1. Four Steps in Diagnosis Process to an Accurate Diagnosis (0:13:00):
A. Step 1: Gather Client Database:
a. Pre-Interview:
- Collect information prior to clinical interview.
- Ask client to bring of meditations.
- Ask client to complete a symptom rating measure.
- Cross-Cutting Level 1 Symptom Measure: Link
- Becomes a treatment outcome measure.
b. Clinical Interview:
i. Purpose:
- Build rapport and obtain information.
ii. Has three phases:
- Phase 1: Intense observation: broad observation of cognitions, affect and behavior – verbal and nonverbal. Don’t interfere with what your client tells you.
- Sort your observations into 4 categories: Cognitions (Thought Content. Thought Process), Affect (Verbal and Nonverbal), Behaviors (Reported and Observed), and Physiology (Reported, Observed, and in Referral).
- This phase ends (around 10 minutes or more) when you can decide if the client is able to present self accurately, or if client has possible impaired communication and/or thinking, unusual experiences/beliefs or heighted affect which require assessment first.
- Clinical Interview Phase 1 Source of Error: Jumping from description of behavior (observation) immediately to judgment! Just observe, don’t make judgments.
- Do you have enough of a “behavior sample” to know if you need to begin with a mental status exam (more off-putting to the client) or take a presenting issues approach?
- If the client is 65 years or older, then do a mental status exam, to determine if the client has some form of cognitive decline or not?
- Phase 2 (0:29:00): Understanding the whole client: Structured data gathering and rapport building for 30 minutes.
- Begin with mental status exam if indicated,
- or
- Begin with the client’s presenting concerns. Broad exploration of the client’s life. This is the meat of your intake interview (around 30 minutes of your 1 hour intake).
- – History of presenting concerns. e.g. are the PTSD symptoms coming back?
- – Personal developmental and social background.
- – Previous mental health history.
- – Physical symptoms and medical conditions.
- – Family history.
- – Medications, prescribed, OTC, alcohol, tobacco, illicit drug use.
- – Organize observations, symptoms, and data that are significant deviations by category: cognition, affective regulation, behavior, and physiology.
Trauma: With every client, you have to ask about trauma.
- Necessary Information About Client’s Trauma:
- Nature of the trauma experienced.
- – meets the DSM-5 definition for “traumatic event”?
- i.e. experienced or witnessed an event when you or someone you saw were or witnessed someone being seriously injured or you thought your life was in danger or you thought you were going to be seriously injured or endangered.
- – severe psychosocial neglect prior to age of 2?
- Necessary Information About Client’s Trauma and Symptoms:
- a. During initial interview:
- Identify all the client’s cognitive, affective, behavioral and physiological symptoms, not just trauma experiences.
- For diagnosis of Traumatic and Stressor-Related Disorders, the symptoms must develop after the traumatic or stressful events.
- Note: Psychosocial stressors are important in pathogenesis of all DSM-5 disorders, but just four are diagnosed as Trauma and Stressor-Related when the person has been exposed to an extreme stressor!
- Clinical Interview Phase II Source of Error:
- – Cultural bias & lack of cultural experience so clinician misinterprets symptoms & data.
- Incorporate the DSM-5 Cultural Formulation Interview (DSM-5, 752-757) into your clinical interview.
- Cultural Formulations Interview: Link
- Supplementary Modules to the Cultural Formulations Interview: Link
- Phase 3 (0:37:00): Focused exploration
- Focused exploration of common symptoms for syndromes that have not been offered by client in Phase II.
- Review with client responses on the DSM-5 Cross-cutting Symptom Measure but not disclosed in interview Phase II.
- e.g. problems with sex, with being abused, etc. issues that are embarrassing.
- Ask about DSM symptoms for syndrome areas not covered so far in interview. Example: unusual thoughts or rituals (e.g. repetitive disorders).
- Review with client any differences in medical record and/or referral information.
- Speak with family member or other informant if needed. Speak with them both together, not separately, so that there’s not a sense of mistrust.
Step 1 Gathering Data is complete when you are able to cluster observations and symptoms into possible syndromes.
B. Step 2: Identify Syndromes (0:39:30):
At the end of the Intake Interview, what additional have you gathered regarding the client’s symptoms and experiences?
Identify syndromes (clusters of signs and symptoms that form a psychological concept such as depression and anxiety) present by considering patterns across the:
- Behavioral Observation Sheet
- Cross-cutting Symptom Measure:
- Client’s Developmental, Psychosocial and Mental History
This requires knowledge of Key Symptoms for each Class of Mental Disorder.
This step ends when you have identified all the syndromes that seem to be present.
Men often express depression as anger and frustration.
Remember: Syndromes are not diagnoses. They are the broad category in the DSM-5, of which there will be disorders.
Step 2 Source of Error:
- Caution: Letting a prior diagnosis shape or limit your identification of other patterns present, and just following the “Medical Referral” by the doctor.
Always conduct your own complete assessment so you have your own complete database.
Prepare a behavioral observation sheet and review for patterns.
C. Step 3: Differential Diagnosis (0:48:06):
Differential Diagnosis Process has two phases:
- i. Generating a Differential Diagnosis List of Possible Diagnoses.
- List all possible diagnoses, diagnoses with criteria symptom sets that include one or more of the client’s identified syndromes.
- – Follow the Othmer “Rule of Five”.
- When you’re trying to do a differential, you should always ask yourself, “What are 5 diagnoses that this might be?”.
- – Consider medical disorders that could cause the symptoms or make symptoms worse.
- – Consider the use of substances (substance-induced mental disorders) as source of symptoms:
- — prescription
- — OTC
- — alcohol, tobacco, and illicit drugs
- DSM-5 Manual provides differential diagnoses information (in order of probability) for each mental disorder.
- ii. Narrowing the List to the Most Probable Diagnoses.
- Move from possible to a smaller list of probable.
- Remove from the list diagnoses whose full DSM criteria sets are not met.
- Look at DSM-5 Handbook of Differential Diagnosis – also available as an app for iPhone/iPad.
D. Step 4: Initial DSM-5 Diagnosis List (0:57:20) :
To make a diagnosis list:
- Verify that each remaining diagnosis meets the DSM-5 diagnostic criteria, or that you are quite positive it is present but you need data to confirm (provisional).
- Correct DSM-5 name with the applicable specifiers.
- – Assign specific ICD 10 code.
PTSD Symptom Criteria: 0:58:00
2. Resources:
Psychiatry.org Diagnosis Assessment: Link
DSM-5 Criteria for PTSD: Brainline.org Link
Treatment for PTSD and/or Brain Injury: Brainline.org Link