Tips for Accurate Diagnosing: A Symptom Is Part of a Pattern

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The tendency to fall into poor diagnostic habits isn’t entirely the fault of students and new practitioners. Supervision deficits and the fact that there is little preparatory training in diagnosis other than a survey of the DSM in most programs are set-ups for such diagnostic habits. The good news is, despite these hurdles, most new clinicians seem interested in honing diagnostic skills because it indeed leads to better treatment outcomes and boosts confidence.

As illustrated in the previous post, one trap is making a diagnostic conclusion from a single symptom. It, unfortunately, is easy for otherwise well-meaning clinicians to latch onto a diagnostic buzzword and quickly transition to whatever diagnosis they are familiar with that harbors it as a key feature.

With that mindset, hallucinations mean Schizophrenia, social awkwardness means Autism Spectrum, obsession means OCD, and the list goes on.

A symptom must be contextualized

It's natural to pick up on a chief complaint or observable symptom, but that item requires contextualization. While the edicts of psychiatry past are often forgotten, we can still take a cue from Emil Kraepelin, the father of modern psychiatric disease classification. Kraepelin (Spitzer et al., 2002, page 487) told us:

“A single symptom, however characteristic is may be, never justifies a diagnosis by itself…”

This is because different diagnoses have similar symptoms, and thus a symptom must be put into perspective. For example, if a clinician picks up on obsessional thinking, it must be considered if it's:

• The actual OCD criteria definition of obsession meaning intrusive thoughts/images/urges
• A colloquial definition of someone that can't let things go, like a tendency to dwell on arguments or someone doing them wrong, like in many personality disorders
• An intensely focused interest, as in Autism Spectrum conditions
• Intrusive memories like in trauma
• Ruminations on negative self-perceptions/guilt like in depression
• Persistent worries about life in general as in generalized anxiety disorder
• Preoccupation about possibly having a disease, as in illness anxiety (hypochondria)

Obsession is not obsession is not obsession; therefore, "obsession" does not equal OCD.

At first glance, it may seem overwhelming to consider how to tease that all apart, but again, simple questioning to the rescue:

1. If the patient uses the word obsession to describe their experience, saying "Tell me more about what you mean by obsessed," and asking for examples of "obsession" will help clarify.
2. If the clinician thinks to themselves, "This person is obsessed," considering the nature of the "obsession" (worry, rumination, intrusive thoughts/images, etc.) will guide you to other questions that will lead to a diagnosis. If, for instance, "Tell me more" leads to the person explaining that their "obsessions" are anticipation of things always going wrong, that's a tip-off to Generalized Anxiety Disorder (GAD), and the attentive clinician will explore if the person exhibits more GAD criteria.

Diagnostic Conclusions Can Take Time

In the meantime, it's OK if you’re not 100 percent sure of a diagnosis, and even seasoned clinicians often take time to know for sure. In fact, some researchers on diagnostic accuracy have recently shown that the soundest diagnostic outcomes are associated with practitioners who take their time (Bruchbiel, et al., 2019).

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Instead of rushing to a conclusion in the first session, clinicians are instead encouraged to digest the information, perhaps in supervision, and prepare follow-up questions to see what pattern the chief symptom is part of. For example, if the clinician perceives that the "obsession" means worry, and we know that worry is often indicative of GAD, in the next session they can follow up:

"Last time we met you described having what you called "obsessions," and explained how that meant often thinking the worst-case scenario is about to happen. I'm curious to know what else happens when those thoughts set in, like how it affects your mood, sleep, ability to focus, things like that."

If the rest of the symptoms align with GAD, there's the answer. If not, such as if the worry is only in particular situations, like relationship-related matters, it's important to keep learning about the pattern. It could be a personality disorder or separation anxiety. This is the important process of differential diagnosis.

If, while you're still clarifying a diagnosis, one needs to be applied, such as for billing purposes, the DSM 5 gives us the “Other” and “Unspecified” categories (formerly collectively referred to as “Not Otherwise Specified” [NOS] in earlier DSM editions) that can hold us over. See What Do "Other" and "Unspecified" Diagnoses Mean? to learn more on utilizing these categories.

Anxiety Essential Reads

Polarization Contributes to Rising Reports of Anxiety

Transforming Anxiety: How to Turn Worry Into Success

A Sure Diagnosis Is Not Required for Treatment to Commence

Even if we’re not entirely sure of the diagnosis, treatment can begin in the form of establishing a therapeutic alliance, implementing stress management, and exploring strengths-based interventions such as cultivating things the client has found helpful in managing. However, despite seeing some gains in treatment without fully knowing the diagnostic picture does not mean clinicians can forget about accuracy.

We find an example of why in the previous post where the person was misdiagnosed for years with bipolar disorder. Over the years, their moods sometimes improved with new stress management skills. However, their earlier providers were remiss in simply applying a revolving door of new coping mechanisms whenever the patient seemed moody, and not contextualizing the moodiness and looking at the broader picture.

There needed to be vigilance to the pattern. This would have shed light on the fact the moods were short-lived, frequent, and reactive to interpersonal issues, as in borderline personality disorder. Meaningful work needed to focus on managing the fears of abandonment that drove the moodiness, not just offering a new coping skill. It otherwise becomes a mere game of symptom “whack-a-mole” and the patient never reaches any sustained stabilization.

In the upcoming three posts we'll consider another source of misdiagnosis: medical mimicry.