ABSTRACT
Any problem can include features of any of the problems below it in the hierarchy. During an assessment, it is worth considering all the diagnostic possibilities from the top down. For example, a person presenting with pervasive low mood, loss of energy and motivation may have a thyroid problem rather than primary depressive illness. The diagnostic hierarchy is complemented by 'onion concept'. The core of the onion represents the personality. Stress and illness can exacerbate the individual's pre-morbid personality characteristics. Medical problems do not only directly cause mental symptoms. Deciding whether to address traumas can wait until the depressive illness layer has been peeled away. Addressing such predisposing issues could form an intermediate/long-term part of the management plan. If the patient finds themselves functioning happily again, they may not wish to tackle their vulnerability by opening such a can of worms – once the lid is off, it is hard to shut the contents away again.
