PRINCIPAL AND PROVISIONAL DIAGNOSIS

By: SOPHIA F. DZIEGIELEWSKI

  

The Principal Diagnosis

The reason an individual is seen by a mental health professional or admitted to an inpatient facility is in DSM-5 termed the principal diagnosis.

Listing the principal diagnosis and just listing any subsequent diagnoses eliminates the need for Axes I and II, which were part of the multi-axial diagnosis in DSM-IV and DSM-IV-TR. This change helps to clarify that in DSM-IV, Axis II was never intended to separate medical and mental health conditions in assessment or treatment. When the principal diagnosis is listed according to DSM-5, it is listed first, but there can be more than one diagnosis as long as each meets the criteria.

If there is more than one diagnosis, they should be listed in terms of attention. At times, determining which diagnosis is the principal one may be difficult. There may also be some confusion related to which mental health diagnosis is the reason for the visit.

In DSM-5, always remember to list the principal diagnosis first. It is generally the “reason for the visit” that is most often linked within the inpatient situation to admission status; in the outpatient setting, it is also the reason the medical services are provided. The principal diagnosis should always be qualified with “(principal diagnosis)” added after it; if it is the reason for the visit, it should be qualified by “(reason for visit)” given after it.

PRINCIPAL AND PROVISIONAL DIAGNOSIS The Practitioner can Use Either of These Terms When the Diagnostic Criteria are Met: Principal diagnosis: Symptoms related to the disorder are the primary reason for the diagnostic assessment and often denotes the request for treatment/intervention. Provisional diagnosis: Diagnosis is determined on the criteria used to verify the duration of the illness or when there is not enough information to substantiate a principal diagnosis.

There may also be more than one diagnosis, and taking into account comorbidity (when two
mental disorders are related and often occur together) is essential. When there is comorbidity (or co-occurrence) and the two diagnoses both present prominent symptoms that need to be addressed, determining which is the primary or principal diagnosis may be even more difficult (Cipani, 2014).

Noting all relevant mental and medical conditions present is essential for the treatment planning to follow. When there is more than one mental disorder, be sure to always list the primary (principal) diagnosis first. (See Quick Reference 3.6.) If both diagnoses seem equally relevant, use clinical judgment to decide which one is more important to the course and treatment, and list that one first.

Q Quick Reference 3.6.UICK REFERENCE 3.6

Helpful Tips for Documenting the Principal Diagnosis ■ Principal diagnosis is most ofen the reason for the visit and is generally listed first. ■ If there are multiple diagnoses, the reason for the visit should always be listed first. ■ For the principal diagnosis, use the phrase (principal diagnosis) or (reason for visit). ■ If there are multiple diagnoses, list them after the principal diagnosis in terms of focus and attention. ■ If there is a medical condition or disorder that appears to be the cause of the mental health disorder, according to the ICD, the medical disorder should be listed before the mental disorder. ■ List the mental disorders that interfere with functioning first, and then list other medical condition(s) that are complicating or are directly or indirectly related to the mental health condition but not the direct cause.

In DSM-5, Axis III—where the medical disorder was listed on a separate axis—was eliminated. Therefore, if the principal diagnosis is a mental disorder that is directly attributed to a medical disorder, the medical disorder (according to the ICD) is listed first. From this perspective, the medical disorder is given the appropriate focus, as the mental disorder is considered to be secondary and may or may not resolve once the medical disorder is addressed.

Previously, in DSM-III such a disorder was referred to as physical disorders and related conditions. In DSMIV and DSM-IV-TR, they were referred to as general medical conditions. In DSM-5, these medical or physical conditions are now referred to as another medical condition.

Because the term mental disorder means a condition that is not directly due to a medical condition, all non-medically trained practitioners need some knowledge of the most common medical conditions that can complicate the diagnosis of mental health conditions. Furthermore, the practitioner needs to be acquainted with the relationship these conditions can have to a mental disorder. Pollak, Levy, and Breitholz (1999) were quick to warn that in the diagnostic assessment, alterations in behavior and mood that mimic a mental disorder may be directly related to a medical illness.

This difference is particularly important to distinguish in that many times clients suffering from a mental disorder may be confused about the symptoms they feel and may not report them clearly. Because most mental health practitioners do not have extensive training in medical disorders and what to expect from one, the misdiagnosis of a medical disorder as a mental health disorder can be fairly common.

Clients at the greatest risk for misdiagnosis in this area include women who are pregnant or after pregnancy (prenatal, perinatal, or neonatal), indigent individuals because of limited resources and access to continued health care, individuals who engage in high-risk behaviors, individuals with a medical illness who exhibit symptoms that might be confused for mental illness, and individuals with chronic conditions, such as those who suffer from major mental disorders and older adults (Pollak et al., 1999).

For example, clients who have been diagnosed with mental disorders such as schizophrenia or bipolar disorder may be unable to perceive, may misperceive, or may simply ignore warning signs of a medical problem (Dziegielewski, 2010). Many of the chronic conditions older adults exhibit may be de-emphasized or ignored as a normal part of aging or as chronic disease progression.

For example, I will never forget a client who presented in a severe acute phase. He had been seen numerous times at the clinic, and his diagnosis was Schizophrenia. He constantly complained of demons invading his brain and voices that would not allow him to think independently. He was convinced that placing a piece of tinfoil under his baseball hat could help to deter the demons’ rays that penetrated his brain with disparaging thoughts. One night while I was working in the crisis unit, he came in for assistance and was extremely delusional, begging for help. He was experiencing auditory hallucinations that were so pronounced he felt his brain would explode. He tried to help himself by wrapping an entire roll of tinfoil on his head with the hope it would turn aside the rays from the demons that were causing him so much discomfort.

Upon assessment, he was so agitated and difficult to assess that I immediately suspected he had stopped taking his medications, but he swore he had not. An immediate referral for a physical exam determined he had a sinus infection that was causing the signs prevalent of his mental disorder to worsen. Once the sinus infection was treated with an antibiotic, his perceptions of demon rays and voices in his head subsided greatly.

This client needed an antibiotic, and receiving an antipsychotic medication would have been secondary to his mental health presentation. Because of his previous mental health disorder, he believed that all his pain was demonic and did not understand that there could be other reasons for it. In presentation, it would have been a true disservice if the medical condition had not been addressed first. Within 3 days of the antibiotic, his previous symptoms almost disappeared.

For cases such as this, whether trained in medical areas or not, practitioners must rule out the signs and symptoms most relevant to a medical condition before the mental health condition can be treated. Therefore, when listing the principal diagnosis as the reason for the visit, practitioners should always list the medical disorder first when a medical disorder is coded “due to another medical condition.”

In summary, according to the ICD, if there is a medical condition that causes the mental health disorder, it has to be listed first. If there are other medical conditions important to the diagnosis, they can be listed as well after the principal diagnosis. As previously stated, in DSM-5 these conditions are referred to as “another medical condition,” replacing the previous listing in DSM-IV as a “general medical condition.”

The Provisional Diagnosis

Many times when a client is interviewed and the initial diagnostic assessment is completed, a principal diagnosis cannot be determined. In these cases, a provisional diagnosis can be assigned. A provisional diagnosis (often referred to in the field as the best-educated clinical guess) is based on clinical judgment and reflects a strong suspicion that an individual suffers from a type of disorder that, for some reason or another, either the actual criteria are not met or the practitioner does not have information available to make a more informed diagnostic assessment.

In practice, a provisional diagnosis can be particularly helpful when information from family or the support system is not available to confirm the diagnosis. There are also disorders for which specific time periods must be met to assign a diagnosis. For example, the criteria for schizophrenia outline that the duration of the illness must be at least 6 months or more. With the first episode or the onset of the disorder, all criteria may be met except for the time frame. Therefore, the provisional diagnosis allows the practitioner to use the term schizophreniform disorder, which meets the same criteria as schizophrenia but has a shorter time frame (less than 6 months and remission does not occur).

The most important thing for the practitioner to remember, however, is that a provisional diagnosis is temporary. Once a provisional diagnosis is given, every attempt must be made to monitor its course and remove it if symptoms are no longer present. When the needed information is gathered or the suggested time frame has been met, the provisional diagnosis should be changed to the primary diagnosis most relevant to current problem behaviors and future treatment.

Information Supportive of the Diagnosis

In DSM-III, DSM-IV, and DSM-IV-TR, supportive information about the diagnosis was listed on Axis IV and Axis V. In DSM-5, by contrast, the non-axial system of diagnosing a mental disorder simply requires adding this supportive information related to the diagnostic assessment.

Separating the stressors experienced and the level of disability on a separate axis is no longer required. The APA (2013), however,states quite clearly that just listing the diagnosis is not enough, and supportive information, although not formalized on a multi-axial system, is still expected.

To assist with providing supporting information, “Medication-Induced Movement Disorders and Other Adverse Effects of Medication,” “Other Conditions That May Be a Focus of Clinical Attention,” may be of help. The criteria outlined in these two categories may help to document the medication-related influences, stressors, and other circumstances that can influence the mental health condition and the diagnostic assessment.

In addition to the conditions listed in these two categories, a new measurement instrument has been introduced to address the level of disability that was previously outlined with the Global Assessment of Functioning (GAF) in DSM-IV and DSM-IV-TR. This measure of disability, which is more quantifiable than the GAF, is published by the World Health Organization and called the World Health Organization Disability Assessment Schedule (WHODAS).

References

SOPHIA F. DZIEGIELEWSK, 2015, DSM-5TM in Action, by John Wiley & Sons, Inc.

Read Also

Completing the Diagnostic Assessment
Medication-Induced Movement Disorders and Other Adverse Effects of Medication

The Psychiatric Evaluation

Diagnostic Principles
Other Conditions That May Be a Focus of Clinical Attention
DIAGNOSTIC AND TREATMENT APPLICATIONS
Documentation of diagnostic assessment of the mental health disorder
Puling It All Together in Completing the Diagnostic Assessment

The Comprehensive Diagnostic Assessment and Evaluation