Clinical Assessment and Diagnosis
Assessment items reward gathering data before acting. Know the components of a mental status exam (appearance, behavior, speech, mood and affect, thought process and content, perception, cognition, insight, judgment, risk), the biopsychosocial-spiritual intake, and DSM-5-TR conventions: criteria sets, duration and impairment requirements, specifiers for severity and course, and the instruction that a substance- or medication-induced condition is diagnosed when it fully explains the picture. Know what screening and measurement tools can and cannot do: PHQ-9 and GAD-7 (severity monitoring, not diagnosis), Beck inventories, C-SSRS or ASQ for suicide risk, AUDIT-C and CAGE for alcohol, MMSE/MoCA for cognition, and a cultural formulation interview.
Traps: (1) assigning a diagnosis from one endorsed symptom or from a label the client brings in; (2) missing a medical mimic such as thyroid disease, sleep apnea, medication side effects, or delirium, or blaming substances without a period of observation; (3) forgetting duration criteria; (4) diagnosing adjustment disorder when full criteria for another disorder are already met; (5) ignoring collateral sources and records when the client minimizes.
Rule of thumb: rule out before you rule in. Substance-induced, medical, and medication-related causes are addressed first; adjustment disorder is a diagnosis of exclusion requiring marked distress or impairment and does not apply once another disorder's criteria are satisfied.
Worked example: a 41-year-old reports low mood, insomnia, and poor concentration for 18 days after a divorce. Because the two-week duration and symptom count for major depressive disorder are met, MDD is the diagnosis; the stressor is noted but does not convert the picture into adjustment disorder.