From Presenting Concern to Case Formulation: Provisional Diagnosis, Differentials and the 5Ps

A client arrives saying, “I can't concentrate, I'm exhausted, and everything feels harder than it should.”

That concern could lead towards several lines of assessment. Sleep, physical health, anxiety, depression, neurodevelopmental differences, medication effects, environmental demands and recent life events may all deserve consideration. Several may be relevant together.

The clinician's task is to establish what is happening, compare plausible explanations and build an account that helps the person decide what to do next.

This is where presenting concerns, differential diagnosis, provisional diagnosis and case formulation connect. Each does a different job. DSM-5-TR and ICD-11 help with diagnostic classification. A biopsychosocial and cultural formulation connects assessment findings with the person's circumstances and an individual plan.

This guide uses a formulation funnel to organise that process: begin broadly, investigate the differences that matter, and develop an explanation that remains open to revision. The funnel is an editorial teaching model, rather than a prescribed assessment protocol.

Information checked 21 October 2026. DSM-5-TR (2022) is still the current DSM edition. The APA published a roadmap for a future edition in January 2026 and has set no release date. WHO published the ICD-11 CDDR in March 2024. Australia has not yet decided to implement ICD-11. [1, 2, 4, 7, 8]

Diagnosis, differential diagnosis and formulation: what is the difference?

For documenting functional impact separately from diagnosis, see the NDIS report checklist for psychologists.

A differential is the comparison process. A provisional diagnosis is a tentative conclusion about a particular diagnosis. A formulation can begin before either process is complete.

Here, provisional diagnosis refers to diagnostic uncertainty. It does not refer to the clinician's registration status. A provisional psychologist may contribute to assessment and diagnostic reasoning within their competence and supervisory arrangements; the qualifier describes the diagnostic conclusion, not who made it. If you are a provisional psychologist, agree with your supervisor how diagnostic conclusions are reviewed before they reach a client or a report. See the supervision agreement guide.

Where DSM-5-TR and ICD-11 fit

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, or DSM-5-TR, is published by the American Psychiatric Association. The International Classification of Diseases, Eleventh Revision, or ICD-11, is published by the World Health Organization. Both provide systems for classifying mental disorders, although their categories, descriptions and diagnostic requirements are not identical. [1, 2]

For ICD-11 mental, behavioural and neurodevelopmental disorders, WHO published the Clinical Descriptions and Diagnostic Requirements, or CDDR, in March 2024. These provide clinical diagnostic guidance alongside ICD-11's classification system. They include culture-related guidance for each disorder and take a lifespan approach. [2, 9]

When applying a diagnostic framework, check the relevant requirements directly. Depending on the condition, this includes symptom patterns, duration, functional effects, developmental features, exclusions and differential considerations.

A screening score adds information. It does not complete that reasoning. The APA says its DSM-5-TR assessment measures should support clinical understanding and decision-making and should not be the sole basis for a diagnosis. [3]

In documentation, identify the framework and version used. Check coding and reporting requirements for the particular setting. Australia endorsed ICD-11 internationally in 2019 but has not yet decided to implement it. Australian public and private hospitals continue to use ICD-10-AM/ACHI/ACS to classify episodes of admitted patient care. The AIHW is coordinating work on a national implementation business case, incorporating IHACPA work on replacing ICD-10-AM. [4, 5, 10] Insurer, funder and service requirements vary, so check the ones that apply to you.

Neither manual supplies a complete explanation of why a particular person's difficulties developed or what keeps them going. That requires an individual formulation.

The formulation funnel: from concern to a testable explanation

The funnel has six stages. You may move backwards and forwards between them as the assessment develops.

Urgent safety or medical concerns may require action at any stage. A person does not need to wait for diagnostic certainty before receiving appropriate support.

1. Start with the presenting concern in everyday terms

“Anxiety” and “executive dysfunction” are broad descriptions. Ask what happens, where, when and with what consequences.

For example:

“I spend two hours checking emails after work, avoid opening messages the next morning, and sleep badly before meetings.”

This provides several assessment targets: checking, avoidance, sleep, workplace demands and the meaning attached to possible mistakes.

Ask what the person most wants to change. The referral question and the client's priority may differ. A referrer may ask about ADHD while the client wants help managing exhaustion and keeping their job. Both belong in the assessment plan.

2. Broaden before narrowing

Gather enough context to avoid treating the first plausible explanation as the only explanation.

Depending on the referral, relevant areas may include:

• Onset, duration, course and previous episodes.
• Developmental history and functioning across settings.
• Sleep, physical health, medication and substance use.
• Mood, anxiety, trauma-related experiences and other relevant symptoms.
• Sensory demands, communication needs and environmental fit.
• Relationships, caregiving, housing, finances, work and education.
• Identity, language, culture, discrimination and experiences of services.
• Existing supports, interests, strengths and strategies that help.

Work within your assessment competence. Where a medical explanation requires investigation, arrange or recommend appropriate medical assessment rather than trying to resolve it through psychological measures alone.

Record where information comes from: client report, observation, records, collateral information or formal assessment. Seek appropriate consent for collateral contact and explain its purpose.

3. Generate a differential that helps you decide what to assess

A useful differential is selective. Listing every possible diagnosis creates paperwork without improving the next decision.

For a person reporting concentration difficulties, plausible explanations might include longstanding attention-regulation differences, current anxiety, disrupted sleep or an interaction between these factors. The assessment question becomes: what information would help distinguish or connect them?

These are illustrative assessment prompts, not diagnostic criteria or rules for excluding conditions. For example, limited childhood records do not by themselves exclude ADHD. Support and compensation may obscure earlier difficulties.

More than one explanation may remain supported. Differential reasoning includes identifying co-occurring conditions and interactions.

4. Make uncertainty explicit

A provisional diagnosis should have a clear basis and a clear outstanding question. Avoid using it as a label for any possibility mentioned during assessment.

When using a formal diagnostic qualifier, consult the relevant manual's recording conventions. “Provisional”, “other specified”, “unspecified” and an unconfirmed differential should not be treated as interchangeable terms.

A useful working-assessment note might say:

“Current findings support further assessment of an anxiety disorder. Duration and the relationship between worry, checking and functional impairment remain unclear. Developmental attention difficulties and sleep disruption also require assessment. No final diagnostic conclusion has been reached.”

This communicates the evidence and next steps without implying that a diagnosis has already been established.

If a provisional diagnosis is warranted, document the supporting findings, what remains unconfirmed, relevant alternatives and how the conclusion will be reviewed. Explain that uncertainty to the client in language they can use.

Build the 5Ps formulation across biological, psychological, social and cultural domains

The 5Ps organise the next question: how do these findings fit together for this person?

Macneil and colleagues (2012) describe a five-P approach covering presenting problems, predisposing, precipitating, perpetuating and protective factors. Their paper is a useful account of the approach, rather than evidence that they originated it. This article considers biological, psychological, social and cultural information across those five categories. [6]

In their 2012 commentary, the authors noted limited research on formulation outcomes and questions about agreement between clinicians. That historical caution is not a current systematic review or evidence that this particular template improves outcomes. Use formulation as a working explanation, invite the client's feedback, and review it against what happens during care. [6]

Across each P, consider biological, psychological, social and cultural information. You do not need an entry in every cell. Record gaps and uncertainty rather than inventing a complete-looking explanation.

A factor may have more than one role. Family involvement might offer practical support while also creating conflict about independence. A strategy that reduces immediate distress may have longer-term costs. Describe the conditions under which each effect occurs.

Use cultural information throughout

Cultural formulation involves asking how the person understands their difficulties, what matters to them, what help feels acceptable and how their social position affects access to care.

Consider language, family and community relationships, identity, spiritual beliefs, experiences of racism or exclusion, and differences between the clinician's assumptions and the person's own explanation. Explore relevance with the individual rather than inferring it from group membership.

The APA's Cultural Formulation Interview has 16 core questions about cultural aspects of presentation and care, an informant version and supplementary modules. The APA says it should enhance understanding and decision-making, not serve as the sole basis for a diagnosis. It is a different resource from a 5Ps template. [3]

For Aboriginal and Torres Strait Islander clients, seek appropriate cultural guidance and consider culturally relevant understandings of social and emotional wellbeing. A generic worksheet cannot establish cultural safety.

A template for organising this stage

The 5Ps Biopsychosocial–Cultural Case Formulation Template, Clinical Edition is a paid PDF available through PsychVault.

The listing includes guided prompts and examples across the five Ps and biological, psychological, social/familial and cultural domains, an executive-summary template, and a treatment-planning section with intervention mapping.

It provides a structure for documenting your reasoning and taking it into supervision. Diagnostic conclusions still require appropriate assessment, reference to current diagnostic guidance and clinical judgement. View the preview and included features before purchasing.

Worked example: moving beyond a list of factors

The following example is fictional and deliberately incomplete. It illustrates formulation reasoning rather than establishing a diagnosis.

Alex seeks help for poor concentration, exhaustion and repeated checking at work. Initial assessment identifies a recent increase in workload, fragmented sleep, fear of mistakes and longstanding difficulty restarting tasks after interruptions. Alex describes a supportive partner and reports functioning better when instructions are written and interruptions are reduced.

An initial 5Ps map might record:

The formulation needs a connecting explanation:

“Our current hypothesis is that increased workload and interruptions have made it harder for Alex to complete tasks. Worry about mistakes appears to prompt repeated checking, extending the working day and reducing sleep. Reduced sleep may then worsen concentration and increase uncertainty about work quality. Written instructions and fewer interruptions appear helpful. The contribution of longstanding attention difficulties remains under assessment.”

This account distinguishes reported information from proposed links. It also suggests what to investigate next.

Ask Alex whether the explanation fits. Perhaps checking follows actual workplace errors and unclear instructions more closely than fear of judgement. Perhaps poor sleep predates the workload change. Either finding should change the formulation.

Link each proposed mechanism to an action and a review point

A completed 5Ps table becomes more useful when it changes the plan.

An improvement after an intervention is useful feedback. It does not, by itself, prove a diagnosis or confirm the proposed cause.

For a fuller example of choosing what to work on next, see From Case Formulation to the Next Session.

Common reasoning errors to check in supervision

• Starting with a preferred diagnosis. Ask what evidence would make you reconsider it.
• Using a symptom score as the conclusion. Integrate it with history, functioning, context and the relevant diagnostic requirements.
• Making all difficulties consequences of one diagnosis. Consider co-occurrence, health changes and environmental demands.
• Turning a possible history into an established cause. Separate what was reported from what you infer.
• Calling an adaptation a maintaining factor without examining its function. Understand what it protects the person from and what alternatives are available.
• Writing strengths without using them. Link protective factors to the actual plan.
• Leaving the client outside the explanation. Invite disagreement and revise the account when it does not fit their experience.

A final check before you document the formulation

Can a reader identify:

1. 1The person's concern and priorities?
2. 2The evidence sources and relevant gaps?
3. 3The alternatives considered and why they remain plausible or have become less likely?
4. 4The diagnostic framework used and the certainty of any conclusion?
5. 5The proposed links between the five Ps and the person's context?
6. 6The agreed actions and the findings that would prompt revision?

Bring the completed formulation to supervision with one more question: what evidence would change this explanation?

For more clinical reasoning and documentation guides, explore the Therapist Resources hub.

Sources and scope

1. 1American Psychiatric Association. About DSM-5-TR. Consult the current manual directly for diagnostic criteria, differential considerations and recording conventions.
2. 2World Health Organization. (2024). Clinical descriptions and diagnostic requirements for ICD-11 mental, behavioural and neurodevelopmental disorders.
3. 3American Psychiatric Association. DSM-5-TR online assessment measures and Cultural Formulation Interview.
4. 4Independent Health and Aged Care Pricing Authority. ICD-11. States that a decision on implementing ICD-11 in Australia has not been made.
5. 5Australian Institute of Health and Welfare. Health Classifications Update 10, August 2026.
6. 6Macneil, C. A., Hasty, M. K., Conus, P., & Berk, M. (2012). Is diagnosis enough to guide interventions in mental health? Using case formulation in clinical practice. BMC Medicine, 10, 111.
7. 7American Psychiatric Association. (2026, 28 January). APA releases roadmap for the future of the DSM.
8. 8American Psychiatric Association. Future DSM: Frequently asked questions. No publication date has been determined.
9. 9World Health Organization. (2024, 8 March). New manual released to support diagnosis of mental, behavioural and neurodevelopmental disorders added in ICD-11.
10. 10Independent Health and Aged Care Pricing Authority. ICD-10-AM/ACHI/ACS.

The funnel, tables and worked example are practical teaching tools developed for this article. They are not validated diagnostic instruments or a mandated formulation format. This guide provides educational information and does not reproduce diagnostic criteria or replace appropriate training, supervision or individual clinical assessment.