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The New Therapist
with Anthony D. Smith, LMHC

Improving Diagnostic Accuracy: 1 Symptom Isn’t Enough

In this multipart series, we’re going to explore common diagnostic mistakes made by new therapists and uncover simple steps to make big differences in your diagnostic accuracy.

The art/science of psychotherapy is an umbrella under which numerous other arts/sciences dwell, amongst which is diagnosis, an area new and seasoned professionals tend to struggle with. For the inquiring word nerd, the term literally means “the difference between.” While many anti-psychiatric diagnosis advocates allege a diagnosis is a mere stigmatizing label, if we recognize the literal definition, the whole point is not to apply labels, but to ascertain what is driving the problem; “Is it this, or that?” Diagnosis can be thought of as recognizing that conditions have similarities that need to be properly distinguished for proper care. While many diagnoses share symptoms, they are not necessarily treated the same. A child’s most noticeable symptoms may be opposition and irritability, but is it a “disruptive behavioral” diagnosis, or due to depression? Each are treated quite differently. Accurate differential diagnosis is necessary because it is the springboard from which we leap.

From early on I witnessed the damage of misdiagnosis. It led to my strong interest in differential diagnosis and ultimately to teaching abnormal psychology for the past 7 years. The interest germinated during my internship at a jail while working with an inmate who clearly suffered from Social Anxiety; he had no history or current symptoms to suggest any other diagnosis. I also recognized the symptoms because as a teen I was debilitated by it myself. The jail psychiatrist opined he was “Paranoid Schizophrenic” simply because, in his interview with the doctor, the inmate said he was “paranoid” others were making fun of him, so he isolated in his cell. While paranoia and social isolation can be symptoms of Schizophrenia, this kneejerk conclusion based on a single symptom description led to a world of hurt.

The socially-anxious man was prescribed an antipsychotic medication and quickly developed serious side effects. While he continued to meet with me, he adamantly refused to see the psychiatrist again, even if I advocated for him that he was not Schizophrenic, and forewent the possibility of an SSRI that could likely have accelerated the improvements in therapy. Over my 20 years in the field, this has played out time and time again. Not always as dramatic, but always tragic. A couple more illustrations drive the point home:

  • In my work providing diagnostic assessments for the juvenile justice system, it often holds true that “diagnostic evaluation is intervention” This is because the child has been misdiagnosed for years, getting improper treatment, and getting in trouble for it. Parents explaining to a therapist that Tommy is restless and has low frustration tolerance leads to an ADHD diagnosis. The therapy attempt zeroes in on calming and focus techniques to no avail. ADHD medications from his Pediatrician just made him lose weight. Meanwhile, Tommy began skipping school a lot so as not to have to deal with the frustrations of learning and feeling cagey.

Upon evaluation, I discovered Tommy not only didn’t have an early history typical of those with ADHD, he harbored significant signs of depression. Tommy confessed to feeling he had no chance at a solid future and that he was carrying a weight. This was not noted in a year’s worth of documentation; only that he says his mood is “irritated.” Diagnosing Tommy with ADHD based on one or two symptoms paved the road to worsening his condition. After three months of bi-weekly treatment Tommy recognized he was no better, and figured he was a hopeless case, exacerbating his depressed mood. If only his clinicians had asked more pointedly about his mood and what was on his mind rather than assuming the restlessness was simply a sign of ADHD. Tommy suffered from Persistent Depressive Disorder, Dysthymic Type, with anxious distress. Irritability/low frustration tolerance, problems focusing, and hopelessness are a classic representation of the disorder, and it is not unusual for there to be superimposed anxiety symptoms (like restlessness).

  • Some patients I worked with in my private therapy practice arrived seeking help for Bipolar Disorder because they had a long history of dramatically-changing moods. Periodic stints in therapy over the years focusing on coping skills and sleep hygiene, so important to Bipolar Disorders, and various medications used for Bipolar Disorder, like lithium, proved minimally helpful at best. A careful history revealed no family background of the disease (Bipolar Disorders having a significant genetic component), and no significant substance abuse or reported medical problems that would likely cause such emotional shifting. The patients complained that their moods got in the way of their relationships, and they often felt abandoned. When asked to explain, it became clear that their moods were reactive to their relationships.

More than once, it added up that their “Bipolar Disorder” was Borderline Personality Disorder, a condition known for significant reactive moods, especially in relation to others. In fact, the personality theorist Theodore Millon, Ph.D., opined it should be called “Cyclic Personality” because of their constant cycling of how they view their relationships and react to them with intensive moods. When treatment of the “Bipolar” patients shifted to addressing their views of themselves and others in relation to them, we were more successful.

Clearly, diagnosing by one symptom is poor practice that leads to poor outcomes. Later this week we’ll digest today’s post and wrap up part 1 by considering ways to think about diagnosis that help to curb this tendency.


Millon, T (1996). Disorders of Personality. New York: Wiley.

Improving Diagnostic Accuracy: 1 Symptom Isn’t Enough

Anthony Smith, LMHC

Anthony Smith is a licensed mental health counselor in Massachusetts with 20 years of experience. He has worked in facilities and in private practice performing therapy and diagnostic evaluations across a wide array of populations both demographically and clinically. This includes 17 years in the forensic arena, where he currently provides assessments for the juvenile courts. Aside from interest in the intersection of psychology and law, Anthony is particularly in interested differential diagnosis and supervision of new practitioners. He regularly teaches abnormal psychology and creates courses on the lived experience of people with mental illness, along with supervising graduate student counselling practicums at a local university. When not providing clinical services, teaching or blogging, Anthony can be found hiking and fly-fishing around the Northeast and American West.


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APA Reference
Smith, A. (2020). Improving Diagnostic Accuracy: 1 Symptom Isn’t Enough. Psych Central. Retrieved on September 18, 2020, from