How to make a Diagnosis
How does a Psychiatrist make a diagnosis?
In a world of sophisticated computerized lab tests the basics of medical-psychiatric diagnosis has not changed. It is based on three things history of the problem, evaluation of the patient, and the response to treatment.
History, History and more History, this is key. One gets as much history from the patient, the patients family and anyone else who may know the patient. the more history the better, especially being true in a specialty where there are no, yes no diagnostic tests. Part of the history come from direct question, some from symptom-problem check lists, some could come from more formal psychological testing.
The Mental Status Examination: The main evaluation tool for the medical doctor is the physical exam, for the psychiatrist where there are very few physical findings that help the diagnosis, it is the what is called the Mental Status Examination. This covers how mental health problems may show themselves, by looking at broad categories such the patients general appearance and motor functioning, their mood or feeling states, their thinking as shows itself in speech and other representations like drawings, the written word, the world of dreams and fantasy and play, and higher cortical functions. Higher cortical functions include things like level or awareness, alertness, and orientation to who you are, where you are and time, attention and concentration, short and longer term memory, ability to organize, use logic, to control and regulate impulses, feelings and thinking.
Response to Treatment: This is an often overlooked part of the evaluation process. Especially when using modern psychiatric medications, the response to medication trials good and bad should be uses as a diagnostic tool to fine tune the process. The response to medication never confirms the diagnosis, but with the history, and the mental status evaluation, and by knowing the progression of the disorder and its symptoms, it will point the diagnostic professional in a direction for further history taking and evaluation.
All three of these should confirm each other, the history, the mental status and course of the disorder, and the response to treatment, and if they don’t then either the diagnosis should be in question, and more history, evaluations and medication trials may be in order. I start out by looking for biologically based medication responsive diagnostic groups that have their own unique symptom clusters, developmental and family history.
Biologically Based Medication Responsive Diagnostic -Symptom Clusters
A) [ ] Unstable Mood: Mood swings, irritability, anger outburst, rage attacks, sad to glad to mad, big unrealistic ideas, need to be the boss, the bully, need little sleep, fast talker, too many ideas, difficult to live with, walking on egg shells, Dr Jeckle & Mr. Hyde
B) [ ] Thinking- Unusual Relatedness -Reality Testing: Blunted, shallow, inappropriate emotions, loss of interest, drive, motivation & ambition, little or disorganized speech, odd, peculiar, strange, paranoid behavior, loaner, isolates self, in their own world, voices, visions
C) [ ] Movement-Impulse: Tics, motor movements of face, eye blinking, twitches, sniffing, snorting, throat clear
D) [ ] Stable Depressive: Sad, tearful, depressed stable mood, lack of pleasure, little to no interest in things, tired, fatigue, mind slow, hard to think, negative about self, past, present , and future, hopeless, better off dead
E) [ ] Anxiety-Somatic: Worried too much about past , present , and future, tense, keyed up, easily fatigued, panic attacks, fears, phobias, shy, avoids things, afraid to sleep or be alone, trouble going and staying in places like school, rituals like hand washing, counting, sequencing, ordering, getting things just right.
F) [ ] Attention-Impulsive: Poor concentration, distractibility, overly active , doesn’t think before talking or acting
G) [ ] The “Atypical Cluster”: Not fitting into the above but yet having some features of many
To see how these principles are applied a good start is the diagnosis of ADHD at ADHDtheDiagnosis