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They sound alike and look alike. They're not the same thing. Here's how to tell the difference between schizophrenia and schizoaffective disorder.

The DSM devotes a chapter to Schizophrenia Spectrum and Other Psychotic Disorders. Included there: delusional disorder (delusions without other schizophrenia symptoms), brief psychotic disorder (psychotic symptoms present less than one month), schizophreniform disorder (symptoms lasting for less than six months), catatonia, and substance/medication-induced and due-to-another-medical-condition psychotic disorder (describe themselves).

What's left: schizophrenia and schizoaffective disorder. Here are the criteria for schizophrenia:

A. Two or more present for bulk of a one-month period: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and/or negative symptoms.

B. Symptoms disturb level of functioning.

C. Signs of disturbance last for at least 6 months.

D. Schizoaffective and bipolar disorder ruled out.

E. Symptoms not due to the effects of a substance or medical condition.

Schizoaffective disorder is diagnosed when these criteria are met. Watch for the difference. It'll come up right away:

A. A major mood episode concurrent with criterion A of schizophrenia.

B. Delusions of hallucinations for two or more weeks without a major mood episode during the lifetime duration of the disorder.

C. A major mood episode is present for the majority of the illness.

D. Symptoms not due to the effects of a substance or medical condition.

Specifiers for schizoaffective disorder include bipolar type, depressive type, and with catatonia.

TL;DR? They're very similar. Both include some combination of delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and/or negative symptoms. But in schizoaffective disorder, a major mood episode is present most of the time (though not 100% of the time). Why not 100%? Because then you'd be looking at MDD or bipolar I with psychotic features. A topic for another blog post

So how do you boil this down into something simple and memorable? How about this: Schizoaffective disorder is like schizophrenia, but includes a big mood component generally occurring alongside psychotic symptoms.

ASWB exam preppers, see if the above helps you answer this question correctly:

A social worker sees a client who reports a lifetime of "seeing things all the time, shadows." He also reports hearing voices, "probably the NSA," which tell him he's "useless and stupid." The voices leave him feeling "pretty sad and really annoyed." Given the symptoms the client describes, what is the MOST likely of the following DSM diagnoses?

A. Major depression with psychotic features

B. Schizophrenia

C. Schizophreniform disorder

D. Schizoaffective disorder

What do you think?

The client appears to meet criteria for some psychotic disorder, given that he reports a lifetime of psychotic symptoms (hallucinations and delusions). The lifetime duration means schizophreniform disorder isn't the correct answer. Narrowing down between the three left standing depends upon your reading of "pretty sad and really annoyed." Sounds like the client gets in a bad mood due to his symptoms. Does that bad mood rise to the level of MDD? It does not. So scratch A. And while you're at it, since schizoaffective disorder requires MDD or bipolar disorder symptoms alongside schizophrenia symptoms, scratch that one as well. Now you're left with one answer, the correct answer as it happens: B, schizophrenia.

For more practice questions from the DSM, about psychotic disorder diagnosis, and other close-call social work situations, sign up with SWTP!

[Post by Will Baum, LCSW]

Given the similarities between bulimia nervosa and anorexia nervosa, binge-eating/purging type, there's room for confusion when making a diagnosis, whether on the ASWB exam or in real life. Let's take a look at what the DSM says about each.

What is anorexia nervosa?

Criteria for anorexia nervosa are as follows:

A. Restriction of energy intake leading to significantly low body weight.

B. Intense fear of gaining weight despite significantly low weight.

C. Disturbance in the way one's body weight or shape is experienced, undue influence of body weight shape on self-evaluation, or persistent lack of recognition of the seriousness of current low body weight.

What are the types of anorexia nervosa?

There are two subtypes in anorexia nervosa:

Restricting type. Weight loss accomplished primarily through dieting, fasting, and/or excessive exercise (not recurrent binging or purging).

Binge-eating/purging type. Recurrent episodes of binge eating or purging (self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

What is bulimia nervosa?

Criteria for bulimia nervosa are as follows:

A. Recurrent episodes of binge eating (overeating in a discrete period of time with a sensed lack of control regarding the eating).

B. Recurrent inappropriate compensatory behaviors to prevent weight gain (e.g., self-induced vomiting, misuse of laxatives, diuretics, or other medications; fasting; excessive exercise).

C. Lasts once a week for three months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. Does not occur exclusively during episodes of anorexia nervosa.

What's the difference between anorexia nervosa, binge/purging-type and bulimia nervosa?

Both anorexia nervosa and bulimia nervosa involve negative self-evaluation of body shape and weight. Both involve behaviors to avoid weight gain such as self-induced vomiting. However, in anorexia nervosa, the disorder leads to significantly low body weight, where bulimia nervosa does not.

The difference is the ways severity is coded for anorexia and bulimia helps highlight the essential difference between the two diagnoses.

For anorexia nervosa, severity is based on body mass index (BMI). For example, "mild" indicates a BMI less than or equal to 17 kilograms per square meter. "Extreme" indicates a BMI of less than fifteen kilograms per square meter.

For bulimia nervosa, severity is based on the frequency of behaviors. For 1-3 episodes per week, a specifier of "mild" is applied. "Extreme" is used for 14 or more episodes per week.

The difference is not the behavior itself, it's the result.

Free ASWB Exam Practice

The ASWB exam often tests to assess knowledge of differentials between commonly occurring DSM disorders like anorexia and bulimia. A sample question:

A 17-year-old client who appears noticeably underweight reports frequently forcing herself to vomit after meals in order to "stay skinny for cheerleading." The MOST likely DSM diagnosis for this client is a type of:

A. Bulimia nervosa

B. Body dysmorphic disorder

C. Rumination disorder

D. Anorexia nervosa

Unless you're caught by the distractors, body dysmorphic disorder (which is not diagnosed when an eating disorder is present) and rumination disorder (not described here), knowing the difference between anorexia and bulimia quickly gets you to the correct answer. The client is "noticeably underweight." You have your essential information. The phrase "a type of" at the end of the question stem is an additional clue. The client is most likely suffering from anorexia nervosa, binge/purging-type. The answer is D.

[Post by  Will Baum, LCSW]

Here's a quick quiz that should help you lock down your ease with defense mechanism. What are defense mechanisms? Wikipedia wants to tell you:

A defense mechanism is an unconscious psychological mechanism that reduces anxiety arising from unacceptable or potentially harmful stimuli. Defense mechanisms are not to be confused with conscious coping strategies. Sigmund Freud was one of the first proponents of this construct.

Okay, but which defense mechanism is which? Here's a short list of examples, courtesy of Simply Psychology. You provide the name of the defense mechanism. Good luck!

1. A young man has no conscious awareness of his desire to hurt his father.

2. A smoker refuses to admit to herself that smoking is bad for one's health.

3. A person comes to believe that their anger toward a rival started with the rival's misbehavior toward them.

4. A person frustrated by their boss, goes home and kicks their dog.

5. An angry person feels relief from working long hours.

How'd you do? Answers are in comments.

There are more defense mechanisms where these came from. Read up on the sites linked above and also here:

• 15 Common Defense Mechanisms (PsychCentral)
• In Defense of Defense Mechanisms (Chart and Podcast from The Psych Files)

To get realistic exam questions about defense mechanisms and much more in SWTP's full-length mock exams, sign up!

Good luck on the exam!

-- Will Baum, LCSW

The theme lately has been anxiety disorders. Let's continue now with generalized anxiety disorder (GAD). Criteria for GAD are pretty straightforward:

A. Excessive anxiety and worry occurring more days than not for at least six months, about a number of events or activities.

B. The worry is difficult to control.

C. The worry comes with three or more of these (or just one in children):

   1. Restlessness, feeling keyed up or on edge.

   2. Being easily fatigued.

   3. Difficulty concentrating or mind going blank.

   4. Irritability.

   5. Muscle tension.

   6. Sleep problems.

Plus the usual...

D. Symptoms cause clinically significant distress or impairment.

E. Not substance induced

F. Not better explained by another condition (e.g., panic, OCD, PTSD, anorexia, somatic symptom disorder, body dysmorphic disorder, illness anxiety disorder, schizophrenia, or delusional disorder).

That is, lots of anxiety, lots of the time. Which is simple enough as far as the social work licensing exam goes, until you get to the "e.g." in letter F. All those rule outs. To be able to identify GAD, you have to be able to identify what it isn't. That means you have to have a pretty good idea what all of those other anxiety and related disorders look like. Suddenly, learning GAD for the exam becomes a little more complicated than expected.

On the test, you might see GAD as a frequent distractor (an appealing answer that isn't the correct answer). It's a catch-all for anxiety-related symptoms. How to ready yourself to tell when GAD's a distractor and when it's the answer? Piecing together your own practice question might help. It could go something like this:

A client tells a social worker he's been an "anxious mess" ever since dropping out of college, worrying about a variety of things "all of the time." He reports difficulty falling asleep even though he's usually exhausted early in the day. He has trouble with self-care like reading or meditating--"my mind just keeps going."

If you leave it there, you've got GAD. Worry for more days than not, significant distress, three of the six offered symptoms. But here's a quiz. Imagine there's an added line. What's the MOST likely diagnosis then?

The client reports everything is easier when he drinks fewer than four cups of coffee in a day.

...or...

The client reports he is "obsessed" with how much he weighs. His MD wants him to put on 20 additional pounds--"but he's a quack."

...or...

The client reports he witnessed a suicide in his college dorm room--"I've never been the same since."

Etc. Now you're into something that may not be GAD. Four cups of coffee--sounds like the symptoms may be "attributable to the physiological effects of a substance." Weigh obsession and weight loss--sounds like anorexia nervosa. Witnessed a suicide--sounds like the client's symptoms might be better explained by PTSD.

And so on. You get the idea.

For more reading about generalized anxiety disorder, check out:

• Generalized Anxiety Disorder (Mayo Clinic)
• Generalized Anxiety Disorder (Wikipedia)
• Generalized Anxiety Disorder Symptoms (PsychCentral)

For exam-style questions about GAD, anxiety disorders, and lots more, sign up for SWTP full-length practice tests!

[Post by Will Baum, LCSW]

Your client reports occasional "freak outs" during which she experiences:

1. Palpitations

2. Sweating

3. Trembling

4. Shortness of breath

5. Choking feelings

6. Chest pain

7. Nausea

8. Dizziness

9. Chills

10. Numbness

11. Feelings of unreality

12. Fear of going crazy

13. Fear of dying

What's she experiencing? That's a panic attack. What's the diagnosis? It's very likely panic disorder. This imaginary client is symptoms in every one of the thirteen categories of symptoms that make up a panic attack. (She only needed to have four to meet initial criteria for a panic disorder diagnosis.) It's as if she entered your office to help you prepare for the ASWB exam. Thanks, client!

In order to fully meet panic disorder criteria, a panic attack needs to be follow by a month or more of either 1) persistent worry about additional panic attacks or 2) significant maladaptive change in behavior related to the attacks (avoidance bx, that is). Also, as with every last diagnosis, panic disorder can only be diagnosed if it's not better explained by substance use or a medical condition. So watch out for an exam question like this:

A client reports a series of panic attacks during which he experiences an accelerated heart rate, shaking, a sensation of being smothered, and heat sensations. He worries "all the time" about future panic attacks and has stopped dating for fear of a panic attack occurring in the middle of a date. What should the social worker do FIRST to help this client?

Before looking at the answers, think of what yours would be. That's generally a good approach to studying, unless you're pressed for time (e.g., in timed mode on a practice exam). What answers might you expect to see as A-D? Maybe these:

A) Diagnose the client with panic disorder

B) Provide psychoeducation about panic attacks

C) Refer client for a medical evaluation

D) Introduce cognitive behavioral techniques for reducing panic.

What do you say? We're in a diagnostic blog post, so the diagnostic answer is tempting. But it's premature to diagnose the client. First things first: rule out an underlying medical condition that may be causing the client's panic-attacky symptoms (the client's symptoms are just about all the ones left of the DSM list of thirteen above) . The client saying he's having panic attacks doesn't mean that's necessarily what's really going on. He should get a clean bill of health, then receive the diagnosis, then the psychoed and CBT. This simple order of operations--rule outs first!--will help get you through many a social work exam item.

Before moving on to helpful links, there's one more thing to note for the diagnosis: Culture-specific symptoms are sometimes seen. The DSM-5 lists tinnitus, headaches, and "uncontrollable screaming or crying" among them. They count too.

Okay, now some helpful links:

• Answers to Your Questions About Panic Disorder (APA)
• Panic Attacks & Panic Disorder (WebMD)
• Panic Disorder (Wikipedia)

For more exam prep re panic disorder and lots more, try SWTP's full-length practice tests. Sign up to get started!

[Post by Will Baum, LCSW]