How does a psychiatrist make a diagnosis?

It’s difficult to come up with a diagnosis when a doctor is seeing a patient. A psychiatrist knows it’s hard to get an accurate diagnosis unless the patient really feels comfortable about opening up and being honest and transparent about all the issues going on.

And so a psychiatrist tries to help people feel comfortable so they can open up and then the doctor can really see what’s going on. For any given diagnosis, there are five or 10 other likely possibilities. Doctors in training are taught this in medical school. It is called “the differential diagnosis.” And since diagnosis drives the treatment plan, this is quite important. For instance, if a person is identified as having depression from bipolar, that means a whole different kind of medication (mood stabilizers) compared to depression from post traumatic stress disorder, or depression from panic, or depression from attention deficit disorder, or simply Major Depression, not related to any other disorder.

To help a patient feel comfortable, a psychiatrist will have a warm and welcoming staff. Also, an inviting and comfortable waiting room. I have a happy “greeter dog” named Sammy to welcome patients in the waiting room while they wait to see me. He will sit with them on the couch and watch the nature picture slide show on TV. I also have wildlife photography on the walls. We have aromatherapy and music playing as well. The main thing is the waiting area is warm and inviting. You don’t want a “Corporate America” waiting room with someone behind glass asking you, “How can I help you today?”

After introductions, the psychiatrist will ask some open-ended questions such as, “What brings you in today?“

The patient may respond with some general responses such as, “I’ve been stressed out a lot lately.“

After getting details about the primary complaint a patient has, the psychiatrist will ask for a history about that issue. When did it start? What makes it better and what makes it worse? What have you done to try to make it better?

At a certain point in the interview, the psychiatrist will gather a list of all the issues going on. There might be insomnia, depression, anxiety, and poor focus.

Then the doctor will ask what came first second, third and fourth? Now we are getting a chronology and a better understanding. Sometimes, the first thing that happened (trauma) leads to the second thing happening (anxiety), and the third thing poor attention. The patient might have a prior diagnosis from a psychiatrist of attention deficit hyperactivity disorder, but a careful history from a careful psychiatrist finds there is post-traumatic stress disorder causing poor focus and lower grades. Then treating the PTSD (with counseling, prazosin for nightmares, propranolol for situational anxiety, and an SSRI like sertraline for depression anxiety), allows counseling to work and brings the person back to a normal life–and good focus.

Here’s a similar situation.

For instance, if a person says poor focus came first, but it came at the same time as they were traumatized and got depression in grade school, and the poor focus seems to go away when the depression goes away for brief periods. There is no PTSD in this case. This suggests that there is a depression causing poor focus, and the psychiatrist might consider prescribing an antidepressant and counseling.

On the other hand, if the patient says insomnia started first and that was related to a trauma, that suggests perhaps considering a sedating anti-anxiety medicine. This might be the generic clonazepam. Also used for spasms of nerve activity like seizures, it might be helpful at night to help deal with the core issue, which is post-traumatic stress. Meditation and other kinds of mindfulness training can help for PTSD, and when that gets better, the depression may well improve dramatically, and the attention issues with it. I’ve seen this happen dozens of times. Depression often causes poor focus.

So a psychiatrist doesn’t just come up with names of problems, but discovers how they occur in a patient’s history, and affect her personal life. Often, one or two diagnoses are the main issues. When they can be dealt with, other issues will get dramatically better as a result.

Diagnosis of specific problems is made by noting the symptoms of the illness. For instance, in depression, a person needs five symptoms for the diagnosis. The diagnosis can be made with fewer symptoms, of course. These symptoms include feeling sad, low energy, low motivation, trouble focusing, lack of pleasure in life, and feeling helpless, hopeless or worthless. Also, a person might have suicidal thoughts. there might also be inappropriate guilt feelings and difficulty managing complex problems.

A correct diagnosis also means ruling out similar diagnoses.

A person might have all the symptoms above for depression, but there are many kinds of depression.

There is depression from untreated ADD, and untreated panic, as well as depression from bipolar disorder or traumatic brain injury or another issue, such as migraine headaches or diabetes.

The psychiatrist then takes a thorough history. Let’s say depression is identified, but the medical history shows chronic insomnia and the patient is overweight. Further questioning shows the patient snores at night and feels very tired in the morning. This patient might have sleep apnea, which means that he stops breathing for short periods of time, many times during the night. That means the brain is getting deprived of oxygen for brief periods. Oxygen levels can sometimes go down to 60 or 70%, whereas 99% is normal. In these situations, it wouldn’t be unusual for depression to occur, and anti-depressants and counseling do not help, because the real problem is the brain isn’t getting enough oxygen.

In a situation like this, to be on the safe side, the psychiatrist might start an anti-depressant while recommending the patient see a sleep specialist as soon as possible to get the sleep disorder identified and treated.

This is an example of a clear diagnosis with a good understanding of related issues, so an effective treatment plan can be made. In this case, the diagnosis would be major depression, with this depression made worse by potentially having untreated sleep apnea, or some other sleep disorder.