Initial Screen with Example Diagnosis and Medication Responsiveness:
Initial Screening Mental Health Symptom-Problem Cluster Checklist with Examples of Diagnoses
and usual Medication responsiveness:
This is a very brief and overly simplest discussion and only meant to be an introduction to some
basic ideas of how to apply findings from a checklist, to start to make a diagnosis, and to begin
thinking about making a biochemical diagnosis, as the first step in choosing a medication.
It is based on an expansion of a symptom-problem check list which is part of a screening tool
used in an initial evaluation with some patients.
See Initial Diagnostic Mental Health History and
Checklist . Screening tools are tools for screening, just that and nothing more. They are not a
substitute for getting a complete history of the individual and their family, and treatment trials by
skilled and competent mental health professionals.
The checklist is presented here with diagnositic examples to help you know how some diagnoses are
provisionally made and what thinking should go into choosing a medication. The check list only
points one to certain diagnositic possibilities which must be confirmed by a complete history, both
personal and familial of the patient, and findings from the mental status evaluation. How to make a
Diagnosis, Diagnostic Symptom Clusters or Groups, MoodAnxietyScreen,
ProSymptomScreenExpanded
Diagnosis of mental health disorders is complex and time consuming, perhaps more so than any
other field of medicine. What makes it so is the uniqueness of an individual’s symptoms picture
based on a multitude of interacting and interconnected factors. These include their external
environmental stressors, the internal milieu and what stresses it may bring, that is their physical
health and status of the body in general, specific brain chemistry and its responsiveness and never to
be forgotten or underestimated is the role their minds psychology, reactivity and responsiveness to
all the other factors. All of these factors are involved in getting the correct descriptive, historical,
developmental, biological specifically biochemical brain chemistry diagnosis. Right Medication for
the Right Diagnosis, Part 1.Intro-A higher standard of care is needed! QandA
More than in any other medical field the patient and their family should be an essential and integral
part of the diagnositic and treatment process.
This information is presented in part for this reason
and to help one to become a more informed consumer for yourself and your loved ones.
DIRECTIONS: 1. CHECK AFTER THE NUMBER IF THAT LIST SEEM TO APPLY GENERALLY
2. THEN CIRCLE AN ITEM OR ITEMS IF THEY MORE MOST SPECIFICALLY APPLY
Attention-Impulsivity Cluster:
If there are no other symptoms-problems from the other clusters, that is no disturbance of Mood
being unstable /irritable/depressed, or Anxiety, or Motor/Vocal Tics , or Relatedness and Reality
Testing, or “Atypical-ness”. Further there are no serious Environmental stressors, Medical
problems or Medications or Abuseable substances, that could also explain this presentation , then
intialscreenwithexapmlediagnosisandmedic (cyrilpuhalla)
http://sites.google.com/site/cyrilpuhalla/intialscreenwithexapmlediagnosisandmedic[3/22/2010 6:02:45 PM]
ADHD may be the diagnosis and the medications of choice would be the neurostimulants.
ADHDtheDiagnosis, ADHD-Stimulant Medications-Intro Q and A, ADHD Fact Sheet
1. [ ] Always moving, on the go, into everything, frigidity, can’t be or sit still, even when
sleeping
2. [ ] Can’t pay attention, focus on boring stuff for 15 minutes when left alone, easily distracted
3. [ ] Doesn’t slow down, to stop and think or, to focus on consequences before talking or doing
4. [ ] Difficulty organizing tasks and activities, looses things, is forgetful, seems not to listen
5. [ ] Seems not learn from making mistakes and from life experiences, difficult to discipline
6. [ ] Excitable, with no mood swings, short fuse, but is able to calm self down, in a reasonably
short time
Temperament-Developmental Cluster:
This cluster may indicate problems seen in the Pervasive Developmental Spectrum, Asperger's-
PDDNOS-Autism. Sometimes the “Atypical Child/Person” may have some of these but not as
pervasively and seriously impairing as the PDD spectrum disorders. There is no medication treatment
for these kinds of problems and the treatment of choice is very specific behavioral and relationship
therapy. However these people can have any other mental health diagnosis and for those that are
biologically based with known medication responsiveness, use the medication indicated for that
cluster. The Atypical Child-Person a proposed special diagnositic entity.
7. [ ] Persistent preoccupation with parts of objects, insistence on doing things over and over
8. [ ] Repetitive body movements like, clapping, finger flicking, rocking, walking on tip toes,
9. [ ] Too sensitive to changes in routine, or surroundings, causing tearfulness, worry, panic,
anger, rage
10. [ ] Colic as infant, fussy, needy, easily upset, hard to please, soothe, calm, whinny irritable
person
11. [ ] Sensitivities to sound, touch, light, taste, smells, textures of things like clothing & foods
12. [ ] Hard to please as a child, slow to warm up, with unpredictable emotional responses
13. [ ] Neither desires or enjoys close relationships, indifferent to praise or criticism,
14. [ ] Likes to be alone doing solitary activities, only close relationship are in family
Unstable Mood Cluster:
This cluster represents the Unstable Mood Spectrum that includes the Bipolar type of mood
disturbance. These have a specific biological basis with these people having an “Excitable Brain”
that results in unpredictable changes in mood, that can be irritable, excitable, with angry-rageful
outbursts, with periods of depression. The periods of depression may be mistaken for the stable
Unipolar Depression and treated with SSRI/NRI type medications with possible catastrophic results.
Diagnostic confusion also occurs because these symptoms may come and go, and specific symptoms
such as anxiety , or distractibility, or physical complaints like insomnia, upset stomach, irritable
bowel, migraine headache may dominate the picture, and be treated symptomatically. A good
example of this is the presence of [HID] Hyperactivity, Impulsivity and Distractibility [29, 30 and
31] as dominating the picture often results in a diagnosis of ADHD, without the examiner being
aware of the other symptoms being present perhaps episodically in the individuals and family
history. Stimulants are used with resulting increase of mood symptoms. The medications of choice
are mood stabilizers , that are divided into three classes, neuroleptics, anti convulsants, and Lithium
in a class by itself. Bipolar and Unstable Mood Disorders, Childhood Bipolar and Atypical Mood
Disorders Q and A, Depression which is it, Unipolar or the unstable Bipolar type, Q and A,
ExcitableBrain, Mood,DxGroups, Unstable Mood Scales Historical Markers, Treatment Scale,
Symptom Picutre
intialscreenwithexapmlediagnosisandmedic (cyrilpuhalla)
http://sites.google.com/site/cyrilpuhalla/intialscreenwithexapmlediagnosisandmedic[3/22/2010 6:02:45 PM]
15. [ ] Often unpleasant, irritable, nasty, mean, excitable, defiant to authorities, bullies peers
16. [ ] Short fuse, easily made angry, can’t calm self down in 20 min, rages lasting from minutes
to hours
17. [ ] Quick and frequent mood swings, ups and downs of feeling states, Dr Jeckle & Mr. Hyde
18. [ ] Too demanding & demands must be met immediately, difficult to live with, walking on
eggshells
19. [ ] Can’t control anger, aggressive, violent, destructive to property, physically hurts others
20. [ ] Injures self on purpose, self mutilates, bangs head, bites self, punches walls
21. [ ] Brief periods of sadness, irritable and whinny, cries over small annoyances and hurts
22. [ ] Talks too much, too fast, difficult to follow, goes off on tangents , talks in circles
23. [ ] Needs little sleep but not tired next , often unable to sleep because mind won’t shut down
24. [ ] Excessive involvement in pleasurable activities, that have high potential for painful
consequences
25. [ ] Too happy, cheerful, enthusiastic, silly, giddy, goofy, overly friendly, even with strange
26. [ ] Mostly high energy states with increase of goal directed activities at home, work, school
socially
27. [ ] Thinks too highly of self, over values abilities, sets unrealistic goals, bossy, needs to be in
charge
28. [ ] Low energy states increase with age, may occur with physical illnesses like headaches, GI
problems
29. [ ] Hyperactive, high energy states correlates strongly with mood and motivation
30. [ ] Impulsive -not thinking of consequences of behavior, speech, goals, plans, and
relationships
31. [ ] Distracted by minor and unimportant things, and changes excessively driven by mood
Depression Cluster:
This represents the stable Unipolar depressive states and their somatic problem equivalents, like
trouble with stomach-intestine, headaches, certain rashes, some fibromyalgia type symptoms, some
“chronic fatigue “ syndromes. Unstable mood symptoms should never dominate the picture either
by family history, the individuals history, or be episodically present. The biological basis has to do
with serotonin-norepinephrine-dopamine in the brain, with medication that increase these
neurochemicals, the selective serotonin-norepinephrine-dopamine inhibitors used as the medications
of choice. The nine symptom-problem clusters are the accepted criterion found in diagnostic
manuals. Unipolar Stable Depressive Disorders Q and A, Suicide, What to Know and What to do.
Q and A
32. [ ] Depression- sad mood, tearful, whiney, easily cries, irritable, feels empty and alone
33. [ ] Interest- diminished pleasure and interest in most things, don’t care, too bored attitude
34. [ ] Body Weight- significant weight loss or gaining, eating too much or too little, not dieting
35. [ ] Sleep- sleeping too much, too little, waking up cant fall back to sleep, never feels rested
36. [ ] Mind/Body Energy- as observed by others either too slowed down or speeded up
37. [ ] Fatigue- loss of energy, always tired, fatigued, no motivation, drive, ambition
38. [ ] Negativity- worthless, guilty, ashamed, negative about self, present , past and future
39. [ ] Concentration- diminished ability to think, remember, concentrate, mind goes blank
40. [ ] Hopelessness- hopeless , recurrent thoughts of death, dying, suicide ideas, attempt, plan
Anxiety cluster:
These represent the usual Anxiety Disorder Spectrum syndromes, that may be present in any other
mental health disorder and if better explained by that disorder, for example during the course of an
Unstable Mood Disorder[ MOC- mood stabilizers] , or as part of a Tourette’s Disorder[ MOCintialscreenwithexapmlediagnosisandmedic
(cyrilpuhalla)
http://sites.google.com/site/cyrilpuhalla/intialscreenwithexapmlediagnosisandmedic[3/22/2010 6:02:45 PM]
neuroleptics], or part of the Schizophrenic spectrum [MOC-neuroleptics], should first be treated with
the medication of choice [MOC] for those disorders. Regardless of the specific anxiety label the
MOC are the SSRI/NRI group of medications, with the benzodiazepine group being used
adjunctively, especially at the initiation of treatment because of possible activating effects of the
SSRI/NRI’s being misperceived and felt as anxiety. Anxiety and its Disorders, OCD Obsessive
Compulsive Disorder, Panic Disorder, School Avoidance and Refusal, Too Much Worry Generalized
Anxiety Disorder
41. [ ] Social Anxiety- Fear , embarrassment of social, performance situation, with unfamiliar
people scrutinizing
42. [ ] Obsessive-Compulsive [OCD]- Worry of not doing rituals, hand washing, checking,
ordering, counting, repeating, praying
43. [ ] Panic- attacks of anxiety, heart pounds, shaking, short of breath, dizzy, lightheaded, losing
control fear
44. [ ] Post Traumatic Stress Disorders [PTSD]- Extreme fear, numbing, avoidance and reexperiencing
trauma, abuse, neglect, catastrophes
45. [ ] Separation Anxiety -Worry over losing & leaving loved one, trouble being & sleeping
alone, need some to go places
46. [ ] School/Work dysfunction due to any Anxiety Disorders-Frequent school work lateness,
avoidance, absences, due to illness, especially early in week
47. [ ] Physical problems like Chronic Fatigue, some Fibromyalgia caused by Anxiety- Always
sick, headaches, migraines, stomach-bowel problems, easily fatigued, allergic, rashes
48. [ ] Generalized Anxiety Disorder -Too worried all the time , keyed up, on edge, tense, irritable,
trouble falling and staying asleep
Thinking Cluster:
Thinking problems can occur in any mental health problem if severe and long lasting and may or
may not represent a “thought disorder in process” as seen in the psychotic and the Schizophrenic
Spectrum Disorders. As with the anxiety problems the medicine of choice for the underlying specific
disorder is usually tried first, however if these symptoms are severe, impairing and long lasting the
neuroleptic medications may be the only ones that can help. In small doses and for a short period of
time they may need to be used adjunctively with other medications. These thinking problems are
often not recognized when subtle or not dominating the picture and yet may lead to significant
distress and school, work and relationship impairment. The importance of recognizing and treating
them cannot be over emphasized. Thinking Problems-Reality Testing Checklist and Early Screening
49. [ ] Speech is odd, peculiar, too vague, too complex, to specific, speaks in riddles
50. [ ] Thinking is illogical, thoughts are disconnected, disorganized, hard to follow
51. [ ] Speech is too pressured, too fast, too much, too emotionally charged, never seems to end
52. [ ] Person speech goes off on tangents, talks in circles, gets off track, changes subjects
frequently
53. [ ] Speaks too little, seems to be struggling to put feeling and thoughts into words, hardly talks
at all
Reality Testing Cluster:
Like thinking problems these can occur in any severe and chronic mental health disorder, and when
subtle are often missed, yet can lead to very serious if not catastrophic outcomes. If these are
present especially with thinking problems, problems with relatedness , and impulsivity the likely
hood dangerousness to self and others possible outcomes is greatly increased. It is essential to find
the causes of these symptoms including ruling out drugs and alcohol problems, medical especially
neurological diagnoses, and any medication prescription or over the counter including food
supplements , and “energy drinks and foods”. If mental health problems are the cause treat the
intialscreenwithexapmlediagnosisandmedic (cyrilpuhalla)
http://sites.google.com/site/cyrilpuhalla/intialscreenwithexapmlediagnosisandmedic[3/22/2010 6:02:45 PM]
underlying disorder and when in doubt use neuroleptic medications.
54. [ ] At times too tuned in to fantasy, their self, too much into their own world, rather than
others
55. [ ] Unaware of time, place, who you are, dazed, lost in time, confused, acting and feeling like
in a dream
56. [ ] Reads hidden insulting or threatening meanings into everyday remarks and events
57. [ ] Holds grudges, unforgiving of insults, injuries or slights
58. [ ] Suspects without sufficient basis that others are out to use, abuse, harm or deceive
59. [ ]Thoughts so loud seem like voices, hearing and seeing things not sure if they are there and
real
60. [ ] Senses, feels , perceives, sees, hears, tastes, smells, things that others aren’t aware of
Relatedness Cluster:
These represent anything from personality traits, to idiosyncratic tendencies, to symptoms of major
and minor mental health issues, and must be taken together with other symptom clusters and
complexes before one can determine what if any diagnostic significance they may have. These may
or may not have specific medication responsiveness depending on what if any underlying disorder
may be present.
61. [ ] Difficult to read as if there is an emotional barrier between the person and others
62. [ ] Poor eye contact, facial expressions, body postures, gestures to communicate feelings
63. [ ] Relatedness, behavior, appearance is odd, peculiar, slightly off, unusual, something not just
right
64. [ ] Responds and relates in shallow, detached manner with restricted flattened emotions
65. [ ] Poor verbal/non verbal give and take in sharing , understanding, and seeking emotional
Responses
Movement-Impulse Cluster:
Because of their episodic, that is coming and going nature, and the fact that they may come out
when there are no stresses, or when there is negative or bad stress, or with good stress like when
having pleasure or fun, these often go unrecognized or dismissed as insignificant, or a phase, or just
normal part of life or development. Yet if present and causing significant distress and impairment
their brain chemistry which often is very responsive to neuroleptic medications should be treated.
Equally if not more important is this same brain chemistry can drive other symptom clusters that are
treated inappropriately and inadequately with other classes of medications. Three crucially
important examples are using the neurostimulants for what appears to be classical ADHD type
symptoms, and using SSRI’s for OCD, or anti convulsant mood stabilizers with or without lithium
carbonate for unstable mood problems or aggression, when the driving brain chemistry is
neuroleptic responsive. Sometimes the response is more selective to the older neuroleptics rather
than the atypicals which may aggravate the symptoms. Diagnoses include classic Tourette’s, and
Motor and Vocal Tic Disorders. TouretteTicDisorders
66. [ ] Simple Motor Tics- rapid meaningless muscle contraction of few muscles like eye blinking
67. [ ] Simple Vocal Tics - sniffs, snorts, clicks, throat clearing, grunts, coughs, barks, yelps,
giggle
68. [ ] Complex Motor- touching, squatting, twirling & retracing steps when walking, repeating
69. [ ] Complex Vocal- saying and repeating words, phrases, part of songs
70. [ ] Motor Driven Compulsions- doing things over and over, rituals driven by tics
71. [ ] Motor Driven “ADHD type symptoms”- over active, impulsive, inattention driven by tics
intialscreenwithexapmlediagnosisandmedic (cyrilpuhalla)
http://sites.google.com/site/cyrilpuhalla/intialscreenwithexapmlediagnosisandmedic[3/22/2010 6:02:45 PM]
This grouping is included for the sake of completeness of initial screening and because of their
prognostic and therapeutic significance.
Conduct-Antisocial Cluster:
If conduct-antisocial problems are due to a medication responsive mental health disorder then there
may be improvement with the appropriate medications. Some of these symptoms represent character
traits or “ego deficits” that may not be helped with pharmacology or the usual psychotherapeutic
modalities.
72. [ ] Shallow affection, love, joy, Lack of appropriate guilt, shame, remorse, sympathy,
compassion
73. [ ] Routinely ignores moral standards, social norms, being deceitful, breaking rules, lying,
stealing
74. [ ] Emotionally tuned in, sensitive, giving, caring, alternating with cold, aloof, distant, selfish
75. [ ] Trouble with the law, truancy, delinquency, arrests, probation, parole violations, violent
Crimes
Other:
This grouping, [75 – 79] is included for the sake of completeness of initial screening and
because of their prognostic and therapeutic significance, often present first to the mental health
professional.
Stammering and stuttering is not thought of as a brain chemistry problem yet is often related to other
mental health problems and has some medication responsiveness. Especially to those related to the
anxiety or movement-impulse disorders, where the predicable responsiveness may occur with the
SSRI’s and the neuroleptics
76. [ ] Stuttering, stammering, words get stuck, can’t speak fluently, trouble pronouncing words
Substances of abuse thought epidemic is still under estimated as a cause and effect of mental health
problems, distress and impairment, need always to be ruled in or out and appropriately and
adequately treated. Mental health treatments are extremely compromised by drug and alcohol
problems treated or not. The excessive use of anything including food, exercise , work, pleasurable
activities , including multimedia electronic entertainment may indicate mental health problem, and
may be used as a “self treatment”.
77. [ ] Over use of drugs, alcohol, tobacco, exercise, food, TV, video games, excessive
Daydreaming
Learning problems, and “soft neurological “ symptoms require specialized testing before they can
be attributed to a mental health diagnosis.
78. [ ] Trouble in reading, spelling, math, speech, requiring special intervention
79. [ ] Hand writing is poor, problems with fine or gross motor co ordination, clumsy, accident
prone and other “soft neurological” symptoms [like minor issues with auditory-visual and other
sensory processing]
Sleep related symptoms are often medication responsive to the an underlying mental health disorder
that is not recognized or inadequately treated, and yet these symptoms not only causing distress and
impairment, and if not treated can continue to fuel the underlying disorder and make complications
and relapses more common.
80. [ ] Bed wetting, deep sleeper, hard to wake up , nightmares, night terrors, sleep walking
intialscreenwithexapmlediagnosisandmedic (cyrilpuhalla)
http://sites.google.com/site/cyrilpuhalla/intialscreenwithexapmlediagnosisandmedic[3/22/2010 6:02:45 PM]
Atypical Cluster: “Atypical-ness” a proposed cluster:
Of special mention is the “Atypical Child/Person” who don’t fit into any of the above clusters or
categories and yet have symptoms and problems that sometime come and go, of many of these and
have unique and unpredictable responses to treatment biochemically with medications and with non
biological modalities. This profile needs to be considered when expected treatment has unexpected
results. The “Atypical Person” may have specific “Atypical” Brain Chemistry and Responsiveness,
that require special psychopharmacological interventions. More than in any other group what ever
medication is chosen one must start very low, and go very slow because of brain chemistry
sensitivity and its unpredicableness . Be prepared for unusual and unpredictable good and bad
effects even at very small doses. Often I use what I call “micro dosing” and use very small doses of
two or more medications to get the desirable effects. This is discussed further elsewhere. The
Atypical Child-Person a proposed special diagnositic entity.
Some of the symptoms-problems seen in this proposed group are:
1) [ ]Uneven development as infant-child, loosing & gaining functions unpredictably like
speech and language
2) [ ]Transitions cause panic anxiety or rage attacks, physical symptoms like hives, irritable
bowel, headaches
3) [ ] Unusual sensitivities to touch, taste, positioning, sound, lights.
4) [ ] Poor eye contact, and poor non verbal communication using gestures, body language
5) [ ] Not getting social rules, and cues from other, not getting the point of jokes or riddles
or social moves
6) [ ] Socially stiff, and awkward, verbally and non verbally, marches to his or her own
drummer
7) [ ] Unusual or peculiar relatedness, but not overtly strange or bizarre, slightly off
emotionally
8) [ ] Something just “not right” about how they relate, respond, react to people, even those
they know well
9) [ ] Get stuck in doing something, and has to finish it, and if not panic, gets angry, or too
upset
10) [ ] Unusually high and over developed abilities in some areas of usually in the area of the
thinking and doing mind, with unusually low function if not actual deficits in other area
especially those related to the experiencing-relationship-feeling mode of the mind.