Psychiatric Diagnosis
The Diagnostic Process
 There are essentially only three parts to making a psychiatric
diagnosis:
- gathering information about your recent and past history of
symptoms
- observing your behavior and emotions during the interview and
- ruling out physical causes of your symptoms.
1. Gathering Information about Symptoms
The present and past history of your symptoms is determined from your
answers to questions such as, "How have you been sleeping compared
to usual?" "Do you ever hear any sounds, noises or voices, that
other people don't hear?" "Has there ever been time when your
friends or family said something about your drinking?" There is
nothing very complicated or mysterious about the questions used to make
your psychiatric diagnosis. It is simply a matter of knowing the symptoms
your diagnosis is based on, and knowing how to "translate" the
psychiatric jargon into questions using everyday language. A good
interviewer will ask you questions that you understand; a bad interviewer
will use too many technical terms.
2. Observing Behavior and Emotions
Because observation is an important part of every evaluation your
psychiatric evaluation actually begins when you are greeted by your
clinician. Diagnostic clues can be found in how fast you talk (people with
mania often talk rapidly and are difficult to interrupt; people with
depression may speak slowly and softly with extended pauses before
answering questions), how you relate to the interviewer (people with
schizophrenia may be distant and detached, whereas people with mania or
certain personality disorders may be overly familiar and sexually
seductive), or how well you can focus on the interview (a person hearing
voices might look up to the ceiling and appear as if she is hearing
someone, even though she may initially deny the reason for this behavior).
You may have a psychiatric disorder that is associated with observable
physical abnormalities. A skin abrasion on one or two fingers maybe seen
if you have bulimia and self-induce vomiting by sticking your fingers down
your throat. If you compulsively wash your hands you might have dry,
reddened and chapped hands.
These types of observations are part of your psychiatric mental status
examination. The mental status exam is analogous to a physical exam - it
is a record of the findings at the time of your exam. In general, the
professional's observations made during your mental status examination
are no different than what you observe in your normal daily interactions
with friends, family and coworkers. If there was something unusual about
the way someone looked, spoke or behaved you would take notice. The
information has meaning to the mental health professional in that certain
patterns of observation suggest certain diagnoses. These observations are
diagnostic clues, but they are not conclusive. A diagnosis is not based on
only a couple of clues, such as hand tremors or soft, slow speech. It is
the pattern of observations, together with the history of your symptoms
that help determine your diagnosis.
3. Ruling Out Physical Causes for Symptoms
The third part of the diagnostic process is to make sure that there are
no physical causes of your symptoms. There are many medical diseases and
medications that can produce symptoms that look psychiatric. Thyroid
disease can masquerade as depression. Adrenal disease can mimic anxiety
and depressive disorders. Different types of cancer can present initially
as symptoms of anxiety or depression. So can HIV infection. Drug and
alcohol use and withdrawal can cause psychosis, anxiety, manic and
depressive symptoms. Consequently, another important part of your
clinician's initial evaluation is to get a thorough medical history.
DSM-IV, The Diagnostic Bible
The current rules, or criteria, used to make your psychiatric diagnosis
are published in the fourth edition of the American Psychiatric
Association's Diagnostic and Statistical Manual for Mental Disorders
(DSM-IV). DSM-IV is an 886-page book that lists the specific diagnostic
criteria for more than 250 disorders.
What's normal and what's a psychiatric disorder?
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