Chapter 3: Diagnosis, formulation, and assessment

What is diagnosis?

Procedure for determining the nature and circumstances of diseased conditions

What is the medical model definition of diagnosis?

A medical procedure for determining the “nature and circumstances of a diseased condition”

What is the non-medical model definition of diagnosis?

Seeking the “cause or nature of a problem or situation”

What are the two most prevalent psychiatric diagnostic systems?

DSM-5-TR and ICD-11

What is DSM-5-TR?

• Diagnostic and Statistical Manual of Mental Disorders

• A manual used to classify mental disorders created by an American psychiatric organization

What does “TR” mean in DSM-5-TR?

Text revision with updated wording and clarifications

What is ICD-11?

• International Classification Disease(ICD)

• An international classification system used to identify health conditions worldwide published by World Health Organization

Which diagnostic system must be purchased?

DSM-5-TR

Why are these systems called psychiatric diagnostic systems?

They are mainly developed by medical doctors specializing in mental health

What do DSM and ICD focus on when making diagnoses?

Observable patterns in thinking, emotion, and behavior

Why are DSM and ICD diagnoses considered descriptive?

Because underlying causes of most conditions are still unknown

What assumption of the medical model cannot yet be fully applied?

That disorders can be identified by their internal biological or psychological origins

How does ICD-11 define a disorder?

A clinically significant disturbance in thinking, emotion control, or behavior caused by dysfunction in underlying processes

According to ICD-11, which processes may be involved?

Psychological, biological, or developmental

How does DSM-5-TR define a disorder?

A syndrome involving clinically significant disturbance in mental functioning

Which areas of functioning are emphasized in DSM-5-TR’s definition?

Cognition, emotion, and behavior

Which diagnostic system includes mental, behavioral, and neurodevelopmental disorders as one section?

ICD-11

What does ICD uses to diagnose?

Diagnostic guidelines that includes essential features required to make diagnosis

What is the prototype model that ICD uses?

Diagnostic guidelines that are written broadly, describe essential features, and rely heavily on clinical judgment rather than strict symptom checklists.

What does ICD uses to diagnose?

Diagnostic criteria, a symptom lists that is stricter and discourage clinical judgement

What is the algorithmic model used by the DSM?

Uses strict, step-by-step criteria where a required number of symptoms must be met to assign a diagnosis.

What is the key difference between ICD-11 and DSM-5-TR in diagnosing GAD?

One emphasizes flexible guidelines and resemblance, while the other requires strict symptom thresholds and timelines

What is the diagnostic code that ICD diagnostic category has and created?

An alphanumeric key assigned to disorder categories for record keeping

How is ICD diagnostic codes best appropriated?

By DSM that allows harmonization of each others(similar to each other)

What does interrater reliability means for a diagnostic category?

When different raters using the same criteria or guidelines reach the same diagnosis much of the time

What is DSM reliability limits?

• It is good on diagnosing categories like post traumatic stress disorder, schizophrenia, autism spectrum disorder

• Poor reliability on major depressions and generalized anxiety disorders

Even when disorders have good diagnostic reliability, what is the problem that rises?

Comorbidity, the multiple disorders co-occuring or being diagnosed at the same time

• Boundaries between disorders often remain fuzzy, validity is not solid

What are the criteria for valid diagnosis?

1. Course of illness(syndrome)

2. Genetics of Family Studies

3. Laboratory Studies

4. Delimiting this one disorder from another(separation diagnosis)

5. Follow-up and Treatment Effects

What are the advantages of DSM and ICD?

• Both share common language for professionals

• Helps people get treatment

• Advances scientific understanding

What is the disadvantage of DSM and ICD?

• Poor reliability and validity

• Medicalize problems and leads to overuse of medications

• Does not explain etiology

• More political than scientific

In trends and future of ICD and DSM, where this moves towards to?

Move toward dimensional diagnosis

• Disorders are still categorized, but severity is rated along continua

• Acknowledges symptoms occur in degrees, not strict boxes

• Uses levels (mild, moderate, severe) to capture variation within one diagnosis

What are the 3 alternatives to DSM and ICD?

• Psychodynamic Diagnostic Manual(PDM)

• Research Domain Criteria(RDoC)

• Hierarchical Taxonomy of Psychopathology(HiTOP)

• Power Threat Meaning Framework(PTMF)

What is Psychodynamic Diagnostic Manual(PDM)?

Overtly theoretical diagnosis that is used by APA

What is the P-axis of PDM?

Personality syndrome, that is used to map healthy and disordered personality functioning

• Personality patterns & level of organization

What does the clinicians dimensionally asses when using the P-axis?

Assess the patient’s level of personality organizations from healthy(9-10) to psychotic(1-2)

What is the PDM’s M-Axis?

Profile of Mental Functioning, that is used to assess mental functioning in:

• Cognitive and emotional processes, identity and relationships, defenses and coping and self-awareness and self-direction

What the PDM’s S-axis?

Subjective Experience, places common symptoms patterns into diagnostic categories

• Takes DSM disorders and describes them

What is the Research Domain Criteria(RDoC)?

NIMH research that uses biological measures rather than observable behaviours to diagnose mental disorders

What are the six domains of RDoC?

• Negative valence systems(fear, anxiety, threat, loss, and frustration)

• Positive valence systems(response to rewards, learning, and habit creation)

• Cognitive System(attention, perception, memory, and language skills)

• Social process(emphasizing development of attachment, social communication skills, and understandings of self and others)

• Arousal and regulatory systems (concerned with arousal, emotional regulation, and sleep-wake cycles);

• Sensorimotor systems (oversee motor behavior and its development).Social processes(emphasizing

What is the critiques about the RDoC?

• Poetical for neuro reductionism

• Overemphasis on biological unit, not factoring economically

What is Hierarchical Taxonomy of Psychopathology(HiTOP?

• Dimensional by plotting pathology along dimensions of severity rather than categorical

• Hierarchical in that its dimensions are divided across different levels

What does dimensions at the top of hierarchy offers on HiTOP?

More general assessments of pathology like social anxiety broadly defined

What does dimensions at the lower hierarchy offers on HiTOP?

Measures distinct ways the higher-level dimensions manifest like performance anxiety or social interaction concerns

What higher and lower-level dimension that are strongly correlated is linked to?

In the hierarchy because they measure overlapping aspects of an area of mental functioning

What is at the top of the hierarchy is called?

Superspectrum level that contains just a single dimension

What is the superspectrum level single dimension is called?

The general dimension of psychopathology that represents “dysfunction, distress, or demoralization common to all forms of mental disorders”

What is below the super spectrum is called?

The spectra level, that consists six basic dimensions of psychopathology

Wha are the six basic dimensions of psychopathology?

• Internalizing(or negative affectivity) spectrum

• Thought disorder spectrum

• Disinhibited externalizing spectrum

• Antagonistic externalizing spectrum

• Detachment spectrum

• Somatoform spectrum

What is HiTOP advantage?

• Captures psychopathology on dimensions, not rigid categories

• Reflects symptom overlap (comorbidity) more accurately

• Represents severity on continua, matching real clinical variation

• Improves research precision by grouping related symptoms

What is HiTOP disadvantages?

• Less practical for clinical diagnosis than DSM/ICD

• Not widely used in everyday clinical settings

• Lacks clear diagnostic cutoffs for treatment and insurance

• More complex and harder to apply quickly in practice

What is Power Threat Meaning Framework(PTMF)?

An alternative non diagnostic conceptual system that is developed by BPS that attributes distress to economic and social injustice, not individual disorders

What the three intertwined concepts of the PTMF?

• Power: what happened to clients

• Threat: focuses on people’s responses to how power impacts them

• Meaning: concern itself with how people make sense of what happens to them

What is formulation?

A hypothesis about a person’s difficulties, which draws from psychological theory

What is conceptualize is formulation?

When practitioner uses concepts from one of these perspectives to conceptualize what is happening with a client and then uses this conceptualization to plan what to do about it

• Not diagnosis

What is integrative evidence-based case formulation?

Four-step model of formulation:

1. Create a problem

2. Make a diagnosis

3. Develop an explanatory hypothesis

4. Plan treatment

What is the 4P model of case formulation

Clinicians gather information about four areas:

1. Preconditions: What preconditions made the client vulnerable to the current presenting problem?

2. Precipitating factors: What events or factors triggered the current problem

3. Perpetuating factors: What factors maintain the problem and prevent it from being solved?

4. Protective factors: What factors have prevented the problem from being worse?

Formulation instead of or in combination with diagnosis?

Formulation focuses on individualized understanding, while diagnosis aids communication and treatment; in practice, they are often used together.

What is an assessment?

Gathering information to understand a person’s difficulties

What is standardization that is involved in assessment?

Clearly defined rules for how to administer and interpret a test instrument are developed

What is a clinical interview?

Clinician talks to client to gather information about the presenting problem

What is an unstructured interview?

The clinician asks the client open-ended questions because there is no script

What is structured interview?

Clinician empoys a clear set of same questions

What is semi-structured interview?

Clinicians still have some flexibility in how they respond.

What is high structured interview?

Follow a fixed set of questions and are administered verbally like a questionnaire.

What is mental status exam?

Structured interview that assess current mental status by cognitive, behavioural, physical functioning

What is Structured Clinical Interview for DSM disorders(SCID)?

Semistructured interview for making DSM diagnoses

What is the personality test?

Measures emotions, interpersonal relationship patterns, levels of motivation, and interest, and attitudes

What is the objective test?

Uses standardized items with limited response choices. self-report personality inventories are objective tests

What is the Minnesota Multiphase Personality Inventory(MMPI)?

A self-report personality inventory that assesses consists of statements to which respondents answer “true”, “false”, or “cannot say”

How many clinical scales on MMPI-2 are there?

Ten

• hypochondriasis, depression, hysteria, psychopathic deviate, masculinity femininity, paranoia, psychasthenia, schizophrenia, mania, and social introversion

How many clinical scales on MMPI-2-RF are there?

Nine

How many clinical scales are there on MMPI-3?

Eight

• demoralization (general unhappiness), somatic complaints, low positive emotions, antisocial behavior, ideas of persecution, dysfunctional negative emotions, aberrant experiences, and hypomanic activation

What do MMPI-2-RF and MMPI-3 lacks?

Discriminant validity by overlapping with one another too much

What the Sixteen Personality Factor(16PF) Questionnaire?

Multiple-choice self-report personality inventory yielding scores on sixteen primary personality factors

What is Beck Depression Inventory(BDI)?

Assess an aspect of functioning rather than the entire personality

• A 21-item self-administered inventory for measuring depression

What is the projective test?

Uses responses to artistic representation to infer aspects of psychological functioning that has open-minded responses

What is the Rorschach inklblot method?

Projective assessment technique in which test-taker responds to ten inkblots

What is Exner’s Comprehensive System (CS)?

An older, standardized way to give and score the Rorschach using norms to compare responses across diagnostic groups.

What is the Rorschach Performance Assessment System (R-PAS)?

A newer, improved system for giving and scoring the Rorschach that uses updated research and norms for better accuracy.

What is Thematic Apperception Test(TAT)?

Projective assessment technique in which test-taker tells stories about pictures on twenty cards(determined by age and gender)

What is behavioural assessment?

Focuses on identifying conditions in the environment that sustain undesirable behaviours

What is the functional analysis?

Consists of judgments about relationships between environmental conditions and client behavior, along with estimates of how these relationships might be modified

What is the ABC recording?

Involves directly observing and recording client behaviours(B) while writing down their antecedents(what comes before them, or “A”), and their consequences(what comes after them, or “C”)

What is the cognitive assessment?

Measures evaluate client’s ways of thinking to assess self-efficacy

What is self-efficacy?

Cognitive estimates of how likely they are to succeed in performing tasks

What the two cognitive assessments?

Beck Depression Inventory(BDI) and Daily Record of Dysfunctional Thoughts(DRDT)

What is Daily Record of Dysfunctional Thoughts(BDI)?

Form with five columns that client records the situation, any accompanying emotions automatic thoughts the situation triggers, a more rational response, and the outcome of the situation

What is the humanistic assessment?

Focus on the underlying meanings that clients assign to their symptoms, with an emphasis on using everyday_(rather than diagnostic) language to describe client problems.

What is Q-sort?

Person-centered assessment in which 100 cards with descriptors written on them are sorted into piles to describe client personality usina evervday lanquaae.

What is the Role construct repertory test(rep test)?

A personality test that identifies a client’s own bipolar meanings and maps how they relate, allowing assessment based on the client’s personal views rather than the clinician’s diagnostic categories.

What is the intelligence test?

Used to calculate intelligence Quotient

• Intelligence is not the same as achievement

How intelligence is calculated?

Dividing mental age (performance score on an intelligence test) by chronological age (how old you are) and multiplying the result by 100.

What is neuropsychological tests?

Psychological tests used to evaluate perceptual, cognitive, and motor skills; often used to infer underlying brain dysfunction.

What is the neurological tests?

A neuropsychological test consisting of nine cards with geometrical designs printed on them. Test-takers are asked to examine the designs and then draw them from memory.

What the Bender Visual Motor Gestalt Test?

A neuropsychological test consisting of nine cards with geometrical designs printed on them. Test-takers are asked to examine the designs and then draw them from memory.

What are the two examples of neuropsychological test batteries?

Halstead-Reitan Neuropsychological Test Battery(HRB) and Luria-Nebraska NEuropsychological Battery

What is the Halstead-Reitan Neuropsychological Test Battery (HRB)?

A set of brain tests that check how well a person sees, hears, feels, talks, moves, pays attention, remembers, and understands information.

What is the Luria-Nebraska Neuropsychological Battery(LNNB)?

A group of brain tests that measure skills like reading, writing, math, memory, language, and movement.

What is the Positron emission topography (PET scan)

Neuroimaging technique in which radioactive isotopes are placed in the bloodstream and gamma rays used to generate images reflecting changes in cerebral blood flow; identifies brain areas active during a given task.

What is the Magnetic resonance imaging (MRI)?

Neuroimaging technique that creates an x-ray-like picture of the brain using the magnetic activity of hydrogen atoms; one kind, the MRI (functional MRI), tracks oxygen levels in the brain's hemoglobin, allowing assessment of blood flow in various brain areas while the person is thinking, feeling, or completing a task.