Diagnoxal runs your case three ways: with prior diagnoses considered, without them, and side-by-side. See where anchoring is shaping the call before the call is final. DSM-5-TR and ICD-11 grounded.
A full analysis takes about 15 minutes.
Machine-generated diagnostic report · condensed
Rule-outs (require decisive data before exclusion)
Decisive next data:
One real case, condensed from a full run of about 15 minutes.
A referred case arrives already labeled. This same case is read twice: once with the referral context and once with the prior label set aside. The two reads are compared before a final call, making any difference in the reasoning visible.
Diagnoxal re-analyzes the raw vignette with prior labels removed, checks every candidate against DSM-5-TR and ICD-11 criteria, and keeps the formulation provisional until medical and substance causes are addressed. It then compares that blinded analysis with one that saw the full context.
A structured second opinion in minutes: a differential with quoted evidence, the tests and questions that would settle it, and documentation ready for the chart. If the two analyses disagree, you find out before the call is final.
A colleague-level second read with medical and substance rule-outs enforced on every case.
Criterion-by-criterion reasoning you can carry into assessment, formulation, and testing decisions.
The same reasoning discipline on every case, and a practice environment to sharpen your own.
A case before a conclusion
Read the full vignette first. Then continue through the reasoning safeguards that test the same case before any final call. Amber marks the safety gates: they can only demote a conclusion, never promote one.
The reasoning sequence
The sequence below follows the same complete case through ten safeguards. Open any stage output to read its clinical prose at your own pace.
Stage 01
The referral label “anxiety not responding to medication” is set aside so it cannot anchor the read. Extracted: a 4-month course of abrupt fear episodes, now near-daily; 6 kg of unintentional weight loss; feeling hot all the time; a fine resting tremor; broken sleep; symptoms that worsened after the sertraline dose went up.
Extracted case summary
A four-month pattern of abrupt, intense-fear episodes includes pounding heartbeat, chest tightness, trembling, sweating, derealization, and nocturnal awakenings. Between episodes, the patient reports persistent hyperarousal, insomnia, irritability, and work-related racing thoughts.
Stage 02
Relevant criterion sets are retrieved for every candidate before any matching begins: panic disorder, generalized anxiety, and anxiety due to another medical condition among them.
Reader-form criterion states
Stage 03
Several possibilities are raised at once, on purpose: panic disorder, generalized anxiety, anxiety due to a medical condition (a thyroid picture), substance or medication-induced anxiety (pseudoephedrine, heavy caffeine, possible SSRI activation), and a bipolar question from the family history.
Diagnostic reasoning and differential considerations
The recurring panic-like phenomenology and subsequent worry or behavioral change support considering a panic syndrome. The timing of onset after sertraline, worsening after a dose increase, and ongoing pseudoephedrine and high caffeine exposure make a medication- or substance-related explanation plausible.
Weight loss, heat intolerance, tremor, diaphoresis, and a family history of thyroid disease keep thyrotoxicosis in the differential. Family history of bipolar disorder and activation after an SSRI also call for collateral about prior elevated or expansive mood, decreased need for sleep, or increased goal-directed activity.
Stage 04
Each criterion is tested against quoted text. Panic-attack features are met. The manic and hypomanic criteria are not met. The vignette states no distinct period of elevated mood was ever observed. The weight loss is recorded as present but not yet explained.
Criterion-by-criterion evidence
Stage 05
A thyroid workup is warranted because weight loss, heat intolerance, tremor, and family history remain live findings. Bipolar spectrum disorders remain an open rule-out pending collateral; the recent weight loss is not assumed to be an anorexia relapse.
Client-facing differential status
Stage 06Gate
An adversarial self-check challenges the medication/substance-attribution working explanation: primary anxiety after the relationship end, an unevaluated thyroid cause, or stimulant effects could instead explain the presentation. The post-cessation course is unknown, so this working explanation is demoted, not promoted. The leading psychiatric label is demoted, not promoted.
Counterargument to the working explanation
Symptoms could represent a new primary anxiety disorder, including panic disorder or generalized anxiety, precipitated by the recent relationship end rather than medication effects. Persistent between-attack symptoms and nocturnal panic could reflect a primary illness.
Hyperthyroidism remains unevaluated despite weight loss, heat intolerance, tremor, and a family history of thyroid disease; it could explain autonomic symptoms. Heavy caffeine use and pseudoephedrine alone might instead be the principal contributors.
The symptom course after stopping sertraline or reducing suspected stimulant exposures is not known. These information gaps lower diagnostic certainty and call for close follow-up and targeted medication or substance changes to observe causal effects.
Stage 07Gate
Thyroid function (TSH / free T4) has not been drawn; daily pseudoephedrine and heavy caffeine are active; the sertraline dose rose six weeks ago. While a medical or substance cause is live, no primary psychiatric label is finalized; the formulation stays provisional.
Etiology-gate formulation
An anxiety syndrome remains a working formulation with etiology undetermined. Medical, substance, and psychiatric explanations remain under consideration, including possible thyrotoxicosis, panic disorder, and bipolar spectrum disorders.
Complete the directed medical and substance workup before attributing the presentation to a primary psychiatric condition.
Stage 08Gate
Every statement is checked back against the vignette. No recent physical examination or laboratory work is documented, so no results are invented. Missing data is named, not filled in.
Grounding limits and findings not fully explained
Stage 09
Client-facing statuses remain provisional while the medical and substance questions are open. Acute suicide risk is described as low; passive wishes are monitored with short-interval follow-up.
Client-facing status and risk formulation
Bipolar spectrum disorders and anxiety due to another medical condition remain open rule-outs. Insomnia Disorder and Generalized Anxiety Disorder remain provisional working considerations.
Acute suicide risk is described as low because there is no intent, plan, or history of attempts; passive wishes of not waking up when exhausted are still monitored. Arrange short-interval follow-up. Functional risk is significant because tremor affects medication preparation and missed shifts. Medical risk remains unanswered until thyroid testing and the other missing data are obtained.
Stage 10
With referral context and blinded to prior labels, the two analyses reach different formulations. That disagreement is a flag for re-evaluation before a final call.
Reconciliation
The analyses disagree. The difference suggests that prior diagnostic labels or treatment history may be anchoring clinical reasoning rather than independently supporting a call.
Treat the difference as a flag for re-evaluation: review the independent reasoning before committing to a final call, and consider collateral history, a structured re-interview, or formal psychometric testing to resolve it.
The complete report
Anxiety syndrome with panic-like episodes: provisional, etiology undetermined.
Medical, substance-related, and primary psychiatric explanations remain under evaluation. The presentation should not be attributed to a primary psychiatric condition while the medical and substance workup is incomplete.
The report’s rule-out list remains open while decisive information is gathered:
Decisive next data
Acute suicide risk is low: there is no intent or plan, and the patient reports only passive wishes of not waking up when exhausted. Functional risk is significant because tremor affects medication preparation and missed shifts; medical risk remains unanswered while weight loss, heat intolerance, tremor, and diaphoresis require directed assessment.
The panic-like phenomenology is clinically important, but the temporal relationship to sertraline, pseudoephedrine, and high caffeine exposure makes medication- or substance-related anxiety plausible. Objective features and family history keep thyrotoxicosis an important medical alternative.
Rapid thyroid testing, mitigation of stimulant exposures, close follow-up, and practical workplace accommodations are recommended while causal explanations are clarified.
Run the evidence twice, compare the reads, and keep unresolved medical and substance causes visible in the report.
Diagnoxal is educational clinical decision-support. It does not establish a diagnosis or replace professional clinical judgment.
What you get after joining
The report format the engine returns, the mind map that ships with the learning module, and all three study surfaces. Real components and real learning paths, shown here.
Report
The case above, as the engine returned it: a headline diagnosis with its status, a differential you can act on, the rule-outs that still need data, the instruments to measure with, and the risk to monitor.
Headline diagnosis
Acute suicide risk is low: the patient denies intent or plan and reports only passive wishes 'wouldn't mind not waking up' when exhausted; there is no history of attempts. Protective factors include employment, supportive nearby parents, and preserved cognition and insight. Functional risk is significant: tremor interfering with drawing medications and missed shifts reflect safety and occupational impairment in a high-stakes environment. Medical risk is unanswered: unexplained 6 kg weight loss, heat intolerance, tremor, and diaphoresis could indicate thyrotoxicosis, which carries systemic risks if untreated. Missing risk data that would change urgency: vital signs, TSH/free T4, and collateral about any prior mood elevation or substance use patterns. Prioritize rapid thyroid testing and mitigation of stimulant exposures; arrange short-interval follow-up and workplace accommodations until safety concerns (tremor, impaired medication preparation) are addressed.
Mind map
The study map highlights 141 documented relationships. Choose a category, then a disorder, to fan out what distinguishes it. Amber marks rule-out edges: the relationships a clinician must not miss.
This study map highlights 81 diagnostic concepts and rule-outs informed by DSM-5-TR (APA, 2022) across 15 categories and 141 relationships of five kinds: differential, rule-out, comorbid, spectrum, and shared symptoms. Open it in the learning module.
Practice
Try one question from the 827-item bank and one card from the 670-card deck here. Case Practice opens its signed-in Learning workspace directly, where you choose a difficulty, submit a diagnosis and reasoning, and review structured feedback.
One multiple-choice question from the quiz bank, with the engine's own explanation once you answer. Open the quiz bank.
One spaced-repetition card from the deck, front and back. Open the deck.
A complete reasoning exercise
Two secondary examples are kept in a collapsed archive so the ICU-nurse journey remains the primary demonstration. The PDF below is another format of that same ICU case, not a third story.
Elena Rodriguez is a 19-year-old Hispanic female undergraduate student who presented to the campus counseling center stating, "I feel like I'm going to explode," and reported frequent episodes of heart palpitations and shortness of breath. She stated these feelings began approximately two months ago, coinciding with mid-term exams, but have not subsided despite the semester ending.
Elena is a nursing major on a full academic scholarship. She is the first in her family to attend college and expressed immense pressure to "make her parents' sacrifices worth it." The onset of her symptoms occurred shortly after she received a 'C' on an Anatomy quiz. Since then, she describes a constant sense of impending doom regarding her academic standing, despite currently holding a 3.8 GPA. She reported difficulty falling asleep (initial insomnia) because she "replays every mistake" she made during the day. She has begun skipping meals to study longer, resulting in a 10-pound weight loss over two months.
Elena works part-time (15 hours/week) as a barista. She admitted to drinking 4–5 cups of coffee daily (up from one). She has stopped attending her bi-weekly dance class, stating she "doesn't deserve to have fun" until her grades improve. She denies feelings of depression or hopelessness but describes herself as "wired and terrified."
Elena grew up in a tight-knit, religious household. No history of trauma or abuse. No past psychiatric treatment. Medically, mild asthma, otherwise healthy. Denies illicit drugs or alcohol.
On examination: appeared her stated age, well-groomed but tired with dark circles. Posture tense, fidgeted with ring throughout interview. Speech rapid and pressured but coherent. Affect anxious and labile; tearful when discussing parents. Denied suicidal or homicidal ideation. Thought process logical but focused on themes of failure and perfectionism. Insight partial.
The patient is a 19-year-old Hispanic female college student presenting with a two-month history of intense anxiety described as 'I'm going to explode,' recurrent palpitations and shortness of breath, insomnia with rumination, increased caffeine use, weight loss from skipped meals, and functional changes including stopping dance class and increased academic worry despite a 3.8 GPA. She denies suicidal ideation and has no prior psychiatric treatment or history of trauma.
The diagnosis is Other Specified Anxiety Disorder (working) because the patient has clinically significant anxiety with autonomic panic-like episodes, marked sleep disturbance, ruminative/perfectionistic worry, behavioral change (stopped dance class, skipped meals), and impaired wellbeing, yet symptom duration (~2 months) is shorter than the duration typically required to establish Generalized Anxiety Disorder. The presentation cannot be attributed definitively to a single cause at this time because there is a clear, discrete academic precipitant (a 'C' on a quiz and midterm exams), a marked recent increase in caffeine intake (from one to 4–5 cups daily), and possible asthma-related sympathomimetic exposure to investigate; each of these could plausibly produce or maintain the current symptom complex. Therefore the working diagnosis labels the anxiety syndrome without assigning a single primary etiology pending targeted evaluation.
Differential considerations: Panic Disorder: Supported by reported recurrent palpitations, shortness of breath, and a sense of imminent catastrophe; however current documentation does not clarify whether attacks are objectively unexpected (out of the blue) or consistently cued by academic stressors, nor does it fully document the required acute symptom cluster and time course for definitive diagnosis. Adjustment Disorder with anxiety: Supported by a clear precipitant (poor quiz grade, exam stress) and recent onset; against it is persistence of symptoms after the semester ended and degree of functional change (weight loss, avoidance) that may indicate a developing primary anxiety disorder. Substance/Medication‑Induced Anxiety (caffeine or bronchodilator): Plausible given the reported jump in caffeine intake and history of asthma; evidence is insufficient to confirm temporal sequencing and intoxication/withdrawal characteristics. Generalized Anxiety Disorder: Phenomenologically consistent with pervasive worry and rumination, but DSM-aligned duration threshold is not yet met. Medical causes (thyroid disease, arrhythmia) remain possible contributors to autonomic symptoms and should be investigated; they are not accepted as primary without confirmatory testing.
Recommendations: (1) Clarify phenomenology and timeline: obtain a focused episode inventory (frequency, onset-to-peak time, duration, associated symptoms during discrete events, whether attacks occur unexpectedly or only in academic/performance contexts). (2) Substance/medication assessment: obtain exact caffeine intake (type, cup size, timing relative to episodes), ask specifically about recent changes in asthma rescue inhaler (short-acting beta-agonist) use or other OTC stimulants, and counsel an empirical reduction/cessation of caffeine for 1–2 weeks with close symptom monitoring. (3) Basic medical evaluation to rule out common medical mimics: order thyroid function testing (TSH ± free T4), 12‑lead ECG to screen for arrhythmia, and request primary-care review for the 10-lb weight loss and skipping meals (nutrition assessment). (4) If history suggests frequent albuterol use or other adrenergic medication change, coordinate with the patient's primary care or pulmonology team to review inhaler regimen and consider trials of spacing/reducing bronchodilator use if clinically safe.
Silas Vane is a 29-year-old Caucasian male employed as a journeyman electrician, referred for a "Fitness for Duty" psychiatric evaluation by the Safety Compliance Office of a large industrial contracting firm. Mr. Vane had been employed for three weeks. During his hiring orientation, he appeared charismatic and knowledgeable, presenting a resume detailing extensive experience with high-voltage systems. However, in his short tenure, site foremen reported that Mr. Vane was frequently tardy, often disappeared for long breaks, and refused to wear mandatory protective gear, labeling it "safety theater for wimps."
The referral was precipitated by a critical incident: Mr. Vane allegedly bypassed a safety lockout on a live circuit breaker to finish a job faster, resulting in a minor explosion that singed an apprentice's eyebrows. When confronted, Mr. Vane reportedly laughed and told the apprentice, "That'll teach you to keep your head on a swivel," and blamed the equipment manufacturers for making "over-sensitive junk."
When the project manager attempted to terminate his contract for gross negligence, Mr. Vane immediately threatened legal action. He claimed he suffered from Post-Traumatic Stress Disorder (PTSD) and Intermittent Explosive Disorder, stating that the stress of the job site triggered his condition. He insisted that firing him would be a violation of the Americans with Disabilities Act (ADA) and demanded a forensic evaluation to prove his "disability status" and secure paid leave.
During the evaluation, Mr. Vane spent the majority of the time detailing his intellectual superiority over his supervisors, whom he described as "clipboard warriors who wouldn't know a neutral wire if it strangled them." He has a four-year-old daughter he has never met; he stated he refuses to pay child support because "the kid is probably not mine, and even if she is, I'm not funding her mother's shopping addiction."
A review of school records and juvenile court documents revealed a diagnosis of Conduct Disorder with onset at age 11. He had a history of initiating physical fights, was caught twice setting small fires in neighbors' mailboxes, and was suspended for stealing prescription medications from the school nurse's office. Notably, a school counselor's note described an incident where Silas killed a stray cat.
Mr. Vane admitted to heavy alcohol use, drinking a "12-pack or so" on weekends and "a few shots" before work to "steady the hands." He also admitted to purchasing oxycodone off the street for "old back injuries." A background check revealed that Mr. Vane's electrician license number actually belonged to a retired worker in a different state. He had been fired from two previous jobs: one for stealing copper wire from a job site to sell for scrap, and another for slashing the tires of a foreman who criticized his work. He is currently awaiting trial for an assault charge related to a bar fight, a detail he omitted during the interview.
Mr. Silas Vane is a 29-year-old journeyman electrician referred for a fitness-for-duty evaluation after workplace safety violations culminating in bypassing a lockout that produced a minor explosion injuring an apprentice; he presents with grandiose, antagonistic self-presentation, documented heavy alcohol use, illicit oxycodone purchase, a pattern of past violent and antisocial acts dating to adolescence, and active adversarial motivations to obtain ADA protections/paid leave.
The working formulation is Malingering (with apparent secondary gain) because the patient seeks ADA protections/paid leave while there are marked discrepancies between his claims and objective findings: license fraud, omission of pending assault charge, recent rapid-onset workplace misconduct culminating in a documented safety breach that contrasts with his asserted disability, and multiple indicators of deceptive/adversarial presentation during the evaluation. The vignette documents objective external incentives (explicit demand for forensic evaluation and threat of legal action when termination was attempted) and concrete contradictory evidence (stolen license number, failure to disclose legal history). At the same time, there is documented heavy alcohol use ('12-pack or so' on weekends; 'a few shots' before work) and illicit oxycodone purchase, which plausibly could produce disinhibition or impair judgment; juvenile records and documented adolescent behaviors (physical fights, arson, theft of medications, killing a stray cat) indicate an enduring pattern of conduct problems that may meet criteria for Antisocial Personality Disorder pending confirmation of age-at-onset for conduct disorder and further collateral.
Differential considerations: Antisocial Personality Disorder: Supported by pervasive pattern of deceit, theft, aggression, nonconformity to safety, and lack of remorse across settings from adolescence to adulthood (school suspensions, juvenile court involvement, workplace theft, arson, cruelty to animals, assault). It remains provisional because the vignette does not explicitly timestamp onset before age 15 in every behavior item, though several adolescent behaviors strongly suggest early-onset conduct problems. Substance/Medication-Induced Behavioral Disturbance: Considered because the patient admits drinking before work and buying illicit oxycodone; these exposures could explain acute disinhibition and dangerous workplace behavior, but the vignette lacks contemporaneous toxicology or explicit intoxication signs, so attribution is premature. Opioid Use Disorder: Documented illicit oxycodone purchase raises concern, but DSM-5-TR symptom counts within a 12-month frame are not provided; thus the diagnosis cannot be confirmed from available data. Alcohol Use Disorder: The pattern described (heavy weekend use and drinking before work) indicates hazardous use and occupational risk but is subthreshold in the record for a formal DSM-5-TR diagnosis without additional symptom/timeframe data. PTSD and Intermittent Explosive Disorder: Patient self-reports these labels, but the vignette contains no trauma exposure or the characteristic symptom clusters required to substantiate PTSD, nor does it document the discrete recurrent explosive episodes with requisite frequency/impact for Intermittent Explosive Disorder; these claims therefore appear part of an adversarial presentation until validated by collateral or testing.
Recommendations: (1) Obtain contemporaneous workplace incident reports, witness statements (apprentice, foremen), and any injury/medical documentation related to the lockout bypass event. (2) Order immediate urine toxicology and blood alcohol level (timing permitting) for current evaluation and obtain any prior toxicology records; request consent to query state prescription drug monitoring program for opioid prescriptions. (3) Request juvenile court, school records, and prior psychiatric/therapy records to timestamp onset of conduct behaviors and any prior diagnoses/treatments. (4) Administer standardized symptom-validity and performance-validity tests and structured malingering/forensic assessment instruments as part of the medicolegal evaluation.
Structured diagnostic reasoning walkthroughs grounded in DSM-5-TR and ICD-11 criteria.
Evaluating both diagnoses independently in a patient with mood instability and interpersonal difficulties.
The critical distinction between ego-dystonic obsessions and ego-syntonic perfectionism.
A trauma-informed differential using ICD-11 CPTSD criteria and DSM-5-TR BPD evaluation.
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Diagnoxal