Diagnostic Complexity
Specialized expertise in conditions that are often missed, misunderstood, or misdiagnosed.
Not everyone fits neatly into diagnostic categories. Some people struggle for years—seeing provider after provider, trying treatment after treatment—without ever receiving a diagnosis that truly captures their experience or leads to effective help.
I specialize in complex cases: presentations that don’t fit the textbook, conditions that mimic each other, symptoms that have resisted previous treatment, and situations where multiple diagnoses overlap and interact. If you’ve been told you’re “treatment resistant,” felt like providers don’t quite understand what you’re experiencing, or wonder if you’ve been misdiagnosed, you’re in the right place.
Why Diagnosis Gets Complicated
Mental health diagnosis is more art than science. Unlike a broken bone that shows up on an X-ray, psychological conditions are defined by patterns of symptoms, behavior, and inner experience. These patterns overlap, evolve over time, and express differently depending on the person.
Some reasons diagnosis becomes complicated:
- Symptom overlap: Many conditions share similar symptoms. Difficulty concentrating, for example, can indicate ADHD, depression, anxiety, trauma, a dissociative disorder, or something else entirely.
- Comorbidity: Most people with one condition have others. Depression often accompanies anxiety, trauma underlies many presentations, personality patterns complicate the picture.
- Atypical presentations: Not everyone manifests conditions in textbook ways. Women with ADHD, adults with autism, men with borderline personality—these presentations are often missed because they don’t match stereotypes.
- History effects: Past trauma, early attachment experiences, and developmental factors shape how conditions present, sometimes obscuring what’s happening now.
- Assessment limitations: Brief clinical interviews often miss what comprehensive evaluation reveals. Many providers lack training in certain conditions or assessment approaches.
- Previous treatments haven’t worked
- Multiple conflicting diagnoses
- Diagnoses that don’t feel right
- Symptoms that don’t fit one category
- Long history of struggling without clear answers
- “Treatment resistant” depression or anxiety
- Providers who seem confused by your case
Commonly Missed or Misdiagnosed Conditions
Certain conditions are frequently overlooked in standard clinical practice.
Complex PTSD
Resulting from prolonged, repeated trauma (often in childhood), Complex PTSD involves not just PTSD symptoms but also difficulties with emotional regulation, self-perception, and relationships. It’s frequently mistaken for bipolar disorder, borderline personality, or treatment-resistant depression. Many people with C-PTSD have been misdiagnosed for years.
Dissociative Disorders
Dissociation often goes unrecognized because providers don’t ask about it or don’t know how to identify it. People with significant dissociation may be diagnosed with schizophrenia (due to hearing internal voices), bipolar disorder (due to mood switches between parts), or BPD (due to identity confusion).
Adult ADHD
ADHD in adults, especially women and those without hyperactivity, is frequently missed. It can present as anxiety, depression, or underachievement without an obvious explanation. Many adults with ADHD have spent years wondering why they struggle with things that seem easy for others.
Autism Spectrum in Adults
Many adults, particularly women and those who have learned to mask, were never identified in childhood. They may have been diagnosed with social anxiety, OCD, depression, or personality disorders. Recognizing autism can reframe a lifetime of feeling different and open pathways to appropriate support.
Personality Disorders
Conditions like borderline, narcissistic, and avoidant personality disorder affect how people relate to themselves and others in pervasive ways. They often underlie “treatment-resistant” anxiety or depression—treatments fail because they’re addressing symptoms rather than underlying personality structure.
Bipolar II and Cyclothymia
The hypomanic episodes of Bipolar II are often missed because they’re less dramatic than full mania. People may receive multiple trials of antidepressants for “resistant depression” without recognizing the bipolar pattern. Cyclothymia—a milder cycling pattern—is even more frequently overlooked.
The Challenge of Differential Diagnosis
Many conditions look similar on the surface. Distinguishing between them requires careful assessment, clinical expertise, and often time. Here are some common diagnostic challenges:
Both involve impulsivity, distractibility, and energy fluctuations. But their patterns differ: ADHD is constant from childhood while bipolar involves discrete episodes. The hyperactivity of ADHD differs from the goal-directed energy of hypomania. These conditions can also co-occur, complicating the picture further.
Both involve emotional dysregulation, relationship difficulties, and often trauma history. C-PTSD emphasizes the trauma symptoms and self-perception changes; BPD emphasizes identity diffusion and the pattern of relationships. Many people meet criteria for both. Understanding the distinction (and overlap) affects treatment approach.
Both involve mood instability, but the patterns differ. Bipolar moods shift over days to weeks and are often unrelated to circumstances. BPD mood shifts are rapid (hours to minutes) and usually triggered by interpersonal events. The identity and relational instability of BPD is absent in pure bipolar disorder.
Internal voices, identity confusion, and unusual experiences can occur in both. But dissociative voices are experienced as inside the head; psychotic voices as coming from outside. Dissociative “parts” involve divided consciousness; schizophrenic symptoms involve a different kind of fragmentation. Misdiagnosis has serious treatment implications.
Both can involve social difficulties and avoidance. But the underlying reasons differ: social anxiety involves fear of judgment while autism involves differences in social understanding and sensory processing. Autistic individuals may have learned to mask, appearing to have social skills they actually find exhausting to perform.
My Approach to Complex Cases
Getting the right diagnosis requires more than matching symptoms to categories. It requires understanding the whole person.
Comprehensive Assessment
I take the time to understand your full history: developmental background, trauma history, family patterns, previous diagnoses, and what’s worked or hasn’t in past treatment. This often means multiple sessions of careful interview before reaching conclusions.
Psychological Testing
When appropriate, I offer comprehensive psychological testing that goes beyond clinical interview. Standardized measures provide objective data that can clarify diagnostic questions and reveal patterns not visible in conversation alone.
Understanding, Not Just Labeling
A diagnosis is a starting point, not an ending point. I’m interested in understanding what’s happening for you specifically—not just which category you fit. Treatment is tailored to your unique presentation, not a generic protocol for a label.
“The goal isn’t to find the perfect label. It’s to understand you well enough to actually help.”
When to Seek Diagnostic Clarity
You might benefit from specialized diagnostic assessment if:
- Treatment hasn’t worked: You’ve tried multiple medications or therapies without meaningful improvement.
- Your diagnosis keeps changing: Different providers have given you different diagnoses, none of which feel complete.
- Something feels missing: Your current diagnosis doesn’t fully explain your experience; there seems to be more going on.
- You suspect something specific: You’ve read about a condition and wonder if it applies to you, but providers haven’t considered it.
- You’re planning major treatment: Before committing to intensive treatment, hospitalization, or significant medication changes, you want clarity.
- Past trauma is involved: Early or complex trauma often creates presentations that don’t fit simple categories.
- You need documentation: For disability, accommodations, or other purposes, you need a thorough evaluation.
- Clarity about what’s actually happening
- Understanding of how different factors interact
- Validation of your experience
- Clear treatment recommendations
- A foundation for more effective therapy
- Documentation for providers, schools, or employers
- A roadmap for moving forward
The Value of Getting It Right
Accurate diagnosis matters because it shapes treatment. When diagnosis is wrong, treatment fails—not because you’re “treatment resistant,” but because you’re receiving treatment for the wrong condition.
Consider the implications:
- Treating bipolar disorder as simple depression can worsen cycling and increase suicide risk
- Standard trauma therapy for someone with dissociation can destabilize rather than heal
- CBT for what’s actually a personality disorder often fails, leaving the person feeling defective
- Antipsychotics given for dissociative symptoms (mistaken for psychosis) don’t address the actual issue
- Stimulants for misdiagnosed ADHD (when it’s actually anxiety or trauma) can make things worse
The right diagnosis leads to the right treatment, which leads to actual improvement. Many people labeled “treatment resistant” aren’t resistant at all—they just haven’t received accurate diagnosis and appropriate treatment.
Some people do have multiple conditions that require concurrent attention. This is complex, but it’s manageable with clear understanding of what’s present and how the conditions interact. A thorough assessment maps this complexity so treatment can be appropriately nuanced rather than one-size-fits-all.
Services for Complex Cases
Diagnostic Consultation
A focused evaluation specifically aimed at diagnostic clarity. This typically involves 2-4 sessions of comprehensive clinical interview, review of records and history, and if indicated, psychological testing. You’ll receive a detailed report with diagnostic conclusions and treatment recommendations.
Best for: People who have a treatment provider but need diagnostic clarification.
Comprehensive Psychological Evaluation
Full psychological testing including cognitive, personality, and symptom-specific measures alongside clinical interview. This provides the most thorough understanding of your psychological functioning and is documented in a detailed written report.
Best for: Complex presentations, documentation needs, or when you want maximum clarity.
Treatment for Complex Conditions
Ongoing psychotherapy tailored to complex presentations. I’m comfortable working with multiple diagnoses, trauma history, personality issues, and presentations that other providers have found challenging. Treatment is adapted to your specific needs, not a rigid protocol.
Best for: People ready for treatment who need a provider skilled in complexity.
Second Opinion
If you’ve received a diagnosis you’re uncertain about or been recommended a treatment you’re hesitant about, I can provide an independent assessment and second opinion. Sometimes confirmation is reassuring; sometimes an alternative perspective reveals new options.
Best for: Anyone facing significant treatment decisions who wants another perspective.
Clarity Is Possible
If you’ve been struggling without clear answers, a thorough evaluation can illuminate the path forward. Schedule a consultation to discuss your situation.