What Is a Provisional Diagnosis Vs. a Differential Diagnosis?

Diagnosis
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Question:

I had an assessment done by a psychiatrist, and on the report was a provisional diagnosis and a differential diagnosis. I'm not too sure what these terms mean. Can you help?  What is a provisional diagnosis vs. a differential diagnosis?

Answer:

Provisional Diagnosis:

Provisional diagnosis means that he is not 100% sure of your diagnosis because he needs more information. It is just what he is guessing to be your most likely diagnosis for the time being based upon what information he has.

Under the newest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a provisional diagnosis would be indicated by putting the specifier "provisional" within parentheses next to the name of the diagnosis.  For example, it might say something like 309.81 Posttraumatic Stress Disorder (provisional).  As more information is gathered and a final diagnosis is made, this specifier could then be removed.

Differential Diagnosis:

Differential diagnosis means there is more than one possibility for what your diagnosis is and he must differentiate between these to determine what your actual diagnosis is.  Determining your correct diagnosis is important in order to choose the best method for treating you.

Unfortunately there are not currently any laboratory tests which can be used to identify depression.  Diagnosis of this disorder is based upon a person's medical history as well as his symptoms.

  In addition, it is necessary to rule out other potential causes for a person's symptoms as there are several other conditions which may, on the surface, appear to be depression.

According to Dr. Michael B. First, Professor of Clinical Psychiatry at Columbia University, New York, and author of the DSM-5 Handbook of Differential Diagnosis, making a good differential diagnosis of depression involves six steps.

Step 1:  Rule Out Malingering and Factitious Disorder

According to First, a doctor's initial step should be to attempt to determine whether a patient is faking his symptoms, either because he has something to gain like avoiding responsibilities (malingering) or because he derives psychological benefit from taking on the role of a sick person (Factitious Disorder).

Step 2:  Rule Out Drug-Related Causes

Certain drugs, both legal and illegal, can cause depression symptoms.  While it is fairly easy to know what prescription drugs a person is using, it may be necessary for doctors to do a bit of investigation when it comes to drugs of abuse.  Clinicians can gain clues about illicit drug use, First says, based upon interviewing the patient and/or his family, looking for signs of intoxication and performing lab tests to screen for the presence of drugs in the person's blood or urine.

Step 3:  Rule Out Any General Medical Conditions

There are numerous conditions which can have depression as a symptom and it is very important to rule these out because the person may require treatment beyond psychotherapy and/or an antidepressant to remove or mitigate the underlying causes of depression.

  In order to learn more about whether a medical condition is causing a patient's depression, a clinician will ask the patient about any previously-diagnosed conditions which may have begun around the same time as his depression.  In addition, he may need to order laboratory tests in order to screen for conditions commonly associated with depression symptoms.

Step 4:  Determine the Specific Primary Disorder

Once other causes have been ruled out, it is then necessary for the clinician to distinguish which specific psychiatric disorder the patient has, differentiating major depressive disorder from related mood disorders and other disorders which often coexist with depression.  This is done following the criteria established in the DSM-5.

Step 5: Differentiate Adjustment Disorders From Residual Other or Unspecified Categories

First suggests that if a patient's symptoms are significant, but below the threshold to make another diagnosis, the clinician should consider giving a diagnosis of Adjustment Disorder, a condition in which the person's symptoms are due to a maladaptive response to a psychological stressor. 

If this category is not appropriate, the clinician could then consider placing the patient's diagnosis into either "Other" or "Unspecified."  "Other" is used to indicated that a person has a cluster of symptoms which do not presently exist as a discrete diagnostic category in the DSM. "Unspecified" is used to indicate that a person's symptoms do not neatly fit into an existing category, although they possibly will as more information is obtained.

Step 6: Establish Boundary With No Mental Disorder

Finally, the clinician needs to make a judgement call regarding whether the patient is experiencing significant impairment or distress in his everyday life that would qualify as being a mental disorder.  In addition, he must distinguish major depressive disorder from grief, which, while it may cause significant impairment and distress, may not necessarily qualify as being a mental disorder.

Sources:

Bentham, Wayne.  "Using the DSM-5 in the Differential Diagnosis of Depression."  Aims Center University of Washington Psychiatry and Behavioral Sciences.  University of Washington.  Accessed:  January 13, 2016.

"Definition of Differential Diagnosis."  MedicineNet.com.  MedicineNet, Inc.  Last reviewed:  August 28, 2013.  Accessed:  January 13, 2016.

Halverson, Jerry L.  "Depression Differential Diagnoses."  Medscape.  Medscape, LLC.  Updated:  November 23, 2015.  Accessed:  January 13, 2016.

LeBano, Lauren.  "Six Steps to Better DSM-5 Differential Diagnosis."  Psych Congress Network.  North American Center for Continuing Medical Education, LLC.  Accessed:  January 13, 2016.

"Major Depression Differential Diagnosis."  Family Practice Notebook.  Family Practice Notebook, LLC.  Accessed:  January 13, 2016.

Tesar, George E.  "Recognition and Treatment of Depression."  Cleveland Clinic Center for Continuing Education.  The Cleveland Clinic Foundation.  Published:  August 2010.  Accessed:  January 13, 2016.

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