Module 2

Clinical Assessment

The systematic evaluation and measurement of psychological, biological, and social factors to answer a clinical question and lead to diagnosis

Signs

An observable trait or behaviour indicative of illness (e.g., tremors).

Symptom

A subjective experience reported by the individual that cannot be directly observed by others (e.g., fatigue).

Assessment Process

Described as both deductive (narrowing down possibilities like a funnel) and iterative (circular, repetitive refinement).

Clinical Interview

A focused and purposeful conversation used to establish rapport, gather information, and test hypotheses. It can be structured, semi-structured, or unstructured.

Mental Status Exam (MSE)

A system for organizing observations made during an interview, providing a "snapshot" of current function (e.g., appearance, mood, cognition).

Functional Assessment

Observation focused on the function of behaviour by analyzing the Antecedent, Behaviour, and Consequence (e.g., Behavior is maintained by Escape, Attention, or Tangibles).

Psychological Testing

Standardized processes to quantify traits or abilities (e.g., IQ, personality) by comparing results to norms to determine if a trait is "unusual".

Diagnose

To recognize a disease/condition by signs and symptoms, classify it, or analyze the cause or nature of a problem.

Disease Model Assumption

Effective treatment depends on accurate classification of the underlying disease.

Why Classify?

To ensure treatment efficacy, collect data for health service planning, track disorder incidence, and control variables for research.

DSM

"Diagnostic and Statistical Manual of Mental Disorders," published by the APA, used mostly in North America, covering only mental illnesses.

ICD

"International Classification of Diseases," published by WHO, used outside of North America, covering all diseases.

Reliability

The degree to which an instrument (or diagnostic system) provides the same measurement when used repeatedly (e.g., Interrater Reliability).

Validity

The degree to which an instrument measures what it claims to measure.

Porous Boundaries

The realization that boundaries between disorders are more blurry than originally thought.

The Dichotomy Dilemma

Classification systems require symptoms to be categorized as either present or absent, creating a false dichotomy because most signs and symptoms vary along a continuum.

Clinical Cutoff

The operational definition of an "unusual" or "extreme" characteristic, often defined as 2 Standard Deviations from the mean or the >95th percentile

RDoC

Research Domain Criteria, developed by NIMH, that describes mental illness as the combined output of multiple psychological/biological systems (Domains of Function) and is not for clinical purposes.

RDoC Domains

Includes Negative Valence, Positive Valence, Cognitive, Social Processes, Arousal/Regulatory, and Sensorimotor Systems.

Etiology

The cause or origin of a mental disorder, including biological, psychological, and social factors that contribute to its development.

Threshold

The level of symptom severity or impairment needed for a diagnosis; when symptoms exceed the threshold, they become clinically significant.

Comorbidity

The co-occurrence of two or more disorders in the same individual (e.g., depression and anxiety).

Sign

An objective, observable indicator of a disorder noted by a clinician (e.g., flat affect, tremors, agitation).

Symptom

A subjective experience reported by the patient (e.g., "I feel sad," "I hear voices").

Clinical Cutoff

A score or point on a test or scale that separates normal functioning from clinical levels of disorder.

Percentile

A statistical measure showing how an individual's score compares to others; for example, being in the 70th percentile means performing better than 70% of people.

Pathogenesis

The biological or psychological process by which a disorder develops from its initial cause to its full manifestation.

Morphology

The structure or form of an organ, brain region, or body part; in psychopathology, it can refer to structural brain abnormalities.

Symptomatology

The set or pattern of symptoms associated with a particular disorder (e.g., the symptomatology of major depression includes sadness, fatigue, and loss of interest).

False Positive

A test incorrectly indicates a disorder when there isn't one.

False Negative

A test incorrectly shows no disorder when one actually exists.

Drapetomania

A historically false psychiatric diagnosis used in the 19th century to pathologize enslaved people who tried to escape slavery — now cited as an example of cultural and ethical bias in diagnosis.

EEG (Electroencephalogram)

A test that measures electrical activity in the brain through electrodes on the scalp; used to detect abnormalities like seizures or sleep issues.

IQ (Intelligence Quotient)

A measure of cognitive ability compared to age-based norms; average IQ = 100, with standard deviation = 15.

MSE (Mental Status Examination)

A structured assessment of a patient's appearance, behavior, mood, thought process, cognition, and insight — used in clinical interviews.

MMPI (Minnesota Multiphasic Personality Inventory)

A widely used personality and psychopathology assessment tool that measures traits and symptoms to help diagnose mental disorders.

DSM (Diagnostic and Statistical Manual of Mental Disorders)

Published by the American Psychiatric Association, it provides standardized criteria and classifications for diagnosing mental disorders (currently DSM-5-TR).

ICD (International Classification of Diseases)

Published by the World Health Organization (WHO); it classifies all diseases, including mental and behavioral disorders (ICD-11).

Reactivity (in relation to assessment)

When a person's behavior changes because they know they are being observed or tested — can affect assessment validity.

Neuropsychological Testing

A set of standardized tests designed to measure brain function through behavior (e.g., memory, attention, language, problem-solving). Used to detect brain injury or neurological disorders.

Iterative

A process that is repeated and refined multiple times to improve accuracy or understanding — often used in diagnostic assessments or research design.

Norms

Average scores or standards derived from a large population, used as a comparison to interpret individual test results.

Nomenclature

The system of naming used to classify disorders or symptoms (e.g., naming conditions in the DSM).

Personality Inventory

A questionnaire assessing personality traits and patterns, often used to identify maladaptive characteristics or disorders (e.g., MMPI, NEO-PI).

Nosology

The classification system of diseases or disorders — the organized framework of how illnesses are categorized.

Taxonomy

The scientific system of classifying and organizing things (like mental disorders) into groups based on shared characteristics.

Validity

The accuracy of a test or measure — whether it truly assesses what it claims to measure (e.g., does a depression scale actually measure depression?).

Reliability

The consistency of a measure — whether results are stable and repeatable across time, situations, or raters.

Standardization

The process of administering and scoring tests in a consistent way, ensuring fairness and comparability across individuals.