Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2867_Библиотеки_им_академика_М_И_Перельмана.pdf
462
A. Palm and C. Rodriguez
Discussion
Approximately 40% of patients with BPD report being previously misdiagnosed
with BD, compared with 10% of patients with other disorders [4, 6]. Interestingly,
20% of people with BPD have been diagnosed with comorbid bipolar disorder, and
15% of patients with bipolar disorder have comorbid BPD [5]. There are several
overlapping symptoms of the two disorders, including suicidality, irritability, impulsivity, and mood instability [2]. Affective instability is also a core feature of both
BD and BPD [2, 6]. Some experts believe that borderline and bipolar are two separate entities [2, 6], while others see them as coexisting on a spectrum [2, 7]. Despite
their many similarities, they are different disorders that necessitate completely different treatments. BPD is treated with dialectical behavioral therapy, while BD is
treated with various pharmacological treatments (antidepressants, mood stabilizers,
lithium), which can all cause unnecessary adverse effects to misdiagnosed patients.
Furthermore, a misdiagnosis would presumably delay the correct treatment of the
patient, leaving them and loved ones with an unrealistic expectation of prognosis
and causing feelings of hopelessness. Considering the fact that BPD has a good
prognosis (65% of patients achieve remission in 4years with proper treatment),
knowing how to differentiate BPD from BD is vital [5, 6].
Plan ofAction, Points theClinician Should Consider, Pitfalls
toAvoid, andPearls ofKnowledge toConsider
• Five out of nine diagnostic criteria for BPD might occur in hypomanic or manic
episodes of BPD, making misdiagnosis or overdiagnosis quite easy, (Fig.1) [7].
• Irritability is a hallmark of BD manic episodes, while frequent angry outbursts
point more toward BPD [1]. It is easy to confuse irritability with angry outbursts.
Irritability refers to a person’s quickness to anger, while angry outbursts refer to
heightened anger or disproportionally angry reaction.
• Mood changes in BD persist for days or weeks, and mood changes in BPD will
change rapidly but only last for minutes or hours [7].
• An enduring pattern (especially outside of manic/depressive episodes) points
more toward BPD, while denable “episodes” with periods of normalcy point
more toward BD [10].
• Fear of abandonment and identity disturbance is a classic trait of BPD.A patient
with BD might also suffer from these, but it is not considered pathognomonic to
BD [1, 7, 10].
• Splitting (a defense mechanism characterized by idealization or devaluation of
an object) is pathognomonic of BPD and is typically absent in BD [1].
• Hostility scores (Buss–Durkee Hostility Inventory) are higher in BPD patients
than in BD [8–10].
• Impulsiveness scores using the Barratt Impulsiveness Scale (attentional, non-
planning, and motor) are markedly higher in patients with BPD [8, 10].
62 Borderline Personality Disorder Misdiagnosed asBipolar Disorder
463
Borderline Personality Disorder (BPD)
• Enduring pattern of affective instability
•
Pattern of unstable & intense interpersonal
1
relationships
• Splitting (A defense mechanism characterized
by idealization or devaluation of an object)
• Fear of abandonment (real or imagined)
Mood changes will happen rapidly but typically last
minutes/hours
10
1
1,7
1
Can be seen in BPD and BD
Identity disturbance (possible in both
•
disorders, but classically associated with
1
BPD)
1
Affective instability
•
1
• Impulsiveness
1
Suicidality
•
1
• Irritability & anger
1,8,9,10
Hostility
Bipolar Disorder (BD)
• Definable episodes of affective instability with
periods of normalcy (euthymia)
• Mood changes are extreme but stable
(comparatively) and persist for days/weeks
• Sleep disturbances (especially in manic episodes;
decreased need for sleep)
1,10
1, 7
1
Fig. 62.1 Similarities and differences in the clinical features of borderline personality disorder
and bipolar disorder
If Misdiagnosed, WasIt Realized Later?
The clinicians, in this case, realized that the patient had an enduring pattern of
behavior even outside of her manic episodes that pointed toward borderline personality disorder. They also determined that the abnormal behavior was not the result
of alcohol misuse. Therefore, they added a diagnosis of borderline personality disorder in addition to the patient’s preexisting bipolar disorder diagnosis [2].
Conclusion
The majority of BPD misdiagnoses are initially diagnosed as BD because of remarkably similar symptomatology. The consequences of this misdiagnosis can be minimized through careful and complete patient history, as well as a thorough
understanding of the nuances that set the two disorders apart.
References
1. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision. Copyright
© 2000 American Psychiatric Association.
2. Peterson Scott N.Misdiagnosis or comorbidity: borderline personality disorder in a patient
diagnosed with bipolar disorder. Am J Psychiat Residents J.
3. Drago A, De Ronchi D.HTR2A gene variants and psychiatric disorders: a review of current
literature and selection of SNPs for future studies; 2007.
4. Ahmad A, Ramoz N, Thomas P, Jardri R, Gorwood P.Genetics of borderline personality disorder: systemic review and proposal of an integrative model; 2014.
5. Ruggero CJ, Zimmerman M, Chelminski I, Young D.Borderline personality disorder and the
misdiagnosis of bipolar disorder. J Psychiatr Res. https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC2849890/. Published April 2010.
6. Gunderson JG, Weinberg I, Daversa MT, et al. Descriptive and longitudinal observations
on the relationship of borderline personality disorder and bipolar disorder. Am J Psychiatry.
2006;163:1173–8.
464
7. Zimmerman M, Morgan TA. The relationship between borderline personality disorder and
bipolar disorder. Dialogues Clin Neurosci. 2013;15(2):155–69.
8. Fiedorowicz JG, Black DW.Borderline, bipolar or both? Frame your diagnosis on patient history. Curr Psychiatry. 2010;9(1).
9. Wilson ST, Stanley B, Oquendo MA, etal. Comparing impulsiveness, hostility, and depression in
borderline personality disorder and bipolar II disorder. J Clin Psychiatry. 2007;68(10):1533–9.
10. Palmer BA, Pahwa M, Geske JR, etal. Self-report screening instruments differentiate bipolar
disorder and borderline personality disorder. Brain Behav. https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC8323027/. Published May 30, 2021.
A. Palm and C. Rodriguez
Chapter 63
Generalized Anxiety Disorder
Misdiagnosed asNonspecic Physical Pain
JonathanSeok
Learning Objectives
By the end of this presentation, the clinician will be able to:
1. Create an appropriate differential diagnosis in patients presenting with generalized anxiety disorder (GAD) by considering all relevant details of the medical
history together with proper GAD screening and diagnostic tools.
2. Evaluate the different components of the medical history and physical examination which indicate the most appropriate screening and diagnostic tools so the
most correct course of further diagnostic procedures needed to reach a denitive
diagnosis can be reached.
3. Discuss the relationship between nonspecic physical pain and GAD.
4. Apply the knowledge gained from the case in a clinical setting where appropriate.
Introduction
The most common mental health disorder in the United States and the world is
generalized anxiety disorder (GAD). GAD is a disorder where the patient has
unfocused worry and anxiety that is not related to current situations or events,
although it can be exasperated by certain and current situations of at least
J. Seok (*)
St. Martinus University Faculty of Medicine, Willemstad, Curacao
e-mail: jonathan.seok@martinus.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
H. Tohid et al. (eds.), The Misdiagnosis Casebook in Clinical Medicine,
https://doi.org/10.1007/978-3-031-28296-6_63
465
466
J. Seok
6months or more [1]. As per the Anxiety and Depression Association of America
(ADAA) , GAD affects 6.8 million adults or 3.1% of the US population [2].
Generalized anxiety disorder can adversely impact a patient’s life and disrupt
daily living. The research shows that GAD is often misdiagnosed with symptoms
often ascribed to physical causes [3]. However, there is no brief clinical measure
for assessing GAD [4]. Generalized anxiety disorder is not only misdiagnosed
but also often associated with other mental health disorders that involve anxiety
such as bipolar disorder (comorbidities) [4–6]. Many of the body’s systems can
be affected by GAD, including the cardiac, pulmonary, and neurological, but it
also affects the musculoskeletal system. This is because the disorder can appear
in several different ways, incorporating physical characteristics in addition to
mental and behavioral ones. The patient in the case study reported musculoskeletal symptoms that can be misinterpreted for actual musculoskeletal issues rather
than GAD [7].
Clinical Case Presentation
A 28-year-old white female presents to the clinic with “complaints of joint pain
(arthralgia) and intermittent low back pain.” [7] The patient does not know or
remember how she injured herself. She is currently a second year graduate student
who cannot sleep at night and is unable to get quality sleep or rest, and she believes
that this is making her feel “restless” or “on edge.” [7] She is constantly worrying
about her performance in school, her family, and her mother as the patient has
recently been diagnosed with stage IV small cell carcinoma. The patient also presents with throbbing headaches that last for a couple of hours at night time and further keep her awake. She is tense most of the day, which in turn causes her to be
stiff. She also cannot pay attention in class and has trouble nishing her homework
[7]. Subjective symptoms are reported as joint pain, lower back pain, headache,
muscle stiffness, difculty sleeping, and difculty paying attention for approximately a year.
Her comorbidities include hypertension, 10+ alcoholic beverages per week
(which indicates possible substance abuse), and depression. The patient was previously diagnosed with posttraumatic stress disorder (PTSD) and treated with
cognitive behavioral therapy (CBT) in February of 2000. The patient was assessed
for GAD by taking the GAD-7 (16/21), the Penn State Worry Questionnaire
(PSWQ) (64/80), and the McGill Pain Questionnaire (42/78). Her score on the
Oswestry Disability Index (ODI) was 38% [7]. Subjective symptoms are as follows: heart rate of 98bpm (tachycardia), blood pressure of 146/92mmHg (hypertension), and a respiratory rate of 24 bpm. She also presented with palpable
muscle tightness in upper trapezius, forward exed head, and increased kyphosis. Patient appears to be heavily sweating and her hands are cold and clammy to
touch [7].
63 Generalized Anxiety Disorder Misdiagnosed asNonspecic Physical Pain
467
Differential Diagnosis
Given the medical history of the patient, the most probable differential diagnosis
could be as follows:
1. Chronic non-cancer or nonspecic physical pain: The patient presents with
“joint pain, low back pain, headache, and muscle stiffness” which are common
symptoms of chronic non-cancer or nonspecic physical pain. Chronic noncancer pain is “moderate or severe pain that lasts six or more months is attributed
to conditions such as neuropathic pain, rheumatoid arthritis, lower back pain,
osteoarthritis, bromyalgia and a range of several other conditions.” [8] However,
the lack of a specic injury or “lack of recall of any mechanism of injury” [7] as
well as a lack of rheumatic disorder is an indicator making the chronic pain more
likely secondary to the primary diagnosis of GAD.
2. Bipolar disorder: The patient states that she is “restless” and “on edge.” [7] This
could be interpreted as a mood swing which is a symptom of bipolar disorder.
Studies have shown that overactive moods can be subjectively mislabeled as
“mood swings” and thus leading to a common misdiagnosis of bipolar disorder
[5, 9]. However by closely following the DSM-5, the patient in the case meets all
the criteria of GAD, and the correct diagnosis of GAD was made.
3. Endocrine disorder: It is important to rule out endocrine disorders such as pheo-
chromocytoma or hyperthyroidism before diagnosing GAD [10, 11]. There is a
biochemical basis of anxiety, and it presents with many endocrine diseases with
muscle weakness, pain, and stiffness as common symptoms [6] of endocrine disorders. The tachycardia and hypertension are also both signs of an endocrine disorder [7]. While the case does not indicate the patient’s lab values, lab work will
help exclude endocrine disorders as the primary cause of this patient’s symptoms.
4. Chronic fatigue syndrome (CFS) : The patient presents complaints of physical
pain unrelated to injury that could be considered as part of the clinical manifestations of CFS but does not present the key feature of debilitating fatigue that
according to the CDC (Centers for Disease Control and Prevention) criteria is
necessary for a diagnosis.
5. Somatic symptom disorder (SSD) : Although the patient presents with physical
pain and constant worry, the DSM-5 criteria are not met as the patient’s anxiety
is not coming from the symptoms she is presenting but from different aspects of
her personal life.
What WasMisdiagnosed inThis Case andWhy?
The patient reported many symptoms that are consistent with musculoskeletal
(MSK) decits which initially led to diagnosing the patient with a MSK issue; however after a thorough clinical history and physical exam, alternative diagnoses were
considered, and the right diagnosis was ultimately made.
468
J. Seok
Discussion
The patient reported “joint pain, low back pain, headache, muscle stiffness, difculty
sleeping and paying attention for approximately a year.” [7] On initial interview and
based on the physical symptoms, the initial diagnosis seems to point toward the nonspecic physical pain. Generalized anxiety disorder (GAD) is characterized by excessive
and persistent worry that is difcult to control. GAD also causes signicant distress or
impairment and occurs on more days than not for at least 6 months [12]. Other features
include psychological symptoms such as apprehension and irritability and physical (or
somatic) symptoms such as increased fatigue and muscular tension [3]. Physical and
somatic symptoms are seen in generalized anxiety disorder. Upon further interviewing,
there were some additional key red ags such as “restless” and “on edge” to describe her
current state [7]. She had also been previously diagnosed with PTSD and treated with
cognitive behavioral therapy. She is constantly worried about her performance in graduate school and her mother. The patient’s mother was recently diagnosed with stage IV
small cell carcinoma. Her constant worrying about her mother’s health and her inability
to pay attention in class and her difculty nishing her school work help providers’
make the correct diagnosis [7, 8]. This information further provides evidence for GAD
rather than nonspecic physical pain as the patient has major stressors in her life [3] and
also highlights the importance of a thorough and complete interview. After further physical exam, hypertension, tachycardia, and increased respiratory rate are all reported in
the case [3, 7]. Patient appears to be profusely sweating and hands are cold and clammy
to touch. These are all symptoms found in GAD rather than nonspecic physical pain [3,
4]. Palpable muscle tightness in the upper trapezius and forward exed head along with
increased kyphosis result from the GAD.While the relationship is poorly understood,
the lack of a direct cause of the tightness or kyphosis points to GAD rather than other
causes [7, 13]. In order to conrm this diagnosis, we need to use the GAD-7 scale as a
means to measure anxiety. Due to the provider’s in-depth interview in the case, the
GAD-7 scale can be lled in, and the patient had a “signicantly high” score on the
GAD-7. Additionally the provider also used the Penn State Worry Questionnaire and the
McGill Pain Questionnaire [7]. These additional diagnostic tools reinforced the initial
diagnosis of GAD from the GAD-7 survey. The scores from the survey coupled her history and symptoms show that the patient has signs that are consistent with a GAD [7, 9,
12]. The results of the outcome measures along with her signicant medical history
point to GAD along with other possible comorbidities.
Plan ofAction, thePoints Clinician Should Consider, Pitfalls
toAvoid, andPearls ofKnowledge toConsider
Screening and monitoring tools can be used by providers to help make the correct
diagnosis, and a few were used to successfully diagnose the patient in the case. The
GAD-7 is a free diagnostic tool and the most common screening to diagnose
GAD.Once successfully diagnosed, good prognosis may require a combination of
treatments specic to the individual patient [3].
63 Generalized Anxiety Disorder Misdiagnosed asNonspecic Physical Pain
469
Stress management techniques such as meditation, deep breathing, progressive
muscle relaxation techniques, exercise, and modifying her diet [7] could lead to
reduction in GAD symptoms. The provider recommended a reduction in the
patient’s alcohol consumption and educated her on alcoholism and the effects that it
has on the mind and the body [14]. Her primary care provider prescribed her paxil,
a selective serotonin reuptake inhibitor to increase her levels of serotonin, which
greatly improved her motivation for therapy. Within 2–3weeks her active range of
motion improved, and the scores on her outcome measures decreased signicantly
[7]. However other medications such as but not limited to buspirone, hydroxyzine,
abecarnil, and other antidepressants can be used to effectively treat GAD [10].
Duloxetine has also shown promise in reducing GAD symptoms [15].
Benzodiazepines have been shown to be effective in treating GAD, but a study
found that benzodiazepines increased the risk of dependence, sedation, and both
work and trafc accidents [14]. Other anxiety disorders, depression [1], or substance abuse often accompany GAD [14], which rarely occurs alone; co-occurring
conditions must also be treated with appropriate therapies [7]. These comorbidities
need to be properly diagnosed along with GAD and not misdiagnosed as GAD by
using the proper screening and diagnostic tools.
Conclusion
Living with generalized anxiety disorder can manifest as a long-term challenge. In
many cases, it occurs contemporaneously with other anxiety or mood disorders.
Generalized anxiety disorder can often be misdiagnosed as chronic non-cancer or
nonspecic physical pain. Many of the body’s systems can be affected by GAD.Do
not confuse a patient’s MSK issues with GAD by looking for pain without a specic
cause. Be ready to get a good history and listen carefully for red ags during the
interview as well as the elevated respiratory rate and heartbeat during the physical
exam [9]. Lab work can also further rule out endocrine issues [11]. Then by using
the correct diagnostic tool of the GAD-7 along with other screening and diagnostic
tools, the patient can be properly diagnosed with GAD. In most cases, GAD
improves with psychotherapeutic intervention or pharmacotherapy. An adjustment
to lifestyle changes, learning coping skills and using relaxation techniques also can
help. In this case, physical therapy was used in conjunction with therapy and medication in order to relieve the MSK issues secondary to GAD [7].
References
1. Tyrer P, Baldwin D. Generalised anxiety disorder. Lancet. 2006;368(9553):2156–66. https://
doi.org/10.1016/S0140- 6736(06)69865- 6.
2. Facts & Statistics: Anxiety and Depression Association of America, ADAA [Internet]. Facts
& Statistics | Anxiety and Depression Association of America, ADAA. [cited 2022Jun22].
Available from: https://adaa.org/understanding- anxiety/facts- statistics
470
3. Locke AB, Kirst N, Shultz CG.Diagnosis and management of generalized anxiety disorder
and panic disorder in adults. Am Fam Physician. 2015;91(9):617–24.
4. Rutter LA, Brown TA. Psychometric properties of the generalized anxiety disorder Scale-7
(GAD-7) in outpatients with anxiety and mood disorders. J Psychopathol Behav Assess.
2017;39(1):140–6. https://doi.org/10.1007/s10862- 016- 9571- 9.
5. Ott CA. Treatment of anxiety disorders in patients with comorbid bipolar disorder. Ment
Health Clin. 2018;8(6):256–63. https://doi.org/10.9740/mhc.2018.11.256.
6. Yu J.Endocrine disorders and the neurologic manifestations. Ann Pediatr Endocrinol Metab.
2014;19(4):184–90. https://doi.org/10.6065/apem.2014.19.4.184.
7. Moorer D, Hocker, K. Generalized anxiety disorder case study 2017. Physiopedia
2018, March 11. May 25, 2022 from https://www.physio- pedia.com/index.
php?title=Generalized_Anxiety_Disorder_Case_Study_2017&oldid=184080
8. Genova A, Dix O, Thakur M, Sangha PS.Chronic non-cancer pain management and addiction:
a review. Cureus. 2020;12(2):e6963. https://doi.org/10.7759/cureus.6963.
9. Munir S, Takov V.Generalized anxiety disorder. In: StatPearls. Treasure Island (FL): StatPearls
Publishing; 2022.
10. Gale CK, Oakley-Browne M. Generalized anxiety disorder. Am Fam Physician.
2003;67(1):135–8.
11. Hall RC, Hall RC. Anxiety and endocrine disease. Semin Clin Neuropsychiatry.
1999;4(2):72–83. https://doi.org/10.1053/SCNP00400072.
12. American Psychiatric Association. Diagnostic and statistical manual of mental disorders
(DSM-5). 5th ed. Arlington, VA: American Psychiatric Association; 2013.
13. Pluess M, Conrad A, Wilhelm FH.Muscle tension in generalized anxiety disorder: a critical review of the literature. J Anxiety Disord. 2009;23(1):1–11. https://doi.org/10.1016/j.
janxdis.2008.03.016.
14. Back SE, Brady KT. Anxiety disorders with comorbid substance use disorders: diagnostic and treatment considerations. Psychiatr Ann. 2008;38(11):724–9. https://doi.
org/10.3928/00485713- 20081101- 01.
15. Hartford JT, Endicott J, Kornstein SG, et al. Implications of pain in generalized anxiety disorder: efcacy of duloxetine. Prim Care Companion J Clin Psychiatry. 2008;10(3):197–204.
https://doi.org/10.4088/pcc.v10n0304.
J. Seok
Part XIII
Pulmonology