The challenge of accurate diagnosis remains at the heart of good psychiatric treatment. In the current state of psychiatry, a confluence of forces has increased this challenge for the clinician. These include practical pressures-such as limited time for diagnostic evaluation, the question of what is reimbursed by insurance, and the issue of directing patients to acute treatments-and also trends in nosology, such as the descriptive focus on signs and symptoms in the current official diagnostic system. The authors offer observations that we hope will help clinicians who have to make difficult diagnostic differentiations often under pressured circumstances. The paper is motivated both by the high frequency of diagnostic errors observed under such conditions and also by the belief that considering symptoms in the context of the patient's sense of self, quality of interpersonal relations, and level of functioning over time will help guide the diagnostic process.