Differential Diagnosis

P S Y C H O P A T H O L O G Y A N D C L I N I C A L S C I E N C E
The Diagnostic Process
Consequences?
DIAGNOSIS
More than 1
diagnosis?

What if it’s incorrect?

What if we miss
SYMPTOMS a diagnosis?
 Provisional Diagnosis

Provisioan l diagnossis
309.81 §Post-traumatic Stress Disorder (Provisional)
Differential Diagnosis

“the process of determining which of two or more

diseases or disorders with overlapping symptoms
a particular client has” and “the distinction
between two or more similar conditions by
identifying critical symptoms present in one but
not the other”.
(APA Dictionary of Psychology, 2022)
The Process
§ List our hypotheses
§ Explanations of client symptoms
§ Use of DSM-5 criteria
§ Series of steps to eliminate explanations
§ Directs our ongoing assessment
§ Questioning narrows down focus
§ Determine
§ Diagnosis
§ Prognosis
§ Treatment
The Toolset

§ Handbook of Differential Diagnoses

§ Dr. Michael First
§ Based on DSM-5
§ Diagnostic criteria
§ Symptoms
§ Requirements for diagnosis
Step 1: Exclude Malingering/Factitious Disorder

§ Malingering
§ Purposeful deception of clinician
§ Symptoms are feigned
§ Partial malingering: Exaggerated
§ Secondary gain motive
§ Factitious disorder
§ Recognised disorder
§ Sick role/attention motive
Step 2: Exclude Substance Use

§ Drug-induced psychiatric symptoms

§ Legal drugs
§ e.g., corticosteroids
§ Illicit drugs
§ Comorbidity of substance disorders
§ DSM exclusion clause
Step 3: Exclude General Medical Condition

§ Illness mirrors psychiatric symptoms

§ Hypothyroidism (depressive)
§ Hyperthyroidism (anxiety)
§ Pre-screening by GP
§ DSM exclusion clause
Step 4: Determine Primary Disorder

§ Current DSM criteria

§ 29 decision-trees/flowcharts
§ Based on presenting symptoms
§ Series of decision points
§ Several trees may be applicable
§ May lead to same diagnosis
§ >1 diagnosis may be appropriate
Decision Tree: Panic Attack
Panic Attack

Due to the Y Panic attacks predominate Y SUBSTANCE/MEDICATION

physiological effects of a in the clinical picture and INDUCED ANXIETY
substance (including are sufficiently severe to DISORDER
medication) warrant clinical attention
N N SUBSTANCE INTOXICATION,
SUBSTANCE WITHDRAWAL
OTHER ADVERSE EFFECT OF
MEDICATION
Decision Trees: Panic Attack

ANXIETY DISORDER DUE TO

Y
Due to the ANOTHER MEDICAL
physiological effects of a CONDITION, WITH PANIC
general medical condition ATTTACKS

Recurrent unexpected
panic attacks Y
accompanied by at least 1 PANIC DISORDER (3.5.5)
month of concern or
maladaptive changes in
behaviour
N
Decision Trees: Panic Attack

Y
Trigger for panic attack is SOCIAL ANXIETY DISORDER
fear of embarrassment in (3.5.4) WITH PANIC
social situations ATTACKS
N

Trigger for panic attack is

fear of specific object Y
(e.g., spiders) or situation SPECIFIC PHOBIA (3.5.3)
WITH PANIC ATTACKS
(e.g., heights, seeing
blood)
N
Decision Trees: Panic Attack

Trigger for panic attack is Y SEPARATION ANXIETY

fear of separation from DISORDER (3.5.1) WITH
major attachment figures PANIC ATTACKS

N
Decision Trees: Panic Attack

Trigger for panic attack is

exposure to a situation
resembling a prior
traumatic experience
occurring in the context of Y Y POSTTRAUMATIC STRESS
intrusion symptoms, Duration of more
than 1 month DISORDER (3.7.1) WITH
avoidance of stimuli PANIC ATTACKS
associated with the N
traumatic stressor,
negative alterations in
cognitions and mood, and ACUTE STRESS DISORDER
alterations in arousal and (3.7.1) WITH PANIC
ATTACKS
activity

N
Decision Trees: Panic Attack

Y
Trigger for panic attack is ILLNESS ANXIETY DISORDER
the threat of having a (3.9.2) WITH PANIC
serious illness ATTACKS
N

Trigger for panic attack is

exposure to a focus of an Y OBSESSIVE-COMPULSIVE
obsessional concern (e.g., DISORDER (3.6.1) WITH
to dirt to an individual PANIC ATTACKS
with contamination
obsession)
N
Decision Trees: Panic Attack

Trigger for panic attack is Y GENERALISED ANXIETY

excessive anxiety and DISORDER (3.5.4) WITH
worry about a number of PANIC ATTACKS
events or activities such as
work or school
performance
N

Failure to meet threshold

Step 5: Failure to Meet Threshold

§ Adjustment Disorder
§ Exaggerated, persistent response
§ Other specified categories
§ Failed to meet full criteria
§ Other Unspecified categories
§ Symptoms align with disorder
§ Symptoms not met
§ No reason given
Step 6: No Mental Disorder

§ Insufficient level distress/dysfunction

§ A reasonable response
§ Life event, e.g., bereavement