How is psychopathology assessed and classified? - Chapter 2

The type of technique employed by clinicians for clinical classification and assessment often depends on their theoretical orientation to psychopathology. These techniques help in diagnosing, finding the best intervention, and evaluating whether the treatment effectively targeted the symptoms of the client.

How can psychopathology be classified?

We need to use categorization and classification in order to gain knowledge about the aetiology and causes of mental health problems. Different approaches are required for the various mental health problems, so classifying them helps in providing good and specialized support and service for sufferers. We can only define success of interventions if there is an objective way of defining what makes out the symptoms of psychopathology.

How were classification systems developed?

Emil Kraepelin (1883-1923) defined a distinct set of symptoms as a syndrome. The World Health Organization followed Kraepelin's scheme and extended the International List of Causes of Death (ICD) with psychological disorders in 1939. 

What are the DSM and the DSM-5?

The American Psychiatric Association (APA) improved classification by developing the first Diagnostic and Statistical Manual (DSM) in 1952. The most recent classification system is the DSM-5, which is the most widely adopted psychopathology classification system.

The Four basic objectives of the DSM-5 are:

1. Sufficient criteria must be provided to achieve a correct differential diagnosis
2. It should discriminate between 'true' psychopathology from normal 'problems in living
3. Diagnostic criteria should allow the application by different clinicians in different settings
4. It should be theoretically neutral, therefore not favoring one theoretical approach over another one

It also provides the following information:

• Essential features of the disorder
• Associated features
• Diagnostic criteria
• Information on differential diagnosis

Diagnosis should be made almost fully on the basis of observable behavioral symptoms, it therefore ignores the nature of the disorder (unless it is certain), and solely focuses on symptoms.

What are problems with the DSM-5?

The DSM-5 classifies psychopathology according to symptoms and not causes. Due to this classification by symptoms, it gives the impression of explaining symptoms, when it is just a different description of the symptoms. Labeling people according to criteria using the DSM-5 can attach stigma or be harmful. It can also lead to the view of disorders being discrete entities, while it has also been suggested that psychopathology may be viewed as rather dimensional. In practice, two or more distinct disorders co-occur, which is called comorbidity. This suggests that most disorders consist of symptoms of hybrid disorders (e.g., mixed anxiety-depressive disorder), rather than independent discrete disorders. Since comorbidity is so common, new terms have been introduced, such as a disorder spectrum. These are presented in a hierarchical structure, with individual discrete disorders as defined in the DSM-5 making up the bottom level of an overarching spectrum. Anxiety and depression are, in this new structure, part of the group of emotional disorders.

The DSM-5 is no longer categorized in a multi-axis system, but now consists of 20 chapters describing disorder families. Users of the DSM-5 are now encouraged to rate the disorders' severity of symptoms on a continuum. Some other changes are:

• Some disorders are now represented by their own chapter, like Obsessive Compulsive Disorder (OCD) and Stress-related disorders.
• Many previously separate autism labels are now incorporated under Autism Spectrum Disorder.
• The new disorder Mood Dysregulation Disorder diagnoses children suffering from persistent irritability.
• Binge eating disorder, skin picking disorder, and hoarding disorder are now independent disorder categories.
• Personality disorders' categorical model stays but has an added dimensional scale.
• Bereavement is no longer excluded as a symptom in major depression.
• PTSD is now included in a new chapter on stress.
• Substance use disorder now combines both substance abuse and substance dependence.

Some criticisms of the DSM-5 are:

• The many changes now require less criteria to be met for a diagnosis. This can turn out good or bad, but it will likely 'medicalise' many normal human emotions and thoughts.
• The new disorder categories (e.g., attenuated psychosis syndrome, seen as a potential precursor to psychotic episodes) that are made to identify people showing early signs of disorders might also again medicalise perfectly fine and healthy people, just because they are showing normal adaptations to life that might seem abnormal at first.
• The new diagnostic criteria can result in lowered rates of diagnosis for some particularly vulnerable populations (e.g., children diagnosed with autism), and there are concerns that the changes to specific learning disabilities (relating to conditions such as dyslexia or other communication disabilities) could disadvantage people with learning disabilities.
• The usage of neuroscience in the diagnostic criteria is called because neuroscience has not been able to help defining mental health problems a lot lately.
• Since disorders are now generally seen as dimensional, any criteria defining a cut-off score is quite arbitrary.

What are alternatives to the DSM?

Over the past decade, alternatives to the DSM have been developed. For instance, in the Research domains criteria (RDoC) approach, classifying psychopathologies in terms of their causes is done by researching causes and then relating them to observable symptoms. Moreover, the Hierarchical Taxonomy of Psychopathology (HiTOP) approach is a recently developed hierarchical classification of psychopathology symptoms that help to predict comorbidity and also higher-order dimensions that reflect associations between lower-order dimensions. Another alternative is network analyses, which assumes that there is some kind of underlying cause or latent variable that connects symptoms together. For example, a lung tumour can explain why an individual experiences chest pains, and a chronic cough. In clinical practice, depression is the name given to the dynamic causal interactions between symptoms, and it is not called the underlying cause. Lastly, the Power Threat Meaning (PTM) Framework represents an attempt to move away from primarily biological and medical models of mental health problems that are based on psychiatric diagnosis and the assumption that mental health problems are disorders of biology and are pathological. Instead, the framework takes a broad view of the causes of psychopathology and views people as social beings whose experiences of distress and troubling behaviour depend on their material, social, environmental, socio-economic, and cultural contexts.

Which assessment methods can be used for psychopathology?

What is the clinical interview?

During the clinical interview, a first form of contact is made, and the clinical psychologist will try to get a general overview of the client as a person and their problems. This can be difficult, as a lot of clients do not give out all information to the therapist, possibly because it is something they are embarrassed about, involving a painful memory or illegal incident. Additionally, they do not have enough insight about themselves to answer questions correctly.

To get hold of standardized information, the therapist can engage in the structured interview to make a diagnosis or form a case formulation. One of those structured interviews which allow clinicians to make decisions about functioning and diagnosis is called Structured Clinical Interview for DSM-IV-TR (SCID). This interview uses a branching method whereby one response the client makes decides which question will be asked next. It is highly reliable for most AXIS I disorder diagnoses. Structured interviews also serve the assessment of overall intellectual and psychological functioning levels. One such example is the Mini Mental State Examination (MMSE), which is reliable and only takes 10 minutes.

Limitations are:

• Low reliability for unstructured interview
• Race and sex might influence responses of client
• Poor self-awareness of client
• Interviewer might also be biased
• Client wants to mislead interviewer

What are psychological tests?

Psychological tests are more structured than clinical interviews. Advantages are:

• Assessment of one trait or specific characteristics.
• A pre-conceived scoring system can be used because the test's response requirements are very rigid (e.g., STAI, State-Trait Anxiety Inventory).
• Statistical norms, by process of standardization, can be used to determine how client's score compare to normal distribution.
• Psychological tests are both reliable and valid.
• Most of the psychological tests go by the psychometric approach, which holds that people have stable underlying traits that are active at different levels in everyone. Psychological tests can be used for example to assess psychopathology symptoms, cognitive or neurological deficits, and intelligence.

Personality Inventories

The Minnesota Multiphasic Personality Inventory (MMPI) is one of the most well-known inventories used by clinical psychologists and psychiatrists. The most recent update, MMPI-2, includes 567 self-statements which the client answers by choosing the best of the three points: 'true', 'false' or 'cannot say'. The inventory only includes questions which were previously responded to differently by a large sample of non-psychiatric patients and psychiatric patients. The test consists of 4 validity scales and 10 clinical scales.

Results from the MMPI are displayed in a graph, presenting a profile that indicates general personality features of the client, potential psychopathology, and emotional needs. The provided validity scales are important because clients might provide false information. The MMPI has good internal reliability and scores on it seem to have very good clinical validity, due to accurate correspondence of clinical diagnoses and symptoms rated by own family members and the clinician. One limitation of the MMPI is that it takes very long. The MMPI-2 is a shorter version with good validity and reliability.

Specific Trait Inventories

The Specific Trait Inventories measures one specific psychopathology, or a functioning that is relevant to psychopathology. The Obsessive Belief Questionnaire (OBQ) is an example to measure cognitive functioning relevant to obsessive compulsive disorder (OCD). These specific tests not only measure characteristics found in observable behaviour but can also measure hypothetical constructs. Nevertheless, most of the specific trait inventories are not subject of validation and reliability tests and are also not standardized.

Projective Tests

Clients taking a projective test are confronted with a fixed set of stimuli that leave room for interpretation because the stimuli are ambiguous. The Rorschach Inkblot Test, the Thematic Apperception Test (TAT) and the Sentence Completion Test are the projective tests that are used most widely. Yet, all of them are less reliable and valid in a considerable amount than more structured tests.

Hermann Rorschach created Rorschach Inkblot Test test by dropping ink onto paper and then folding it in half, creating a symmetrical image, called an inkblot. The test consists of 10 official ink blots. There is a highly structured scoring system which clinicians can use to compare the client's score with a set of standardized personality norms that might indicate psychopathology. Nevertheless, the test is often subject to the clinician's interpretation of the client's responses. It can be a valid and reliable test though to detect thought disorders possibly indicating schizophrenia or the risk of developing it.

The Thematic Apperception Test (TAT) is an example of a projective test, and it requires clients to create a dramatic story around a picture which displays people in vague and ambiguous situations. The whole test consists of 30 of these pictures, which are all in black and white. The 'hero' is the character of the picture with whom the client identifies, and in that way the client describes what he feels, as if he was part of the scene. The TAT may in that way express expectations the client holds about relationships with various people in his life (e.g., parents, romantic partner). This test can be used well after a client was matched with an appropriate form of therapy or to evaluate individuals accused of violent crimes.

The Sentence Completion Test gives clients sentences that are uncompleted and which they need to fill in with their own words. This can indicate how a client might be biased in thinking or processing information from his or her psychopathology. The test was applied for example to combat veterans with post-traumatic stress disorder. The clinician will find from the sentence completion which ways of thinking should be targeted.

• Projective tests are becoming less and less popular over the years. Reasons are:
• They often reveal information just relevant to the psychodynamic approach, an approach which is experiencing decline in popularity itself.
• They have low reliability.
• They infer psychopathology when there is otherwise little evidence for it (such as the Rorschach Test), with exception of indications for schizophrenia.
• They contain intrinsic cultural biases.
• They are labour-intensive and in return give little objective information.
• Computerised Adaptive Testing (CAT)
• Contemporarily, psychological tests can be administered and completed via computer, scored by the computer, and interpreted by the computer. This is known as computerised adaptive testing (CAT). CAT uses existing data to streamline and individualise the measurement process optimally selecting questions from a large bank of questions and responses.

Intelligence Tests

Intelligence tests aim to measure intellectual ability. The first intelligence test was created in 1905 by the French psychologist Alfred Binet. Most are standardized, having a score of 100 as the mean and 15 or 16 as score for standard deviation. Advantages of intelligence tests include high internal consistency, high test-retest reliability, and good validity.

Intelligence tests are used in variety of situations by clinicians:

• They are used together with other measures of ability for the diagnosis of learning and intellectual disabilities.
• They are used for the assessment of individuals with disabilities, so they can be provided with support for specific needs. Best used for this is the Wechsler Adult Intelligence Scale (WAIS), which covers a range of different ability scales.
• They are used in neurological evaluations as part of an assessment battery.

There are also limitations of using intelligence tests:

• Intelligence is a hypothetical and inferred construct.
• There is a cultural bias, many IQ tests being based on middle class majority ethnic background views, making the intelligence dependent on the reliability and validity of the individual IQ test.
• They are 'static' tests that capture intellectual ability at one point in time. They do not measure the potential of acquisition of new cognitive abilities.
• Many other skills are not contained in measures and conceptions of intelligence (e.g., music ability), making our current conceptions too narrow.

What are biologically based assessments?

Neurological impairment tests deal with identifying if cognitive deficits in an individual can be attributed to brain damage, and if so, which brain areas have been affected. This is done by using EEG, PET scans and fMRI scans, blood tests, and chemical analysis of cerebrospinal fluid. Neurological tests are also very important in an assessment, and help measure perceptual, cognitive, and motor performance. By finding a specific cognitive deficit it can become easier to identify the area of ​​brain damage. The Adult Memory and Information Processing Battery (AMIPB), the Halstead-Reitan Neuropsychological Test Battery and the Mini Mental State Examination (MMSE) are the tests commonly used by clinical neuropsychologists.

Psychophysiological tests

To gather information about emotionally based psychological problems, psychophysiological tests can be very helpful. The electrodermal responding, also known as the galvanic skin response (GSR) or skin conductance response (SCR), measures changes in sweat gland activity by electrodes attached to the fingers. A polygraph records the changes in skin conductance caused by emotional responses (e.g., fear, anxiety).

Neuroimaging techniques

The electromyogram (EMG), measuring the electrical activity in muscles, and the electrocardiogram (ECG), measuring heart rate. The lie detector is not used as often anymore, especially less in cases of finding evidence of criminal guilt, as arousal not attributed to lying can be detected and interpreted falsely as lying. The electroencephalogram (EEG) is an assessment measure that records underlying electrical activity, by attaching electrodes to the scalp. Unusual brain patterns in different brain areas can be localized.

One technique to provide images of the brain is the computerized axial tomography (CAT). For that the patient needs to lie in a large tube and 3D versions are formed of the brain. With these images abnormal growths or enlargements of the ventricles can be detected. The positron emission tomography or PET scans use radiation to develop images. Participants emit gamma radiation, which comes from small given amount of a radioactive drug. Areas colored brightly in the image indicate high metabolism of glucose in the brain. Furthermore, the magnetic resonance imaging (MRI) is a scanning technique which creates visual pictures of the brain by placing a participant inside a circular magnet that makes the hydrogen atoms in the body move.

What is meant by reliability and validity of assessment methods?

To be sure that assessment methods provide objective information about clients, it is important to be sure about two things, namely reliability and validity. Reliability means that the method will still provide the same result when used by different clinicians on different occasions. Second, we need to be sure that the assessment has validity. This means that it actually measures what it claims to measure. For instance, if a test assesses anxiety, then scores on the test should correlate well with other ways of measuring anxiety.

What is the concept of clinical observation?

Direct observation allows the assessment of frequency of a specific behaviour, what precedes the behaviour, and what follows it. An ABC chart can be used for this assessment, including A) what occurs before the target behavior takes place B) what the individual had done C) what consequences follow the behaviour.

Advantages of clinical observation are:

• An important objective measure of the behavior frequency is provided, as well as for what precedes and follows behaviour.
• Greater external or ecological validity than for other testing ways (e.g., self-reports) is provided.
• The context in which behavior takes place might provide hints to workable answers.

Drawbacks of clinical observation:

• Time consuming assessment.
• Behavior in one context of observation might not be typical to behavior in another context.
• The observed individual might act differently because the observer is present. Analogue observation takes place in a controlled environment where the client can be observed secretly.
• Poor inter-observer reliability.
• Expectations of observer can influence data.

In self-observation or self-monitoring, the client keeps track of his own behavior, and notes down when and in what contexts certain behaviors take place. Ecological momentary assessment (EMA) is a method in which the client makes use of electronic diaries to capture self-observation. It helps lower the frequency of undesirable behaviors.

What is cultural bias in assessment?

Many tests can be culturally biased and in return do not yield a correct picture of an individual's mental health. Not all ethnic groups score the same on assessment tests, consequently they are often given different diagnoses and popular ethnic stereotypes influence the medical and psychiatric practice. Also, clinicians often make judgments in unstructured interviews that are influenced by socioeconomic stereotypes.

What are examples of cultural bias in assessment?

Cultural anomalies can be identified in a number of different ways. For example, some ethnic groups score differently on assessment tests than others. For example, American Asians often score higher on most scales of the MMPI compared to White Americans. Moreover, Black Americans have a higher rate of diagnosis of disorders such as alcoholism or schizophrenia, whereas White Americans are more likely to be given the diagnosis of major depression.

What are causes of cultural bias in assessment?

There are a number of causes of cultural anomalies in assessment and diagnosis. First, there are different manifestations of mental health symptoms in different cultures. Secondly, there might be a language barrier between client and clinician. Thirdly, perception of psychopathology is influenced by religion and spiritual beliefs. Fourthly, culture differences affect client-clinician relationships. Lastly, there are different perceptions on what is considered 'normal' and 'abnormal'. The judgment of clinicians is often also influenced by the confirmatory bias, which means that clinicians only pay attention to information that supports their initial hypotheses and ignore information that does not support it.

What is case formulation?

In case formulation, an approach is used which tries to formulate a psychological explanation from clinical information and from there on develop a plan for therapy. This approach works from an established theoretical account to explain problems the client is experiencing. This collaborative way of therapy consists of six components:

1. Creation of a list of the client's problems
2. Identification and description of the underlying psychological mechanism of the problem
3. How these mechanisms generate the problem
4. Events that led up to the problem
5. How these events may have caused the problem regarding the psychological mechanism
6. Development of a treatment scheme and prediction of possible obstacles

The theoretical approach of the therapist determines the construction of the case formulation. The ABC approach aims at explaining the client's problems by the cognitive-behavioral model by explaining (A) antecedents (B) beliefs and (C) consequences of an event. In the psychodynamic approach the problems of a client can be viewed as interactions between various 'actors' (family members). Clinicians like to use diagrams to represent their formulations.

Advantages of the case formulation approach include:

• Flexibility in understanding the client's problems, regardless of any previous diagnoses they have received.
• A collaborative form of treatment.
• A basis of theoretical understanding of psychopathology.
• The past history of the client is considered.
• Appropriate treatment can be administered to target specific needs, even in complex cases that do not easily fit standard diagnostic categories.