Assessing and Diagnosing Abnormality (Chapter 3) PDF

Chapter 3 wavebreakmedia/Shutterstock Assessing and Diagnosing Abnormality CHAPTER OUTLINE Assessment and Diagnosis Along the Shades of Gray Continuum...

Chapter 3 wavebreakmedia/Shutterstock Assessing and Diagnosing Abnormality CHAPTER OUTLINE Assessment and Diagnosis Along the Shades of Gray Continuum Chapter Integration Extraordinary People: Marya Hornbacher Shades of Gray Discussion Assessment Tools Chapter Summary Challenges in Assessment Key Terms Diagnosis 60  Assessment and Diagnosis Along the Continuum When you drink alcohol, how many drinks do you normally have in one 2-hour period? Less than More than 1 drink 2 drinks 3 drinks 4 drinks 5 drinks 6 drinks 1 drink 6 drinks Diagnostic Not binge drinking systems define Binge drinking (for women) threshold Symptoms meet criteria for alcohol abuse Occasional drinking with Normal No disorder Disorder Multiple social and legal problems Abnormal no significant problems due to alcohol abuse Assessment tools Assessment tools can also Diagnostic systems assume can be based on a be based on a threshold that we can define a threshold continuum model. point that divides the above which a disorder is present. continuum into acceptable behavior and problematic behavior. As a student, you have taken a variety of tests intended to Currently, the diagnostic guidelines use a threshold–a spe- assess your learning in different subjects. Similarly, mental cific cutoff point–to determine if a psychological disorder is health professionals use various tests or tools to assess present and therefore seem to oppose a continuum model. In- mental health. Some assessment tools described in this chapter creasingly, however, researchers and clinicians are building a are based on the assumption that behaviors or feelings lie continuum perspective into the diagnostic process. For exam- along a continuum—the task is to determine where an indi- ple, the most recent version of the manual used to diagnose vidual’s experiences fall along that continuum. For example, a disorders in the United States, the DSM-5-TR, defines personal- questionnaire that asked you about your drinking behavior ity disorders at least somewhat in line with a continuum model. might have several options indicating different levels of drink- For most disorders, however, the DSM-5-TR and other diagnostic ing. The researcher doing a study on predictors of drinking systems set criteria for when a person’s behaviors and feelings behavior might be interested in what factors predict where cross the line into a disorder, even in the absence of a purely people fall along the continuum from little or no drinking to a scientific way to draw that line. great deal of drinking. A clinician may be interested in charting There are advantages and disadvantages both to a contin- how a person’s drinking behavior changes over the course of uum approach to assessment and diagnosis and to a categorical therapy. Other tools, however, are more like true/false tests: approach that focuses on thresholds and cutoffs for identifying They are based on the assumption that there is a threshold for disorders. The continuum approach captures the nuances in the behaviors they are assessing, and that either people have people’s behaviors better than does a categorical approach. these behaviors or they do not. For example, some researchers The continuum approach also does not assume that we know set the threshold for an alcohol “binge” for women at four where the cutoff is for problematic behavior. But the continuum drinks (see the chapter “Substance Use and Gambling Disorders”). approach can make it more difficult to communicate information Thus, a person who regularly drinks this amount or more about people, in part because we often think more in categori- in one sitting would be considered a binge drinker, whereas cal terms. For example, saying that a person is a binge drinker a person having three drinks would not be considered a may convey more information to a therapist or researcher than binge drinker. saying that the person drinks moderately to heavily. Assessment and Diagnosis Along the Continuum 61 62 Chapter 3 Assessing and Diagnosing Abnormality Extraordinary People Marya Hornbacher By her late twenties, nervosa and to a young woman’s ability to recover Marya Hornbacher ap- from these disorders. peared to be an amaz- But those who knew her had doubts that she was ing success story. She well, as she recounts in her book Madness (2008). had published her first She was drinking, which was nothing new for her. But book, Wasted, which the volume and ferocity of her drinking surprised ev- was heralded as an elo- eryone around her. Even though she is a petite woman, quent account of her it took a dozen glasses of wine or hard liquor to even many years with severe give her a buzz. Marya seemed to have boundless en- eating disorders, and ergy and was bouncing off the walls much of the she was sought after time—that is, except when she went crashing down for speaking engage- into depression and retreated into her bed for days on STR/AP Photos ments and readings end. Hoping to gain some control over her life, she across the United States and Europe. Apparently resorted to controlling her eating again and began to cured of her disorder, Hornbacher served as a living lose weight rapidly. testament both to the horrors of bulimia and anorexia Marya Hornbacher presents a puzzling picture. De- an X-ray or bloodwork, psychological assessment has spite periods of time with stable psychological func- the same purpose, which is to collect information, tion she showed signs of alcohol abuse, mood swings, draw conclusions, and develop a treatment plan. and a lingering eating disorder. Why does Marya expe- Before a person can be diagnosed with a psycho- rience these symptoms and why do they stabilize, but logical disorder an assessment is first performed. As- come back? “Why” is often the most common ques- sessment is the process of evaluating psychological, tion. And, it is not a question that is easily answered, social, and emotional functioning through a variety of which is frustrating. There will always be unanswered clinical methods. Psychological assessment often in- questions when it comes to psychological dysfunc- cludes interviews, observations, psychological and tion, but to begin answering these questions we must neurological tests to determine the client’s presenting first understand what disorders are present. These problem and clinical description. Meaning, a variety symptoms will qualify Marya for several diagnoses of assessment methods are used in combination to that we will discuss in other chapters, including eating determine if a psychological disorder might be present disorders, substance use disorders, and bipolar disor- in an individual. der. However, the first step is to think about how Many types of information are gathered during an Marya’s symptoms impact her ability to function and assessment, including current symptoms and ways of how to best assess her behaviors. The assessment and coping with stress, recent events and physical condi- diagnosis of symptoms is the focus of this chapter. tions, drug and alcohol use, personal and family his- tory of psychological disorders, cognitive functioning, How are psychological disorders evaluated? and sociocultural background. The information gath- While working out one day, you twist your ankle and ered in an assessment is used to determine the appro- feel a sharp sensation of pain. Your pain increases priate diagnosis for a person’s problems. The diagnostic over the next few hours, the ankle begins to swell and process involves using the assessment data to deter- you cannot bear weight to walk. What’s the diagnosis? mine if the pattern of symptoms is consistent with the If you went to the emergency room you would not be diagnostic criteria for a specific mental disorder. The provided with a diagnosis until the medical doctor ran criteria used to assign a diagnosis is based on an estab- some tests. However, after an X-ray and examination lished classification system, such as the DSM-5-TR or it’s likely that you would be diagnosed with a fractured ICD-10, which we will discuss later in this chapter. ankle and a treatment plan would be designed for your Symptoms that cluster together are called a syndrome. care and recovery. Psychological evaluation is not When symptoms cluster together in specific patterns much different in this respect. While we do not have a diagnosis is given that identifies the characteristics the ability to evaluate psychological symptoms with of a specific disorder.  Assessment Tools 63 Although some clinicians avoid making diagno- Types of Validity for a Questionnaire or Test. There ses from fear of labeling a person and simplifying their FIGURE 1 are a number of types of validity. humanity, the process is not about applying a label to a problem--or a person. Instead, it is about understand- ing the problems experienced by the individual and Content validity: Test assesses all important helping to provide information and effective treat- aspects of a phenomenon. ments related to the problem. Various tools of assess- ment provide important information about the individual’s personality characteristics, cognitive Face validity: Predictive validity: Test appears to measure Test predicts the behavior it function, emotional well-being, and biological func- what it is supposed to is supposed to measure. tioning. Additionally, we will discuss contemporary measure. classification systems used to diagnose psychological disorders. These standardized diagnostic system en- hances effective communication among mental health Types of validity professionals, facilitates research, and informs the community on best practices for the treatment of psy- chological disorders. Concurrent validity: Construct validity: Test yields the same results Test measures what it is as other measures of the supposed to measure, not ASSESSMENT TOOLS same behavior, thoughts, or feelings. something else. A number of assessment tools have been developed to help clinicians gather information. The assessment process must include tools that are valid, reliable, and standardized. These terms may be unfamiliar, so let’s about many things?” has face validity because it seems first discuss these important concepts and then look to assess symptoms of anxiety. If it also meets other at specific types of assessment tools. standards of validity, researchers are more likely to trust its results. Content validity is how well an instrument (i.e., a Validity test or questionnaire) appropriately measures the con- If you administer a test to determine a person’s behav- tent, theory, or phenomenon being studied. For ex- iors and feelings, you want to be sure that the test is ample, questions on an AP Chemistry exam should be accurate. The accuracy of a test in assessing what it is limited to the topics actually taught in that class and supposed to measure is called its validity. For exam- unrelated material, like History or French, should not ple, when a new test is developed to measure symp- appear. This matching between test questions and the toms of depression, its accuracy must be tested to content helps to ensure content validity. ensure it is a valid instrument. One way to do this is to One purpose of research is to make predictions compare the new test to an existing and proven test, about future behaviors. Predictive validity addresses such as the Beck Depression Inventory (BDI). If the how well an instrument that is used for assessment, new test accurately measures depression, then the out- like a survey, can predict future behavior. An anxiety come of the new test should be similar to or correlate measure has good predictive validity if it correctly pre- with the results of the BDI. This is an example of dicts which people will behave in anxious ways when concurrent (or convergent) validity, which is the extent confronted with stressors in the future. to which a test yields the same results as other, estab- Construct validity is the extent to which a test mea- lished measures of the same behavior, thoughts, or sures what it is supposed to measure and not some- feelings. thing else altogether (Cronbach & Meehl, 1955). As we discuss in the chapter “Looking at Abnor- Consider the construct validity of multiple-choice ex- mality,” there are currently no definitive blood tests, ams in school. They are supposed to measure a stu- brain scans, or other objective tests for any of the psy- dent’s knowledge and understanding of content. chological disorders presented in this book. Fortu- However, they may also measure the student’s ability nately, the validity of a test can be estimated in a to take multiple-choice tests—that is, their ability to number of other ways (Figure 1). A test is said to have determine the instructor’s intent in asking each ques- face validity when, on face value, the items seem to tion and to recognize any obviously incorrect answer measure what the test is intended to measure. For ex- choices. For example, if a chemistry exam actually ample, a questionnaire for anxiety that asks “Do you measures a student’s understanding of chemistry, the feel jittery much of the time?” and “Do you worry exam can be said to have construct validity; but if it 64 Chapter 3 Assessing and Diagnosing Abnormality Finally, many of the assessments we examine in Types of Reliability for a Questionnaire or Test. FIGURE 2 this chapter are interviews or observational measures Reliability can be determined in several ways. that require a clinician or researcher to make judg- ments about the people being assessed. These tests Test-retest reliability: Alternate form reliability: should have high interrater, or interjudge, reliability. Test produces similar results Two versions of the same when given at two points test produce similar results. That is, different raters or judges who administer and in time. score the interview or test should come to similar con- clusions when they are evaluating the same people. Types of reliability Standardization One important way to improve both validity and reli- ability is to standardize the administration and inter- Internal reliability: Interrater, or interjudge, pretation of tests. A standard method of administering Different parts of the same reliability: Two or more raters a test prevents extraneous factors from affecting a per- test produce similar results. or judges who administer and score a test come to similar son’s response. For example, if the test administrator conclusions. were to deviate from the written questions, suggesting the “right” answer to the respondents, this would re- duce the validity and reliability of the test. In contrast, if the administrator of the test only read aloud the specific questions on the test, this would increase the shows how a clever student with little knowledge of validity and reliability of the test. Similarly, a standard chemistry but a strong ability to take multiple-choice way of interpreting results (e.g., scores above a certain exams, it does not. cutoff are considered extreme) makes the interpreta- tion of the test more valid and reliable. Thus, stan- Reliability dardization of both the administration and the interpretation of tests are important to their validity It is important that a test provides consistent informa- and reliability. tion about a person. The reliability of a test indicates With these concepts in mind, let’s explore some its consistency in measuring what it is supposed to commonly used assessment tools. measure. As with validity, there are several types of reliability (Figure 2). Test-retest reliability describes how consistent the results of a test are over time. If a Clinical Interview test supposedly measures an enduring characteristic Much of the information for an assessment is gath- of a person, then the person’s scores on that test ered in an initial interview, which is the clinical inter- should be similar when he or she takes the test at two view. This is exactly as the title implies, it’s an different points in time. For example, if an anxiety interview or discussion. A clinical interview is typi- questionnaire is supposed to measure people’s general cally a face-to-face conversation between a mental tendencies to be anxious, then their scores should be health professional and a client where information is similar if they complete the questionnaire this week gathered about the client’s behavior, attitudes, emo- and then again next week. Typically, measures of gen- tions, life history, and personality. A mental status eral and enduring characteristics should have higher exam, is used to organize the information collected test-retest reliability than measures of transient char- during the interview and systematically evaluate the acteristics. client through a series of questions. This process A problem with reliability might arise when peo- helps to determine the client’s current mental status. ple take the same test a second time, they may try to Each part of the mental status examination is de- give the same answers so as to seem consistent. For signed to look at a different area of mental function this reason, researchers often will develop two or to thoroughly capture the objective and subjective as- more forms of a test. When people’s answers to dif- pects of psychological function (Finney, Managar, & ferent forms of a test are similar, the tests are said to Heilman, 2016). have alternate form reliability. Similarly, a researcher In the mental status exam, the clinician asks may split a test into two or more parts to determine various questions that relate to five (5) categories of whether people’s answers to one part of a test are information. First, the clinician assesses the indi- similar to their answers to another part. When there vidual’s appearance and behavior, which includes is similarity in people’s answers among different overt physical behaviors, appearance, body lan- parts of the same test, the test is said to have high guage, level of cooperation, and facial expressions. internal reliability. This is something we all do when we meet someone  Assessment Tools 65 new. Does this person make appropriate eye contact or do they stare a little too long? Is he or she dressed TABLE 1 Sample Structured Interview neatly and well groomed, or do they appear dishev- ANXIETY DISORDERS eled? Do their clothing choices best fit the weather? The ability to care for one’s basic grooming indi- Panic Disorder Questions cates how well one is functioning in general. All of Have you ever had a panic attack, when you suddenly these observations help provide insight into the cli- felt frightened, anxious, or extremely uncomfortable? ent’s behavior. If Yes: Tell me about it. When does that happen? Second, in a mental status exam a clinician will (Have you ever had one that just seemed to come take note of the individual’s thought processes, includ- out of the blue?) ing how coherently and quickly he or she speaks. Are If panic attacks took place in expected situations: the client’s thoughts linear, organized and goal-directed Did you ever have one of these attacks when you or disorganized, off-topic and rambling? Third, the cli- weren’t in (EXPECTED SITUATION)? nician will evaluate the individual’s mood and affect. Have you ever had four attacks like that in a 4-week Does he or she appear down and depressed, or per- period? haps elated or euphoric? What mood does the client If No: Did you worry a lot about having another one? report feeling and does the outward reflection of this (How long did you worry?) emotion match? It is important to note if the affect is When was the last bad one (EXPECTED OR UNEX- appropriate or inappropriate. Meaning, if the client PECTED)? reports feeling happy, and they appear happy, then the Now I am going to ask you about that attack. affect is appropriate to mood. What was the first thing you noticed? Then what? Fourth, the clinician will observe the individual’s During the attack... intellectual functioning, which can be assessed in a... were you short of breath? (have trouble catching variety of ways, including how well the person speaks, your breath?) responds to questions, and shows any indications of... did you feel dizzy, unsteady, or as if you might memory or attention difficulty. The last category as- faint? sesses the client’s general awareness to their surround-... did your heart race, pound, or skip? ing and their orientation to time, person, and place,... did you tremble or shake? which is called sensorium. The clinician will will as-... did you sweat? sess the sensorium by determining whether the indi-... did you feel as if you were choking? vidual understands where they are, when they are, and... did you have nausea, upset stomach, or the feel- who they are. If the individual can provide this infor- ing that you were going to have diarrhea? mation then they are appropriately oriented, or “ori-... did things around you seem unreal or did you ented times three.” feel detached from things around you or detached The interview can be delivered in a variety of for- from part of your body? mats, including structured, unstructured, and semi- Source: Data from First, Spitzer, Gibbon, & Williams, 1997. structured. In structured interviews, clinicians ask the individual a series of standardized questions about symptoms and use concrete criteria to score responses. Structured interviews offer the benefits of standard- The mental status exam is a useful but subjective ization and reliability but lack flexibility to ask client- assessment. Evaluations can vary significantly specific questions (Table 1). An unstructured interview between practitioners depending upon their clinical is another option for mental health professionals in skills level and ability to elicit responses from the which open-ended questions are asked and directed by client. This process also depends upon practitioners the clinician based on the client’s responses. Semi- to use their best clinical judgment to combine the in- structured interviews combine standardized with terview information with other subjective and objec- ­open-ended questions that allow clinicians to follow tive findings (Norris, Clark, & Shipley, 2016). up with specific questions in order to gather more personalized information (Bridley & Daffin, 2018). These interviews help clinicians to determine whether Symptom Questionnaires the client’s symptoms qualify for a diagnosis. Re- When clinicians or researchers want a quick way to cently, researchers have sought to develop computer- determine a person’s symptoms, often they will ask the ized methods of testing that might retain validity person to complete a self-report symptom question- while saving time and resources compared to face-to- naire. There is no shortage of self-report instruments face interviews; these methods are not yet widely used on the Internet. The clinician might direct a client to a (Gibbons, Weiss, Frank, & Kupfer, 2016). particular example and ask that it be completed before 66 Chapter 3 Assessing and Diagnosing Abnormality meeting. These questionnaires can be generalized and decades resulted in disinterest by researchers until the cover a wide variety of symptoms that represent sev- test was restructured in the 2000s (Sellbom, 2019). eral disorders or focused on the symptoms of a specific This current instrument includes 10 clinical disorder. It is important to note that these instruments scales that assess 10 major categories of psychological are not used to diagnose a psychological disorder and characteristics or problems, such as paranoia, anxiety, individuals using such Internet-based assessments on social introversion and vulnerability to eating disor- their own should consult with a professional. ders, substance abuse, and poor functioning at work The BDI-II is one of the most widely used self- (Sharf, Rogers, Williams, & Henry, 2017). The MMPI report symptom instruments in both research and clini- presents respondents with sentences describing moral cal practice for assessing depression. The most recent and social attitudes, behaviors, psychological states, form of the BDI has 21 items, each of which describes and physical conditions, and ask them to respond 4 levels of a given symptom of depression ranging from “true,” “false,” or “can’t say” to each sentence. Here “I do not feel unhappy” to “I am so unhappy that I can’t are some examples of items from the MMPI: stand it” measured on a scale of 0 to 3. The respondent I would rather win than lose in a game. is asked to indicate which description best fits how I am never happier than when alone. he or she has been feeling in the past week. The items My hardest battles are with myself. are scored to indicate the level of depressive symptoms I wish I were not bothered by thoughts about sex. the person is experiencing. Cutoff scores have been I am afraid of losing my mind. ­established to indicate moderate and severe levels of When I get bored, I like to stir up some excitement. depressive symptoms (A. Beck & R. Beck, 1972; Garcia- People often disappoint me. Batista, Guerra-Pena, Cano-Vindel, Herrera-Martinez, & Medrano, 2018; Westhoff-Bleck et al., 2019). The MMPI was developed empirically, meaning Multiple recent studies have found that the first that a large group of possible inventory items was edition of the BDI provides high levels of discrimina- given to psychologically “healthy” people and to peo- tion for depressive symptomatology and that the BDI- ple with various psychological problems. The items II is an effective screening tool in predicting and that reliably differentiated groups of people were in- detecting major depressive disorder. While the BDI cluded in the inventory. should not be used as a singular diagnostic measure, it The validity of test interpretation relies heavily on is extremely quick and easy to administer and has good examinees’ efforts to be genuine and forthcoming in test-retest reliability (Westhoff-Bleck et al., 2019). their responses and can be completely invalidated by Clinicians treating depressed people also use the feigning or intentional over-reporting or fabrication of BDI to monitor those individuals’ symptom levels symptoms and clinical characteristics. Four validity from week to week. An individual may be asked to scales assess the person’s general test-taking attitude complete the BDI at the beginning of each therapy and whether they answered the items on the test in a session, and both the individual and the clinician then truthful and accurate manner. A respondent’s scores have a concrete indicator of any changes in symptoms. on each scale are compared with scores from the pop- ulation, and a profile of the respondent’s personality and psychological problems is derived (Sharf et al., Personality Inventories 2017). Also, these validity scales determine whether Personality inventories are questionnaires designed to the person responds honestly to the items on the scale assess people’s typical ways of thinking, feeling, and or distorts his or her answers in a way that might in- behaving. These inventories are used as part of an as- validate the test (Table 2). For example, the Lie Scale sessment procedure to obtain information on people’s measures the respondent’s tendency to respond to well-being, self-concept, attitudes and beliefs, ways of items in a socially desirable way in order to appear coping, perceptions of their environment, social re- unusually positive or good (Sharf et al., 2017). sources, and vulnerabilities. Because the items on the MMPI were chosen for The most widely used personality inventory in their ability to differentiate people with specific types professional clinical assessments is the Minnesota Mul- of psychological problems from people without psy- tiphasic Personality Inventory (MMPI), which has been chological problems, the concurrent validity of the translated into more than 150 languages and is used in MMPI scales was “built in” during their development. more than 50 countries (Groth-Marnat & Wright, The MMPI may be especially useful as a general 2016). The original MMPI was developed in the 1930s screening device for detecting people who are func- by Starke Hathaway and Charnley McKinley. In 1989, tioning very poorly psychologically. an updated version was published as the MMPI-2, fol- However, many criticisms have been raised about lowed by the MMPI-2-RF (MMPI-2 Restructured the use of the MMPI in culturally diverse samples Form) in 2008. The failure to update the test for ­several (Groth-Marnat & Wright, 2016). The norms for the  Assessment Tools 67 TABLE 2 Clinical and Validity Scales of the Original MMPI The MMPI is one of the most widely used questionnaires for assessing people’s symptoms and personalities. It also includes scales to assess whether respondents are lying or trying to obfuscate their answers. CLINICAL SCALES Scale Number Scale Name What It Measures Scale 1 Hypochondriasis Excessive somatic concern and physical complaints Scale 2 Depression Symptomatic depression Scale 3 Hysteria Hysterical personality features and tendency to develop physical symptoms under stress Scale 4 Psychopathic deviate Antisocial tendencies Scale 5 Masculinity-femininity Sex-role conflict Scale 6 Paranoia Suspicious, paranoid thinking Scale 7 Psychasthenia Anxiety and obsessive behavior Scale 8 Schizophrenia Bizarre thoughts and disordered affect Scale 9 Hypomania Behavior found in mania Scale 0 Social introversion Social anxiety, withdrawal, overcontrol VALIDITY SCALES Scale Name What It Measures Cannot say scale Total number of unanswered items Lie scale Tendency to present favorable image Infrequency scale Tendency to falsely claim psychological problems Defensiveness scale Tendency to see oneself in unrealistically positive manner Source: Adapted from Minnesota Multiphasic Personality Inventory (MMPI). original MMPI—the scores considered “healthy”— child interact with other children to determine what were based on samples of people in the United States situations provoke aggression in the child. The clini- not drawn from a wide range of ethnoracial back- cian can then use information from behavioral obser- grounds, age groups, and social classes. In response to vation to help the child learn new skills, stop negative this problem, the publishers of the MMPI established habits, and understand and change how he or she re- new norms based on more representative samples of acts to certain situations. A couple seeking marital eight communities across the United States. Still, con- therapy might be asked to discuss with each other a cerns persist that the MMPI norms do not reflect topic on which they disagree. The clinician would ob- variations across cultures in what is considered nor- serve this interaction, noting the specific ways the mal or abnormal. In addition, some question the lin- couple handles conflict. For example, one member of guistic accuracy of the translated versions of the the couple may lapse into statements that blame the MMPI and the comparability of these versions to the other member for problems in their marriage, escalat- English version (Dana, 2005). Ideally, the MMPI-2 ing conflict to the boiling point. should be administered as a part of a battery of psy- Direct behavioral observation has the advantage of chological tests, so that other testing can either con- not relying on individuals’ reporting and interpretation firm or deny results suggested by the MMPI-2. of their own behaviors. Instead, the clinician sees first- hand how the individuals handle important situations. Behavioral Observation One disadvantage is that individuals may alter their be- havior when they are being watched. Another disadvan- and Self-Monitoring tage is that different observers may draw different Clinicians often will use behavioral observation of in- conclusions about individuals’ skills; that is, direct be- dividuals to assess deficits in their skills or their ways havioral observations may have low interrater reliability, of handling situations. The clinician looks for specific especially in the absence of a standard means of making behaviors and what precedes and follows these the observations. In addition, any individual rater may behaviors. For example, a clinician might watch a miss the details of an interpersonal interaction. For 68 Chapter 3 Assessing and Diagnosing Abnormality e­ xample, two raters watching a child play with others on with important information that can be used in the a playground might focus on different aspects of the diagnostic process. Defining and classifying intelli- child’s behaviors or be distracted by the chaos of the gence is a complicated process and there is no one playground. For these reasons, when behavioral obser- explanation that is used as a benchmark. Theories of vation is used in research settings, the situations are intelligence range from having one general intelli- highly standardized and observers watch for a set list of gence, such as (g), to certain primary mental abilities, behaviors. Finally, direct observation may not be possi- and to multiple category-specific intelligences. ble in some situations. In that case, a clinician may have In clinical practice, intelligence tests are used to de- a client role-play a situation, such as the client’s interac- termine an individual’s level of cognitive functioning, tions with an employer. and consists of a series of tasks that involve both verbal Since mental health professionals cannot be with and nonverbal skills (Bridley & Daffin, 2018). Studies clients every day, clinicians may require self-monitoring on these tests have shown that they are generally reliable to gather information about the individual’s behavior. and valid tools of measurement. However, these instru- Traditionally, assessment of psychiatric symptoms ments have been criticized as lacking cultural specificity relies on the client’s retrospective report to a trained with bias in favor of White, middle-class people. It is hy- interviewer. However, with the emergence of smart- pothesized that this can evoke stereotype threat among phones there are new and innovative ways for client’s people of color due to implied negative stereotypes to self-monitor. For example, recent studies have about a person’s culture, gender, or age which causes examined the use of self-monitoring of mood using doubt about his or her abilities, resulting in lower scores. Patient Reported Outcome Measures (PROMs) which Despite these concerns, when working with children in previously was performed by using paper-based and educational and developmental settings, intelligence more recently computer-based questionnaires. The testing is still a central component of how children are widespread access to mobile networks and the rapid assessed. The results of such testing are used to inform evolution of smartphone technology have led to an recommendations for educational and service-based in- increased focus on the use of smartphone applica- terventions and programming (Forscher et al., 2019; tions for this process with promising results (Schwartz, Freeman & Chen, 2019; Ruhl, 2020). Schultz, Rieder, & Saunders, 2016). These tests were designed to measure basic intel- Smartphone-based questionnaires are a viable ap- lectual abilities, such as the ability for abstract reason- proach that can be effectively used in long-term daily ing, verbal fluency, and spatial memory. The term IQ, self-monitoring. This approach has advantages because or intelligence quotient, is used to describe a method of behaviors such as social interaction, physical motion, comparing an individual’s score on an intelligence test speech, travel pattern data, and mood states can be re- with the performance of individuals in the same age ported in real time without the inconvenience of log- group. An IQ score of 100 means that the person per- ging to a computer. Studies show high levels of formed similarly to the average performance of other compliance of self-monitoring through smartphone people of the same age. apps which increases the likelihood that self-ratings Intelligence tests are controversial in part because would be less prone to recall bias. Active real-time mon- there is little consensus as to what is meant by intelli- itoring through time-stamped prompts have also been gence (Sternberg, 2015). The most widely used intel- noted; however, there are few validated self-report mea- ligence tests assess verbal and analytical abilities but sures designed for this purpose and more research is do not assess other talents or skills, such as artistic needed (Tsanas et al., 2016). Like any self-report assess- and musical ability. Some psychologists suggest that ment, self-monitoring is open to biases about what indi- success in life is as strongly influenced by social skills viduals notice about their and other talents not measured by intelligence tests as behavior and are willing to it is by verbal and analytic skills. It is further argued report. However, individuals that characteristics such as social skill, artistic ability, can discover the triggers of and physical movement are themselves forms of intel- unwanted behaviors through ligence. A highly accomplished politician with keen self-monitoring, which in people skills but with limited skills in mathematics, turn can lead them to change for example, would be considered quite intelligent these behaviors. (Gardner, 2008; Sternberg, 2015). Another important criticism of intelligence tests is that they are biased in favor of middle- and upper-class, Intelligence Tests educated individuals because such people are more fa- Assessing an individual’s miliar with the kinds of reasoning assessed on the tests Smartphone apps are becoming a new and effective level of intelligence provides (Sternberg, 2015). In addition, educated European way to self-monitor. Tolgart/iStock/Getty Images mental health professionals Americans may be more comfortable taking intelligence  Assessment Tools 69 tests, because testers often are also European Americans  he Bender-Gestalt Test. On the left are the figures T and the testing situation resembles testing situations in FIGURE 3 as presented to the clients. On the right are the their educational experience. In contrast, different cul- figures as copied by a child with a brain tumor that is tures within the United States and in other countries creating perceptual-motor difficulties. may emphasize forms of reasoning other than those as- sessed on intelligence tests, and members of these cul- tures may not be comfortable with the testing situation. A “culture-fair” test would have to include items that are equally applicable to all groups or that are different for each culture but psychologically equiva- lent for the groups being tested. Attempts have been made to develop culture-fair tests, but the results have been disappointing. Even if a universal test were cre- ated, making statements about intelligence in differ- ent cultures would be difficult because different nations and cultures vary in the emphasis they place on “intellectual achievement.” Neuropsychological Tests If the clinician suspects neurological impairment in a person, neuropsychological tests may be useful in de- Sattler, J. M. Foundations of Behavioral, Social and Clinical Assessment of Children, tecting specific cognitive deficits such as a memory 6th Edition, Figure 12-1, 399. Copyright © 2014 by Jerome M. Sattler, Publisher, Inc. All rights reserved. Used with permission. problem, as seen in cases of dementia. One frequently used neuropsychological test is the Bender-Gestalt Test (Bender, 1938). This paper-and-pencil test as- sesses individuals’ sensorimotor skills by having them Computerized tomography (CT) is an enhance- reproduce a set of nine drawings (Figure 3). People ment of X-ray procedures. In CT, narrow X-ray beams with brain damage may rotate or change parts of the are passed through the person’s head in a single plane drawings or be unable to reproduce the drawings. from a variety of angles. The amount of radiation ab- When asked to remember the drawings after a delay, sorbed by each beam is measured, and from these they may show significant memory deficits. The measurements a computer program constructs an im- Bender-Gestalt Test appears to be good at differentiat- age of a slice of the brain. By taking many such im- ing people with brain damage from those without ages, the computer can construct a three-dimensional brain damage, but it does not reliably identify the spe- image showing the brain’s major structures. A CT cific type of brain damage a person has (Groth-Marnat scan can reveal brain injury, tumors, and structural & Wright, 2016). abnormalities. The two major limitations of CT tech- More extensive batteries of tests have been devel- nology are that it exposes patients to X-rays, which oped to pinpoint types of brain damage. Two of the can be harmful, and that it provides an image of brain most popular batteries are the Halstead-Reitan Test structure rather than brain activity. (Reitan & Davidson, 1974) and the Luria-Nebraska Positron-emission tomography (PET) can provide Test (Luria, 1973). These batteries contain several a picture of activity in the brain. PET requires inject- tests that provide specific information about an indi- ing the patient with a harmless radioactive isotope, vidual’s functioning in several skill areas, such as con- such as fluorodeoxyglucose (FDG). This substance centration, dexterity, and speed of comprehension. travels through the blood to the brain. The parts of the brain that are active need the glucose in FDG for nu- Brain-Imaging Techniques trition, so FDG accumulates in active parts of the Increasingly, neuropsychological tests are being used brain. Subatomic particles in FDG called positrons with brain-imaging techniques to identify specific def- are emitted as the isotope decays. These positrons col- icits and possible brain abnormalities. Clinicians use lide with electrons, and both are annihilated and con- brain imaging to determine if a patient has a brain in- verted to two photons traveling away from each other jury or tumor. Researchers use brain imaging to search in opposite directions. The PET scanner detects these for differences in brain activity or structure between photons and the point at which they are annihilated people with a psychological disorder and people with and constructs an image of the brain, showing those no disorder. Let us review existing brain-imaging tech- areas that are most active. PET scans can be used to nologies and what they can tell us now. show differences in the activity level of specific areas 70 Chapter 3 Assessing and Diagnosing Abnormality (EEG) measures electrical activity along the scalp produced by the firing of specific neurons in the brain. EEG is used most often to detect seizure activity in the brain and can also be used to detect tumors and stroke. EEG patterns recorded over brief periods (such as ½ second) in response to specific stimuli, such as the individual’s viewing of an emotional picture, are referred to as evoked potentials or event- related potentials. Clinicians can compare an individu- al’s response to the standard response of healthy individuals. Heart rate and respiration are highly responsive to stress and can be easily monitored. Sweat gland activity, known as electrodermal response (formerly called galvanic skin response), can be assessed with a device that detects electrical conductivity between CT scans can detect structural abnormalities such two points on the skin. Such activity can reflect emo- as brain tumors. Puwadol Jaturawutthichai/Alamy Stock tional arousal. Psychophysiological measures are Photo used to assess people’s emotional response to spe- cific types of stimuli, such as the responses a veteran with posttraumatic stress disorder might have to of the brain between people with a psychological dis- scenes of war. order and people without a disorder. Another procedure to assess brain activity is sin- gle photon emission computed tomography, or SPECT. Projective Tests The procedures of SPECT are much like those of PET A projective test is based on the assumption that when except that a different tracer substance is injected. It is people are presented with an ambiguous stimulus, less accurate than PET but also less expensive. such as an oddly shaped inkblot or a captionless pic- Magnetic resonance imaging (MRI) has several ture, they will interpret the stimulus in line with their advantages over CT, PET, and SPECT technology. It current concerns and feelings, relationships with oth- does not require exposing the patient to any radiation ers, and conflicts or desires. People are thought to or injecting radioisotopes, so it can be used repeatedly project these issues onto their description of the “con- for the same individual. It provides much more finely tent” of the stimulus—hence the name “projective detailed pictures of the anatomy of the brain than do tests.” Proponents of these tests argue that they are other technologies, and it can image the brain at any useful in uncovering the unconscious issues or mo- angle. Structural MRI provides static images of brain tives of a person or in cases when the person is resis- structure. Functional MRI (fMRI) provides images of tant or is heavily biasing the information he or she brain activity. presents to the assessor. Two of the most frequently MRI involves creating a magnetic field around the used projective tests are the Rorschach Inkblot Test brain that causes a realignment of hydrogen atoms in and the Thematic Apperception Test (TAT). the brain. When the magnetic field is turned off and Upon hearing the word Rorschach, people are on, the hydrogen atoms change position, causing them likely to think of ambiguous shapes or inkblots. One to emit magnetic signals. These signals are read by a person may see a bat, while another may see a bird. computer, which reconstructs a three-dimensional We’ve all seen references to the the Rorschach Inkblot image of the brain. To assess activity in the brain, many Test, commonly referred to as the Rorschach, in mov- images are taken only milliseconds apart, showing how ies and media for decades. This test was developed in the brain changes from one moment to the next or in 1921 by Swiss psychiatrist Hermann Rorschach and response to some stimulus. Researchers are using MRI consists of 10 cards, each containing a symmetrical to study structural and functional brain abnormalities inkblot in black, gray, and white in color. The trained in almost every psychological disorder. examiner tells the respondent something like “People may see many different things in these inkblot pic- Psychophysiological Tests tures; now tell me what you see, what it makes you Psychophysiological tests are alternative methods to think of, what it means to you” (Exner et al., 2008). CT, PET, SPECT, and MRI used to detect changes in This is a test in which subjects’ perceptions of inkblots the brain and nervous system that reflect emotional are recorded and then analyzed using psychological and psychological changes. An electroencephalogram interpretation.  Challenges in Assessment 71 The basic idea behind this test is the client will responses to the TAT cards. Some cards may stimu- project unconscious aspects of their personality by late more emotional responses than others or no re- giving meaning to ambiguous images. Clinicians are sponse at all. These cards are considered to tap the interested in both the content and the style of the individuals’ most important concerns. individual’s responses to the inkblot. In the content Clinicians operating from psychodynamic per- of responses, clinicians look for particular themes spectives value projective tests as tools for assessing or concerns, such as frequent mention of aggression the underlying conflicts and concerns that individu- or fear of abandonment. Important stylistic features als cannot or will not report directly. Clinicians oper- may include the person’s tendency to focus on small ating from other perspectives question the usefulness details of the inkblot rather than the inkblot as a of these tests. The validity and reliability of all the whole or hesitation in responding to certain inkblots projective tests have not proven strong in research (Exner et al., 2008). A meta-analysis of the Ror- (Groth-Marnat & Wright, 2016; Mihura, Meyer, Du- schach test recently found that the variables that mitrascu, & Bombel, 2013). In addition, because provided the strongest empirical support were those these tests rely so greatly on subjective interpreta- related to perceptual processes (Yazigi et al., 2016). tions by clinicians, they are open to a number of bi- Since its conception, this test has been sur- ases. Finally, the criteria for interpreting the tests do rounded by controversy with researchers questioning not take into account an individual’s cultural back- whether the Rorschach is a useful and valid tool for ground (Dana, 2005). clinicians. For some, this method is a sensitive and accurate tool for showing the inner workings of the mind and detecting a range of mental conditions, in- CHALLENGES cluding latent problems that other tests or direct ob- IN ASSESSMENT servation cannot reveal. While some critics refer to this test as pseudoscience that lacks scientific reliabil- Some challenges that arise in assessing psychological ity and validity. Psychologists have argued the psy- problems is the individual’s inability or unwillingness chologist administering the test can also project his or to provide information. In addition, special challenges her unconsciousness on to the inkblots when inter- arise when evaluating children and people from cul- preting responses, this creating a biased interpreta- tures different from that of the assessor. tion. For example, if the person being tested sees a bra, a male psychologist might classify this as a sexual Resistance to Providing response, whereas a female psychologist may classify Information it as clothing. Critics of the test also suggest a lack of reliability as it is possible for two different testers to One of the greatest challenges to obtaining valid infor- create two different personality profiles for the same mation from an individual can be his or her resistance person. The Rorschach has also been criticized for its to providing information. Sometimes the person does validity. Does the test measure what it is supposed to not want to be assessed or treated. For example, when measure? Rorschach was clear that his test measured a teenager is forced to see a psychologist because of disordered thinking (as found in schizophrenia) and parental concern about his behavior, he may be resis- this has never been disputed. But whether it accurately tant to providing any information. Because much of measures personality as well is up for debate (Searls, the information a clinician needs must come directly 2017). from the person being assessed, resistance can pres- The results of the Rorschach test are not cut-and- ent a formidable problem. dried, like an IQ or blood test. But, then again, how Even when a person is not completely resistant can the complexities of the human mind ever be re- to being assessed, he or she may have a strong inter- duced to one simple score? Like other assessments, est in the outcome of the assessment and therefore no one tool should be used solely to make diagnostic may be highly selective in the information he or she decisions. These assessments are best used in combi- provides, may bias his or her presentation of the in- nation with other instruments and clinical expertise to formation, or may even lie to the assessor. Such best service the client. problems often arise when assessments are part of a The TAT consists of a series of pictures. The indi- legal case, as when parents are fighting for custody vidual is asked to make up a story about what is hap- of their children in a divorce. When speaking to psy- pening in the pictures (Murray, 1943). Proponents of chologists who have been appointed to assess fitness the TAT argue that people’s stories reflect their con- for custody of the children, each parent will want to cerns and wishes as well as their personality traits and present himself or herself in the best light and also motives. As with the Rorschach, clinicians are inter- may negatively bias his or her reports on the other ested in both the content and the style of people’s parent. 72 Chapter 3 Assessing and Diagnosing Abnormality Evaluating Children changes in the child’s behavior and corresponding events in the child’s life. A researcher studying chil- Consider the following conversation between a mother dren’s functioning may ask parents to complete ques- and her 5-year-old son, Jonathon, who was sent home tionnaires assessing the children’s behavior in a from preschool for fighting with another child. variety of settings. Parental perception and awareness about psycho- Mom: Jonathon, why did you hit that boy? logical illness in children and adolescents is an impor- Jonathon: I dunno. I just did. tant determinant of early detection and treatment (Abera, Robins, & Tesfaye, 2015). Because parents Mom: But I want to understand what happened. typically spend more time with their child than any Did he do something that made you mad? other person does, they potentially have the most Jonathon: Yeah, I guess. complete information about the child’s functioning and the best sense of how the child’s behavior has or Mom: What did he do? Did he hit you? has not changed over time. Unfortunately, however, Jonathon: Yeah. parents are not always accurate in their assessments of their children’s functioning. One study found that Mom: Why did he hit you? in 63 percent of cases, parents and children disagreed Jonathon: I dunno. He just did. Can I go now? on what problems had brought the child to a psychiat- ric clinic (Yeh & Weisz, 2001). Parents’ perceptions Mom: I need to know more about what happened. of their children’s well-being can be influenced by (Silence) their own symptoms of psychopathology and by their Mom: Can you tell me more about what happened? expectations for their children’s behavior (Keeton, Jonathon: No. He just hit me and I just hit him. Teetsel, Dull, & Ginsburg, 2015; Nock & Kazdin, Can I go now? 2001). Indeed, parents sometimes take children for assessment and treatment of psychological problems Anyone who has tried to have a conversation with as a way of seeking treatment for themselves. a distressed child about why he or she misbehaved has Parents may also suffer from a psychological dis- some sense of how difficult it can be to engage a child order or exhibit psychological dysfunction that can in a discussion about emotions or behaviors. Even have a direct impact on the behavioral issues displayed when a child talks readily, his or her understanding of by the child. As a result, they may be unwilling to ac- the causes of his or her behaviors or emotions may knowledge or seek help for the child’s difficulties. Nu- not be very well developed. Children, particularly pre- merous studies support the notion that parental school-age children, cannot describe their feelings or psychological well-being influences the overall mental associated events as easily as adolescents or adults health of the child (Breaux, Harvey, & Lugo-Candelas, can. Young children cannot express in words whether 2014). For example, the children of anxious parents they feel afraid, overwhelmed, or helpless. However, often display more psychological dysfunction such their behaviors provide parents, families, and profes- as, fears or worries, lower perceptions of control, be- sional with important clues about how they are af- havioral inhibition, insecure attachments, and social fected. Young children may not differentiate among isolation relative to their peers. There is also evidence different types of emotions—often just saying that they of deficits in academic and social functioning. Studies feel “bad.” When distressed, children may talk about that examined parental self-reports suggest that psy- physical aches and pains rather than the emotional chopathology symptoms may play a role in the prog- pain they are feeling. Or a child might show distress nosis of behavioral, social, and emotional outcomes only in nonverbal behavior, such as making a sad face, of children with behavior problems (Breaux et al., withdrawing, or behaving aggressively, adolescents 2014; Keeton et al., 2015). may become disruptive, withdrawn, or resistant to au- Parents with mental health issues can not only thority (NCTSN, 2010; National Scientific Council negatively impact the development of their child’s on the Developing Child, 2005/2014). mental health, but also keep them from receiving the These problems with children’s self-reporting of assessment, diagnosis, and treatment that they need. emotional and behavioral concerns have led clinicians Resistance to mental health services is often a reflec- and researchers to rely on other people, usually adults tion of a parental attitudes that has been shown to in the children’s lives, to provide information about influence help-seeking decisions. Additionally, beliefs children’s functioning. Parents are often the first that mental health problems are caused by child’s per- source of information about a child’s functioning. A sonality or relational issues, negative perceptions of clinician may interview a child’s parents when the mental health services, and perceived stigma associ- child is taken for treatment, asking the parents about ated with mental health problems have all been  Challenges in Assessment 73 associated with reduced help-seeking behavior (Rear- including parents and trained clinicians (De Los don et al., 2017). Reyes et al., 2015). Such discrepancies may arise be- Culture is a critical factor when discussing paren- cause these other adults are providing invalid assess- tal assessment of their child’s behavior and decision ments of the children whereas the teachers are to seek out mental health services since such wide providing valid assessments. The discrepancies may variation exists among different groups. For example, also arise because children function differently in dif- Eastern cultures place a strong emphasis on interde- ferent settings. At home, a child may be well behaved, pendence and a child’s obligation to, and reliance on, quiet, and withdrawn, while at school the same child his or her family. These various practices among cul- may be impulsive, easily angered, and distractible. tures impact how abnormal behavior is defined and can be seen as undesirable in one culture, but very Evaluating Individuals Across desirable in another. For example, enmeshment be- tween a mother and child is endorsed in Japan, such Cultures that overt displays of clinginess and neediness are A number of challenges to assessment arise when considered adaptive. Socially anxious behaviors such there are significant cultural differences between the as being shy, timid, and reserved are viewed favorably client and the therapist (Dana, 2005; Paniagua & in Asian countries, and sleeping with a parent is a Yamada, 2013). Mental health treatments have been common and socially acceptable practice in Vietnam, shown to be more effective when therapists demon- Thailand, India, Indonesia, Japan, and China. West- strate multicultural competence and the treatment ern mothers attributed a child’s proximity-seeking and aligns with their culture (Soto, Smith, Griner, Rodri- demanding behaviors to attention seeking and self- guez, & Bernal, 2018). Unfortunately, the diversity of interest, whereas Japanese mothers attributed them to clinician identities continues to lag behind the general a need for security and interdependence. Taken to- population, leading to frequent cultural mismatching gether, these findings suggest that Asian parents may in patient/clinician relationships. When this occurs, be less likely to pathologize certain behaviors than the likelihood for miscommunication and subpar parents from Western cultures (Nguyen & McAloon, treatment increases, worsening the health disparities 2018). that already exist between these marginalized popula- Additionally, even if the family believes the child’s tions and the dominant cultural groups (Dominguez, behaviors is disruptive or unwanted, the decision to 2017). For example, racialized clients are less likely than seek out services remains influenced by one’s culture. White patients to state concerns, seek information, or Researchers have focused on identifying the factors feel trust, thereby decreasing the likelihood of im- that best predict access to mental health services provement in treatment (Alegria, Nakash, & Johnson, since many children and adolescents are still in need 2018). Additionally, research has shown that there is of assistance. Family and child characteristics, includ- underutilization of mental health care among several ing ethnoracial, family socioeconomic, and insurance ethnoracial groups across the lifespan (Liang, Matheson, status, living in an urban or rural area, and severity of & Douglas, 2016). the child’s problems have all been implicated in A lack of culturally competent professionals also ­determining the likelihood of service utilization. leads to disparities in diagnostic rates and ultimately ­Overall, studies suggest that being White, having in- treatments outcomes. Studies have shown that chil- surance coverage (in the USA), living in an urban dren from racialized groups receive poorer quality area, and having a child with more severe mental mental health care than their White counterparts. Ad- health problems increases the likelihood of a family ditionally, recent research found that mental health accessing treatment. Barriers to treatment reported by professionals (psychiatrists, social workers, psycholo- parents include concerns about the effectiveness or gists) were more likely to assign a diagnosis to White negative consequences of treatment, feeling blamed youth as compared to African American or Latinx for the child’s issues, the detrimental impact of per- youth. Racialized groups and people of color (POC) ceived negative attitudes of others, as well as personal more often receive diagnoses of disruptive- or conduct-­ discomfort surrounding mental health (Reardon et al., related disorders than White individuals (Liang et al., 2017). 2016). Additional cultural factors, such as symptom Teachers also provide information about chil- presentation and figurative expressions of distress, dren’s functioning. Teachers and other school person- among others, may influence how parents recognize nel (such as guidance counselors and coaches) are and report their problems, which may influence often the first to recognize that a child has a problem ­diagnoses. and to initiate an intervention to address the problem. Cultural biases can arise when everyone suppos- Teachers’ assessments of children, however, are often edly is speaking the same language but has a unique different from the assessments made by other adults, cultural background. There is evidence that African 74 Chapter 3 Assessing and Diagnosing Abnormality clinician’s culture. We discuss examples of cultural differences in the presentation of symptoms through- out this book. One of the most pervasive differences is in whether cultures experience and report psycho- logical distress in emotional or somatic (physical) symptoms. European Americans tend to view the body and mind separately, whereas many other cul- tures do not make sharp distinctions between the ex- periences of the body and those of the mind (Paniagua & Yamada, 2013). Following a psychologically dis- tressing event, European Americans tend to report that they feel anxious or sad, but members of many other cultures tend to report having physical aches Cultural differences between clients and clinicians can lead and maladies. To conduct an accurate assessment, to misinterpretations of clients’ problems. LightField Studios/ clinicians must be aware of cultural differences in the Shutterstock manifestation of disorders and in the presentation of symptoms, and they must use this information cor- Americans in the United States are over-diagnosed as rectly in interpreting the symptoms individuals re- having symptoms of schizophrenia (Neighbors, Trier- port. Cultural differences are further complicated by weiler, Ford, & Muroff, 2003). Some investigators be- the fact that not every member of a culture conforms lieve that cultural differences in the presentation of to what is known about that culture’s norms. Within symptoms play a role (Kirmayer, 2001). African every culture, people differ in their acceptance of Americans may present more intense symptoms than cultural norms for behavior. European Americans, and these symptoms then are misunderstood by European American assessors as DIAGNOSIS representing more severe psychopathology. Some Eu- Recall that a diagnosis is a label we attach to a set ropean American assessors may be too quick to diag- of symptoms that tend to occur together. This set of nose psychopathology in African Americans because symptoms is called a syndrome. Typically, several of negative stereotypes. symptoms make up a syndrome, but people differ in Even when clinicians avoid all these biases, they which of these symptoms will be most prominent. are still left with the fact that people from other Some of the symptoms that make up the syndrome we cultures often think and talk about their psychologi- call depression include sad mood, loss of interest in cal symptoms differently than do members of the one’s usual activities, sleeplessness, difficulty concen- trating, and thoughts of death. But not everyone who becomes depressed experiences all these symptoms— Syndromes as Clusters of Symptoms. Syndromes FIGURE 4 for example, some people lose interest in their usual are clusters of symptoms that frequently co-occur. activities but never really feel sad or blue, and only a The symptoms of one syndrome, such as symptoms subset of depressed people have prominent thoughts of depression, can overlap the symptoms of another syndrome, such of death. as symptoms of anxiety. Syndromes are not lists of symptoms that all peo- ple have all the time if they have any of the symptoms at all. Rather, they are lists of symptoms that tend to Symptoms of Symptoms of co-occur within individuals. The symptoms of one depression anxiety syndrome may overlap those of another. Figure 4 shows the overlap in the symptoms that make up de- Depressed mood Fatigue Excessive worry pression (see the chapter “Mood Disorders and Loss of interest Sleep Restlessness Suicide”) and anxiety (see the chapter “Anxiety, Weight loss disturbances Irritability Obsessive-Compulsive, Trauma, and Stressor-Related Worthlessness, guilt Concentration Muscle tension Disorders”). Both syndromes include the symptoms problems Suicidal thoughts fatigue, sleep disturbances, and concentration prob- lems. However, each syndrome has symptoms more specific to it. For centuries, people have tried to organize the confusing array of psychological symptoms into a limited set of syndromes. A set of syndromes and the  Diagnosis 75 rules for determining whether an individual’s symp- existing disorders the theoretical framework remained toms are part of one of these syndromes constitute a resulting in the low reliability of the diagnoses. For classification system. example, one study found that four experienced clini- One of the first classification systems for psycho- cians using the first edition of the DSM to diagnose logical symptoms was proposed by Hippocrates in the 153 patients agreed on their diagnoses only 54 percent fourth century bce. Hippocrates divided all mental of the time (Beck, Ward, Mendelson, Moch, & disorders into mania (states of abnormal excitement), Erbaugh, 1962). This low reliability eventually led psy- melancholia (states of abnormal depression), para- chiatrists and psychologists to call for a radically new noia, and epilepsy. In 1883, Emil Kraepelin published system of diagnosing mental disorders. the first modern classification system, which is the basis of our current systems. Current systems divide DSM-III, DSM-IIIR, DSM-IV, DSM-IV-TR, DSM-5 the world of psychological symptoms into a much and DSM-5-TR larger number of syndromes than did Hippocrates. In response to the concerns about the reliability of We will focus on the classification system most widely disorders outlined in DSM-I and DSM-II, the American used in the United States, the Diagnostic and Statistical Psychiatric Association published the DSM-III in 1980. Manual of Mental Disorders, or DSM. The classifica- This third edition was followed in 1987 by a revised tion system used in Europe and much of the rest of third edition, known as DSM-III-R, and in 1994 by the world, the International Classification of Disease a fourth edition, known as DSM-IV, revised as DSM- (ICD), has many similarities to the most recent edi- IV-TR in 2000. These newer editions improved diagno- tions of the DSM (Clark, Cuthbert, Lewis-Fernández, sis by replacing the vague descriptions of disorders Narrow, & Reed, 2017). with specific and concrete criteria for each disorder. These criteria are in the form of behaviors people Diagnostic and Statistical Manual must show or experience, or feelings they must report, in order to be given a diagnosis. of Mental Disorders (DSM) The DSM authors focused on making the criteria For more than 60 years, the official manual for diag- for each disorder as descriptive as possible for profes- nosing psychological disorders in the United States sionals to best identify symptoms of these various dis- has been the Diagnostic and Statistical Manual of orders. As a result, each disorder is defined by a set of Mental Disorders of the American Psychiatric Asso- diagnostic criteria and text containing information ciation (APA) now in the fifth edition, with text revised about the disorder. A good example is the diagnostic (2022), known as DSM-5-TR. The development of a criteria for panic disorder, which are given in Table 3. classification system was motivated by professionals A person must have 4 of 13 possible symptoms as well to improve communication about the types of pa- as meet other criteria in order to be diagnosed with tients that were cared for in hospitals. The DSM has panic disorder. These criteria reflect the fact that not drastically changed since the first edition which was all the symptoms of panic disorder are present in ev- published in 1952 and contained the 60 psychologi- ery individual. cal disorders. The DSM has evolved since that time There are two other elements that distinguish the through four major revisions into the classification latter editions of the DSM from their predecessors. system for psychiatrists, physicians and mental First, the later editions specify how long a person health professionals that describe the critical fea- must show symptoms of the disorder in order to be tures of mental disorders (American Psychiatric given the diagnosis (see Table 3, item B). Second, the Association, 2022). criteria for most disorders require that symptoms in- This classification system will always reflect the terfere with occupational or social functioning. This time in which is it designed and utilized. This also emphasis on symptoms that are long-lasting and se- makes it a system that will never be complete and revi- vere reflects the consensus among psychiatrists and sions are a necessity. Early editions of this system psychologists that abnormality should be defined in (DSM-I and DSM-II) reflect the heavy influence of the terms of the impact of behaviors on the individual’s psychoanalytic theory, which was widely popular at ability to function and on his or her sense of well-be- that time. As subsequent research learned more about ing (see the chapter “Looking at Abnormality”).