The last item we’ll examine in this series, for now, is the precision point of recognizing when something in one disorder evolves to require a concurrent diagnosis. It may seem like splitting hairs, but a particular symptom’s severity in one diagnosis can escalate to the point of needing to be recognized as its own condition. This is not an uncommon occurrence, but may be overlooked, especially by beginning practitioners who have not had enough clinical exposure to recognize the phenomenon. Consider that accurate diagnosis helps keep what’s important in treatment in the spotlight. Perhaps it is necessary to justify additional session approval from an insurance company, or maybe you take ill and your client is transferred to a colleague. Both situations call for a conveyance of the needs of the patient which are inherent in the diagnosis.
First, it is not unusual to encounter symptoms of one diagnosis that are “owned” by another disorder. To clarify, for example, let’s look at panic. The section on Panic Disorder in the DSM-5 notes that in order to qualify for Panic Disorder the person must not simply have had a panic attack. They must fear future panic attacks and avoid situations that may bring them on. Many people panic without fear of future attacks and avoiding situations that could encourage it. For example, it is not unusual for patients to become so overwhelmed with worry in Generalized Anxiety Disorder, or with fear of abandonment in Dependent and Borderline Personality Disorders, that they panic. The attacks are usually in the face of a specific situation, and, while they don’t enjoy them, the patient doesn’t necessarily fear more attacks, which would be required for Panic Disorder. In fact, it’s noted in the Panic Disorder section of the DSM-5 that we can add a “with panic” specifier onto disorders (e.g., Depersonalization/Derealization Disorder, With Panic). If, however, the panic attacks take on a life of their own, and become a focus of their own regular clinical attention, an additional diagnosis of Panic Disorder may be assigned.
Another example is that sometimes binge eating and bulimic behavior is part of the self-destructiveness of Borderline Personality patients. It usually centers around a stressor at a specific point in time and is fleeting. Should that eating-disordered behavior extend to last for at least three months, it starts to meet full criteria for Binge Eating Disorder, or Bulimia Nervosa, and a concurrent diagnosis will become warranted because it must be specifically-addressed.
One last example involves folks with Generalized Anxiety Disorder, who worry, of course, about things in general. However, some evolved a tendency for their worry to focus on possibly having a serious disease, they start researching diseases and going to a lot of doctors. This tends to happen in the 30s, 40s and 50s, as they see others start suffering physical conditions. Perhaps they have had a major medical complication of their own and develop a sensitivity to physical discomforts, becoming preoccupied with the idea they have a serious illness. A concurrent diagnosis of Illness Anxiety Disorder, historically known as Hypochondriasis, becomes warranted. There is because now there is the additional clinical focus of managing worry about medical complications and the inherent doctor-seeking behaviors, etc. that follow, disrupting the lives of the patient and their family.
Remember, this is not about being “label-happy” as many in the anti-psychiatry circles may try to make you believe. A diagnosis allows us to conceptualize what is occurring, keep what’s important in the spotlight, and apply appropriate treatment. As you progress in your practice, keep an eye on symptoms that are particularly intense and may be starting to expand to complete, independent diagnoses of their own. It would be irresponsible to simply chalk up the eating-disordered behaviors to the person’s Borderline condition and go on addressing fears of abandonment and self-loathing, hoping that the eating-disordered behavior will dissolve without pointed intervention, especially since it requires a multi-disciplinary approach given it’s medical component.
In the past month, the Improving Diagnostic Accuracy series has examined several diagnostic stumbling blocks I have witnessed regularly over the years, and issues that students and supervisees have brought to the table. Future posts in the Improving Diagnostic Accuracy series will address sorting out the influence of substances, the need for flexibility in your diagnosing, and refining thoroughness in the diagnostic evaluation. Hopefully what has been addressed so far is helping improve your practice, but feel free to reach out to me to cover topics in diagnostic practice you may struggle with. For the near future, we will be switching gears and examining how to refine assessing Major Depression and special treatment considerations that could boost your practice with depressed patients.
Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.