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 The Roadmap to Diagnosis
Patient interview Informants Laboratory data and imaging

Building blocks of data

History of present illness: Chapter 8
Previous mental health history: Chapter 8 I. Gather a
Psychological Personal and social background: Chapter 8 Medical
testing complete
Family history: Chapter 8 records
database.
Physical symptoms: Chapter 9
Mental status examination: Chapter 10

II. Identify
Syndrome B Syndrome C Syndrome A
syndromes.

Disorder A III. Create a wide-ranging

Disorder B differential diagnosis.
Disorder C

IV. Choose a working

Diagnosis A diagnosis for further
evaluation and
treatment.

Diagnosis A V. Identify comorbid

Diagnosis B diagnoses and arrange
Diagnosis C in order of importance.

VI. Check up with a

Diagnosis A!
formulation.

More history Testing Response to VII. Reevaluate as new

treatment data emerge.
Diagnosis Made Easier
 Also by James Morrison

DSM-5-TR Made Easy: The Clinician’s Guide to Diagnosis

The First Interview, Fourth Edition

Interviewing Children and Adolescents: Skills and Strategies

for Effective DSM-5 Diagnosis, Second Edition
with Kathryn Flegel

The Mental Health Clinician’s Workbook:

Locking In Your Professional Skills

When Psychological Problems Mask Medical Disorders:

A Guide for Psychotherapists, Second Edition
Diagnosis
Made Easier
Principles and Techniques
for Mental Health Clinicians
THIRD EDITION

James Morrison

THE GUILFORD PRESS

New York  London
Copyright © 2024 The Guilford Press
A Division of Guilford Publications, Inc.
370 Seventh Avenue, Suite 1200, New York, NY 10001
www.guilford.com

All rights reserved

No part of this book may be reproduced, translated, stored in a retrieval

system, or transmitted, in any form or by any means, electronic, mechanical,
photocopying, microfilming, recording, or otherwise, without written permission
from the publisher.

Printed in the United States of America

This book is printed on acid-free paper.

Last digit is print number: 9 8 7 6 5 4 3 2 1

The author has checked with sources believed to be reliable in his efforts to
provide information that is complete and generally in accord with the standards
of practice that are accepted at the time of publication. However, in view of the
possibility of human error or changes in behavioral, mental health, or medical
sciences, neither the author, nor the editor and publisher, nor any other party
who has been involved in the preparation or publication of this work warrants
that the information contained herein is in every respect accurate or complete,
and they are not responsible for any errors or omissions or the results obtained
from the use of such information. Readers are encouraged to confirm the
information contained in this book with other sources.

Library of Congress Cataloging-in-­Publication Data

Names: Morrison, James R., 1940– author.
Title: Diagnosis made easier : principles and techniques for mental health
clinicians / James Morrison.
Description: Third edition. | New York : The Guilford Press, [2024] |
Includes bibliographical references and index.
Identifiers: LCCN 2023037220 | ISBN 9781462553419 (hardcover) |
ISBN 9781462553402 (paperback)
Subjects: LCSH: Mental illness—Diagnosis. | Mental health services. |
BISAC: MEDICAL / Nursing / Psychiatric & Mental Health | PSYCHOLOGY
/ Psychotherapy / Counseling
Classification: LCC RA469 .M67 2024 | DDC 616.89/075—dc23/eng/20231016
LC record available at https://lccn.loc.gov/2023037220
Guilford Press is a registered trademark of Guilford Publications, Inc.
For my editor and friend of many years, Kitty Moore
About the Author

James Morrison, MD, is Affiliate Professor of Psychiatry at Oregon

Health and Science University in Portland. His long career includes exten-
sive experience in both the private and public sectors. With his acclaimed
practical books—including, most recently, DSM-5-TR Made Easy, The
Mental Health Clinician’s Workbook, and The First Interview, Fourth Edi-
tion—Dr. Morrison has guided hundreds of thousands of mental health pro-
fessionals and students through the complexities of clinical evaluation and
diagnosis.

vi
Contents

Introduction ix

PART I The Basics of Diagnosis

1 The Road to Diagnosis 3

2 Getting Started with the Roadmap 7

3 The Diagnostic Method 14

4 Putting It Together 24

5 Coping with Uncertainty 44

6 Multiple Diagnoses 58

7 Checking Up 70

PART II The Building Blocks of Diagnosis

8 Understanding the Whole Patient 89

9 Physical Illness and Mental Diagnosis 100

10 Diagnosis and the Mental Status Examination 118

PART III Applying the Diagnostic Techniques

11 Diagnosing Depression and Mania 129

12 Diagnosing Anxiety, Fear, Obsessions, and Worry 167

13 Diagnosing Psychosis 185

vii
viii  Contents

14 Diagnosing Problems of Memory and Thinking 216

15 Diagnosing Substance Use and Other Addictions 238

16 Diagnosing Eating and Sleeping Disorders 250

17 Diagnosing Personality and Relationship Problems 272

18 Beyond Diagnosis: Compliance, Suicide, Violence 293

19 Patients, Patients 303

Appendix: Diagnostic Principles 329

References and Suggested Reading 331

Index 341
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 indepen-
dent study. That was before I undertook a completely unscientific survey
of practicing health care professionals, to learn how they had learned about
mental health diagnosis. What I found surprised me.
For most of the practitioners I surveyed, training in the refined art
of diagnosis was—well, no training at all. Most of the professional schools
at which my interviewees trained presented no formal course material on
diagnosis, and still do not do so. Even in medical schools, students and resi-
dents are expected to know the current diagnostic criteria, but they receive
little if any exposure to a method for making diagnoses. Almost to a person,
my sample endorsed the sentiment “I learned diagnosis through on-the-
job training.” Similarly, chapters and books that strive to teach clinicians
how to perform a competent clinical evaluation focus on the product, while
largely ignoring information about the process.
That process is neither simple nor intuitive, and I’d certainly never
describe it as easy. But after decades of experience and long consideration,
I believe it can be explained in a way that is straightforward and compre-
hensible—in short, we can make diagnosis easier.
In this book, I present a way of thinking about diagnostic problems.
The material doesn’t depend much on the vagaries of the latest diagnostic
standards or code numbers. Instead, I focus on the essential characteris-
tics of mental disorder, which have been recognized for decades. What’s
imperative to learn is the scientific method—yes, and the art—of evaluat-
ing patients and arriving at logical diagnoses consistent with the facts.
Part I focuses on the process of diagnosis. Learning how to diagnose
accurately involves systematically applying logical, easily understood prin-
ciples to information of several different types, assembled from a variety of
sources. Although real life requires us to confront many diagnostic issues
at once, for convenience I’ve divided the tasks into chapters. By the end of
ix
x  Introduction

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 diag-
nosis. But when learning new material, you must 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
presented the diagnostic method first.
Finally, in the chapters of Part III, we’ll sift through a great deal of
clinical 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-5-TR 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 his-
tories. Before you read my analysis of each clinical example, I recommend
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 prob-
lem than by passively reading what someone else has written. I think you’ll
benefit from engaging with the histories to find the clues that will direct
you to the diagnosis. And by the way, to preserve privacy while illustrating
the teaching points, I have changed personal details of some patients so
that their own mothers would not recognize them; but the vast majority I
simply made up.
You may wonder why each decision tree endpoint reads “Consider. . . .”
Why not just write down a name 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 the trap of
rushing headlong into diagnostic closure before you have all the necessary
facts.
Figure 1.1 of this book (which is reproduced on the front endpaper) pro-
vides a roadmap that shows the diagnostic process graphically. The Appen-
dix (which for convenience we’ve reproduced on the back endpaper) lists
the diagnostic principles I consider important to apply in making a mental
health diagnosis. In the interest of space and economy, I’ve put quite a lot of
information relevant to currently recognized major diagnoses into tables in
Chapters 3 and 6. Table 3.2 provides a differential diagnosis for each major
diagnosis; Table 6.1 lists the illnesses that are commonly comorbid.
 Introduction  xi

If, after reading this book, you still have questions about mental health
diagnosis, you can email me at [email protected]. I try to answer every
email I receive.

Terminology
Throughout this edition, I’ve largely used the terms used by DSM-5-TR,
but you’ll find a few places where I haven’t done so—for several reasons.
(1) Some of the new terms are frankly clumsy to use. So, for example, I’ve
continued to use dysthymia and dysthymic disorder instead of the official per-
sistent depressive disorder. (DSM-5 officially allowed the shorter term as a
synonym; in DSM-5-TR that is no longer the case.) (2) I’ve also continued
to use mood disorder as a general term to encompass conditions described
in both the bipolar and depressive disorders chapters—it’s just a matter
of economy of space. Bipolar depression serves as shorthand that I think
readers will have no problem understanding. (3) I’ve sometimes substituted
the older, shorter term dementia for the new, somewhat clumsy major neu-
rocognitive disorder. On the other hand, I’ve tried to expunge terms such as
substance dependence and substance abuse—in their DSM-IV meanings. If
you see one of them, I mean it in the more general sense.
And here’s another term that deserves explanation. I’ve personally
continued to use the criteria for somatization disorder, even though DSM-5
replaced it with somatic symptom disorder. In its proper place (p. 111), I’ve
explained my feelings about the new diagnostic criteria and the old; here,
I will simply urge readers to pay careful note that there are two names to
consider, but only one set of criteria that, to me, makes any sense. To avoid
confusion, however, I’ve largely continued to use the new DSM-5-TR ter-
minology—or, sometimes, a weasel expression, somatizing disorders.

Acknowledgments
In the end, every writer owes a debt that can never be paid to the many
unseen people who provide inspiration, guidance, and courage. Of course,
there are the innumerable clinicians and countless patients who have, how-
ever unwittingly, furthered my own education and helped show me the way.
But among the people I can identify, I owe special thanks to my wife, Mary.
Though she has midwifed each of my books, for this one she also provided
prenatal checkups in the form of careful reviews of the manuscript. I also
xii  Introduction

want to mention Eric Fesler, to whom I owe an unusual debt: Though not a
health care professional himself, he has repeatedly sent my way notes and
observations concerning mental health issues and resources. I also salute
my collaborators at The Guilford Press, including (but not, as they say, lim-
ited to) Anna Brackett, who over the years has been the editorial project
manager on many editions of my various books—she’s the brilliant person
of infinite patience who holds my hand through the final stages of publica-
tion. I truly appreciate the superb copyediting of Deborah Heimann, who
has saved me from myself over and again. Carolyn Graham, in so many
ways on so many occasions, has stepped in to help fix my solecisms and
omissions.
Finally, and most especially, I want to thank my longtime editor and
friend , Kitty Moore, to whom this book is gratefully dedicated.
Part I
The Basics of Diagnosis
1 The Road to Diagnosis

Carson
Years ago I evaluated Carson, a 29-year-old graduate student in psy-
chology. He had always lived in the town where he was born, supported
by numerous 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’s mood was at its nadir (usually in the late fall),
he had trouble 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 entire summer and early fall, though he admit-
ted that he was prone to be “sensitive to the minor vicissitudes of life.”
This meant, his wife told me, that he sometimes felt down when things
weren’t going well.
As a teenager, Carson had experimented with both alcohol and
drugs. Once, when withdrawing from a 3-day run of amphetamine use,
he had briefly become depressed, but his mood had lifted spontane-
ously within a few days. His girlfriend had agreed to marry him only
on the condition that he “clean up his act”; now he swore he had been
completely clean and sober for the 4 years they had been together. He
had never had symptoms of mania, and he thought his physical health
was excellent.
Medication had helped Carson get through college, after which
he had spent the summer searching for a graduate fellowship. Finally,
though the economy was depressed and few positions were available
in the social sciences, he was offered a graduate fellowship with a gen-
erous stipend in a well-­regarded department. Despite this triumph,
his celebration was muted: His new university was nearly 2,500 miles
away, in a part of the country where he’d never lived before.
On a Friday afternoon in late June, at his regular clinician’s
request, Carson appeared for an emergency evaluation. He sat slumped
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