9/4/2025 Diagnosis and assessment

How to understand a person’s experiences and aid in diagnosis

asking questions

Definition of diagnosis

process of identifying and classifying a psychological disorder

• helps guide treatment decisions and consider prognosis

Why do we diagnose?

drawn from a broad scientific approach

• classification is central to all sciences

• diagnosis = categorizing based on shared attributes or relation

• taxonomy: system of scientific classification

Taxonomy for psychopathology

DSM-5-TR

• includes the taxonomy and diagnosis of disorders

• most recently updated in 2013

• has a list of symptoms or diagnostic criteria for each diagnosis

• includes “text” to describe research on disorders (background info on the diagnosis)

• text (TR part) was updated and released on spring 2022

How is the DSM powerful?

massive everyday consequences for every person in the world, e.g.:

• contributes to who enlists in the armed forces

• may determine classroom planning and educational enrollment

• legal contexts: judges, lawyers, and juries consider it in adjudicating and sentencing crimes

• everyday contexts: determines paperwork nurses, doctors, psychologists, and social workers complete each work day

• directs how hundreds of billions of dollars are spent the work force each year, and not just in mental health fields but also government, HR, education, law, pharmacy, and advertising

Story of the DSM

prior to WW2, psychopathology was believed to be extremely rare and debilitating

• throughout WW2, military doctors saw their case loads expand (e.g. soldiers with psychological issues)

• recognized that mental health problems were emerging in “ordinary” people in response to extraordinary circumstances

Development of the first psychopathology taxonomy

William Menninger

• 1 million American soldiers treated for mental health problems during and after WW2

• doctors were asked to treat disorders they had never seen before and head no idea existed

• War Bulletin Medical document 203 provided a synopsis of the types of most common mental health problems seen in medical practice

• postwar: document was adapted for nonmilitary use and became the DSM-1

2 key points about the DSM

1. it’s a categorical taxonomy

   • either an individual meets a set of diagnostic criteria or does not)

2. it is atheoretical

   • classifies poeple based on concrete, observable symptoms…

   • not on etiology, hypotheses, or ideas about those symptoms

   • offers no perspectives on why such disorders may exist

Who creates the DSM today?

committees of experts who have researched and treated different areas of psychopathology

• represent 16 different countries

• fields of psychiatry, psychology, social work, nursing, epidemiology, pediatrics, neurology, speech and hearing specialist

• 13 different work groups from 160 people

• solicited public feedback 3x during writing process

Why is the DSM useful?

• creates a common language for the field

• facilitates communication among professionals, parents, clients, advocates, policy makers

• leads to common treatments for specific disorders

• promotes research on causes, prevalence, consequences

Strengths of the DSM

• attempts to avoid the dogma of theory and inference

• strives to place greatest importance on observable or reportabel behavior

• evolving document that changes as we learn more

  • e.g. Rett’s syndrome was removed when the cause was discovered ← mutation on a particular chromosome

• reliability

Reliability (2 types)

a measure of replicability or “repeatability”

1. inter-rater reliability: different clinicians can agree on a diagnosis if given the same info (moderate to high)

2. test-retest reliability: flexible in allowing for change and remission over time, but a person will receive same diagnosis on Monday vs Wednesday (high)

Alternatives to the DSM

International classification of disease (ICD)

ICD

Taxonomy from WHO

• used to classify all diseases and not just psychopathology

• now in its 11th edition

Differences between the ICD and DSM

rare, but a few examples on differences:

• fewer people would be diagnosed as having PTSD by ICD than DSM (due to differences in degree of impairment required and duration of symptoms)

• difference in alcohol dependence

How do clinicians figure out a diagnosis?

• psychological assessment: comprehensive, systematic process of gathering info about a client

• often begins with a clinical interview (aka a formal review of symptoms, life history, and mental status)

• can be unstructured, semi-structured, or structured (with identical questions asked of each person)

  • ordered in most loose to most rigorous

Domains clinicians are interested in for mental status

• appearance and behavior

• thought processes (how is the individual thinking?)

• mood and affect (is this congruent with the individual’s experiences?)

• intellectual functioning (can the individual adapt to changes to their environment?)

• oriented to time, place, and person

Purpose of testing

built as a supplement to clinical interviews

• can help quantify self-reports or offer additional or new info

• history of psychological testing follows the pattern of history in the field

  • early tests aimed to assess the unconscious (like psychoanalytic theory)

  • tests used today tend to be symptom checklists or performance tests through detailed scientific measurement

Technical name for psychological testing

psychometrics

Psychometrics

scientific measurement of psychological traits, like emotions, cognitions, and behaviors

• offers a way to quantify differences across people

• can build psychological tests that reduce the subjectivity of descriptions like “terrible”

• most psychological tests are standardized, meaning that the administration and scoring are the same for everyone who completes the test

How are tests developed?

tests are norm-referenced

• tests are developed on a large group of ppl, or the standardization sample

• offers understanding of breadth of ways ppl might respond to it

• provides a set of percentiles for scoring test

• e.g. can compare an individual’s report of their anxiety to the average levels reported in a standardization sample (other college students or others seeking treatment for anxiety)

Multi-informant assessment

With client’s consent, assessments can include interviews with other people other than a client

• e.g. past mental health providers, family members, referral sources, etc.

Why don’t we diagnose based on biomarkers?

biomarkers or other susceptibilities doesn’t mean you will develop a condition, and not having biomarkers doesn’t mean you will not develop it

• currently no biomarkers (e.g. blood tests, brain scans, or other physical indicators) that reliably and accurately differentiate someone with a particular disorder from someone who does not have that disorder

Consequences of lack of established biomarkers

contributes to public skepticism of the mental health field

• but not having biomarkers is not unusual across health fields: similar issues seen for allergy tests, chronic pain disorders, migraines, etc.

Dimensionality

many psychopathologists believe diagnoses should be dimensional

• rather than operating along do you have a diagnosis or not (categorical diagnoses), we should rate severity, frequency, and variety of symptoms

Dimensionality pros and cons

would provide a richer view of psychopathology but… it’s also unwieldy and not very practical

• the DSM sometimes makes attempts to offer dimensional specifiers to diagnosis (e.g. noting symptoms are mild, moderate, or severe)

Comorbidity

having more than one psychological disorder at the same time

• very common

• for some disorder, it’s the rule and not the exception

• difficult to understand individual diagnoses

• some people believe dimensionality will help with frequent comorbidity

How can labeling make people feel?

anything from positive (relief) to negative (a shock or blow)

Diagnoses and stigma

part of studying psychopathology is accepting that diagnosis often comes with stigma

• 3 types of stigma linked with it

3 types of stigma associated with psychopathology

1. public

2. structural

3. self

Public stigma

negative and inaccurate stereotypes towrads people with psychopathology

• e.g. dangerous, incompetent, incapable, can control their symptoms

Structural stigma

barriers in policies, institutions, and societal norms that limit opportunities and access to care for individuals with mental health conditions

• disclosing a diagnosis of psychopathology has been linked to discrimination in hiring, housing access, insurance coverage, loan/credit refusal, etc.

• research on psychopathology is also chronically underfunded relative both to other health conditions and to the economic burden of psychopathology

Self stigma

when people with psychopathology come to believe the negative attitudes and messages they fear

• shown to worsen psychological health and response to treatment