Tips for Accurate Diagnosing: One Symptom Isn't Enough

The art/science of psychotherapy is an umbrella under which numerous other arts/sciences dwell. Among these is diagnosis, an area with which new and seasoned professionals tend to struggle. For the inquiring word nerd, diagnosis literally means “the difference between.”

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The Importance of Accurate Diagnosis

While many anti-psychiatric diagnosis advocates allege that a diagnosis is a mere stigmatizing label, if we recognize the literal definition, the whole point is not to apply labels, but to ascertain what is driving the problem: “Is it this or that?”

Diagnosis can be thought of as recognizing that conditions have similarities that need to be accurately distinguished for proper care. While many diagnoses share symptoms, they are not necessarily treated the same way. A child’s most noticeable symptoms may be opposition and irritability—but are such symptoms due to a “disruptive behavioral” diagnosis or due to depression? Each is treated quite differently. Accurate differential diagnosis is necessary because it is the springboard from which we leap.

Witnessing a Misdiagnosis

Early in my career, I witnessed a disturbing case of misdiagnosis. It led to my strong interest in differential diagnosis and ultimately to my teaching abnormal psychology since 2013. During my internship at a jail, I was working with an inmate who clearly suffered from social anxiety; he had no history or current symptoms to suggest any other diagnosis. I also recognized the symptoms because, as a teen, I suffered from social anxiety myself.

A jail psychiatrist, on the other hand, opined that this man was “paranoid schizophrenic” simply because, in his interview with the doctor, the inmate said he was “paranoid” others were making fun of him, so he isolated in his cell. While paranoia and social isolation can be symptoms of schizophrenia, this kneejerk conclusion based on a single symptom description led to a world of hurt.

The socially anxious man was prescribed an antipsychotic medication and quickly developed serious side effects. While he continued to meet with me, he adamantly refused to see the psychiatrist again, even if I advocated for him that he was not schizophrenic, and thus forewent the possibility that a selective serotonin reuptake inhibitor (SSRI) could likely have accelerated the improvements in therapy.

Over my 20 years in the field, this has played out time and again. Not always as dramatic, but always tragic.

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A Restless Boy Means it's ADHD

In my work providing diagnostic assessments for the juvenile justice system, it often holds true that “diagnostic evaluation is intervention.” This is because the child has been misdiagnosed for years, getting improper treatment, and getting in trouble for it. It's not unusual to encounter a case like Tommy (name altered):

Tommy's parents explained to a therapist that he was often restless and had low frustration tolerance; an ADHD diagnosis ensued. The therapy attempt zeroed in on calming and focus techniques to no avail. ADHD medications from his pediatrician just made him lose weight. Meanwhile, Tommy began skipping school a lot so as not to have to deal with the frustrations of learning and feeling cagey. Chronic truancy brought him to the court's attention.

Upon evaluation, I discovered Tommy not only didn’t have an early history typical of those with ADHD, but he also harbored significant signs of depression. Tommy confessed to feeling he had no chance at a solid future and that he was carrying a weight. This was not noted in months' worth of documentation, only that he says his mood is “irritated.”

Diagnosing Tommy with ADHD based on one or two symptoms paved the road to worsening his condition. After three months of bi-weekly treatment, Tommy recognized he was no better and figured he was a hopeless case, exacerbating his depressed mood. If only his clinicians had asked more pointedly about his mood and what was on his mind rather than jumping to the conclusion that he suffers from ADHD because he's a restless boy!

Tommy actually suffered from persistent depressive disorder, dysthymic type, with anxious distress. Irritability, low frustration tolerance, problems focusing, and hopelessness are a classic representation of the disorder, and it is not unusual for there to be superimposed anxiety symptoms (like restlessness).

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They're Moody, So They're Bipolar

Some patients I worked with in my private therapy practice arrived seeking help for bipolar disorder because they had a long history of dramatically-changing moods. Periodic stints in therapy over the years focusing on coping skills and sleep hygiene—so important to bipolar disorders—and various medications used for bipolar disorder, like lithium, proved minimally helpful at best.

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A careful history revealed no family background of the disease (bipolar disorders having a significant genetic component) and no significant substance abuse or medical problems that would likely cause such emotional shifting. The patients complained that their moods got in the way of their relationships, and they often felt abandoned. When asked to explain, it became clear that their moods were reactive to their relationships. This is in contrast to the more sustained, endogenous mood changes of bipolar conditions.

More than once, it added up that their “bipolar disorder” was borderline personality disorder, a condition known for significant reactive moods, especially in relation to others. In fact, the personality theorist Theodore Millon, Ph.D. (1996), opined it should be called “cyclic personality” because of their constant cycling of how they view their relationships and react to them with intense moods. When treatment of the “bipolar” patients shifted to addressing their views of themselves and others in relation to them, they met with more treatment success.

Symptoms Do Not Exist in a Vacuum

Clearly, diagnosing by one symptom is poor practice. Jumping to conclusions as if a complained-of psychiatric symptom existed in a vacuum leads to poor outcomes. Practitioners shouldn't stop at the complained-of symptom. Instead, one symptom should beg more inquiry, particularly:

• What other behaviors or experiences accompany it?
• What other conditions have similar symptoms to your initial diagnostic hunch and could possibly also account for it (differential diagnosis)?

In the next post, we'll further digest this information and consider ways to think about diagnosis that may help curb the tendency to diagnose based on one symptom.