mirror of
https://github.com/magnus919/agent-skills.git
synced 2026-09-21 08:36:33 +03:00
c312b36166
Agent harnesses truncate file reads around ~60k characters, so the largest dsm5 reference files (up to 132k chars) were being cut off mid-file (reported: "The neurodevelopmental file was truncated"). - Split 15 reference files over 50k chars into a small index (original filename preserved, so all existing links keep resolving) plus part files of <= ~40k chars each, organized by disorder group - Updated SKILL.md routing rows to point at indexes and read the part for the condition; added large-file handling guidance - Updated dsm5/README.md What You Get table; documented the size convention in 00-overview-and-method.md (Maintaining this library) - Verified: no reference file exceeds 50k chars (66 files), all 466 relative links resolve, validators pass, lookup.py lists all parts Co-authored-by: factory-droid[bot] <138933559+factory-droid[bot]@users.noreply.github.com>
36 KiB
36 KiB
Symptom Cluster Tables — Cross-Cutting Differentials
Part of the cross-cutting differentials chapter reference — index: 40-cross-cutting-differentials.md
Summarized and paraphrased from DSM-5-TR (American Psychiatric Association, 2022). This file is for orientation and education; verify exact criteria wording, codes, and recording procedures against the official DSM-5-TR before any formal clinical, legal, insurance, or research use.
The universal rule-outs (apply to almost every mental disorder)
Three exclusions recur across nearly every criteria set in the manual. They should be considered before any primary mental disorder is assigned, and they are often the first thing that separates overlapping candidates:
- Physiological effects of a substance or medication. Symptoms caused by substance intoxication or withdrawal, or by the side effects of a medication, are diagnosed as substance/medication-induced disorders (or intoxication/withdrawal) rather than as independent mental disorders (see 25-substance-related-and-addictive-disorders.md). Typical culprits: stimulants (mania-like states, psychosis, anxiety, insomnia), alcohol and sedatives (depression, anxiety during withdrawal, sleep disturbance), cannabis (anxiety, psychosis, depersonalization), and medications such as steroids (mania, psychosis, depression), bronchodilators and thyroid preparations (anxiety), and anticholinergics (delirium, cognitive change).
- Another medical condition. Symptoms that are the direct physiological consequence of a medical condition (e.g., hypothyroidism, hyperthyroidism, cardiac disease, stroke, Parkinson's disease, seizure disorders, autoimmune disease) are diagnosed as "[disorder] due to another medical condition" (e.g., F06.4 anxiety disorder due to hyperthyroidism; F06.31 depressive disorder due to hypothyroidism, with depressive features) or as a neurocognitive disorder. The manual stresses that mental disorders are themselves medical conditions, and it warns against ever grounding a mental disorder diagnosis in "unexplained" physical symptoms without a medical workup (see 18-somatic-symptom-and-related-disorders.md).
- For mood and psychotic presentations: has a manic or hypomanic episode ever occurred? This single question separates unipolar from bipolar illness and separates several psychotic conditions. Any lifetime history of a fully syndromal manic or hypomanic episode rules out major depressive disorder and persistent depressive disorder (their Criterion E exclusions), and rules out disruptive mood dysregulation disorder. The first depressive episode of a bipolar disorder is usually indistinguishable from unipolar depression at that moment — the history of past (hypo)mania is decisive and must be sought actively, often from collateral informants (see 12-bipolar-and-related-disorders.md and 13-depressive-disorders.md).
For the full assessment approach — interview structure, Level 1/Level 2 cross-cutting measures, cultural formulation, and the candidate-condition method — see 02-assessment-and-differential.md. For safety screening before or during any of this, see 01-safety-and-boundaries.md.
Symptom cluster tables
For each cluster: the symptom or experience, the conditions to consider (with the chapter reference), and one key distinguishing feature per condition. These tables are the entry point; the head-to-head comparisons carry the deeper comparisons.
Inattention / poor concentration / mind racing
| Symptom or experience | Conditions to consider | Key distinguishing features |
|---|---|---|
| Inattention, distractibility, forgetfulness | ADHD (10-neurodevelopmental-disorders.md) | Symptoms from childhood (several before age 12), present in two or more settings, persistent rather than episodic; 6 of 9 symptoms (5 for age 17+) for ≥6 months; not better explained by mood, anxiety, dissociative, personality, or substance conditions |
| Difficulty concentrating because of worry | GAD (14-anxiety-disorders.md) | Concentration difficulty is one of six associated symptoms; the worry spans multiple domains, is hard to control, ≥6 months; inattention is secondary to worry and absent outside worry |
| Racing thoughts, distractibility, increased activity | Bipolar disorder, manic/hypomanic episodes (12-bipolar-and-related-disorders.md) | Episodic: distinct periods of elevated/expansive/irritable mood with increased energy, a clear change from baseline (mania ≥1 week, hypomania ≥4 days); racing thoughts and distractibility occur inside episodes, not continuously |
| Poor concentration nearly every day | Major depressive episode (13-depressive-disorders.md) | One of nine symptoms in a ≥2-week episode with depressed mood or loss of interest/pleasure; concentration returns with mood recovery |
| Problems with concentration | PTSD (16-trauma-and-stressor-related-disorders.md) | One of six arousal/reactivity symptoms; requires a Criterion A trauma exposure and intrusion/avoidance/negative-cognition symptoms; onset or worsening after the event |
| Mental slowing or racing thoughts from substances | Substance/medication effects (25-substance-related-and-addictive-disorders.md) | Stimulant intoxication can produce hyperactivity, racing thoughts, and distractibility; sedatives and alcohol impair concentration; symptoms track use, intoxication, or withdrawal; first onset after substance use onset suggests a substance cause |
Fatigue and low energy
| Symptom or experience | Conditions to consider | Key distinguishing features |
|---|---|---|
| Fatigue or loss of energy | Major depressive disorder (13-depressive-disorders.md) | One of nine symptoms, nearly every day during a ≥2-week episode; accompanied by depressed mood or anhedonia and other neurovegetative changes |
| Low energy or fatigue | Persistent depressive disorder (13-depressive-disorders.md) | One of six B-criteria symptoms in a ≥2-year (≥1 year in youth) depressed mood |
| Fatigue from disrupted sleep | Sleep disorders (21-sleep-wake-disorders.md) | Insomnia disorder (≥3 nights/week, ≥3 months), obstructive sleep apnea (snoring, breathing pauses, daytime sleepiness), restless legs syndrome; fatigue from sleep disruption resolves with sleep treatment |
| Fatigue with sleepiness | Hypersomnolence disorder (21-sleep-wake-disorders.md) | Excessive sleepiness despite ≥7 hours of sleep, ≥3 times/week for ≥3 months; distinguish sleepiness (falling asleep) from fatigue (exhaustion without sleepiness) — the most common diagnostic error |
| Hypothyroidism, anemia, other medical causes | Medical conditions; depressive disorder due to another medical condition (13-depressive-disorders.md, 14-anxiety-disorders.md) | Fatigue is a classic symptom of hypothyroidism and anemia; a medical workup (thyroid function, blood count) is part of the assessment; if mood symptoms are the direct physiological consequence of the condition, code "[disorder] due to another medical condition" |
| Fatigue during substance withdrawal | Substance withdrawal (25-substance-related-and-addictive-disorders.md) | Stimulant withdrawal includes fatigue plus dysphoric mood, insomnia or hypersomnia, increased appetite; alcohol/sedative withdrawal also produces fatigue; symptoms track cessation of use |
| Chronic fatigue presentations | Medical conditions; other specified somatic symptom disorder (18-somatic-symptom-and-related-disorders.md) | Chronic fatigue syndrome / myalgic encephalomyelitis is not a DSM-5-TR disorder; rule out medical causes, and consider somatic symptom disorder or other specified somatic symptom and related disorder only on positive features (distress plus excessive response), never on "unexplained" symptoms alone |
Sleep disturbance
| Symptom or experience | Conditions to consider | Key distinguishing features |
|---|---|---|
| Difficulty initiating/maintaining sleep, early-morning awakening | Insomnia disorder (21-sleep-wake-disorders.md) | ≥3 nights/week for ≥3 months, despite adequate opportunity for sleep; not better explained by another sleep disorder or by mental/medical conditions; may be coded with a comorbid disorder when severe enough to warrant independent attention |
| Insomnia or hypersomnia nearly every day | Major depressive episode (13-depressive-disorders.md) | One of nine symptoms in an episode; insomnia often persists after the depressive episode resolves (in at least 40%–50% of individuals) |
| Sleep disturbance with worry | GAD (14-anxiety-disorders.md) | One of six associated symptoms of GAD (difficulty falling/staying asleep or restless, unsatisfying sleep) |
| Decreased need for sleep | Mania/hypomania (12-bipolar-and-related-disorders.md) | Feels rested after little sleep (e.g., ~3 hours) — distinct from insomnia (wants to sleep but cannot); a core distinguishing feature of manic/hypomanic episodes |
| Nightmares, sleep disturbance after trauma | PTSD (16-trauma-and-stressor-related-disorders.md) | Recurrent distressing dreams related to the traumatic event (intrusion) plus sleep disturbance (arousal); onset after Criterion A trauma |
| Sleep disturbance with substance use | Substance/medication effects (25-substance-related-and-addictive-disorders.md) | Stimulant intoxication (insomnia), alcohol/sedative withdrawal (insomnia), stimulant withdrawal (insomnia or hypersomnia); substance/medication-induced sleep disorder is diagnosed when the substance is etiologically related |
| Snoring, breathing pauses, unrefreshing sleep | Obstructive sleep apnea hypopnea (21-sleep-wake-disorders.md) | ≥5 apneas/hypopneas per hour with symptoms, or ≥15 per hour regardless; bed-partner report of snoring/pauses; confirm with sleep study |
| Sleep schedule mismatch | Circadian rhythm sleep-wake disorders (21-sleep-wake-disorders.md) | Sleep normalizes when the schedule matches the endogenous rhythm (delayed phase type) or a shift-work schedule explains it |
Irritability and anger
| Symptom or experience | Conditions to consider | Key distinguishing features |
|---|---|---|
| Irritability | Major depressive disorder (13-depressive-disorders.md) | In children/adolescents, irritable mood can substitute for depressed mood; in adults, irritability may appear with anxious distress or mixed features; confined to the episode |
| Irritability during episodes | Bipolar disorder, mixed states (12-bipolar-and-related-disorders.md) | Irritable mood counts toward mania/hypomania (4 symptoms required if mood is only irritable, 3 if elevated/expansive); mixed-features specifier adds manic symptoms to a depressive episode; episodic and a clear change from baseline |
| Recurrent aggressive outbursts out of proportion | Intermittent explosive disorder (24-disruptive-impulse-control-and-conduct-disorders.md) | Verbal or physical aggression twice weekly on average for 3 months, or 3 damaging/injuring outbursts in 12 months; impulsive/anger-based, not premeditated; age ≥6; not better explained by mood, psychotic, personality, medical, or substance conditions |
| Angry/irritable mood with defiance | Oppositional defiant disorder (24-disruptive-impulse-control-and-conduct-disorders.md) | 4 of 8 symptoms (angry/irritable mood, argumentative/defiant behavior, vindictiveness) for ≥6 months with a non-sibling; not during the course of a psychotic, substance use, depressive, or bipolar disorder; not DMDD |
| Tantrums over change or sensory input | Autism spectrum disorder (10-neurodevelopmental-disorders.md) | Meltdowns tied to changes in routine or sensory overload, in the context of social-communication deficits and restricted/repetitive behaviors; unlike ODD/IED, aggression is reactive to specific triggers and the ASD criteria are met |
| Intense anger, difficulty controlling anger | Borderline personality disorder (27-personality-disorders.md) | One of nine criteria; anger and affective instability are typically triggered interpersonally, last hours to a few days, and occur within a lifelong pattern of unstable relationships, identity, and impulsivity |
| Irritability, agitation with substances | Substance intoxication/withdrawal (25-substance-related-and-addictive-disorders.md) | Alcohol and stimulant intoxication (irritability, aggression, mood lability), sedative/alcohol withdrawal (agitation, anxiety, irritability); symptoms track use and resolve with clearance |
| Irritability from medical causes | Medical conditions; neurocognitive disorders (26-neurocognitive-disorders.md) | New irritability/agitation with cognitive change, inattention, or confusion suggests delirium (acute, fluctuating, medical emergency) or a neurocognitive disorder with behavioral disturbance; endocrine and neurological causes should be considered |
Psychotic-like experiences
| Symptom or experience | Conditions to consider | Key distinguishing features |
|---|---|---|
| Delusions, hallucinations, disorganized speech/behavior, negative symptoms | Schizophrenia spectrum (11-schizophrenia-spectrum-and-other-psychotic.md) | 2 of 5 symptoms for ≥1 month (at least one of the first three), total disturbance ≥6 months for schizophrenia; schizophreniform 1–6 months; brief psychotic disorder 1 day–1 month |
| Psychotic symptoms only during mood episodes | Mood disorder with psychotic features (13-depressive-disorders.md, 12-bipolar-and-related-disorders.md) | Delusions/hallucinations occur exclusively within major depressive or manic episodes; content usually mood-congruent; schizoaffective disorder requires ≥2 weeks of psychosis without prominent mood symptoms and mood symptoms for the majority of the illness |
| Psychosis tied to substance use | Substance/medication-induced psychotic disorder (11-schizophrenia-spectrum-and-other-psychotic.md, 25-substance-related-and-addictive-disorders.md) | Onset during or soon after intoxication/withdrawal or medication exposure; if psychosis persists about 1 month after acute effects clear, reconsider an independent disorder; stimulants, cannabis, phencyclidine, alcohol (withdrawal) are common culprits |
| Psychosis from a medical cause | Psychotic disorder due to another medical condition; delirium; neurocognitive disorder (11-schizophrenia-spectrum-and-other-psychotic.md, 26-neurocognitive-disorders.md) | New-onset psychosis after age 40, visual or olfactory hallucinations, fluctuating attention, or known neurological/endocrine/autoimmune illness warrant a medical workup; delirium is acute and fluctuating with inattention |
| Flashbacks, dissociation (not true hallucinations) | PTSD/acute stress disorder (16-trauma-and-stressor-related-disorders.md); dissociative disorders (17-dissociative-disorders.md) | Flashbacks are tied to the traumatic event and occur without other psychotic features; dissociation keeps reality testing intact; dissociative amnesia is absent in psychotic disorders |
| Culturally or religiously sanctioned experiences | Cultural concepts of distress (02-assessment-and-differential.md); schizophrenia and dissociative chapters (11, 17) | Hearing a deity's voice in a religious context, bereavement experiences of the deceased, and culturally accepted possession states are not counted as psychotic symptoms; assess whether experiences are culturally normative before labeling them |
Anxiety and fear
| Symptom or experience | Conditions to consider | Key distinguishing features |
|---|---|---|
| Excessive worry, multiple domains | GAD (14-anxiety-disorders.md) | ≥6 months, more days than not, difficult to control, 3 of 6 physical symptoms (1 in children) |
| Recurrent unexpected panic attacks | Panic disorder (14-anxiety-disorders.md) | ≥1 unexpected attack (4 of 13 symptoms) followed by ≥1 month of worry about more attacks or maladaptive behavior change; not due to substance/medical causes |
| Fear of negative evaluation | Social anxiety disorder (14-anxiety-disorders.md) | Fear/avoidance of scrutiny situations, fear of humiliation/rejection, typically ≥6 months |
| Fear of a specific object/situation | Specific phobia (14-anxiety-disorders.md) | Immediate fear nearly every time the stimulus is encountered, typically ≥6 months; no characteristic cognition |
| Anxiety after trauma | PTSD/acute stress disorder (16-trauma-and-stressor-related-disorders.md) | Symptoms tied to a Criterion A event; intrusion, avoidance, negative cognitions, arousal (PTSD >1 month; ASD 3 days–1 month) |
| Anxiety from intrusive thoughts, neutralized by rituals | OCD (15-obsessive-compulsive-and-related-disorders.md) | Obsessions are intrusive/unwanted and drive compulsions (>1 hour/day or distress); worry in GAD concerns real-life topics and has no compulsions |
| Fear of having a serious illness | Illness anxiety disorder (18-somatic-symptom-and-related-disorders.md) | Preoccupation with having/acquiring illness with no or only mild somatic symptoms, ≥6 months; care-seeking or care-avoidant type |
| Fear about separation | Separation anxiety disorder (14-anxiety-disorders.md) | Fear/anxiety about separation from attachment figures (3 of 8 symptoms; ≥4 weeks in children, typically ≥6 months in adults) |
| Restlessness, feeling keyed up | Medication-induced akathisia (30-medication-induced-movement-disorders.md) | Subjective restlessness and urge to move from antipsychotics/other medications; mimics anxiety but is medication-induced; distinguish from agitation and GAD restlessness |
| Panic-like symptoms from medical causes | Anxiety disorder due to another medical condition (14-anxiety-disorders.md) | Hyperthyroidism, pheochromocytoma, cardiac arrhythmias, asthma, vestibular dysfunction can produce panic-like symptoms; onset after ~45 or atypical symptoms (vertigo, loss of consciousness, slurred speech, amnesia) suggest medical or substance causes |
| Anxiety with substance use | Substance/medication-induced anxiety disorder (14-anxiety-disorders.md, 25-substance-related-and-addictive-disorders.md) | Stimulants, caffeine, and cannabis can cause anxiety during intoxication; alcohol, sedatives, and opioids during withdrawal; symptoms track use |
Low mood and anhedonia
| Symptom or experience | Conditions to consider | Key distinguishing features |
|---|---|---|
| Depressed mood/anhedonia with no history of mania | Major depressive disorder (13-depressive-disorders.md) | 5 of 9 symptoms for ≥2 weeks; Criterion E excludes any past manic/hypomanic episode |
| Depressive episodes with past (hypo)mania | Bipolar depression (12-bipolar-and-related-disorders.md) | Identical MDE criteria plus a lifetime history of mania (bipolar I) or hypomania (bipolar II); elicit the history actively — depression usually dominates the course |
| Chronic low mood | Persistent depressive disorder (13-depressive-disorders.md) | Depressed mood more days than not for ≥2 years (≥1 year in youth) with 2 of 6 symptoms; may be diagnosed with MDD when both are met |
| Low mood after a loss | Bereavement/grief; prolonged grief disorder (13-depressive-disorders.md, 16-trauma-and-stressor-related-disorders.md) | Grief's predominant affect is emptiness and loss with dysphoria in waves tied to reminders; an MDE shows persistent depressed mood, self-critical rumination, and lowered self-esteem; grief can trigger an MDE; prolonged grief disorder requires ≥12 months (≥6 months in youth) since the death plus yearning/preoccupation and 3 of 8 additional symptoms |
| Mood symptoms after a stressor, below MDE threshold | Adjustment disorder (16-trauma-and-stressor-related-disorders.md) | Symptoms within 3 months of an identifiable stressor, not meeting criteria for another disorder; end within 6 months of the stressor's termination |
| Depressed mood from medical illness | Depressive disorder due to another medical condition (13-depressive-disorders.md) | Direct physiological consequence of a medical condition (e.g., hypothyroidism, stroke, Parkinson's disease); establish the condition and a temporal association |
| Depressed mood from substances | Substance/medication-induced depressive disorder (13-depressive-disorders.md, 25-substance-related-and-addictive-disorders.md) | Alcohol/sedative intoxication, stimulant withdrawal, and many medications (steroids, some antihypertensives, interferon); symptoms track use and usually resolve within days to weeks of stopping |
Cognitive complaints / "brain fog"
| Symptom or experience | Conditions to consider | Key distinguishing features |
|---|---|---|
| Cognitive decline interfering with independence | Major neurocognitive disorder (26-neurocognitive-disorders.md) | Significant decline from a prior level in one or more of six domains; deficits interfere with independence (e.g., paying bills, managing medications) |
| Cognitive decline not interfering with independence | Mild neurocognitive disorder (26-neurocognitive-disorders.md) | Modest decline; independence preserved but with greater effort or compensatory strategies |
| Concentration/memory complaints during low mood | Depression-related cognitive complaints ("pseudodementia") (13-depressive-disorders.md, 26-neurocognitive-disorders.md) | Cognitive difficulty is part of an MDE (diminished concentration is a criterion symptom); effort-dependent performance, affective symptoms prominent, onset tied to the episode; resolves or improves with mood treatment; no progressive decline |
| Lifelong inattention/organization problems | ADHD (10-neurodevelopmental-disorders.md) | Onset before age 12, persistent, present in multiple settings; not a decline from a prior level |
| Cognitive complaints from sleep loss | Sleep deprivation; OSA (21-sleep-wake-disorders.md) | Insufficient sleep opportunity or OSA (snoring, pauses, sleepiness) produces concentration and memory complaints; correct the sleep problem and reassess |
| Cognitive change from medications | Medication effects (25-substance-related-and-addictive-disorders.md, 30-medication-induced-movement-disorders.md) | Sedatives, anticholinergics, and other medications impair attention and memory; temporal link to medication start or dose change |
| Cognitive change from substances | Substance/medication-induced neurocognitive disorder (25-substance-related-and-addictive-disorders.md, 26-neurocognitive-disorders.md) | Alcohol, inhalants, and sedatives can cause substance-induced mild/major NCD; alcohol use disorder and persistent heavy use are associated with persistent cognitive impairment |
Somatic symptoms without clear medical cause
| Symptom or experience | Conditions to consider | Key distinguishing features |
|---|---|---|
| Distressing somatic symptoms with excessive response | Somatic symptom disorder (18-somatic-symptom-and-related-disorders.md) | ≥1 distressing/disrupting somatic symptom plus ≥1 of three excessive-response features (disproportionate thoughts about seriousness, high health anxiety, excessive time/energy); typically >6 months; diagnosis rests on positive features, never on "unexplained" symptoms alone; medical illness does not exclude it |
| Illness preoccupation with few symptoms | Illness anxiety disorder (18-somatic-symptom-and-related-disorders.md) | Preoccupation with having/acquiring a serious illness; somatic symptoms absent or mild; ≥6 months; high health anxiety; care-seeking or care-avoidant type |
| Neurological symptoms incompatible with disease | Functional neurological symptom disorder (conversion disorder) (18-somatic-symptom-and-related-disorders.md) | Altered voluntary motor or sensory function with positive evidence of incompatibility (e.g., Hoover's sign, tremor entrainment, tubular visual field); a rule-in diagnosis, not a diagnosis of exclusion |
| Somatic presentations of mood/anxiety | Depression and anxiety with somatic presentation (13-depressive-disorders.md, 14-anxiety-disorders.md) | Panic attacks, pain, fatigue, GI complaints may be idioms of distress; check for the full mood/anxiety criteria sets; in many cultures somatic symptoms are the primary expression of depression |
| Medical conditions still to rule out | Medical workup first (18-somatic-symptom-and-related-disorders.md) | Always ensure a reasonable medical evaluation before considering a somatic disorder; never tell a patient symptoms are "all in your head" |
| Intentional symptom production with identified deception | Factitious disorder (18-somatic-symptom-and-related-disorders.md) | Falsification or induction of illness with identified deception, evident even without obvious external rewards; imposed on self (F68.10) or another (F68.A) |
| Intentional production for external incentive | Malingering (not a mental disorder) | Intentionally produced symptoms for external gain (money, avoiding work/legal consequences); not a DSM-5-TR diagnosis — consider it when the incentive is clear; factitious disorder and malingering can coexist |
Dissociative experiences
| Symptom or experience | Conditions to consider | Key distinguishing features |
|---|---|---|
| Two or more personality states plus amnesia | Dissociative identity disorder (17-dissociative-disorders.md) | Disruption of identity with distinct personality states (or possession) plus recurrent gaps in recall; not part of a culturally accepted practice; not substance/medical |
| Feeling detached from self or surroundings | Depersonalization/derealization disorder (17-dissociative-disorders.md) | Persistent/recurrent depersonalization and/or derealization with intact reality testing (the key distinction from psychosis); onset typically before the mid-20s |
| Inability to recall autobiographical information | Dissociative amnesia (17-dissociative-disorders.md) | Retrograde memory loss inconsistent with ordinary forgetting; not due to substances, head injury, seizures, or neurocognitive disorder |
| Dissociation after trauma | PTSD with dissociative symptoms (16-trauma-and-stressor-related-disorders.md) | Depersonalization/derealization tied to posttraumatic reminders, within full PTSD criteria; flashbacks and numbing are common; dissociation may also meet acute stress disorder criteria (3 days–1 month) |
| Transient dissociative symptoms with stress | Borderline personality disorder (27-personality-disorders.md) | Transient, stress-related paranoid ideation or severe dissociative symptoms (one of nine criteria) within a lifelong pattern of instability |
| Voice-hearing without dissociative amnesia | Psychotic disorders (11-schizophrenia-spectrum-and-other-psychotic.md) | Schizophrenia hallucinations are typically auditory and accompanied by delusional explanations; DID voices are experienced as ego-alien and DID has amnesia; dissociative amnesia is absent in psychotic disorders |
| Substance-induced detachment | Substance effects (25-substance-related-and-addictive-disorders.md, 17-dissociative-disorders.md) | Cannabis, hallucinogens, ketamine, MDMA, and salvia can cause depersonalization/derealization; about 15% of DPDR cases are precipitated by substances; if symptoms persist without further use, the disorder may apply |
| Possession states, dissociative trance | Cultural/religious practices (17-dissociative-disorders.md, 02-assessment-and-differential.md) | Culturally accepted possession and trance are not diagnosed as disorders (DID Criterion D; dissociative trance is excluded when culturally normative) |
Eating/weight change
| Symptom or experience | Conditions to consider | Key distinguishing features |
|---|---|---|
| Restriction to significantly low weight | Anorexia nervosa (19-feeding-and-eating-disorders.md) | Restriction leading to significantly low weight plus intense fear of weight gain plus disturbance in body weight/shape experience; restricting (F50.01) vs. binge-eating/purging (F50.02) types |
| Binge eating with compensation | Bulimia nervosa (19-feeding-and-eating-disorders.md) | Binges (large amount + loss of control) plus inappropriate compensatory behaviors, ≥1/week for 3 months; self-evaluation unduly influenced by weight/shape |
| Binge eating without compensation | Binge-eating disorder (19-feeding-and-eating-disorders.md) | Binges ≥1/week for 3 months with ≥3 of 5 associated features and marked distress; no regular compensatory behaviors |
| Avoidance/restriction without body image concern | ARFID (19-feeding-and-eating-disorders.md) | Eating disturbance (lack of interest, sensory avoidance, or fear of aversive consequences) with weight loss/failure to gain, nutritional deficiency, supplement dependence, or psychosocial interference; no fear of weight gain or body image disturbance |
| Appetite/weight change with low mood | Major depressive episode (13-depressive-disorders.md) | Significant weight change (e.g., >5% in a month) or appetite change nearly every day is one of nine symptoms; not driven by weight/shape concerns |
| Weight loss from medical illness | Medical conditions (19-feeding-and-eating-disorders.md, 13-depressive-disorders.md) | GI disease, hyperthyroidism, malignancy cause weight loss without fear of weight gain or body image disturbance; consider depressive disorder due to another medical condition when mood is involved |
| Weight/appetite change with substances | Substance effects (25-substance-related-and-addictive-disorders.md) | Stimulants suppress appetite (weight loss); stimulant withdrawal increases appetite; alcohol misuse contributes to weight change |
Obsessive/compulsive behaviors
| Symptom or experience | Conditions to consider | Key distinguishing features |
|---|---|---|
| Obsessions and compulsions | OCD (15-obsessive-compulsive-and-related-disorders.md) | Intrusive unwanted thoughts/urges/images plus repetitive behaviors or mental acts to neutralize them; >1 hour/day or clinically significant distress; insight specifiers (good/fair, poor, absent/delusional) |
| Perfectionism, orderliness, control | Obsessive-compulsive personality disorder (27-personality-disorders.md) | Pervasive pattern (4 of 8 criteria) of order/perfectionism/control without true obsessions and compulsions; ego-syntonic; both OCPD and OCD can be diagnosed |
| Restricted interests and routines | Autism spectrum disorder (10-neurodevelopmental-disorders.md) | Repetitive behaviors, insistence on sameness, fixated interests, sensory sensitivities within ASD criteria; behaviors may be pleasurable/reinforcing rather than anxiety-driven; no obsessions |
| Motor/vocal tics | Tic disorders (10-neurodevelopmental-disorders.md) | Sudden, rapid, recurrent, non-rhythmic movements or vocalizations; premonitory urges; Tourette's disorder = multiple motor and ≥1 vocal tic >1 year; tics are not aimed at neutralizing obsessions |
| Difficulty discarding possessions | Hoarding disorder (15-obsessive-compulsive-and-related-disorders.md) | Persistent difficulty discarding due to perceived need to save and distress at discarding; clutter compromises living areas; not due to OCD obsessions, depression, psychosis, or neurocognitive disorder |
| Hair pulling, skin picking | Trichotillomania, excoriation disorder (15-obsessive-compulsive-and-related-disorders.md) | Recurrent pulling/picking with repeated attempts to stop; not preceded by obsessions; not to improve a perceived appearance defect (which would be BDD) |
| Rumination in depression | Major depressive disorder (13-depressive-disorders.md) | Mood-congruent rumination (guilt, worthlessness) without compulsions; unlike obsessions, it is not experienced as intrusive/unwanted |
| Thought insertion, delusional preoccupation | Psychotic disorders (11-schizophrenia-spectrum-and-other-psychotic.md) | OCD with absent insight/delusional beliefs is not a psychotic disorder; thought insertion and delusions are psychotic symptoms — the distinction rests on the presence of obsessions/compulsions and absence of other psychotic features |
Personality-pattern presentations (the "borderline/bipolar/ADHD/trauma overlap")
| Symptom or experience | Conditions to consider | Key distinguishing features |
|---|---|---|
| Mood instability, impulsivity, unstable relationships | Borderline personality disorder (27-personality-disorders.md) | Lifelong pattern (5 of 9 criteria) beginning by early adulthood; mood shifts are hours-to-days, interpersonally triggered, with fear of abandonment, identity disturbance, chronic emptiness, self-harm; not discrete episodes |
| Episodic mood and energy changes | Bipolar I/II (12-bipolar-and-related-disorders.md) | Discrete episodes (mania ≥1 week, hypomania ≥4 days) that are a clear change from baseline, with decreased need for sleep and increased goal-directed activity; bipolar II's hypomania is often unrecognized |
| Childhood-onset inattention/hyperactivity | ADHD (10-neurodevelopmental-disorders.md) | Persistent symptoms since childhood (before age 12) across settings; impulsivity and emotional dysregulation are lifelong and trait-like, not episodic |
| Symptoms after trauma | PTSD (16-trauma-and-stressor-related-disorders.md) | Irritability, hypervigilance, reckless behavior, sleep disturbance follow a Criterion A event; avoidance and intrusion are present; distinguishes trauma-driven dysregulation from personality disorder |
| Behavior/mood change with substance use | Substance effects (25-substance-related-and-addictive-disorders.md) | Intoxication, withdrawal, and induced disorders produce mood lability, impulsivity, and behavioral change that track substance use |
Sleepiness in the day
| Symptom or experience | Conditions to consider | Key distinguishing features |
|---|---|---|
| Sleepiness despite ≥7 hours of sleep | Hypersomnolence disorder (21-sleep-wake-disorders.md) | Excessive sleepiness ≥3 times/week for ≥3 months with lapses into sleep, prolonged nonrestorative sleep (>9 hours), or difficulty waking; sleep inertia in ~40% |
| Snoring, pauses, sleepiness | Obstructive sleep apnea hypopnea (21-sleep-wake-disorders.md) | ≥5 apneas/hypopneas per hour with symptoms or ≥15/hour regardless; obesity, hypertension, bed-partner report; confirm with sleep study |
| Irresistible sleep attacks with cataplexy | Narcolepsy (21-sleep-wake-disorders.md) | Recurrent need to sleep ≥3 times/week for 3 months plus cataplexy (brief emotion-triggered muscle weakness), CSF hypocretin deficiency, or MSLT findings (mean latency ≤8 min with ≥2 SOREMPs); types 1 and 2 |
| Hypersomnia with low mood | Depression, atypical features (13-depressive-disorders.md) | Hypersomnia (≥10 hours/day or ≥2 hours more than usual) can be an atypical depressive feature; depression's hypersomnia is accompanied by mood and other neurovegetative symptoms |
| Sleepiness from substances | Substance effects (25-substance-related-and-addictive-disorders.md) | Sedatives, alcohol, opioids, cannabis cause daytime sleepiness; stimulant withdrawal produces sleepiness; substance/medication-induced sleep disorder when etiologically related |
| Sleepiness from schedule mismatch | Circadian rhythm sleep-wake disorders, shift work (21-sleep-wake-disorders.md) | Sleepiness tied to work schedule or delayed sleep phase; sleep normalizes when the schedule matches the endogenous rhythm; not due to intrinsic sleep pathology |
Worked example
Presentation: "I can't concentrate, I'm exhausted, and my mind won't shut off."
- Candidates (from the cluster tables): ADHD, GAD, MDD, bipolar spectrum, PTSD, sleep disorder, substance/medication effects, medical condition.
- Criteria features noted: ADHD — onset before 12, two or more settings, lifelong; GAD — ≥6 months worry about multiple domains, 3 of 6 symptoms; MDD — 5 of 9 symptoms for ≥2 weeks with depressed mood or anhedonia; bipolar — any past (hypo)mania; PTSD — Criterion A exposure, intrusion/avoidance/arousal; sleep — insomnia ≥3 nights/week for ≥3 months; substance/medical — timeline of use and physical health.
- Met/unmet/unknown: met — GAD-style worry and MDD-style low energy may both be present; unknown — onset before 12 (needs collateral), any past hypomanic episode (needs collateral), sleep pattern (needs diary), substance timeline (needs history), thyroid/anemia status (needs labs).
- Universal rule-outs applied: no current substances; thyroid and blood work pending; past (hypo)mania unknown — must be asked directly.
- Presentation to the person: "The symptoms are real. They are consistent with more than one possibility — an anxiety disorder, a depressive disorder, a sleep problem, or effects of substances or a medical condition. To sort them, a clinician would want to know when this started, whether you've had periods of unusually high energy and little need for sleep, what your sleep actually looks like, and a basic medical check. The next step is to gather that information and revisit the possibilities."
- Never stated: "You have X." The candidates and the discriminating information are the output.