Assessing Psychological Disorders (chapter 3)
Learning Objectives
L03.1 Define clinical assessment in terms of the goals of assessment and key components of high-quality assessments.
L03.2 Discuss how projective tests, personality inventories, and intelligence testing are used to determine a person's mental functioning.
L03.3 Explain the benefits of administering neuropsychological testing, neuroimaging, and psychophysiological assessment to individuals with psychological disorders.
L03.4 Describe the strengths and weaknesses of categorical, dimensional, and prototypical approaches to classifying mental disorders.
Assessing Psychological Disorders
Clinical assessment: systematic evaluation and measurement of psychological, biological, and social factors in an individual presenting with a possible psychological disorder.
Diagnosis: process of determining whether the individual's problems meet all criteria for a psychological disorder, as defined in DSM-5 (American Psychiatric Association, 2013).
DSM-5/DSM-5-TR: classification system used to identify disorders; DSM-5-TR is the 2022 text revision.
Chapter focus: assessment and diagnosis within a real case, development of DSM into a widely used classification system, and the array of assessment techniques clinicians use.
Key Concepts in Assessment
The assessment process has been likened to a funnel: start broad, then narrow to the most relevant areas.
Three core concepts determine the value of assessments:
reliability: consistency of measurement
validity: whether the tool measures what it is designed to measure
standardization: applying norms and standardized procedures to ensure consistency across measurements
Important components of clinical assessment include:
clinical interview and mental status exam (formal or informal)
medical examination when needed
behavioral observation and assessment
psychological tests (if needed)
The Clinical Interview
Core method used by psychologists, psychiatrists, and other mental health professionals.
Gathers information on current/past behavior, attitudes, emotions, and life history related to the presenting problem.
Clinicians determine when the problem started and identify life events (stress, trauma, illness) that may have occurred around the same time.
Information on interpersonal/social history, family background, upbringing, sexual development, religious attitudes, cultural concerns, and educational history is routinely collected.
Organization of information via a mental status exam (MSE).
The Mental Status Exam (MSE)
A systematic observation of an individual's behavior, often performed quickly during interviewing.
Five categories (as summarized by the notes on Frank):
Appearance and behavior: overt behavior, attire, posture, facial expressions; examples include psychomotor retardation.
Thought processes: rate and continuity of speech; content; possibility of delusions or ideas of reference; hallucinations (assessed via routine questions).
Mood and affect: predominant feeling state (mood) and the affect accompanying statements (appropriate vs. inappropriate, blunted/flat).
Intellectual functioning: rough estimate of vocabulary, abstractions, memory, general intelligence.
Sensorium: awareness of surroundings (person, place, time); oriented to person/place/time.
In Frank’s case, the MSE revealed persistent motor behavior (twitch), appropriate appearance, reasonable speech, anxious mood, normal intelligence, and orientation; these guided further assessment toward OCD.
The MSE contributes to preliminary disorder hypotheses and directs subsequent diagnostic activities.
The Clinical Interview: Confidentiality and Trust
Information gathered is protected by confidentiality (privileged communication) in most states.
Exceptions: risk of harm to patient or others may warrant disclosure.
Clinicians must inform patients about confidentiality and its limits at the outset of the interview.
Real-world example: cases where sensitive information emerges late in treatment, underscoring the limits of confidentiality and the need for trust.
Semistructured Clinical Interviews
Unstructured interviews vary across clinicians; semistructured interviews use carefully phrased questions to elicit consistent information across patients.
Advantages: standardized queries improve reliability and ensure coverage of important disorder-specific aspects.
Disadvantages: reduces spontaneous dialogue, may miss information not addressed by the structured questions.
Fully structured interviews administered by computer are not widely adopted, though some settings use them.
Example: Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5) (Brown & Barlow, 2014).
First asks about bothersome thoughts/images/impulses (obsessions) or repetitive behaviors/thoughts (compulsions).
Uses a 9-point rating scale (0 = never to 8 = constantly) for obsessions (Persistence/Distress and Resistance) and for compulsions (Frequency).
Obsessions examples: 1) Doubting, 2) Contamination, 3) Nonsensical urges, 4) Aggressive urges, 5) Unwanted sexual thoughts/images, 6) Unwanted religious thoughts/images, 7) Accidental harm, 8) Horrific images, 9) Nonsensical thoughts/images, 10) Other; Compulsions examples: 1) Checking, 2) Washing, 3) Counting, 4) Internal repetition, 5) Adhering to rules, 6-7) Other.
Table 3.1 (ADIS-5) provides sample questions and the specifics of how to rate persistence, distress, resistance, and frequency.
Physical Examination
Often the first contact is with a primary care physician; a physical exam may be recommended if a year has passed since the last one.
Medical conditions or substances can mimic or influence psychological symptoms (e.g., hyperthyroidism with GAD symptoms; hypothyroidism with depression).
The clinician must determine whether a medical condition or substance use is causal or coexisting with the mental disorder.
Example: depression with concurrent hypothyroidism or sedation; substance-induced mood disorder if mood symptoms align with substance use and remit with cessation.
Behavioral Assessment
Extends the MSE by using direct observation of thoughts, feelings, and behaviors in specific contexts.
Especially useful for children or individuals unable to report their experiences.
Methods include home/workplace observations, analogue environments (simulated situations), or role-plays.
Example: autism spectrum disorder studies using analogue settings to assess social behaviors and plan treatment.
Hypothetical/novel methods: hypnosis-based analogue assessments and neuroimaging-based analogue simulations.
ABCs of Observation (Antecedents-Behavior-Consequence): beneficial for identifying patterns and designing targeted interventions.
Self-monitoring (self-observation): clients record occurrences of target behaviors (e.g., cigarettes smoked, triggers) to facilitate change; technology and smartphones increasingly used.
Behavior checklists and rating scales (e.g., Brief Psychiatric Rating Scale, 7-point scale 0-6) used pre- and post-treatment to measure change.
Reactivity: observer presence can alter behavior; self-monitoring can also influence behavior (e.g., increasing talking in class when monitored).
Psychological Testing
Tests are designed to be reliable and valid; most tests are not entertainment or casual measures but tools for cognitive, emotional, or behavioral assessment.
Major test types include:
Projective testing: ambiguous stimuli elicit projection of unconscious processes (Rorschach, TAT, sentence-completion).
Personality inventories: self-report questionnaires assessing traits; emphasis on predictive validity (Meehl, 1945).
Intelligence testing: measures cognitive abilities to predict academic performance and related outcomes.
Neuropsychological testing: assesses brain function and structure to infer brain dysfunction.
Neuroimaging: imaging brain structure/function; includes CT, MRI, PET, SPECT, fMRI.
Psychophysiological assessment: measures nervous system changes related to emotional/psychological events (EEG, ERP, GSR).
Projective Testing
Rooted in psychoanalytic theory; tests rely on ambiguous stimuli to reveal unconscious aspects through responses.
Common measures:
Rorschach Inkblot Test: 10 inkblots; standardized administration and scoring through Exner’s Comprehensive System; controversy over reliability/validity; newer standardized systems exist (R-PAS).
Thematic Apperception Test (TAT): 30 (often 20 used) cards; patients tell stories about pictures; used to infer motives, conflicts, and personality dynamics.
Problems: while historically influential, projective tests have limited reliability/validity as diagnostic tools; often used as icebreakers or for therapeutic rapport rather than definitive diagnosis.
Key historical points: Exner’s Comprehensive System (2003) and Rorschach Performance Assessment System (Meyer & Eblin, 2012); ongoing debate about validity.
The Minnesota Multiphasic Personality Inventory (MMPI)
MMPI-2 (567 items) and MMPI-2-RF are empirically-based personality inventories used to identify patterns suggestive of specific disorders.
Administration: true/false format; no straightforward item-by-item interpretation; rely on patterns across scales.
Primary scales: Validity scales (to detect response bias) and Clinical Scales (e.g., Hypochondriasis, Depression, Hysteria, Paranoia, Schizophrenia, etc.).
Common validity scales include: Cannot Say (CNS), Variable Response Inconsistency (VRIN), True Response Inconsistency (TRIN), Infrequency (F and Fp), Lie (L), Correction (K), and Symptom Validity (FBS).
MMPI-2-RF emphasizes a dimensional view of impairment rather than a yes/no disorder diagnosis.
Reliability and validity: high when administered with standardized procedures; criticisms include potential misuse or misinterpretation; some studies question whether MMPI-based diagnoses improve treatment outcomes.
Example: a case profile (James S.) showed high validity scale scores and a high psychopathic deviation score, suggesting aggressive/antisocial tendencies and potential deception in testing.
Historical context: original MMPI items were revised due to cultural and gender bias; MMPI-2 updated normative samples (1980 Census-based) and added items addressing modern issues.
Practical note: clinicians use computer scoring and interpretation to reduce reliability concerns.
Intelligence Testing
Purpose: originally to predict academic success; measures involve reasoning, memory, attention, verbal comprehension, and processing.
Key tests:
Stanford-Binet (Stanford-Binet 5): uses deviation IQ; compares performance to same-age peers rather than using mental age for all ages.
Wechsler Scales: WAIS-IV (adults), WISC-V (children), WPPSI-IV (preschool); include verbal and performance (nonverbal) scales; provide full cognitive profile.
IQ vs. intelligence: IQ is a relative score used for educational placement; intelligence is a broader construct that includes adaptation, creativity, problem-solving, and information processing.
Limitations: language differences, cultural factors, and test-taking experience can influence scores; IQ is reliable and generally valid for predicting academic outcomes but does not capture all forms of intelligence or real-world functioning.
Neuropsychological Testing
Purpose: to pinpoint brain dysfunction by measuring cognitive abilities and observing performance on tasks requiring language, attention, memory, motor skills, learning, and abstraction.
Common screens and batteries:
Bender Visual-Motor Gestalt Test: simple screening using line-copying tasks; detects potential brain dysfunction in children; not precise for location.
Luria-Nebraska Neuropsychological Battery; Halstead-Reitan Neuropsychological Battery: comprehensive batteries for adolescents and adults; assess multiple domains with diverse tasks (e.g., rhythm perception, grip strength, tactile tasks).
Validity and reliability: higher reliability and validity when used as screening tools in conjunction with other assessments; risks include false positives/negatives.
Practical considerations: neuropsychological testing can be time-consuming; used when neurodevelopmental or learning disorders are suspected.
Neuroimaging: Pictures of the Brain
Rationale: visualize brain structure and function to identify abnormalities linked to psychological disorders.
Structural imaging:
CT (CAT) scans: X-ray-based; identify tumors, injuries, structural abnormalities; relatively quick; involves radiation exposure.
MRI: high-resolution images using magnetic fields; distinguishes tissue variations; newer MRI variants reduce time; potential claustrophobia issues.
Functional imaging:
PET: uses radioactive tracers to measure metabolic activity; detects “hot spots” of glucose/blood flow; provides data on brain function; expensive and requires stillness for accurate imaging.
SPECT: similar to PET but uses different tracers; cheaper and more accessible; somewhat less accurate.
fMRI (BOLD-fMRI): measures blood-oxygen-level-dependent changes to infer brain activity in real time; increasingly preferred due to temporal/ spatial resolution and noninvasiveness.
Emerging neuroscience: neuroreceptor imaging (radiolabeled ligands) to study receptor-level activity; potential for more precise mapping of neurochemical processes.
Large-scale initiatives: NIH Human Connectome Project and ENIGMA Consortium aim to map brain connectivity and genetics to understand brain-behavior relationships across disorders.
Practical notes: neuroimaging information should be integrated with clinical evidence; imaging is rarely diagnostic by itself but can inform treatment planning and understanding of etiology.
Psychophysiological Assessment
Measures nervous system changes linked to emotional/psychological events; data can be collected from brain and peripheral systems.
Examples:
EEG: measures electrical activity of the brain; alpha waves associated with relaxed wakefulness; delta waves linked to deep sleep; ERP/evoked potentials reveal brain responses to stimuli.
GSR (galvanic skin response): measures sweat gland activity as an index of arousal.
Heart rate, respiration, and other autonomic indicators; used in contexts like PTSD, sexual functioning studies, headaches, and hypertension.
Applications: biofeedback uses real-time physiological data to teach self-regulation of bodily responses.
Limitations: requires specialized skill; results can be variable due to procedural factors.
The ABCs of Observation
Observational assessment focuses on the here-and-now and the sequence of events: Antecedents, Behavior, Consequences (ABC).
Example: in the violent boy case, antecedent was mother asking to put glass away; behavior was throwing the glass; consequence was lack of reprimand; patterns can suggest reinforcement maintaining the behavior.
Formal observation uses operational definitions to ensure target behaviors are observable and measurable; observers record each occurrence with antecedent and consequence for pattern detection.
Self-monitoring: individuals record their own behavior to reveal patterns and triggers (e.g., smoking times/locations).
Reactivity: the mere act of observation can alter behavior; reactivity can complicate data interpretation.
Diagnosing Psychological Disorders
Diagnostics combine idiographic (individualized) and nomothetic (generalized) approaches:
Idiographic: tailor understanding and treatment to the individual’s unique personality, culture, and circumstances.
Nomothetic: use accumulated knowledge about a disorder to inform prognosis and treatment; derive general classifications.
Diagnosis definition: identification of a specific psychological disorder based on symptom patterns and impairment.
Nosology: the system of classifying disorders; includes taxonomy, nomenclature, and the DSM/ ICD frameworks.
DSM-5: current primary nosology in the U.S.; DSM-5-TR is the 2022 text revision; ICD-10 is the World Health Organization counterpart.
Diagnostic reliability and validity: critical for credible classification; reliability concerns can lead to bias if clinicians disagree; validity concerns relate to whether criteria truly capture the disorder.
Comorbidity: common overlap of multiple disorders within the same individual; demonstrates the fuzzy boundaries of categories.
Labeling and stigma: diagnoses can stigmatize; the language used should avoid equating the person with the disorder.
Classification Issues and Approaches
Three main approaches to classification:
Classical (pure) categorical: each disorder has a clear underlying cause; disorders are discrete and non-overlapping.
Dimensional: disorders are described along continua (severity, frequency, intensity) rather than as categories.
Prototypical: combines essential features with nonessential variations; resembles real-world categories but with some fuzziness at boundaries.
Evolution of the DSM/ nosology:
Kraepelin’s classic approach influenced early biology-based categorization (e.g., dementia praecox, manic-depressive psychosis).
DSM-III (1980) shifted to atheoretical, highly reliable criteria focused on clinical presentation; DSM-III-R, DSM-IV, and ICD-10 followed.
DSM-5 (2013) maintained much of DSM-IV structure while incorporating dimensional and cross-cutting symptom measures; DSM-5-TR (2022) adds updates like prolonged grief disorder.
ICD-10-CM codes are used globally alongside DSM for compatibility and billing.
Cross-cutting and dimensional measures in DSM-5:
Cross-cutting symptom measures assess common symptoms (e.g., anxiety, depression, sleep problems) across disorders to monitor treatment response.
Dimensional severity ratings (0-4 scale) accompany categorical diagnoses to aid treatment planning and monitoring.
Cultural formulation: DSM-5 emphasizes cultural context, involving the patient’s cultural reference group, language, beliefs about illness, and social supports; the DSM-5 Cultural Formulation Interview provides a structured approach to these questions.
Criticisms and Considerations in DSM-5 and Nosology
Comorbidity remains prevalent; the boundaries between disorders are fuzzy, raising concerns about diagnostic reliability and usefulness for treatment specificity.
Emphasis on reliability can come at the expense of validity if categories become overly rigid or simplistic.
Labeling and stigma persist; the language used in diagnosis can influence self-perception and life opportunities.
Historical evolution shows that classifications are influenced by societal attitudes and public policy (e.g., homosexuality was once listed as a psychiatric disorder and later removed; PMDD was debated before incorporation).
PMDD (Premenstrual Dysphoric Disorder): debated for years due to concerns about normalcy, stigma, and symptom timing; ultimately included in DSM-5 within the mood disorders chapter.
The future of nosology may move toward dimensional or spectrum models that better reflect shared features across disorders and neurobiological underpinnings, though full adoption requires more data.
Cultural and Contextual Considerations in Diagnosis
DSM-5-TR and DSM-5 integrate cultural considerations through cultural formulation and questions about language, cultural exposure, and supports.
The guidelines acknowledge that disabilities and distress are culturally interpreted and that some behaviors may be considered normal in one culture and abnormal in another.
Cautions: avoid over-pathologizing culturally sanctioned behaviors or natural variations in mood and behavior.
PMDD and Other Controversies in Classification
PMDD: evolution from LLPDD (late luteal phase dysphoric disorder) to PMDD in DSM-IV/ DSM-5; research supports existence but debates continue about prevalence, overlap with mood disorders, and treatment implications.
Broader controversies: pathologizing normal experiences (e.g., grief, menstruation-related symptoms); balancing research advance with caution about over-diagnosis and medicalization.
Beyond DSM-5: Dimensions and Spectra
The field is exploring dimensional approaches and spectra to supplement discrete diagnoses.
Personality disorders may reflect maladaptive extremes of normal traits rather than discrete categories; genetic and biological data often support dimensional views.
Anxiety and mood disorders may be conceptualized along a negative affect continuum rather than as isolated categories.
Neurobiological findings increasingly point to patterns of cognitive/affective processing that cut across traditional categories, suggesting integration of biological data with psychological and social information.
Concept Check 3.1 (Recap of Mental Status Categories) — Practice
Part A: Identify which MSE component is described in scenario items (e.g., speech rate, thought content, orientation).
Part B: Determine reliability (R) and validity (V) judgments for various tests (e.g., EEG, Rorschach, structured vs. open-ended interviews).
Concept Check 3.2 (True/False Diagnosing Statements) — Practice
Statements address distinctions among: classical vs. prototypical approaches; DSM-5 distinctions on organically vs. psychologically based disorders; comorbidity; diagnostic validity and reliability; labeling risks.
Summary of Key Points
Clinical assessment combines information from interviews, MSE, medical examinations, behavioral observation, and testing to understand a patient and guide treatment.
Reliability, validity, and standardization are essential to ensure consistent, accurate assessments across clinicians and over time.
The clinical interview and MSE provide a preliminary, rapid snapshot that guides deeper assessment, but may need corroboration from behavioral assessments and structured tests.
Behavioral assessment and self-monitoring offer granular data on observable behaviors and patterns, with reactivity as a potential confound.
Psychological tests come in several forms (projective tests, personality inventories, intelligence tests, neuropsychological tests, neuroimaging, and psychophysiological measures), each with specific strengths, limitations, and appropriate applications.
Projective tests have historical importance but limited diagnostic validity; they are best used as adjuncts or rapport-building tools.
The MMPI family emphasizes empirical patterning and validity scales to detect response bias; interpretation centers on patterns across scales rather than individual item judgments.
Intelligence testing provides reliable estimates of cognitive abilities and academic potential; be mindful of culture and language factors.
Neuropsychological testing helps localize brain dysfunction, but false positives/negatives exist; used alongside other assessments.
Neuroimaging offers insight into brain structure and function; CT is structural; MRI provides higher resolution; PET/SPECT/ fMRI illuminate metabolic activity and brain function; advances include real-time imaging and receptor-level studies.
Psychophysiological assessment links emotional/psychological processes to measurable physiological changes; biofeedback leverages this information for treatment.
Diagnosis relies on both idiographic (individualized) and nomothetic (generalizable) information; DSM-5-TR provides a prototypical approach with dimensional components and cross-cutting measures.
Nosology continues to evolve with debates about reliability, validity, comorbidity, stigma, and cultural relevance; future directions include dimensional and spectrum-based models.
A thorough assessment integrates cultural context, acknowledges potential biases, and uses impairment criteria to determine whether criteria meet disorder thresholds.
Key Terms
clinical assessment: systematic evaluation of psychological, biological, and social factors
diagnosis: determination that factors meet criteria for a disorder
reliability: consistency of measurement
validity: measurement of what is intended
standardization: use of norms and consistent procedures
mental status exam: structured observational framework for cognition and behavior
behavioraI assessment: direct observation of thoughts, feelings, and behaviors in specific contexts
self-monitoring: client-recorded observation of their own behavior
projective tests: ambigous stimuli used to reveal unconscious processes
Rorschach: inkblot test; Exner’s Comprehensive System; controversy over reliability/validity
Thematic Apperception Test (TAT): storytelling about pictures to reveal motives
MMPI/MMPI-2/MMPI-2-RF: empirically based personality inventories with validity scales
validity scales: CNS, VRIN, TRIN, F, FBS, L, K, etc.
intelligence quotient (IQ): a deviation IQ comparing performance to same-age peers
Stanford-Binet, WAIS/WISC/WPPSI: major intelligence tests
neuropsychological testing: assesses brain-behavior relations using cognitive tasks
CT (CAT) scan: structural brain imaging via X-rays
MRI: high-resolution structural imaging using magnetic fields
PET: functional imaging using radioactive tracers
SPECT: functional imaging using different tracers, cheaper than PET
fMRI: functional imaging using blood-oxygen-level dependency (BOLD)
ERPs: event-related potentials measured via EEG
psychophysiological assessment: measures like heart rate, respiration, GSR
comorbidity: co-occurrence of multiple disorders in one person
nosology: system of classification for diseases
taxonomy: general scientific classification
nomenclature: names/labels of disorders
culture formulation: assessment of cultural context in diagnosis
PMDD: premenstrual dysphoric disorder; debated inclusion; now in mood disorders in DSM-5
dimensional/spectrum approaches: models that characterize disorders along continua or overlapping spectra rather than strict categories
impairment: level of distress/functional disruption sufficient to meet diagnostic criteria
prototypical approach: essential features plus nonessential variations for classification
cross-cutting measures: universal symptom measures that cut across disorders (e.g., anxiety, sleep problems) used in DSM-5
Notes on LaTeX formatting in this document
Diagnostic criteria and scales are often described with enumerated items and scale ranges. Where applicable, these have been presented with LaTeX formatting, for example:
Major Depressive Episode criteria: A.$ Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either depressed mood or loss of interest or pleasure.
The nine symptoms (1–9) listed under criterion A are typically treated as a set for determining the presence of a major depressive episode. The use of mathematical notation here is to indicate the quantitative thresholds (e.g., 5 or more symptoms within a 2-week period).
Cross-cutting dimensional scale example: DSM-5 uses a 0–4 severity scale for some symptoms, where 0 = none and 4 = extreme; the exact phrasing in the DSM-5 manual reflects these ordinal scales.
In the context of the ADIS-5, a 9-point rating scale for obessions and compulsions is described; for example, Persistence/Distress (0–8) and Resistance (0–8) for obsessions, and Frequency (0–8) for compulsions.
The Brief Psychiatric Rating Scale is described as a 7-point scale from 0 to 6.
The MMPI validity scales and clinical scales are listed in tables; the MMPI-2 items include dozens of sample statements and the interpretation relies on pattern matching to scales (e.g., Hypochondriasis, Depression, Schizophrenia, etc.).
End of Notes