Key Takeaways
- A provisional diagnosis is a doctor’s best guess based on your symptoms until more information is gathered.
- A differential diagnosis helps doctors figure out which condition you have by ruling out other causes.
- The provisional diagnosis is an important first step to begin treatment even before the final diagnosis.
Getting the right diagnosis is crucial to getting the right treatment, so doctors are careful when diagnosing depression or any other mental disorder. Based on your presenting symptoms, they may make a provisional diagnosis until they are able to get more information about your condition. A provisional diagnosis is essentially their “best guess” based on the information they have.
The provisional diagnosis differs from what is known as a differential diagnosis. The provisional and differential diagnoses are two different steps in the process of diagnosing a mental health condition. They both serve essential, but differing, purposes.
What Is a Provisional Diagnosis?
A provisional diagnosis means that a doctor is not 100% sure of a diagnosis because more information is needed. With a provisional diagnosis, a doctor makes an educated guess about the diagnosis you most likely have.
You can think of a provisional diagnosis as a temporary or working diagnosis. It can help guide the initial treatment process until a more formal diagnosis is made.
Under the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a provisional diagnosis is indicated by placing the specifier “provisional” in parentheses next to the name of the diagnosis. For example, it might say something like “309.81 Post-traumatic Stress Disorder (provisional).”
This provisional specifier is removed once more information is gathered and a final diagnosis is made.
A provisional diagnosis may also be given when a person does not meet the full diagnostic criteria for a specific condition, despite having many symptoms. Researchers suggest that a provisional diagnosis recognizes that each person’s experience is unique. While they may not have all the symptoms necessary to diagnose the condition, they would still benefit from treatment.
Making a Provisional Diagnosis
A provisional diagnosis is a tentative diagnosis that a doctor makes after looking at a person’s presenting symptoms, medical history, examination, and preliminary tests. However, the doctor may realize that they need more information to feel comfortable making a definitive diagnosis.
The purpose of providing a provisional diagnosis is so that a person can begin receiving treatment and to help guide further evaluation. Based on this initial diagnosis, a doctor may order additional tests and assessments to confirm their findings.
What Is a Differential Diagnosis?
A differential diagnosis means that there is more than one possibility for your diagnosis. A doctor must differentiate between multiple diagnoses to determine the correct one and make an appropriate treatment plan.
For instance, there are currently no lab tests to identify depression. Instead, the diagnosis is based on your history and your symptoms.
It is also necessary to rule out other potential causes because many medical and mental health conditions have similar or overlapping symptoms as each other.
According to Dr. Michael B. First, Professor of Clinical Psychiatry at Columbia University and author of the DSM-5 Handbook of Differential Diagnosis, making a good differential diagnosis of depression involves the six steps listed below.
Step 1: Rule Out Malingering and Factitious Disorder
According to Dr. First, a doctor’s initial step should be an attempt to determine whether patients are not fully honest about their symptoms. In general, there are two possible reasons for this: malingering disorder or factitious disorder.
Step 2: Rule Out Drug-Related Causes
Certain drugs—both legal and illegal—can cause the same symptoms as depression when misused or even when used as prescribed. These can include the drugs listed below.
Prescription and Over-the-Counter Drugs
For instance, the following are medications that can cause the symptoms of depression:
- Anticholinergic drugs: Such as Bentyl (dicycloverine)
- Anticonvulsants: Tegretol (carbamazepine), Topamax (topiramate), and Neurontin (gabapentin)
- Benzodiazepines: Xanax (alprazolam), Restoril (temazepam), and Valium (diazepam)
- Beta-blockers: Metoprolol and Inderal (propranolol)
- Corticosteroids: Cortisone, prednisone, methylprednisolone, and triamcinolone
- Drugs that affect hormones: Birth control pills and estrogen replacement therapy
- Opioids: Oxycodone, morphine, and fentanyl
- Statins and other cholesterol-lowering drugs: Such as Lipitor (atorvastatin)
Illicit or Recreational Drugs
Below are illicit drugs that can cause the symptoms of depression:
Clinicians can gain clues about illicit drug use, Dr. First says, by interviewing the patient. Sometimes, the family is interviewed as well. They can also look for signs of intoxication and perform blood or urine tests to screen for the presence of both licit and illicit drugs.
Step 3: Rule Out Other Medical Conditions
There are various general medical conditions that can present with psychiatric symptoms. For this reason, it is very important to rule out any underlying conditions when making a diagnosis because they often require unique treatment.
For instance, you might be going to therapy and taking antidepressants for your symptoms of depression. However, if hypothyroidism is causing your depression symptoms, you’ll need to undergo treatment for this right away.
To rule conditions out, clinicians will ask about previously diagnosed conditions. They are particularly interested in those that may have begun around the same time as depression. Lab tests may be ordered to screen for conditions commonly associated with the symptoms of depression.
Some general medical conditions commonly mistaken for depression include:
- Autoimmune disorders (such as rheumatoid arthritis and lupus)
- Chronic fatigue syndrome
- Diabetes
- Fibromyalgia
- Hypothyroidism
- Lyme disease
- Sleep disorders
Step 4: Determine the Primary Disorder
Once other potential causes have been eliminated, it is necessary to distinguish which specific psychiatric disorder the patient has.
Clinicians must differentiate major depressive disorder from related mood disorders and other disorders which often coexist with depression. This is done by following the criteria established in the DSM-5.
Step 5: Differentiate It From Other Categories
There are times when a person’s symptoms are significant but below the threshold to make a diagnosis or the symptoms are clearly related to stress or a trauma.
Dr. First suggests that the clinician consider a diagnosis of adjustment disorder. This is a condition in which the emotional or behavioral symptoms occur within a few months of an identifiable stressor and are severe enough to cause marked distress or significant impairment in functioning.
If symptoms are present and significant but don’t meet full criteria for an established diagnosis, and they are not related to a clear stressor, the categories of “other specified” or “unspecified” might be applied.
Other Specified
Indicates that a person has a cluster of symptoms characteristic of a disorder, but they do not meet the full criteria for the disorder in a diagnostic class in the DSM-5. This allows communication of the specific reason the presentation does not meet the criteria.
Unspecified
Indicates that a person’s symptoms are characteristic of a disorder, but a diagnostician chooses not to specify the reason the criteria are not met, such as in an emergency room where there is insufficient information.
Step 6: Establish Boundary
Finally, clinicians need to make a judgment call. They need to determine whether the patient is experiencing significant enough impairment or distress in everyday life and that this impairment has lasted long enough for it to qualify as a mental disorder.
Provisional vs. Differential Diagnoses: Key Differences
Provisional Diagnosis
Best guess based on limited information
Helps guide further testing and treatment
May change based on new information
Differential Diagnosis
Lists all potential conditions that might cause symptoms
Helps narrow down possible causes
Helps identify the most likely diagnosis
A provisional diagnosis is typically given after the first or second appointment and is based on the doctor’s clinical impressions, findings from history, or clinical examination. It may be an educated guess, but it indicates that the doctor is still not 100% committed to it and may change based on new information.
A differential diagnosis involves the process of differentiating a condition from those that have similar symptoms. The provisional diagnosis often indicates what a doctor thinks the most likely diagnosis is among all of the potential diagnoses.
The primary differences between the provisional and differential diagnoses boil down to when they are given and the purpose they serve.
The provisional diagnosis is often given at the beginning of the process. It provides a starting point but lacks confirmation.
The differential diagnosis focuses on listing the conditions that might match a patient’s symptoms. It can help doctors collect the information they need to rule out other causes. As more information is collected, a provisional diagnosis can then become a final diagnosis.
What Comes Next
Properly diagnosing depression or any other mental health condition is the first step in treating the whole person. With a proper diagnosis, you can work with a doctor or mental health professional to come up with an effective treatment plan.
The treatment you need depends on your specific diagnosis as well as other factors. It may involve a combination of medications, psychotherapy, and lifestyle changes to get back in balance and feel like yourself again.
