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Differential Diagnosis
Exploring the Framing Bias
Instructor: Dr. Dawn-Elise Snipes
Executive Director:, Counselor Education and Training
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery

Counseling CEUs are available at
~ Define the framing bias
~ Explore medial, substance and mood symptoms which may overlap
~ Identify how many “problem” behaviors are semi-functional adaptations to help the person survive
~ Develop an understanding for how a positive change in any one area can lead to positive changes throughout the system


Framing Bias
~ Tendency to react to a particular set of symptoms in different ways depending on how or where it is presented
~ Medical practitioners: Depression, Anxiety, Physical
~ May miss bipolar, substance intoxication or withdrawal, normal reactions to psychosocial stressors
~ Mental health clinicians: Mental health, normal reactions to psychosocial stressors
~ May miss medical, substance
~ Substance abuse clinicians: Substance, normal reactions
~ May miss mental health and medical
Framing Bias
~ Problem (Finding the cause of the symptoms)
~ If it is caused by medical, psychosocial issues, psychotropics will (likely) not help much
~ If it is caused by substances, psychotropics may help “bridge the gap”
~ If symptoms are caused by a mental health issue which exists independently of substance use, recovery needs to address both
Framing Bias
~ Find the cause of low water pressure
~ Leaks:
~ Water pressure coming into the house is fine, but doesn’t make it to where it needs to be
~ Dripping faucets, running toilet, poor fittings
~ Crack in the line
~ Pressure reducing valve malfunctioning

Anxiety: Generalized
~ Symptoms
~ At least 6 months of “excessive anxiety and worry” about a variety of events and situations.
~ The presence for most days over the previous six months of 3 or more (only 1 for children) of the following symptoms:
~ Feeling wound-up, tense, or restless
~ Easily becoming fatigued or worn-out
~ Concentration problems
~ Irritability
~ Significant muscle tension
~ Difficulty with sleep


Anxiety: Panic Disorder
~ Symptoms
~ Palpitations, pounding heart, or accelerated heart rate
~ Sweating
~ Trembling or shaking
~ Sensations of shortness of breath or smothering
~ Feeling of choking
~ Nausea or abdominal distress
~ Feeling dizzy, unsteady, lightheaded, or faint
~ Derealization (feelings of unreality) or depersonalization (being detached from oneself)
~ Fear of losing control or going crazy or dying
~ Paresthesias (numbness or tingling sensations)
~ Chills or hot flushes


Depression and Dysthymia
~ Major Depressive Episode
~ A. Five (or more) of the following have been present nearly every day during the same 2-week period
~ depressed mood most of the day
~ markedly diminished interest or pleasure in all, or almost all, activities
~ significant changes in eating patterns.
~ insomnia or hypersomnia
~ psychomotor agitation or retardation nearly every day
~ fatigue or loss of energy
~ feelings of worthlessness or excessive or inappropriate guilt
~ diminished ability to think or concentrate, or indecisiveness,
~ recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation
~ Symptoms
~ A distinct period of abnormally and persistently elevated, or irritable mood, lasting at least 1 week
~ Inflated self-esteem or grandiosity
~ Decreased need for sleep
~ More talkative than usual or pressure to keep talking
~ Flight of ideas or subjective experience that thoughts are racing
~ Distractibility
~ Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
~ Excessive involvement in pleasurable activities that have a high potential for negative consequences

~ Disorder in which the person experiences both manic and depressive type symptoms
~ Symptoms can alternate, co-occur(mixed) or be present to a greater or lesser degree (hypomania/persistent depressive disorder)
Cyclothymic Disorder
~ Symptoms
~ For at least 2 years, the presence of numerous periods of hypomanic symptoms and numerous periods of depressive symptoms that do not meet criteria for a Major Depressive Episode.
~ During the above 2-year period (1 year for children or adolescents), the person has not been without symptoms for more than 2 months

Physical Issues
~ Physical conditions can mimic intoxication or withdrawal
~ Physical conditions can worsen during use or withdrawal
~ People use to self-medicate physical (and emotional) conditions
~ Effective treatment involves addressing physical AND emotional conditions AND treatment side effects which are unpleasant.
Medical Disorders – Overview
~ Depressive-Like Symptoms
~ Diabetes
~ Hypothyroid
~ Fibromyalgia
~ Chronic Fatigue
~ Polycystic Ovarian Syndrome / Menopause
~ Lupus
~ Adrenal issues
~ Manic-Like Symptoms
~ Hyperthyroid
~ Lupus
~ Substance toxicity/poisoning

Medical Disorders
~ Anxiety
~ Hyperthyroid
~ Hormone imbalances
~ Low blood sugar
~ Heart problems (SVT, lack of oxygenation, irregular heartbeat)
~ Serotonin syndrome

Medical Issues
~ Chronic Fatigue
~ Fatigue
~ Sore Throat
~ Loss memory and loss of concentration
~ Enlarged lymph nodes in the neck
~ Muscle pain that is unexplained
~ Joint pain that can move from joint to joint without any signs or swelling.
~ Headaches
~ Exhaustion
~ Pain in the abdominal region
~ Having allergies or other sensitivities
~ Chest pains
~ Bloating/Diarrhea
~ Dry mouth
~ Being dizzy when standing up, or having problems with balance and fainting
~ Irregular heartbeats
~ Morning stiffness
~ Jaw pain
~ Nausea
~ Having night sweats and chills
~ Depression, anxiety, panic
~ Being short of breath
~ Tingling Sensations in your extremities
~ Vision blurring, eye pain, sensitivity to light or dry eyes.
~ Gaining or losing weight.

Medical: Diabetes
~ Symptoms
~ Frequent urination
~ Unusual thirst
~ Extreme hunger
~ Unusual weight loss
~ Extreme fatigue and irritability
~ Anxiety


Medical: Diabetes
~ Hypoglycemia (low blood sugar) (200k+/year)
~ Nervousness
~ Sweating
~ Intense hunger
~ Trembling
~ Weakness
~ Palpitations
~ Trouble speaking/Word Slurring
~ Difficulty concentrating

Medical: Fibromyalgia (over 3 mil./year)
~ Chronic muscle pain, muscle spasms, tightness, or weakness
~ Moderate or severe fatigue and decreased energy
~ Insomnia or waking up feeling just as tired as when you went to sleep
~ Difficulty remembering, concentrating
~ Irritable bowel syndrome
~ Tension or migraine headaches
~ Jaw and facial tenderness
~ Sensitivity to : odors, noise, lights, medications, foods, and cold
~ Feeling anxious or depressed
~ Numbness or tingling in the face, arms, hands, legs, or feet
~ Reduced tolerance for exercise
~ A feeling of swelling in hands and feet
~ Dizziness

Medical: Hypertension
~ Hypertension
~ Severe headache
~ Fatigue or confusion
~ Vision problems
~ Chest pain
~ Difficulty breathing
~ Irregular heartbeat
~ Blood in the urine
~ Pounding in your chest, neck, or ears

If you have any of these symptoms, see a doctor immediately. You could be having a hypertensive crisis that could lead to a heart attack or stroke.
Medical: Heart Issues
~ Shortness of breath
~ Palpitations
~ A faster heartbeat
~ Weakness or dizziness
~ Nausea
~ Sweating

Medical: Lupus (200k+/year)
~ Painful or swollen joints and muscle pain
~ Unexplained fever
~ Red rashes, most commonly on the face
~ Chest pain upon deep breathing
~ Unusual loss of hair
~ Pale or purple fingers or toes from cold or stress (Raynaud's phenomenon)
~ Sensitivity to the sun
~ Swelling (edema) in legs or around eyes
~ Mouth ulcers
~ Swollen glands
~ Extreme fatigue
~ Confusion
~ Dizziness
~ Depression
~ Mania / Extreme excitability

Polycystic Ovarian Syndrome (200k+/year)

~ Infrequent, absent, and/or irregular menstrual periods
~ Increased hair on the face, chest, torso, thumbs, or toes
~ Cysts on the ovaries
~ Acne, oily skin, or dandruff
~ Weight gain usually with extra weight around the waist
~ Male-pattern baldness or very thin hair
~ Patches of skin on the neck, arms, breasts, or thighs that are thick and dark brown or black
~ Skin tags — excess flaps of skin in the armpits or neck area
~ Pelvic pain
~ Anxiety or depression
~ Sleep apnea — when breathing stops while asleep

Medical:Thyroid (200k+/year)
~ Palpitations / Fast heart rate
~ Heat intolerance
~ Nervousness
~ Insomnia
~ Breathlessness
~ Increased bowel movements
~ Light or absent menstrual periods
~ Fatigue
~ Trembling hands
~ Weight loss
~ Muscle weakness
~ Warm moist skin
~ Hair loss



~ Fatigue
~ Weakness
~ Weight gain
~ Coarse, dry hair, hair loss
~ Dry, rough pale skin
~ Cold intolerance
~ Muscle cramps/muscle aches
~ Constipation
~ Depression
~ Irritability
~ Memory loss
~ Abnormal menstrual cycles
~ Decreased libido

Serotonin Syndrome
~ Symptoms
~ Agitation or restlessness
~ Confusion
~ Rapid heart rate and high blood pressure
~ Dilated pupils
~ Loss of muscle coordination or twitching muscles
~ Muscle rigidity
~ Heavy sweating
~ Diarrhea
~ Headache
~ Shivering or Goose bumps
~ High fever
~ Seizures
~ Depression
~ Opiates
~ Antianxiety/Benzodiazepines
~ Depressants/Barbiturates
~ Inhalants (including paint)
~ Alcohol
~ Withdrawal or recovery from stimulant intoxication/use
~ Cannabis intoxication
~ Mania
~ Ecstasy/MDMA
~ Methamphetamine
~ Cocaine
~ Steroids
~ Caffeine
~ Ginseng overuse
~ Energy drinks/preworkout supplements
~ Rare-ish side effect when SSRIs given to someone who has bipolar

~ Anxiety
~ Caffeine
~ Decongestants
~ Preworkout supplements / Energy drinks
~ Alcohol (esp. early withdrawal)
~ Cannabis/Spice intoxication
~ Medication side effects, including SSRIs

~ Mood and physical symptoms can all be caused by
~ Physical conditions
~ Substances (including withdrawal, intoxication and “rebalancing”)
~ Organic mood issues
~ Psychosocial stressors
~ Full and effective recovery requires identifying and addressing both
~ the presenting symptoms to provide proximal relief
~ The underlying cause(s) of the presenting symptoms

Additional Brief Texts
~ Comorbidity: Addiction and Other Mental Illnesses [Printed 2009]
~ MDMA Abuse (Ecstasy) [Revised 2006]
~ Marijuana Abuse [Printed 2005]
~ Therapeutic Community [Printed 2002]
~ Anabolic Steroid Abuse [Revised 2006]
~ Cocaine: Abuse and Addiction [Revised 2009]
~ Hallucinogens and Dissociative Drugs [Printed 2001]
~ Heroin: Abuse and Addiction [Revised 2005]
~ HIV/AIDS [Revised 2006]
~ Inhalant Abuse [Revised 2009]
~ Methamphetamine: Abuse and Addiction [Revised 2006]
~ Tobacco Addiction [Revised 2009]
~ Prescription Drugs Abuse and Addiction [Revised 2005]

Spanish Version of Texts
~ Abuso de la MDMA (Éxtasis) [Revised 2006]
~ Alucinógenos y Drogas Disociativas [Printed 2003]
~ La Comunidad Terapéutica [Printed 2003]
~ Abuso de la Marihuana [Revised 2005]
~ La Heroína: Abuso y Adicción [Revised 2005]
~ Adicción al Tabaco [Printed 2007]
~ Esteroides Anabólicos Abuso [Revised 2007]
~ Cocaina Adicción y Abuso [Revised 2010]
~ Abuso de Inhalantes [Revised 2005]
~ Abuso y Adicción a la Metanfetamina [Revised 2007]
~ Medicamentos de Prescripción – Abuso y Adicción [Printed 2001]
~ VIH/SIDA [Printed 2006]