DIAGNOSIS AND ASSESSMENT

Diagnosis
CHAPTER 3:
DIAGNOSIS AND ASSESSMENT The classification of disorders by symptoms and signs.

Advantages of diagnosis:
Abnormal Psychology

Facilitates communication among professionals

Advances the search for causes and treatments

Cornerstone of clinical care

DIAGNOSIS AND ASSESSMENT CLASSIFICATION AND

DIAGNOSIS
Stigma against mental illness.

Treated differently by others

Diagnostic and Statistical Manual
Difficulty finding a job of Mental Disorders (DSM) published by American Psychiatric
Categories do not capture the uniqueness of a person. Association

The disorder does not define the person. First edition published in 1952
She is an individual with schizophrenia, not a “schizophrenic”
Current edition is the 5th edition (2013)
Classification may emphasize trivial similarities

Relevant information may be overlooked.

OVERVIEW OF THE DSM-5 OVERVIEW OF THE DSM-5

DSM-IV’s organizational structure failed to reflect shared features

or symptoms of related disorders and diagnostic groups
like psychotic disorders with bipolar disorders
internalizing (depressive, anxiety, somatic)
externalizing (impulse control, conduct, substance use)
• DSM-5 restructuring better reflects these interrelationships,
within and across diagnostic chapters
DSM-IV does not adequately address the lifespan perspective,
including variations of symptom presentations across the
developmental trajectory, or cultural perspectives
DSM-5’s chapter structure, criteria revisions, and text outline
actively address age and development as part of diagnosis and
classification
Culture is similarly discussed more explicitly to bring greater
attention to cultural variations in symptom presentations

OVERVIEW OF THE DSM-5 OVERVIEW OF THE DSM-5

The multiaxial system in DSM-IV is not required to make a

DSM-5 tries to integrate neuroscience and findings from
mental disorder diagnosis and has not been universally used
neuroimaging, genetics, cognitive research
DSM-5 has moved to a nonaxial documentation of diagnosis
DSM-5 will be more amenable to updates in psychiatry and
(formerly Axes I, II, and III), with separate notations for important
neuroscience, making it a “living document” and less susceptible
psychosocial and contextual factors (formerly Axis IV) and
to becoming outdated than its predecessors
disability (formerly Axis V)
 OVERVIEW OF THE DSM-5

Not Otherwise Specified (NOS) has been used as a “catch-all” for

patients who didn’t fit into the more specific categories. NOS
language is eliminated in DSM-5.

There will now be an option for designating Not Elsewhere

Classified (NEC) which will typically include a list of specifiers as
to why the patient’s clinical condition doesn’t meet a more
specific disorder.

The phrase “general medical condition” is replaced in DSM-5 with

“another medical condition” where relevant across all disorders.

OVERVIEW OF THE DSM-5 OVERVIEW OF THE DSM-5

Too many diagnoses?

Should relatively common reactions be pathologized? Steps for Better Differential Diagnosis

Comorbidity Step 1: Rule Out Malingering and Factitious Disorder

Presence of a second diagnosis Step 2: Rule Out Substance Etiology 

45% of people diagnosed with one disorder will meet criteria for a Step 3: Rule Out Disorder Due to a Another Medical
second disorder
Condition
Reliability in everyday practice
OVERVIEW OF THE DSM-5
Steps for Better Differential Diagnosis
Step 4: Determining the Specific Primary Disorder
Diagnostic groupings in DSM-5 are organized around common
presenting symptoms
Choosing among the primary disorders - what is closest to
presenting symptoms
Ruling out other explanations for the behavior — other related
disorders, what specific disorder?
OVERVIEW OF THE DSM-5
Steps for Better Differential Diagnosis
Step 6: Establish Boundary With No Mental Disorder
Evaluate symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas
of functioning. 
What does it mean to be clinically significant?
THIS DEPENDS ON CLINICAL JUDGMENT   because the distress is not a psychological dysfunction.
OVERVIEW OF THE DSM-5
Steps for Better Differential Diagnosis
Step 5: Differentiate Adjustment Disorders From Residual Other or
Unspecified Categories
Some people have subthreshold symptoms that are still severe
enough to cause clinically significant distress or impairment.
If symptoms are a maladaptive response to a psychosocial
stressor, then use Adjustment Disorder
Minimising the diagnosis of Not Elsewhere Classified (NEC)
OVERVIEW OF THE DSM-5
Steps for Better Differential Diagnosis
Step 6: Establish Boundary With No Mental Disorder
Symptoms must represent an internal biological or
psychological dysfunction in the patient.
Ex. A patient mourning the loss of a close family member may
experience uncomplicated bereavement, which causes a great
deal of distress but would not qualify as a mental disorder
 CORNERSTONES OF DIAGNOSIS
AND ASSESSMENT

ASSESSMENT FOR DIAGNOSIS

Reliability and Validity - There is a whole branch of psychology
devoted to psychometrics

OVERVIEW OF RELIABILITY OVERVIEW OF VALIDITY

Consistency of measurement How well does a test measure what it is supposed to measure?

Inter-rater - Observer agreement Content validity - Extent to which a measure adequately samples the
domain of interest, e.g., all of the symptoms of a disorder
Test-retest - Similarity of scores across repeated test administrations
or observations Criterion validity - Extent to which a measure is associated with
another measure (the criterion)
Alternate Forms - Similarity of scores on tests that are similar but
not identical Concurrent - Two measures administered at the same point in time

Internal Consistency - Extent to which test items are related to one Predictive - Ability of the measure to predict another variable
another measured at some future point in time
OVERVIEW OF VALIDITY ASSESSMENT OF STRESS

Construct validity (Cronbach & Meehl, 1955) Stress

A construct is an abstract concept or inferred attribute
Subjective experience of distress in response to perceived
Involves correlating multiple indirect measures of the attribute environmental problems

e.g., self-report of anxiety correlated with increased HR, shallow Self-Report Stress Checklists
breathing, racing thoughts
Faster way to assess stress
Important for validating our theoretical understanding of psychopathology

Method for evaluating diagnostic categories Test-retest reliability low

PSYCHOLOGICAL ASSESSMENT CLINICAL INTERVIEWS

Techniques employed to: Informal/less structured interviews

Describe client’s problem Interviewer attends to how questions are answered

Determine causes of problem Is response accompanied by appropriate emotion?

Arrive at a diagnosis Does client fail to answer question?

Good rapport essential to earn trust

Develop a treatment strategy
Empathy and accepting attitude necessary
Monitor treatment progress
Reliability lower than for structured interviews
Conducting valid research
Structured interviews
Ideal assessment involves multiple measures and methods - Interviews, personality inventories,
intelligence tests, etc. All interviewers ask the same questions in a predetermined order
PSYCHOLOGICAL TESTS
Personality Tests

Self-reported Personality Inventories

Minnesota Multiphasic Personality Inventory (MMPI)

Yields profile of psychological functioning

Specific subscales to detect lying and faking “good” or “bad”

Projective Tests

Rorshach Inkblot Test and Thematic Apperception Test (TAT)

Projective hypothesis

Responses to ambiguous stimuli reflect unconscious processes

PSYCHOLOGICAL TESTS
Intelligence tests (IQ tests)

Assess current mental ability

Wechsler Scales

Wechsler Adult Intelligence Scale, 4th ed. (WAIS-IV)

Wechsler Intelligence Scale for Children, 4th ed. (WISC-IV)

Wechsler Preschool and Primary Scale for Children, 3rd ed. (WPPSI-III)

Stanford-Binet, 5th ed. (SB5)

Used to predict school performance, diagnose learning disabilities or intellectual developmental disorder
(mental retardation), identify gifted children, as part of a neuropsychological examination

Lower IQs associated with higher psychopathology and mortality

BEHAVIORAL AND COGNITIVE BEHAVIORAL AND COGNITIVE
ASSESSMENT ASSESSMENT
Observe behavior as it occurs

Focus on aspects of environment Sequence of behavior divided into segments

Antecedents and consequences

Characteristics of the person
Behavioral Assessments often conducted in lab setting
Frequency and form of problematic behaviors
e.g., mother and child interact in a lab living room
Consequences of problem behaviors
Interaction observed through one-way mirror or videotaped for later
coding

SELF-OBSERVATION COGNITIVE-STYLE
QUESTIONNAIRES
Self-monitoring

Individuals observe and record their own behavior

Use to help plan treatment targets

e.g., moods, stressful events, thoughts, etc. Format often similar to personality tests
Ecological Momentary Assessment (EMA)
Dysfunctional Attitude Scale (DAS)
Collection of data in real time using diaries or smart phones

Reactivity Identifies maladaptive thought patterns

The act of observing one’s behavior may alter it
“People will think less of me if I make mistakes”
Desirable behaviors tend to increase whereas undesirable behaviors decrease
NEUROBIOLOGICAL ASSESSMENT: PSYCHOPHYSIOLOGICAL
BRAIN IMAGING ASSESSMENT
Computerized Axial Tomography (CT or CAT scan) Psychophysiology
Reveals structural abnormalities by detecting differences in tissue density Study of bodily changes that accompany psychological characteristics or events
Magnetic Resonance Imaging (MRI)
Electrocardiogram (EKG)
Similar to CT but higher quality
Heart rate measured by electrodes placed on chest
fMRI (functional MRI)
Electrodermal responding (skin conductance)
Images reveal function as well as structure
Sweat-gland activity measured by electrodes placed on hand
Measures blood flow in the brain

Positron Emission Tomography (PET scan) Electroencephalogram (EEG)

Brain function Brain’s electrical activity measured by electrodes placed on scalp

CULTURAL AND ETHNIC

DIVERSITY AND ASSESSMENT
Cultural Bias in Assessment

Measures developed for one culture or ethnic group may not

be valid or reliable for another.

Not simply a matter of language translation

Meaning may be lost

Cultural bias can lead to minimizing or exaggerating psychological

problems