The importance of diagnoses

Proper assessments and diagnoses are important to understand a patient’s problems and determine the best course of treatment for the individual.

However, in many cases the patient’s presenting symptoms do not neatly fall into the categories described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

This can make it hard for clinicians to properly determine whether pathology exists – and in the case that it does, which specific disorder(s) best conceptualize the patient’s problems. This ability to determine the most helpful and valid diagnosis among different possibilities is known as differential diagnosis.  

Below, I describe a few diagnostic considerations for common disorders in order to provide some further insight when conducting psychodiagnostics assessments.

Depressive and Bipolar Disorders

Mood disorders, such as depressive and bipolar disorders, are episodic. This means that people with mood disorders experience long periods where they have low/elevated mood and times where they feel relatively stabilized.

The primary difference between depressive and bipolar disorders is the presence of (hypo)manic episodes. People who have experienced a full-blown episode will always be diagnosed with Bipolar I whereas those who have experienced depressive episodes and hypomanic episodes will be diagnosed as Bipolar II.

In terms of depressive episodes, it takes two weeks of meeting criteria for a major depressive episode to be diagnosed with major depressive disorder. Additionally, we must also take into consideration the length of the depressive episode. In cases where a person has experienced depressive symptoms for more than two years (without more than a 2 month period of feeling okay), then diagnosis becomes persistent depressive disorder.

Here’s a useful post to learn more about the specific symptoms of manic and depressive episodes if you’re interested!

Anxiety Disorders

Anxiety disorders can sometimes look quite similar to each other. For example, a person with social anxiety disorder and agoraphobia may both be likely to avoid social situations. However, the difference can be elucidated by the specific fear.

For example, people with social anxiety are usually avoiding social situation because they fear negative evaluation. They are worried that other people are looking at them and thinking poorly of them (e.g., “they think I’m being weird, too quiet, or look stupid”).

On the other hand, agoraphobia is a fear of being in a situation where they may not be able to get away if they were to have embarrassing or panic symptoms. In this case, the worry is them having a panic attack in a crowd and not being able to get help quick, for example.

Another example where additional consideration is necessary is a fear of flying. In certain cases, this might be a fear of dying on a plane (which is more specific phobia), whereas some people with panic disorder or agoraphobia might be afraid that a plane could lead to a panic attack.

Obsessive Compulsive and Related Disorder

Obsessive-Compulsive Disorder (OCD) is a disorder that is characterized by intrusive thoughts (obsessions) and behaviours they feel compelled to engage in because of intrusive thoughts or rules (compulsions).

Sometimes, OCD can look quite similar to generalized anxiety disorder because they can both include worries. OCD and GAD can be distinguished through their qualities: OCD is typically a little more magical (i.e., “something bad will happen if I don’t sort everything a certain way) whereas GAD worries are about everyday things (finances, health, relationships).

Moreover, OCD-related thoughts and compulsions tend to be ego-dystonic, which means that the worries are inconsistent with their worldviews or how they view themselves. For example, a person with OCD may have intrusive thoughts about hurting somebody else despite thinking of themselves as a very kind and compassionate person. In contrast, GAD-related thoughts are typically ego-syntonic, which means that their worries are consistent with what is important to them (a person worried about finances will worry about exactly that).

Here’s a useful article on further differentiating between GAD and OCD if you’re interested!

Trauma and Stressor-Related Disorders

depression and anxiety. The intrusive thoughts may also feel like possible OCD too.

The main way to determine whether a diagnosis of post-traumatic stress disorder (PTSD) should be provided is the presence of a ‘trauma event’.

A trauma event in PTSD is very specific in that it must relate to a time where a person experienced an event that was life-threatening or could have led to potential death. Therefore, although some events can be very traumatizing, such as a very strict household or having parents constantly yelling at you, this may not be classified as a ‘trauma-event’ in the context of PTSD.

In this case, it may be that a person may meet diagnostic criteria for a depressive disorder or an anxiety disorder, but not PTSD. It is also possible that a person may meet criteria for PTSD and other comorbid disorders.

Schizophrenia and Psychotic Disorders

Schizophrenia and psychotic disorders are defined primarily by hallucinations and delusions (fixed beliefs even when the evidence does not suggest it).

The difference between schizophrenia and other psychotic disorders is usually differentiated by the length of these symptoms. Schizophrenia lasts longer than 6 months; schizophreniform disorder lasts 1-6 months; and brief psychotic disorders typically lasts less than one month.

Schizoaffective disorder is differentiated by the presence of mood symptoms (e.g., depression) inside a larger psychotic episode. On the other hand, bipolar and depressive disorders can also report psychotic symptoms. The way to tell the difference is by understanding whether the psychotic symptoms exist only inside the mood episode, or vice versa. Whichever one is dominant is likely to be the stronger diagnosis.

Personality Disorders

Some personality disorders can look similar to other types of mental health challenges. For example, borderline personality disorder can be quite similar to bipolar disorders and obsessive-compulsive personality disorder can look similar to OCD.

To determine whether the issue is more likely to be a personality disorder or something else, there are a few considerations that can take place. First, personality disorders are quite fixed. Unlike mood disorders, which happen episodically, personality disorders are fairly stable in how they present themselves.

Secondly, personality disorders tend to be pervasive across a broad range of contexts and can begin in early adolescents. On the other hand, disorders, such as OCD, can get worse when they are feeling stressed and may be more likely to occur in adulthood for some individuals.

Pathology and Normal Responses to Stress

Diagnoses should be helpful. And not all problems require diagnosis. Therefore, it is important for clinicians to consider when a person may not necessarily require a diagnosis.

For example, a person who reports social anxiety because they are presenting for the first time next week in front of their entire school may not necessarily have social anxiety disorder. Just the same, a person who has been feeling low for a little while because they recently got out of a romantic relationship may not have depression. And someone who spends a bit more time keeping things orderly may not necessarily have OCD.

It’s important to determine whether a person’s response to stress is above and beyond how typical people might feel in the same situation. Some factors to take into account are: time frame of symptoms, amount of distress, and how much these symptoms affect the person’s lives.

Although the DSM-5 provides guidelines for helping with diagnoses, it does require some judicious consideration by the clinician. The DSM-5 is certainly not perfect and a human touch is needed to ensure adequate diagnoses!

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Best wishes,