Why do I get more and more diagnoses after seeking help for my mental health?

1. High Prevalence of Comorbidity

A primary reason for multiple diagnoses is that co-occurring mental disorders are considered the norm rather than the exception in clinical practice.

• Co-occurring Psychiatric Conditions: Many disorders are highly comorbid. For instance, the majority of individuals with Bipolar I disorder have a history of three or more co-occurring mental disorders. Similarly, about 60% of individuals with Bipolar II disorder have three or more co-occurring mental disorders, with anxiety disorders being the most common. Eating disorders often co-occur with symptoms or full syndrome illnesses like mood or anxiety disorders.

• Substance Use and Dual Diagnosis: Patients seeking treatment for mental health frequently have Substance Use Disorders (SUDs), leading to a "dual diagnosis". For example, anxiety and depression are reported in up to 40% of patients with alcohol use disorder (AUD). Current substance use can significantly impact psychiatric symptoms and complicate treatment course.

• Psychiatric and Medical Comorbidity: High rates of physical disorders are associated with psychiatric patients (ranging from 24% to 60%). The accrual of medical problems, particularly in the elderly, increases medical-psychiatric comorbidity. These medical issues can significantly complicate the course and prognosis of mental disorders.
  

2. The Diagnostic Process Encourages Multiple Diagnoses

The structured clinical evaluation process is designed to identify all relevant issues, leading inherently to multiple labels. The general convention in the DSM-5 is to allow multiple diagnoses to be assigned for presentations that meet criteria for more than one disorder.

• Mandate for Comprehensive Assessment: Clinicians must pursue a thorough assessment to identify comorbid conditions. The initial psychiatric interview aims to obtain information to establish a criteria-based diagnosis, leading to treatment decisions. A comprehensive interview often involves a psychiatric review of systems to rule in or rule out various diagnoses.

• Overlapping Symptoms: The boundaries between many psychiatric disorder "categories" are fluid. Symptoms that form the essential features of one disorder may occur, at varying levels of severity, in many other disorders. For example, anxiety symptoms often coexist with depressive disorders, and psychotic symptoms can be present in both schizophrenia and mood disorders. Clinicians must look beyond prototypical presentations that neatly fit into single DSM categories to fully uncover possible disorders.

• Differential Diagnosis and "Other Specified" Categories: The process of distinguishing one diagnosis from many possibilities (differential diagnosis) can lead to the articulation of several related conditions. Furthermore, if a presentation does not meet the full criteria for any specific disorder but still causes clinically significant distress, "other specified" or "unspecified" categories may be used.

• Identifying Physiological Causes: Psychiatric symptoms can be manifestations of underlying medical conditions or substance use. Ruling out these "secondary" causes is essential for diagnosis. If the disturbance is attributable to both a medical condition and substance use, or a medical condition is causing a specific psychiatric syndrome, both diagnoses (e.g., Psychotic Disorder Due to Another Medical Condition, plus the substance use disorder) may be given.
  

3. Diagnostic Shifts and Evolving Presentations Over Time

A patient's symptom trajectory may require a change or addition to the diagnosis over time, often resulting in a sequential accumulation of labels.

• Ongoing Assessment: The evaluation and assessment of complex diagnoses should be an ongoing matter because conditions can change over time. For instance, if substance abuse stops, a different underlying condition may come to the surface that was previously obscured.

• Evolution of Illness: Some illnesses begin as one diagnosis and evolve into another. For example, many bipolar illnesses begin with one or more depressive episodes, and a substantial proportion of individuals initially diagnosed with Major Depressive Disorder (MDD) will later receive a bipolar disorder diagnosis. Similarly, 5%–15% of individuals with Bipolar II disorder will eventually develop a manic episode, which necessitates a change of diagnosis to Bipolar I disorder.

• Initial Provisional Diagnoses: Certain diagnoses are explicitly temporary. For example, schizophreniform disorder is a provisional diagnosis if the symptoms last less than six months; if symptoms persist beyond that duration, the diagnosis must be changed to schizophrenia.

• Prognosis of Secondary Illnesses: Roughly one-third of individuals initially diagnosed with substance-induced psychosis are later diagnosed with a schizophrenia spectrum disorder or bipolar disorder, indicating a progression or clarification of the underlying chronic illness.

• Exacerbation of Personality/Co-occurring Disorders: Stressors, such as chronic pain or emotional duress, may exacerbate symptoms of pre-existing personality disorders, which often leads to the diagnosis of an additional adjustment disorder if the stress-related disturbance exceeds what would be attributable solely to the personality disorder.