How to Assess Past Psychiatric Diagnoses (Correctly)
This is Part 2 in our series on Past Psychiatric History.
Read Part 1: Framework and Essential Components to understand how this domain fits into comprehensive psychiatric evaluation.
Past diagnoses shape treatment decisions and how patients understand themselves. Your job is to systematically extract what diagnoses exist in the chart and in the patient’s memory, document their sources, and note any discrepancies. This creates the foundation for clinical reasoning – but that reasoning comes later. Right now, focus on accurate extraction.
Learning Objectives
After reading this section, you should be able to:
- Identify reliable sources for extracting previous psychiatric diagnoses
- Differentiate between chart-documented and patient-reported diagnoses
- Evaluate diagnostic discrepancies for accuracy and context
- Document diagnoses with clear source attribution (“per chart” vs. “per patient”)
Start With Chart Review
Before interviewing the patient, review available documentation:
Previous psychiatric notes – Diagnostic impressions from psychiatrists, psychologists, therapists
Problem lists – Active and inactive diagnoses in the electronic medical record
Discharge summaries – Hospital and partial hospitalization diagnoses often reflect more thorough evaluation
Psychological testing reports – May identify ADHD, autism, learning disorders not documented elsewhere
đź’ˇ Clinical Pearl: Pay attention to diagnostic inconsistencies. If one provider diagnosed major depression and another diagnosed bipolar disorder, this discrepancy warrants exploration with the patient.
Interview the Patient
After chart review, interview the patient to confirm, clarify, and add to documented diagnoses.
Core Questions to Ask
- “Has a doctor or therapist ever given you a mental health diagnosis?”
- “Are you aware of having any diagnoses like depression, anxiety, or bipolar disorder?”
- If chart diagnoses weren’t mentioned: “I see you’ve been diagnosed with [diagnosis]. Were you aware of that?”
- After they name one: “Have you been given any other diagnoses?”
When They Say “No” or “I Don’t Know”
Many patients do not spontaneously report certain conditions such as neurodevelopmental disorders (ADHD, autism), substance use disorders, personality disorders, or neurocognitive conditions when asked whether they have “psychiatric diagnoses.” While I have not found specific research describing this as a studied phenomenon, it reflects my clinical experience. Patients often readily report diagnoses like depression, anxiety, bipolar disorder, or schizophrenia, but conditions such as ADHD or autism may only emerge later in the interview, often when reviewing current or past medications. On several occasions, I have discovered an ADHD diagnosis only after asking why a patient was prescribed a stimulant medication. They might casually reply, “Oh, I was diagnosed with ADHD as a kid,” even though they had not mentioned it earlier. The same is often true for substance use disorders, which patients may not volunteer until asked directly or until a medication such as buprenorphine, methadone, or naltrexone appears in their record. Because substance use history is a core component of every psychiatric evaluation, these diagnoses are less likely to be missed, but the pattern still illustrates the value of probing beyond initial answers and reviewing medication history carefully.
Ask specifically:
- “Has anyone mentioned ADHD or autism?”
- “Do you have any diagnoses related to learning, attention, or development?”
- “Have you been told about substance use problems or addiction?”
Follow-Up for Context
Once a patient names a diagnosis, gather context:
- “Who gave you this diagnosis – a psychiatrist, therapist, or primary doctor?”
- “About how long ago?”
- “Do you remember how old you were when you received the diagnosis?”
- “What was happening when you got this diagnosis – were you in the hospital or in crisis?”
- “Are you still being treated for this?”
💡 Clinical Pearl: The reliability of a past diagnosis depends greatly on who made it, in what setting, and under what circumstances. A diagnosis established by a psychiatrist after longitudinal evaluation carries more weight than one made during an emergency visit or acute crisis. The American Psychiatric Association emphasizes documenting both source and context—including clinician type, setting, and timing—since diagnostic stability and accuracy vary widely across clinical environments.
Diagnosis Drift: Bipolar Disorder (DSM-IV vs DSM-5)
Why this matters: Bipolar disorder diagnoses made before 2013 (under DSM-IV) require special scrutiny.
The key change: DSM-IV allowed diagnosis based on mood symptoms alone (elevated, expansive, or irritable mood). DSM-5 requires BOTH abnormal mood AND persistently increased energy or activity. This stricter criterion reduced bipolar diagnoses by 30 to 50% across all age groups – one of the few adult psychiatric diagnoses to decrease under DSM-5.
In children specifically: DSM-IV criteria were often applied to chronic, severe irritability without true episodic changes. DSM-5 introduced Disruptive Mood Dysregulation Disorder (DMDD) for chronic irritability and clarified that bipolar disorder requires episodic presentations.
Clinical implication: When you see bipolar disorder diagnosed before 2013, especially in children or during crisis presentations, explore: Was this based on true episodic changes in mood AND energy? Or chronic irritability? Crisis diagnosis or longitudinal observation?
What to Document
Your documentation should specify both the diagnoses and their sources, creating a clear baseline for diagnostic reasoning.
| Documentation Level | What to Include | Example | When to Use This Level |
|---|---|---|---|
| Standard | List of diagnoses with clear source attribution (“per chart” or “per patient”) | “Major Depressive Disorder (per chart). Patient aware of diagnosis.” | Routine evaluations where sources align and history is straightforward; brief follow-up visits |
| Detailed | Standard + Patterns of diagnostic change, discrepancies with analysis | “Chart lists Major Depressive Disorder (Dr. Jones (Outpatient Psychiatrist), 2023) Alcohol use disorder (Emergency Department, 2018). Bipolar disorder (per patient) made during crisis presentation approximately 5 years ago but cannot recall diagnosing provider or specific symptoms prompting diagnosis.” | Complex diagnostic histories; evolving or conflicting formulations; medicolegal contexts; teaching cases; consultation documentation |
Consistently documenting the source and context of prior diagnoses prevents circular reasoning and supports accurate formulation later in the evaluation.
Why This Information Matters
Diagnostic labels map how others have understood the patient’s struggles. Your role is to extract and document these labels precisely; interpretation comes later. Right now, your job is accurate extraction and documentation of what diagnoses exist and where they came from.
Understanding past diagnoses provides several critical functions. First, it reveals diagnostic consensus or uncertainty. When multiple providers across time agree on a diagnosis, this strengthens diagnostic confidence. When diagnoses shift frequently or conflict, this signals diagnostic uncertainty requiring careful reassessment. Second, it identifies documentation gaps. When patients report diagnoses not in the chart, this may indicate treatment elsewhere, documentation failures, or the patient’s interpretation of symptoms rather than formal diagnoses. Third, it prevents anchoring bias. Seeing how others conceptualized the illness doesn’t determine your formulation – it provides one data point among many. Your independent assessment may confirm, refine, or revise prior diagnoses.
Source attribution – documenting who made the diagnosis and when – is essential for both clinical reasoning and medicolegal documentation. A bipolar diagnosis from an emergency physician during a single crisis encounter requires different interpretation than the same diagnosis from a psychiatrist following months of careful observation. Crisis diagnoses may reflect acute presentations that don’t represent the patient’s longitudinal course. Outpatient diagnoses based on sustained observation typically carry more weight.
This foundation prepares you for the next component: understanding when and why those diagnoses led to psychiatric hospitalizations. Hospitalization history reveals illness severity, treatment response, and crisis patterns that further contextualize the diagnostic picture.
Next in this series: Part 3 – Psychiatric Hospitalization History: When, Where, Why, and What It Reveals About Illness Severity
Previous post: Part 1 – Framework and Essential Components: Understanding the Scope of Past Psychiatric History
