Diagnosis Made Easier

Diagnosis
Made Easier
Principles and Techniques
for Mental Health Clinicians
James Morrison
The Guilford Press
New York London
© 2007 The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
www.guilford.com
All rights reserved
No part of this book may be reproduced, translated, stored in a
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Printed in the United States of America
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Last digit is print number: 987654321
Library of Congress Cataloging-in-Publication Data
Morrison, James R.
Diagnosis made easier : principles and techniques for mental
health clinicians / James Morrison.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-1-59385-331-0
ISBN-10: 1-59385-331-9
1. Mental illness—Diagnosis. 2. Mental health services.
I. Title.

6 Multiple Diagnoses 56
7 Checking Up 68
PART II The Building Blocks of Diagnosis
8
Understanding the Whole Patient 87
9 Physical Illness and Mental Diagnosis 98
10 Diagnosis and the Mental Status Examination 116
PART III Applying the Diagnostic Techniques
11
Diagnosing Depression and Mania 127
12 Diagnosing Anxiety and Fear 164
13 Diagnosing Psychosis 182
14 Diagnosing Problems of Memory and Thinking 213
15 Diagnosing Substance Misuse
and Other Addictions
235
vii
16 Diagnosing Personality and Relationship Problems 248
17 Beyond Diagnosis: Compliance, Suicide, Violence 267
18 Patients, Patients 277
Appendix: Diagnostic Principles 301
References and Suggested Reading 303
Index 309
viii Contents
Introduction
When I set out to write about the diagnostic process, I envisioned a text
that could both complement classroom teaching and provide a guide for in
-
dependent study. That was before I undertook a completely unscientific
survey of practicing health care professionals, to learn how they had

Part I, you’ll see how seasoned clinicians unite their experience with new
information to create a working diagnosis.
The three chapters of Part II explore the social and other background
data you need to understand each patient’s mental health diagnosis. Of
course, this is the stuff you need to have first, so you can make the diagno
-
sis. But when learning new material, you have to start somewhere, and I
have judged that many (probably most) of my readers already have some
familiarity with interviewing and information gathering. That’s why I’ve
gone ahead and presented the diagnostic method first.
Finally, in the chapters of Part III, we’ll sift through a great deal of clin
-
ical material to see how the Part I methods and the Part II data apply to
various clinical disorders. We won’t consider every disorder, or even all the
varieties of the main disorders; other manuals (including my own DSM-IV
Made Easy) handle that chore. Rather, we’ll concentrate on the issues and
illnesses that mental health clinicians confront every day.
To illustrate the diagnostic methods, I’ve included over 100 patient
histories. Before you read my analysis of each clinical example, I recom-
mend that you try working through the decision trees and writing up your
own list of relevant diagnostic principles. It has been amply proven that we
all learn far more efficiently by actively thinking about the solution to a
problem, rather than just passively reading something printed on a page. I
think you’ll benefit from the practice of thinking about the histories and de-
termining how their clues direct you to the diagnosis.
You may wonder why each decision tree endpoint reads “Consid
-
er . . .” Why not just name the disorder and move on? After much thought
about these diagrams, I have decided that the more tentative wording is
safer. Without being too prescriptive, I want to encourage you to avoid a

hold my hand through the final stages to make this book possible. These
people are the best in the business. I am indebted to the fine writing and
teaching of George Staley. And innumerable clinicians and countless pa-
tients have, however unwittingly, furthered my own education and helped
show me the way.
Introduction xi

PART I
The Basics
of Diagnosis

1 The Road to Diagnosis
Carson
Years ago I evaluated Carson, a 29-year-old graduate student in psychol
-
ogy. He had always lived in the town where he was born, among numer
-
ous relatives and friends. Through a long history of repeated depressive
episodes, he had taken antidepressant medications on and off for a decade.
At one time or another he had complained of trouble concentrating on his
studies, of worries that he wouldn’t be able to find a job, and of fears that
he would become chronically depressed like his maternal grandmother.
When Carson was at his worst (usually in the late fall), he had trou-
ble sleeping and eating, so he was pretty thin by the time Christmas rolled
around. Each spring his mood picked up, and he invariably felt well the en-
tire summer and early fall, though he admitted that he was prone to be
“sensitive to the minor vicissitudes of life.” What he meant, his wife told
me, was that he sometimes felt down when things weren’t going well.
A typical teenager, Carson had experimented with both alcohol and
drugs. Once, when withdrawing from a 3-day run of amphetamine use, he

As you can imagine, a lot rides on an evaluation like Carson’s. If you were
his clinician, you would need to answer a lot of questions. What’s wrong? Is
it the same as his previous problems with depression? Does he need treat-
ment at all? If so, what’s most likely to help? Should he have more medi-
cine, or a different antidepressant, or psychotherapy? What should you tell
Carson and his wife—should they postpone their move? What should Car-
son tell his new boss? The answer to each of these important questions
would depend on your assessment of his condition. To be helpful, it must
be based on information that will assist you in finding a road to the future.
Reaching an initial destination on that road—we can call it a diagnosis—is
what this book is all about.
The ancient Greek term diagnosis means “distinguishing” or “dis
-
cerning.” Beyond the word itself, the concept of distinguishing one disease
from another is crucially important to patients and medical scientists alike.
As British psychiatrist R. E. Kendell wrote a generation ago, without diag
-
nosis our journals would print only case reports and opinions.
When a person goes to a medical doctor with a physical complaint, in
most cases the diagnosis conveys three sorts of information: the nature of
the problem (symptoms, signs, and history), its cause, and the physical
changes that consistently occur as a result. Any disorder that clearly meets
these criteria can be called a disease. Take pneumonia, for example. This
term tells us that the patient feels weak and tired, and that the person suf
-
fers from the symptoms of shortness of breath, fever, and a cough that pro
-
duces sputum. But only after we learn the results of sputum cultures and
other tests do we learn that the cause of the pneumonia is bacteria growing
in the patient’s lungs, causing the air sacs to fill with fluid and cells, pro

read a lot about these building blocks in the Part II database quarry.
Pages 87–123.
• Level II. Identify syndromes. Syndromes are collections of symp-
toms that go together to produce an identifiable illness. Major de-
pression is a syndrome; so is alcoholism. Page 9.
•
Level III. Construct a differential diagnosis. Differential diagnosis is
just a term for all of the disorders you think that a patient could
have. You don’t want to overlook any possibilities, however un
-
likely, so at first you must cast a very wide net. Page 14.
•
Level IV. Using a decision tree, select the most likely provisional di
-
agnosis for further evaluation and treatment. Page 19.
•
Level V. Identify other diagnoses that might be comorbid with your
principal diagnosis. Arrange multiple diagnoses according to the ur
-
gency of their need for treatment. Page 56.
•
Level VI. Write a formulation as a check on your evaluation. This
brief statement of your patient summarizes your findings and con
-
clusions. Page 79.
•
Level VII. Reevaluate your diagnoses as new data become available.
Page 81.
The Road to Diagnosis 5
6 THE BASICS OF DIAGNOSIS

implies information about the main character’s surroundings, culture, fam
-
ily, and social milieu. Sometimes this material is called the back story, and it
provides texture and layers of meaning that illuminate the motives, ac
-
tions, and emotions of the characters. So it is with patients—all of whom
7
have their back stories, too, which clinically we call personal and social his
-
tory. For the same reasons that a play is more compelling when we under
-
stand what motivates its characters, this information is not just interesting
but often highly relevant, even vital, to diagnosis. I consider this informa
-
tion to be so important that Chapter 8 is devoted to discussing childhood
background, current living situation, and family history, especially of mental
disorder. Medical background (Chapter 9) is another important part of your
evaluation. Finally, you’ll make use of the MSE (Chapter 10)—though per
-
haps not quite as much use as you’d initially think. Throughout Part I of
this book, we’ll be examining these various parts of the mental health eval
-
uation and how we can use them to create a diagnosis.
In the real world, patients, like Shakespeare’s sorrows, tend to come
not as single spies, but in battalions. As a result, you may not have enough
time to gather all the material you need for a complete initial evaluation.
That’s OK. The task here is to learn how the job is done when conditions
are ideal; with practice, you will later become able to accomplish the same
thing in the course of a busy office day or frantic emergency room evening.
Symptoms and Signs

-
haps altered blood pressure, and
a physician with a stethoscope
would hear crackling sounds of
fluid in the lungs. Carson’s signs
of mental illness included tear
-
fulness and slumped posture.
The sets of signs and symp
-
toms sometimes intersect. At
times in this book, I may talk
about a sign that could be a symp
-
tom (see the sidebar “Symptoms
and Signs”). You’ll have to put up with that ambiguity; it’s part of the clini-
cal mystique. So why, you may want to know, do we need to note that there
is a difference? The reason is that because signs are more objective, we
can rely on them more than symptoms. In fact, one of the diagnostic princi-
ples that we’ll use later on is that “signs trump symptoms”—not always,
but often enough that it justifies paying attention to the differences be-
tween signs and symptoms. For example, despite his doubt that he felt de-
pressed, Carson’s tearfulness and slumped shoulders told another story.
Symptoms (and signs) are useful in two ways. First, like Carson’s
panic attack, they signal that something is wrong. In the same way, suicidal
thoughts, poor appetite, or hearing voices can indicate the need for a men
-
tal health evaluation. The second use of signs and symptoms is to set us on
the path to an appropriate diagnosis: Repeated public intoxication suggests
alcohol dependence; an arrest for shoplifting should prompt an evaluation

life’s no longer worth living, the purchase becomes ominous. If I break
down in tears during a professional meeting, it could mean that I am de
-
pressed and need treatment. But suppose I’ve just received a text message
that my sister has died unexpectedly; then I’m only reacting normally in
the context of appalling news.
And so we come to the syndrome, a Greek term first used nearly 500
years ago that means “things running or occurring together.” More than
just a collection of symptoms and signs, it should be more fully understood
as symptoms, signs, and events that take place in a recognizable pattern and
10 THE BASICS OF DIAGNOSIS
Symptoms and Signs
Mental health doesn’t have a lot of signs, but here are a few of them: weeping, sighing,
pacing, weight loss, tattered clothing, and poor hygiene. Some indicators can be either
a sign or a symptom, depending on who notices. Carson wouldn’t have complained
about his own slumped posture, but his wife or a next-door neighbor might notice it
and mention it to a clinician. Depending on circumstances, nearly any behavior that can
be observed by others and that is usually treated as a sign could be a symptom in
-
stead.
Until about 1850, clinicians didn’t discriminate between signs and symptoms;
now whole books are devoted to the concept. Recently, however, there have been a few
indications that we may once again be blurring the boundary, at least in the United
States. In the late 1990s, concern that medical people too often ignored patients’ pain
led to calling pain a “fifth vital sign.” The intent of this was that pain would be docu
-
mented at every clinical visit, along with the four classical (and undeniable) vital
signs—temperature, blood pressure, pulse, and respiration rate. Technically, however,
pain is a complaint that can only be a symptom, because of its innate subjectivity.
Sometimes we clinicians get careless in our speech and forget the very real dif-

cians to choose among competing hypotheses about how and why mental
disorders develop. Perhaps this facilitates communication between clini
-
cians endorsing different schools of thought—for instance, a behaviorist
and a psychoanalyst could amicably discuss Carson’s diagnosis—but it
wouldn’t help them agree about treatment.
Creating a collection of symptoms, signs, and other features that reli
-
ably identifies homogeneous groups of patients is only a part of disease
identification. The next phase is to see whether the selection process can
help predict the future—that is, whether it is valid (see the sidebar “Valid
-
ity and Reliability”). Here’s how it is done. Researchers follow up patients
from the group being studied to learn their outcomes: After several years,
do they continue to have similar symptoms and respond uniformly to treat
-
ment, or do different diagnoses become apparent with time?
An excellent example occurred during the middle years of the 20th
century, when the term hysteria was still in common use as a diagnosis. By
tracking down patients who had been diagnosed with hysteria, researchers
learned that years later some were completely well, whereas others now
Getting Started with the Roadmap 11
Syndrome: Symptoms, signs, and
events that occur in a particular
pattern and indicate the existence
of a disorder.
had a physical illness that could explain the symptoms that their doctors
had once thought to be emotional in origin. Oh yes, and quite a few still
seemed to have symptoms that were, well, hysterical in origin. These re
-

from one time or individual to another.
Take weapons of mass destruction, for example. If politicians and journalists re
-
peatedly state that that some country (let’s say Iraq) is making them, the reports might
seem reliable. But such a claim would only be valid if investigators verified it, perhaps
by actually finding such weapons during an inspection. If severely depressed patients
repeatedly complain that they awaken early in the morning and cannot get back to
sleep, we can say that early morning insomnia is a reliable characteristic of depression.
But not until double-blind sleep studies, possibly using electroencephalograms (EEGs),
affirm the observation would we call it validated.
tate research into new treatments. And the more narrowly defined the syn
-
dromes are, the better the predictions based on them will be.
Ultimately, we would like to know that a syndrome can be supported
by laboratory or imaging findings that are similar to those for pneumonia.
But so far, almost no objective laboratory tests have been devised in the
mental health field. Without definitive testing, it is hard to attribute causes,
without which we cannot really say that we have identified a mental dis
-
ease. Syndrome remains the dominant conception of mental disorder, and it
is likely to stay that way for many years into the future. But that’s OK—the
concept works well, and there is simply no good alternative.
Of course, there’s a lot more to diagnosis than just identifying syn
-
dromes. Otherwise, you’d now be finishing a pamphlet rather than begin
-
ning a book. In Chapter 11 you can find a fuller discussion of Carson and his
problems, which turned out to be a little more complicated than they first
appeared. Now, however, we’ll move on to a discussion of a diagnostic
method that many experienced clinicians use, though few realize it.