother with HFA (high functioning autism).  Yet he couldn’t see that the teen’s symptoms were simply a different manifestation of the DSM criteria — and it never occurred to him to take a second look at the mom’s depression (which cleared up for good with the administration of Adderall for her hypo-active ADD.)

My point?  Attentional Disorders ALSO look different in males and females.

While their first doctor was well enough informed to make an accurate ADD/Autistic spectrum differential that many other doctors might have missed, he still did not have the information he needed to help the females.

According to Dr. Patricia Quinn (National Center for Girls and Women with ADHD),

For some time, it has been held that women with ADHD are more likely to internalize symptoms and become anxious and depressed and to suffer emotional dysregulation than males with the disorder. 

Recent evidence confirms that girls with ADHD are 5.4 times more likely to be diagnosed with major depression and three times more likely to be treated for depression before their eventual ADHD diagnosis.

Current Psychiatry Reports, ’08 Oct;10(5):419-23. Review. PMID: 18803916 [PubMed-indexed for MEDLINE]

Are you beginning to see the importance of a great differential diagnosis?

Further Complications

Even if the ADD diagnosis is clear, there is an extremely high probability of other disorders complicating diagnoses. One clinical study reported that only 12% of adults referred to their clinic had stand-alone ADD (without any other psychiatric diagnoses.)

While I question a lot of things that might explain those extreme statistics, the point remains that a good differential diagnostician must be ready-willing-and-ABLE to look at the entire spectrum to make an initial diagnosis, and to make SURE he or she hasn’t overlooked the possibility of comorbid conditions as well as co-occuring conditions.

I thought Comorbid meant “co-occurring”

It does, in a sense, but “comorbid” includes a statistical element.  In order for conditions to be comorbid, the number of people in the first population who also meet the diagnostic criteria for the second must be higher to a statistically significant degree, than the number of people in the general population who meet the diagnostic criteria for the second condition.

Let’s say that you are diagnosed with diabetes as well as ADD.

Your ADD would certainly make it harder for you to be regimented in the care of your diabetes, and fluctuating blood sugar would have a negative effect on concentration and mood — but we still wouldn’t say that those two conditions were comorbid. We don’t see a higher incidence of diabetes in ADDers than in the general population.  So that’s a clear example of “co-occuring” but NOT “comorbid.”

Depression is another matter altogether, as you can see from Dr. Quinn’s research above – it is what is called a “high” comorbid in ADDers.

An excellent ADD doctor might know very little about diabetes until he had to learn about it because one of his ADDers was struggling as a result of diabetes.  But for us to consider him an excellent ADD doctor, he simply must know a great deal about depression AND ADD in order to make an appropriate differential.  [Click HERE for a list of ten questions that will help you find one of those doctors]

Stay tuned . . . in additional articles in this series, I will expand on each of the points above.

Your connection to articles about Diagnosis and Comorbidities will be found on the lower of the two menubars at the top of the site, far left on the lighter grey menubar, in the drop-down category :

A.Hopefully Helpful – 1.The Attentional Spectrum – b.Dances with Diagnosis

If you visit often, you may also catch an article or two on this topic a on the list of links to newest content on the skinny column to your immediate right (newest on top).

HOWEVER you do it, stay tuned — there’s A LOT to know, and a lot more to come.
Get it here, while it’s free for the taking!

As always, if you want notification of new articles – in a the Differential Dx. or Comorbids Series – or any new posts on this blog – give your name and email to the nice form on the top of the skinny column to the right.  (You only have to do this once, so if you’ve already asked for notification about a prior series, you’re covered for this one too) STRICT No Spam Policy

If you’d like some one-on-one (or group) coaching help with anything that came up while you were reading this article (either for your own life, that of a loved one, or as coaching skills development), click the E-me link  <—here (or on the menubar at the top of every page) and I’ll get back to you ASAP (accent on the “P”ossible!)

More ADD/EF Info:

Articles in the Executive Functioning/Differential Dx/Comorbids series:

• ABOUT Executive Functions
• What ARE Executive Functions?
• Zebras, hoof-beats and Dr. House: Differential Diagnosis
• ABOUT ADD Comorbidities – Comorbid or Co-occuring?
• ADD Seldom Rides Alone
• ODD & Oppositional Rising
• ABOUT ADD and Sleep Struggles
• Differential Diagnosis – distinguishing ADD from Comorbidities
• Overfocusing: Cognitive Inflexibility and the Cingulate Gyrus (Stubborn or STUCK?)
• Remembrance of Selves Past

Articles about meds/non-meds, diagnosis & doctors:

• ABOUT Non-Medical Alternatives
• ADD Meds Info for Moms Part I: Titration Trouble
• Top Questions to Ask to find a GRRRRreat! ADD Doc
• Top Ten Meds questions
• Top Ten Stupid Comments from ADD-Docs

Related articles ’round the net

• Medication For ADHD – Stupid Diagnostic Questions (corepsychblog.com)
• ADHD Medications: Your Medical Team (corepsychblog.com)
• ADHD Diagnosis and Misdiagnosis- 175 Problems That Can Look Like ADHD  (Differential Diagnoses often mistaken for Inattentive ADD)
• Depression in Family Practice (pdresources.wordpress.com)
• New findings validate the accuracy of autism diagnosis in children with Down syndrome (eurekalert.org)
• People and pickle jars: the pros and cons of diagnostic labels (purplepersuasion.wordpress.com)
• Tales from the ADD Dark Side (addandsomuchmore.com)
• Mind Science – Critical Thinking Matters (corepsychblog.com)

Related article to comments below:

• The patient is a partner in their illness management and health maintenance (kevinmd.com)