Diagnosing Psychiatric Disorders

Diagnosing psychiatric disorders can be difficult, and below are some algorithmic approaches for learners.

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Is the anxiety in the background of euthymia (normal mood)? If so, then it is likely a primary anxiety disorder, such as generalized anxiety disorder. If the anxiety is in the background of a depressed mood, then depression with anxious features should override a primary anxiety disorder diagnosis. Another thing to consider is if the patient’s “anxiety” is actually heightened excitement, restlessness, and fidgeting from hypomania. In this case, bipolar II should be considered. Some other clues would be if the anxiety is very episodic in nature (i.e. – months of having no anxiety symptoms at all).

Diagnostic Flow Chart for Anxiety Fig. 1

Is the psychosis occurring during a manic episode (mania with psychotic features)? Is the psychosis occurring in a depressive episode (depression with psychotic features)? If the psychosis only ever happens during periods of euthymia, then schizoaffective disorder should be considered.

Diagnostic Flow Chart for Psychosis Fig. 2

Be comfortable with using Unspecified or Other Specified Disorder diagnoses when you are not sure if a patient meets full criteria for a diagnosis.

Don't be afraid to use adjustment disorder for patients seen in emergency settings. Not everything is a recurrence of an existing mental disorder (e.g. - recurrent major depressive episode).

You don't always have to give a diagnosis. Don't be afraid to use V Codes and Z Codes!