Chapter 3

Question 1

Clinical assessment

Answer 1

Clinical assessment is the systematic evaluation and measurement of psychological, biological, and social factors in an individual presenting with a possible psychological disorder.

Question 2

Diagnosis

Answer 2

Diagnosis is the process of determining whether the particular problem afflicting the individual meets the criteria for a psychological disorder, as set forth in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, or DSM-5

Question 3

Reliability

Answer 3

Reliability is the degree to which a measurement is consistent

We expect, in general, that presenting the same symptoms to different physicians will result in similar diagnoses. One way psychologists improve their reliability is by carefully designing their assessment devices and then conducting research on them to ensure that two or more raters will get the same answers (called interrater reliability). They also determine whether these techniques are stable across time. In other words, if you go to a clinician in March and are told you have an IQ of 110, you should expect a similar result if you take the same test again in April. This is known as test-retest reliability.

Question 4

Validity

Answer 4

Validity is whether something measures what it is designed to measure; in this case, whether a technique assesses what it is supposed to (Asmundson et al., 2002). Comparing the results of one assessment measure with the results of others that are better known allows you to begin to determine the validity of the first measure. This comparison is called concurrent validity. For example, if the results from a standard but very long IQ test were essentially the same as the results from a new brief version, you could conclude that the brief version had concurrent validity. Predictive validity is how well your assessment tells you what will happen in the future. For example, does it predict who will succeed in school and who will not (which is one goal of an IQ test)?

Question 5

Standardization

Answer 5

Standardization is the process by which a certain set of standards or norms is determined for a technique to make its use consistent. The standards might apply to the procedures of testing, scoring, and evaluating data. To illustrate, the assessment might be given to large numbers of people who differ on important factors, such as age, race, gender, socioeconomic status, and diagnosis; their scores would then be used as a standard, or norm, for comparison purposes. For example, if you are a recently immigrated male, 19 years old, and from a middle-class background, your score on a psychological test should be compared with the scores of others like you and not with the scores of very different people, such as a group of Canadian women of Asian descent in their 60s from working- class backgrounds. Reliability, validity, and standardization are important to all forms of psychological assessment

Question 6

Clinical assessment consists of strategies and procedures that help clinicians acquire the information they need to understand their patients and assist them.

Answer 6

These procedures include a clinical interview and, within the context of the interview, a mental status exam that can be administered either formally or informally, often a thorough physical examination, behavioural observation and assessment, and psychological tests (if needed).

Question 7

The Clinical interview

Answer 7

The clinical interview, the core of most
clinical work, is used by psychologists,
psychiatrists, and other mental health
professionals. The interview gathers information on current and past behaviour, attitudes, and emotions, as well as a detailed history of the individual’s life in general and of the presenting problem. Clinicians determine when the specific problem first started and identify other events (e.g., life stress, trauma, physical illness) that might have occurred about the same time. In addition, most clinicians gather at least some information on the patient’s current and past interpersonal and social history, including family makeup (e.g., marital status, number of children, student currently living with parents), and on the individual’s upbringing. Information on sexual development, religious attitudes (current and past), relevant cultural concerns (such as stress induced by discrimina- tion), and educational history are also routinely collected. To organize information obtained during an interview, many clinicians use a mental status exam.

Question 8

The Mental Status Exam

Answer 8

In essence, the mental status exam involves the systematic observation of somebody’s behaviour. In the mental status exam, clini- cians organize their observations in a way that gives them sufficient information to determine whether a psychological disorder might be present. For the most part, the exams are performed relatively quickly by experienced clinicians in the course of interviewing or observing a patient.

The exam covers five categories: appearance and behaviour, thought processes, mood and affect, intellectual functioning, and sensorium.

Appearance and behaviour. The clinician notes any overt physical behaviours, such as Frank’s leg twitch, as well as the individual’s dress, general appearance, posture, and facial expression. For example, very slow and effortful motor behaviour is sometimes referred to as psychomotor retardation and may indicate severe depression.

Thought processes. When clinicians listen to a patient talk, they’re getting a good idea of that person’s thought processes. They might look for several things here. For example, does the person talk really fast or really slowly? Does the patient make sense when he or she talks or are ideas presented with no apparent connection? In some patients with schizophrenia, a disjointed speech pattern, referred to as “looseness of association,” is quite noticeable. In addition to rate or flow and continuity of speech, what about the content? Is there any evidence of delusions (distorted views of reality)? A typical delusion involves delusions of persecution, where someone thinks people are after him and out to get him all the time. The individual might also have ideas of reference, where everything everyone else does somehow relates back to him. Hallucinations are things a person sees or hears but that really aren’t there. For example, the clinician might ask, “Do you ever see things or maybe hear things when you know there is nothing there?

Mood and affect. Mood is the predominant feeling state of the individual, as we noted in Chapter 2. Does the person appear to be down in the dumps or continually elated? Does she or he talk in a depressed or hopeless fashion? Are there times when the depression seems to go away? Affect, by contrast, refers to the feeling state that accompanies what we say at a given time. If a friend told you his or her mother has died and is laughing about it, or if your friend has just won the lottery and is sobbing, you would think it inconsistent. A mental health clinician would note that your friend’s affect is “inappropriate.”

Intellectual functioning. Clinicians make a rough estimate of others’ intellectual functioning just by talking to them. Do they seem to have a reasonable vocabulary? Can they talk in abstractions and metaphors (as most of us do much of the time)? How is the person’s memory? We usually make some gross or rough estimate of intelligence that is noticeable only if it deviates from normal, such as concluding the person is
above or below average intelligence.

Sensorium. Sensorium is our general awareness of our surroundings. Does the individual know what the date is, what time it is, where they are, who they are, and who you are? People with permanent brain damage or dysfunction—or temporary brain damage or dysfunction, often due to drugs or other toxic states—may not know the answer to these ques- tions. If the patient knows who he or she is and who the clinician is and has a good idea of the time and place, the clinician would say that the patient’s sensorium is “clear” and is “oriented times three” (to person, place, and time).

they allow the clinician to make a preliminary determination of which areas of the patient’s behaviour and condition should be assessed in more detail and perhaps more formally. If psychological disorders remain a possibility, the clinician may begin to hypothesize which disorders might be present. This process, in turn, provides more focus for the assessment and diagnostic activities to come.

Question 9

Semistructured Clinical Interviews

Answer 9

Different patients seeing different psychologists or other mental health professionals might encounter markedly different types and styles of interviews.

Unstructured interviews follow no systematic format. Semistructured interviews are made up of questions that have been carefully phrased and tested to elicit useful information in a consistent manner, so clinicians can be sure they have inquired about the most important aspects of particular disorders.

Clinicians may also depart from set questions to follow up on specific issues—thus the label “semistructured.” Because the wording and sequencing of questions has been carefully worked out over many years, the clinician can feel confident that a semistructured interview will accomplish its purpose.

The disadvantage, of course, is that it robs the interview of some of the spontaneous quality of two people talking about a problem. Also, if applied too rigidly, this type of interview may inhibit the patient from volunteering useful information that is not directly relevant to the questions being asked. For these reasons, fully structured interviews administered wholly by a computer have not caught on, although they are used in some settings.

An increasing number of mental health professionals routinely use semistructured interviews. Some are quite specialized. For example, Frank’s clinician, in probing further into a possible obsessive-compulsive disorder, might use the Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5) (Brown & Barlow, 2014)—developed specifically for diagnosing anxiety disorders—or the Structured Clinical Interview for DSM-5 (SCID-5) (First, Williams, et al., 2015)—developed to assess a variety of the disorders discussed in the chapters of this text. These two structured interviews were designed for use in making diagnoses according to the criteria contained in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM- 5). According to the ADIS-IV interview schedule (Dinardo et al., 1994), the clinician first asks if the patient is bothered by thoughts, images, or impulses (obsessions) or currently feels driven to repeat some behaviour or thought over and over again (compulsions). Based on an eight-point rating scale that ranges from “never” to “occasionally” to “constantly,” the clinician then asks the patient to rate each obsession on two measures: persistence-distress (how often it occurs and how much distress it causes) and resistance (types of attempts the patient makes to get rid of the obsession). For compulsions, the patient provides a rating of their frequency.

Question 10

Physical examination

Answer 10

If the patient presenting with psychological problems has not had a physical exam in the past year, a clinician might recommend one, with particular attention to the medical conditions sometimes associated with the specific psychological problem. Many problems presenting as disorders of behaviour, cogni- tion, or mood may, on careful physical examination, have a clear relationship to a temporary toxic state. This toxic state could be caused by bad food, the wrong amount or type of medicine, or the onset of a medical condition. For example, thyroid difficulties, particularly hyperthyroidism (overactive thyroid gland), may produce symptoms that mimic certain anxiety disorders, such as generalized anxiety disorder. Hypothyroidism (underactive thyroid gland) might produce symptoms consistent with depression. Certain psychotic symptoms, including delusions or hallucinations, might be associated with the development of a brain tumour. Withdrawal from cocaine often produces panic attacks, but many patients presenting with panic attacks are reluctant to volunteer information about their addiction, which may lead to an inappropriate diagnosis and improper treatment.

Usually, psychologists and other mental health professionals are well aware of the medical conditions and drug use and abuse that may contribute to the kinds of problems described by the patient. If a current medical condition or substance abuse situation exists, the clinician must ascertain whether it is merely co-existing or causal, usually by looking at the onset of the problem. If a patient has experienced severe bouts of depression for the past five years but within the past year also developed hypothyroid problems or began taking a sedative drug, then we would not conclude the depression was caused by the medical or drug condition. If the depression developed simultaneously with the initiation of sedative drugs and diminished considerably when the drugs were discontinued, we would be likely to conclude the depression was part of a substance-induced mood disorder.

Question 11

Behavioural assessment

Answer 11

Behavioural assessment takes this process one step further by using direct observation to formally assess an individual’s thoughts,
feelings, and behaviour in specific situations or contexts; this information should explain why he or she is having difficulties at this time.

Young children or individuals who are not
verbal because of the nature of their disorder or because of cognitive deficits or
impairments are not good candidates for
clinical interviews.

In addition to talking with a
client in an office about a problem, some go to the person’s home or work to observe the person
- Others set up role-play simulations in a clinical setting

In behavioural assessment, target behaviours are identified and observed with the goal of determining the factors that seem to influence those behaviours

• The ABCs of Observation
• Self-Monitoring

Question 12

The ABCs of Observation - Behavioural assessment

Answer 12

Observational assessment is usually focused on the here and now

the clinician’s attention is usually directed to the immediate behaviour, its antecedents (or what happened just before the behaviour), and its consequences (what happened afterward).

To use the example of the young boy, an observer would note that the sequence of events was: (1) his mother asking him to put his glass in the sink (antecedent), (2) the boy throwing the glass (behaviour), and (3) his mother’s lack of response (consequence).

This sequence (the ABCs) might suggest that the boy was being reinforced for his violent outburst by not having to clean up his mess. And because there was no negative consequence for his behaviour (his mother didn’t scold or reprimand him), he will probably act violently the next time he doesn’t want to do something

This is an example of a relatively informal observation. During the home visit, the clinician took rough notes about what occurred. Later, in his office, he elaborated on the notes. A problem with this type of observation is that it relies on the observer’s recollection and on his or her interpretation of the events. Formal observation involves identifying specific behaviours that are observable and measurable. For example, it would be difficult for two people to agree on what “having an attitude” looks like. A formal observation, however, clarifies this behaviour by specifying that this is “any time the boy does not comply with his mother’s reasonable requests.” Once the target behaviour is selected and defined, an observer writes down each time it occurs, along with what happened just before (antecedent) and just after (consequence). The goal of collecting this information is to see whether there are any obvious patterns of behaviour and then to design a treatment based on these patterns.

Question 13

Self-Monitoring - Behavioural assessment

Answer 13

People can also observe their own behaviour to find patterns, a technique known as self-monitoring or self-observation (Haynes et al., 2011). People trying to quit smoking may write down the number of cigarettes they smoke and the times when and places where they smoke. This observation can tell them exactly how big their problem is (e.g., they smoke two packs a day) and what situ- ations lead them to smoke more (e.g., talking on the phone). The use of smartphones is becoming common in these types of assessments (e.g., Faurholt-Jepsen et al., 2015; Swenderman et al., 2015). The goal here is to help clients monitor their behaviour more conveniently. When behaviours occur only in private (such as purging by people with bulimia nervosa), self-monitoring is essential. Because the people with the problem are in the best position to observe their own behaviour throughout the day, clinicians often ask patients to self-monitor their behaviour to get more detailed information.

A more formal and structured way to observe behaviour is through checklists and behaviour rating scales, which are used as assessment tools before treatment and then periodically during treatment to assess changes in the person’s behaviour (Maust et al., 2012). Of the many such instruments for assessing a variety of behaviours, the Brief Psychiatric Rating Scale (Clarkin et al., 2008), assesses 18 general areas of concern. Each symptom is rated on a seven-point scale from 0 (not present) to 6 (extremely severe). The rating scale screens for moderate to severe psychotic disorders and includes such items as somatic concern (preoccupation with physical health, fear of physical illness, hypochondriasis), guilt feelings (self-blame, shame, remorse for past behaviour), and grandiosity (exaggerated self-opinion, arrogance, conviction of unusual power or abilities; American Psychiatric Association, 2006).

A phenomenon known as reactivity can distort any observational data. Any time you observe how people behave, the mere fact of your presence may cause them to change their behaviour (Haynes et al., 2011). To test reactivity, you can tell a friend you are going to record every time she says the word like. Just before you reveal your intent, however, count the times your friend uses this word in a five-minute period. You will probably find that your friend uses the word less often when you are recording it. Your friend will react to the observation by changing the behaviour. The same phenomenon occurs if you observe your own behaviour, or self-monitor. Behaviours people want to increase, such as talking more in class, tend to increase, and behaviours people want to decrease, such as smoking, tend to decrease when they are self-monitored (Cohen et al., 2012). Clinicians sometimes rely on the reactivity of self-monitoring to increase the effective- ness of their treatment

Question 14

Psychological Testing

Answer 14

the tests used to assess psychological disorders must meet the strict standards we have noted. They must be reliable—so two or more people administering the same test to the same person will come to the same conclusion about the problem—and they must be valid—so they measure what they say they are measuring.

Psychological tests include specific tests to determine cognitive, emotional, or behavioural responses that might be associated with a specific disorder and more general tests that assess long- standing personality features. Specialized areas include intelligence testing to determine the structure and patterns of cognition. Neuropsychological testing determines the possible contribution of brain damage or dysfunction to the patient’s condition. Neurobiological procedures use imaging to assess brain structure and function.

• Projective Testing
• Personality Inventories
• Intelligence Testing

Question 15

Projective Testing

Answer 15

psychoanalytic workers developed several assessment measures known as projective tests. They include a variety of methods in which ambiguous stimuli, such as pictures of people or things, are presented to a person who is asked to describe what he or she sees. The theory here is that people project their own personality and unconscious fears onto other people and things—in this case, the ambiguous stimuli— and, without realizing it, reveal their unconscious thoughts to the therapist.

Because these tests are based in psychoanalytic theory, they have been, and remain, controversial. Even so, the use of projective tests is quite common, with a majority of clinicians administering them at least occasionally and many doctoral programs providing training in their use (Durand et al., 1988); the number of programs offering training in projective testing may be declining, however (Piotrowski, 2015). Two of the more widely used projective tests are the Rorschach inkblot test and the Thematic Apperception Test.

Rorschach developed a series of inkblots, initially to study perceptual processes and then to diagnose psychological disorders. The Rorschach inkblot test is one of the early projective tests. In its current form, the test includes 10 inkblot pictures that serve as the ambiguous stimuli (see ■ Figure 3.4). The examiner presents the inkblots one by one to the person being assessed, who responds by telling what he or she sees

Much of the early use of the Rorschach is extremely controversial because of the lack of data on reliability or validity, among other things. Until relatively recently, therapists administered the test any way they saw fit, although one of the most important tenets of assessment is that the same test be given in the same way each time—that is, according to standardized procedures. If you encourage someone to give more detailed answers during one testing session but not during a second session, you may get different responses as the result of your administering the test differently on the two occasions—not because of problems with the test or with administration by another person (interrater reliability).

To respond to the concerns about reliability and validity, John Exner developed a standardized version of the Rorschach inkblot test, called the Comprehensive System (Exner, 2003). Exner’s system of administering and scoring the Rorschach specifies how the cards should be presented, what the examiner should say, and how the responses should be recorded

Varying these steps can lead to varying responses by the patient. Despite the attempts to bring standardization to the Rorschach test, its use remains controversial. Critics of the Rorschach question whether research on the Comprehensive System supports its use as a valid assessment technique for people with psychological disorders

The Thematic Apperception Test (TAT) is perhaps the best- known projective test, after the Rorschach. It was developed in 1935 by Morgan and Murray (Bellak, 1975). The TAT consists of a series of 31 cards: 30 with pictures on them and 1 blank card, although only 20 cards are typically used during each administra- tion (see ■ Figure 3.5). Unlike the Rorschach, which involves asking for a straightforward description of what the test taker sees, the instructions for the TAT ask the person to tell a dramatic story about the picture. The tester presents the pictures and tells the client, “This is a test of imagination, one form of intelligence.” The person being assessed is asked to “let your imagination have its way, as in a myth, fairy story, or allegory” (Stein, 1978, p. 186). Again like the Rorschach, the TAT is based on the notion that people will reveal their unconscious mental processes in their stories about the pictures.

Several variations of the TAT have been developed for different groups, including a Children’s Apperception Test and a Senior Apperception Test. In addition, modifications of the test have evolved for use with a variety of racial and ethnic groups. These modifications have included changes not only in the appearance of people in the pictures but also in the situations depicted.

Unlike recent trends in the use of the Rorschach, the TAT, and its variants continue to be used inconsistently. How the stories people tell about these pictures are interpreted depends on the examiner’s frame of reference and on what the patient may say. It is not surprising, therefore, that questions remain about its use in psychopathology

Despite these problems, the TAT is still widely used, and some clinicians continue to report that they find it valuable in guiding their diagnostic and treatment decisions. Despite the popularity and increasing standardization of these tests, most clinicians who use projective tests have their own methods of administration and interpretation. When used as icebreakers, for getting people to open up and talk about how they feel about things going on in their lives, the ambiguous stimuli in these tests can be valuable tools. Their relative lack of reliability and validity, however, make them less useful as diagnostic tests. Concern over the inappropriate use of projective tests should remind you of the importance of the scientist–practitioner approach. Clinicians are not only responsible for knowing how to administer tests but also need to be aware of research that suggests the tests have limited usefulness as a means of diagnosing disorders.

Question 16

Personality Inventories

Answer 16

Although many personality inventories are available, we look at the most widely used personality inventory in North America, the Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1943).

the MMPI and similar inventories are based on an empirical approach, that is, the collec- tion and evaluation of data. The administration of the MMPI is straightforward. The individual being assessed reads statements such as “I cry easily,” or “I believe I am being followed,” and answers either “true” or “false.”

Obviously, clinicians have little room for interpretation of MMPI responses, unlike responses to projective tests such as the Rorschach and the TAT. A problem with administering the MMPI, however, is the time and tedium of responding to the 550 items on the original version and now the 567 items on the MMPI-2. A version of the MMPI is also now available that is appropriate for adolescents—MMPI-A (Nezami & Butcher, 2000). Individual responses on the MMPI are not examined; instead, the pattern of responses is reviewed to see if it resembles patterns from groups of people who have specific disorders (e.g., a pattern similar to a group with schizophrenia). Each group is represented on separate standard scales

Fortunately, clinicians can have these responses scored by computer; the program also includes an interpretation of the results, thereby reducing problems of reliability. Given the potential for some people to answer in ways that would downplay their problems—faking answers to MMPI items, such as “Someone has control over my mind”—the MMPI includes four scales that determine the validity of each administration. For example, on the Lie scale (L), one statement is “I have never had a bad night’s sleep.” Answering “true” to this is an indication that the person may be falsifying answers to look good. The other scales are the F, or Infrequency scale, which measures false claims about psychological problems or determines whether the person is answering randomly; the K, or Defensiveness scale, which assesses whether the person sees himself or herself in unrealistically positive ways; and the Cannot Say scale, which simply measures the number of items the test taker did not answer.

Figure 3.6 is an MMPI profile or summary of scores from an individual being clinically assessed; we’ll call him James First, let’s see what this 27-year-old man’s MMPI profile tells us about him (note that these scores were obtained on the previous version of the MMPI). The first three data points represent scores on the L, F, and K scales; the high scores on the L and K scales were interpreted to mean that James made a naive attempt to look good for the evaluator and may have been trying to fake an appearance of having no problems. Another important part of his profile is the very high score on the Pd (psychopathic deviation) scale, which measures the tendency to behave in antisocial ways. The interpretation of this score is that James is “aggressive, unreliable, irresponsible; unable to learn from experience; may initially make a good impression but then psychopathic features will surface in longer interactions or under stress.”

The MMPI is one of the most extensively researched assessment instruments in psychology (Cox et al., 2009; Friedman et al., 2014). (Vern Quinsey, emeritus professor of psychology at Queen’s University at Kingston, once quipped that every man, woman, and child on the planet will eventually publish an MMPI study.) The original standardization sample—the people who first responded to the statements and set the standard for answers—included many people from Minnesota who had no psychological disorders and several groups of people who had particular disorders. The more recent versions of this test, including the MMPI-2 and the MMPI-A, eliminate problems with the original version, problems partly resulting from the original selective sample of people and partly resulting from the wording of questions (Ranson et al., 2009). For example, some questions were sexist. One item on the original version asks the respondent to say whether she has ever been sorry she is a girl (Worell & Remer, 1992). Another item reads, “Any man who is willing to work hard has a good chance of succeeding” (Hathaway & McKinley, 1943). Other items were criticized as insensitive to cultural diversity. Items dealing with religion, for example, referred almost exclusively to Christianity (Butcher et al., 1990). The MMPI-2 has also been standardized with a sample that adequately reflects the composition of the general population, including black people and Aboriginal people for the first time. In addition, new items have been added that deal with contemporary issues, such as type A personality, low self- esteem, and family problems.

The reliability of the MMPI is excellent when it is interpreted according to standardized procedures, and thousands of studies on the original MMPI attest to its validity with a range of psychological problems (Butcher, 2009; Nichols, 2011). But a word of caution is necessary here. Some research suggests that the infor- mation provided by the MMPI—although informative—does not necessarily change how clients are treated and may not improve their outcomes (Lima et al., 2005).

In addition to the MMPI, another example of an instrument used to assess an important aspect of personality functioning is the Revised Psychopathy Checklist (PCL-R). The MMPI profile of James discussed earlier illustrates a constellation of behaviours and characteristics that some refer to as psychopathy. Psychopathy can be assessed directly using the PCL-R, which was developed by forensic psychologist Robert Hare and his colleagues at the University of British Columbia (Hare, 1991, 1993; Hare et al., 2012). Since psychopaths are cunning and manipulative pathological liars, it is difficult to use self-report measures to assess psychopathy, especially in forensic settings (as a psychopath would likely lie and deny the existence of characteristics that would place him or her in a bad light). Hare developed the PCL-R as an instrument to assess the characteristics of psychopathy by using a semistructured interview with the client, along with material from institutional files (e.g., records from correctional institutions) or significant others. The PCL-R consists of a checklist of 20 characteristics, including pathological lying and superficial charm. Adelle Forth of Carleton University and her colleagues developed a youth version of the PCL-R

Question 17

Intelligence Testing

Answer 17

In 1904, a French psycholo- gist, Alfred Binet, and his colleague, Théodore Simon, were commissioned by the government of France to develop a test that would identify “slow learners” who would benefit from remedial help. The two psychologists identified a series of tasks that presumably measured the skills children need to succeed in school, including tasks of attention, perception, memory, reasoning, and verbal comprehension. Binet and Simon gave their original series of tasks to a large number of children; they then eliminated those tasks that did not separate the slow learners from the children who did well in school. After several revisions and sample administrations, they had a test that was relatively easy to administer and that did what it was designed to do—predict academic success. In 1916, Lewis Terman of Stanford University translated a revised version of this test for use in North America; it became known as the Stanford-Binet test.

The test provided a score known as an intelligence quotient (IQ). Initially, IQ scores were calculated by using the child’s mental age. For example, a child who passed all the questions on the seven-year-old level and none of the questions on the eight- year-old level received a mental age of seven. This mental age was then divided by the child’s chronological age and multiplied by 100 to get the IQ score. There were problems, however, with using this type of formula for calculating an IQ score. For example, a four-year-old needed to score only one year above his or her chronological age to be given an IQ score of 125, although an eight-year-old had to score two years above his or her chronologi- cal age to be given the same score (Bjorklund, 1989). Current tests use what is called a deviation IQ. A person’s score is compared only with scores of others of the same age. The IQ score, then, is really an estimate of how much a child’s performance in school will deviate from the average performance of others of the same age.

In addition to the revised version of the Stanford-Binet (Stanford-Binet V; Roid & Pomplun, 2005), another set of intelligence tests, developed by psychologist David Wechsler, is widely used. The Wechsler tests include versions for adults (Wechsler Adult Intelligence Scale, WAIS-IV), for children (Wechsler Intelligence Scale for Children-Fifth Edition, WISC-5), and for young children (Wechsler Preschool and Primary Scale of Intelligence- Revised, WPPSI-IV). All these tests contain verbal scales (which measure vocabulary, knowledge of facts, short-term memory, and verbal reasoning skills) and performance scales (which assess psychomotor abilities, nonverbal reasoning, and ability to learn new relationships).

In both American and Canadian samples, the adult version of this intelligence test—the WAIS-III—has been shown to tap four distinct intellectual abilities: verbal comprehension, perceptual organization, processing speed, and working memory (Saklofske et al., 2000; Wechsler, 1997). The fact that these same compo- nents have been supported in both Canadian and U.S. samples has been interpreted by some as evidence that the WAIS-III “is ‘portable’ across cultural boundaries” (Saklofske et al., 2000, p. 438). Others have been less optimistic about the portability of these intelligence tests to people from other countries and cultures, since these tests were developed and standardized largely with people from the majority culture in the United States. For example, several studies have documented lower than average scores on the verbal scales on the first two versions of the WISC in Canadian First Nations children (Beiser & Gotowiec, 2000; Seyfort et al., 1980; St. John et al., 1976; see also review by Mushquash & Bova, 2007) and a large majority of a sample of Canadian Inuit children scored in what was then called the “mentally retarded” range when their scores on the second version of the WISC were compared with the usual norms. These data suggest that children from these groups may have some difficulty understanding many of the test items or that many of the items may be tapping different abilities and skills in children from these cultural groups than in children from the majority population (Mushquash & Bova, 2007; Wilgosh et al., 1986). The findings caution against indiscriminate use of these tests with cultural groups outside those on whom the test was originally normed.

One of the biggest mistakes non-psychologists (and a distress- ing number of psychologists) make is to confuse IQ with intelligence. An IQ is a score on one of the intelligence tests we just described. An IQ score significantly higher than average means that the person has a significantly greater than average chance of doing well in our educational system. By contrast, a score significantly lower than average suggests the person will probably not do well in school. Does a lower than average IQ score mean a person is not intelligent? Not necessarily. First, numerous reasons exist for a low score. If the IQ test is administered in English and that is not the person’s native language, the results will be affected.

Perhaps more important, however, is the lack of general agreement about what constitutes intelligence (Weinberg, 1989). Remember that the IQ tests measure abilities, such as attention, perception, memory, reasoning, and verbal comprehension. But do these skills represent the totality of what we consider intelligence? Some recent theorists believe that what we think of as intelligence involves much more, including the ability to adapt to the environment, the ability to generate new ideas, and the ability to process information efficiently (Sternberg, 1988). We will discuss disorders that involve cognitive impairment, such as neurocognitive disorder and intellectual disability, and IQ tests are typically used in assessing these disorders. Keep in mind, however, that we will be discussing IQ and not necessarily intelligence. In general, however, IQ tests tend to be reliable and to the extent that they predict academic success, they are valid assessment tools.

Question 18

Neuropsychological Testing

Answer 18

Sophisticated tests have been developed that can pinpoint the location of brain dysfunction (Goldstein, 2000). Fortunately, these techniques are generally available and relatively inexpensive.

Neuropsychological testing measures abilities in areas such as receptive and expressive language, attention and concentration, memory, motor skills, perceptual abilities, and learning and abstraction in such a way that the clinician can make educated guesses about the person’s performance and the possible existence of brain impairment. In other words, this method of testing assesses brain dysfunction by observing its effects on the person’s ability to perform certain tasks. Although you do not see damage, you can see its effects.

A simple neuropsychological test often used with children is the Bender Visual-Motor Gestalt Test (Canter, 1996). A child is given a series of cards on which are drawn various lines and shapes. The task is for the child to copy what is drawn on the card. The errors on the test are compared with test results of other children of the same age; if the number of errors exceeds a certain amount, then brain dysfunction is suspected. This test is less sophisticated than other neuropsychological
tests because the nature or location of the
problem cannot be determined with this test.

The Bender Visual-Motor Gestalt Test can
be useful for psychologists, however,
because it provides a simple screening
instrument that is easy to administer and can detect possible problems. Two of the most popular advanced tests of organic damage that allow more precise determinations of
the location of the problem are the Luria-
Nebraska Neuropsychological Battery and the Halstead-Reitan Neuropsychological Battery
- These offer an elaborate battery of tests to assess a variety of skills.
- For example, the Halstead-Reitan Neuro-
psychological Battery includes the Rhythm
Test (which asks the person to compare
rhythmic beats, to test sound recognition,
attention, and concentration), the Strength of Grip Test (which compares the grip of the right and left hands), and the Tactile Performance Test (which requires the test taker to place wooden blocks in a form board while blindfolded, to test learning and memory skills

Research on the validity of neuropsychological tests
suggests they may be useful for detecting organic damage and
cognitive disorders. Canadian researchers have played a very important role in this crucial area of scientific endeavour

More recent evidence suggests that performance on neuropsychological tests may even be useful in predicting the development of certain cognitive disorders. For example, one study by researchers at the
University of Toronto found that a neuropsychological test
battery was quite accurate in predicting the development of Alzheimer’s disease in people who were part of the longitudi- nal Canadian Study of Health and Aging. Performance on tasks such as delayed verbal recall at the initial testing session with initially healthy participants accurately predicted whether or not the test taker developed Alzheimer’s disease five or ten years later (Tierney et al., 2005). Most often, though, neuro-psychological tests are used to help differentiate those who already have a given cognitive disorder from those people who do not. And neuropsychological tests are often quite accurate in doing so (e.g., Tierney et al., 1996). With this use of neuro- psychological tests, however, we face the issue of false positives and false negatives. For any assessment strategy, the test will occasionally show a problem when none exists (false positive) and will not find a problem when indeed some diffi- culty is present (false negative). The possibility of false results is particularly troublesome for tests of brain dysfunction; a clinician who fails to find damage that exists might miss an important medical problem that needs to be treated. Fortunately, neuropsychological tests are used primarily as screening devices and are routinely paired with other assessments to improve the likelihood that real problems will be found.

Question 19

Images of Brain Structure

Answer 19

The first neuroimaging technique, developed in the early 1970s, uses multiple X-ray exposures of the brain from different angles; that is, X-rays are passed directly through the head. As with any X-ray, these are partially blocked or attenuated more by bone and less by brain tissue. The degree of blockage is picked up by detec- tors in the opposite side of the head. A computer then reconstructs pictures of various slices of the brain. This procedure, which takes about 15 minutes, is called a computerized axial tomography (CAT) scan or CT scan. It is relatively non-invasive and has proved useful in identifying and locating abnormalities in the structure or shape of the brain. CT scans are particularly useful in locating brain tumours, injuries, and other structural and anatomical abnormalities. One difficulty, however, is that these scans, like all X-rays, involve repeated X-radiation, which poses some risk of cell damage (Filippi, 2015).

Several more recently developed procedures give greater resolution (specificity and accuracy) than a CT scan without the inherent risks of X-ray tests. A now commonly used scanning technique is called nuclear magnetic resonance imaging (MRI). The patient’s head is placed in a high-strength magnetic field through which radio frequency signals are transmitted. These signals “excite” the brain tissue, altering the protons in the hydrogen atoms. The alteration is measured, along with the time it takes the protons to “relax” or return to normal. Where there are lesions or damage, the signal is lighter or darker. Technology now exists that allows the computer to view the brain in layers, which enables precise examination of the structure. Although an MRI is more expensive than a CT scan and originally took as long as 45 minutes, this is changing as technology improves. Newer versions of MRI procedures take as little as 10 minutes; the time and cost are decreasing yearly. Another disadvantage of MRI at present is that someone undergoing the procedure is totally enclosed inside a narrow tube with a magnetic coil surrounding the head. People who are somewhat claustrophobic often cannot tolerate an MRI, as demonstrated in a study by a team at the University of British Columbia (McIsaac et al., 1998).

Although neuroimaging procedures are useful for identifying damage to the brain, only recently have they been used to determine structural or anatomical abnormalities that might be associated with various psychological disorders. We review some tantalizing studies in subsequent chapters on specific disorders.

Question 20

Images of Brain Functioning

Answer 20

Several widely used procedures are capable of measuring the actual functioning of the brain, as opposed to its structure. The first is called positron emission tomography (PET). Someone undergoing a PET scan is injected with an imaging tracer, a chemical attached to a radioactive isotope. The chemical component of a PET tracer is carefully selected to target a specific function in the body—for example, a metabolic process or neuro- transmission. The PET scanner uses rings of detectors to measure the radioactive decay of the tracer, which accumulates at certain sites. Images representing the distribution of the tracer in the body are constructed.

One tracer, for example, allows the measurement of the rate of cerebral glucose metabolism, in essence a way to assess brain function. To obtain clear images, the individual undergoing the procedure must remain motionless for the duration of the scan. Typical clinical brain PET scans take 30 minutes, while research imaging of processes like neurotransmitter function can take from 60 to 120 minutes. PET images can be superimposed on anatomical MRI images to show the precise location of the active areas. PET scans are also used to supplement MRI and CT scans in localizing the sites of trauma caused by head injury or stroke, as well as in localizing brain tumours.

More important, PET scans are used
increasingly to look at varying patterns of glucose metabolism that might be associ- ated with different disorders. Recent PET scans have demonstrated that many patients with early Alzheimer’s-type dementia show reduced glucose metabolism in the parietal lobes. Other intriguing findings have been reported for obsessive-compulsive disorder and bipolar disorder. For example, as we will learn in more detail in Chapter 8, excess activity in the dopamine neurotransmitter system has been implicated in manic states among patients with bipolar mood disorder. Researchers at the University of British Columbia Mood Disorders Clinical Research Unit used PET to identify the brain regions involved in dopamine overactivity among a group of patients with bipolar disorder who were tested during the manic state (Yatham et al., 2002). In this same study, the researchers also used PET to examine the effects of drug therapy on dopamine activity in bipolar disorder by testing patients twice: before and after drug treatment. Despite the exciting uses of PET for increasing understanding of many forms of abnormal behaviour, PET scanning is very expensive: in addition to the cost of setting up the facility (approximately $6 million), a cyclotron and chemistry facility must be onsite or close enough that the radioactive PET tracers can be transported quickly. Therefore, these facilities are available only in large medical centres.

A second procedure used to assess brain functioning is called single photon emission computed tomography. It works very much like PET, although a different tracer substance is used, and it is somewhat less accurate. It is also less expensive, however, and requires far less sophisticated equipment to pick up the signals. For this reason, it is used more frequently. The most exciting advances involve MRI procedures that have been developed to work much more quickly than the regular MRI (Filippi, 2015). Using sophisticated computer technology, these procedures take only milliseconds and, therefore, can actually take pictures of the brain at work, recording its changes from one second to the next (e.g., Stern et al., 2000). Because these procedures measure the functioning of the brain, they are called functional MRI, or fMRI. For example, fMRI was used by Kent Kiehl, Andra Smith, Robert Hare, and their colleagues at the University of British Columbia to explore how brain activity might be linked to the emotional responses of psychopaths (Kiehl et al., 2001). Their findings suggested that the emotional differences so often observed in psychopaths may be linked to a weakened input from limbic structures—the part of the brain responsible for regulating our emotional experiences. Today, fMRI has largely replaced PET scans in the leading brain-imaging centres (Cabeza & Nyberg, 2000), because it allows researchers to see the immediate response of the brain to a brief event, such as seeing a new face. This response is called an event-related fMRI.

Brain imagery procedures hold enormous potential for illuminating the contribution of neurobiological factors to psychological disorders. A review by Ruth Lanius and her colleagues in London, Ontario, has illuminated the contributions of various brain-imaging techniques to our understanding of post-traumatic stress disorder (PTSD; Lanius et al., 2006). For example, studies using fMRI have shown that PTSD participants who report primarily dissocia- tive (numbing-type) responses to listening to scripts about their traumas showed very different patterns of brain activation than PTSD participants who experienced primarily hyperarousal patterns to trauma scripts. This finding suggests two distinct subtypes of patients with PTSD, with different neural mechanisms underlying their post-traumatic symptoms.

Neuroimaging research has not yet produced diagnostic tools or tests, however. Many researchers and clinicians are attempting to discover neurological (or biological) markers of specific psychological disorders or traits associated with them (e.g., suicidal tendencies).

Question 21

Psychophysiological assessment

Answer 21

Yet another method for assessing brain structure and function specifically and nervous system activity more generally is called psychophysiological assessment. As the term implies, psychophysiology refers to measurable changes in the nervous system that reflect emotional or psychological events. The measurements may be taken either directly from the brain or peripherally from other parts of the body.

Frank feared that he might have seizures. If we had any reason to suspect he might really have periods of memory loss or exhibit bizarre, trance-like behaviour, even if only for a short time, it would be important for him to have an electroencephalogram (EEG). Measuring electrical activity in the head related to the firing of a specific group of neurons reveals brain wave activity, the low-voltage electrical current ongoing in the brain, usually from the cortex. A person’s brain waves can be assessed in both waking and sleeping states. In an EEG, electrodes are placed directly on various places on the scalp to record the different low- voltage currents.

We have learned much about EEG patterns in the past decades. Usually, we measure ongoing electrical activity in the brain. When brief periods of EEG patterns are recorded in response to specific events, such as hearing a psychologically meaningful stimulus, the response is called an event-related potential or evoked potential. EEG patterns are often affected by psychological or emotional factors and can be an index of these reactions. In a normal, healthy, relaxed adult, waking activities are characterized by a very regular pattern of changes in voltage termed alpha waves.

Many types of stress-reduction treatments attempt to increase the frequency of the alpha waves, often by relaxing the patients in some way. The alpha wave pattern is associated with relaxation and calmness. During sleep, we pass through several different stages of brain activity, at least partially identified by EEG patterns. During the deepest, most relaxed stage, typically occurring one to two hours after a person falls asleep, EEG recordings show a pattern of delta waves. These brain waves are slower and more irregular than the alpha waves, which is perfectly normal for this stage of sleep. We see in Chapter 5 that panic attacks occurring while a person is sound asleep come almost exclusively during the delta wave stage. If frequent delta wave activity occurred during the waking state, it might indicate dysfunction of localized areas of the brain.

Extremely rapid and irregular spikes on the EEG recordings of someone who is awake may reflect significant seizure disorders, depending on the pattern. The EEG recording is one of the
primary diagnostic tools for identifying seizure disorders. Psychophysiological assessment of other bodily responses may also play a role in assessment. These responses include heart rate, respiration, and electrodermal responding (skin conductance), formerly called galvanic skin response, which is a measure of sweat gland activity controlled by the peripheral nervous system. Remember from Chapter 2 that the peripheral nervous system and, in particular, the sympathetic division of the automatic nervous system are very responsive to stress and emotional arousal.

Assessing psychophysiological responding to emotional stimuli is very important in many disorders, one being PTSD. Stimuli, such as sights and sounds, associated with the trauma evoke strong psychophysiological responding, even if the patient is not fully aware of the nature of the trauma because memories of it are inaccessible.

Psychophysiological assessment is also used with many sexual dysfunctions and disorders. For example, sexual arousal can be assessed through direct measurement of penile circumference in males or vaginal blood flow in females in response to erotic stimuli, usually movies or slides (see Chapter 11). As remarked by Queen’s University at Kingston researcher Meredith Chivers and her colleagues, sometimes the individual might be unaware of specific patterns of sexual arousal (Chivers et al., 2010).

Physiological measures are also important in the assessment and treatment of conditions such as headaches and hypertension (Hazlett-Stevens & Bernstein, 2012); they form the basis for the treatment we call biofeedback. In biofeedback, levels of physiological responding, such as blood pressure readings, are fed back to the patient (provided on a continuous basis) by meters or gauges so the patient can try to regulate these responses.

Physiological assessment is not without its limits, for it requires a great deal of skill and some technical expertise. Even when administered properly, the measures sometimes produce inconsistent results because of procedural or technical difficulties or the nature of the response itself. For this reason, only clinicians specializing in certain disorders for which these measures are particularly important are likely to make extensive use of psychophysiological recording equipment, although more straightforward applications, such as monitoring heart rate during relaxation exercises, are more common. Psychophysiological assessment of genital responses (for the purpose of determining someone’s sexual preferences), for example, requires much technical and clinical expertise (Lalumière & Harris, 1998). Sophisticated psychophysiological assessment is most often used in theoretical investigations of the nature of certain psychological disorders, particularly emotional disorders (Barlow, 2002; Heller et al., 1998).

Question 22

Diagnosing Psychological Disorders

Answer 22

Thus far, we have looked at Frank’s functioning on a very individual basis; that is, we have closely observed their behaviour, cognitive processes, and mood, and we have conducted semistructured interviewing, behavioural assessment, and psychological tests. These operations tell us what is unique about Frank, not what they may have in common with other individuals or even with each other.

Learning how Frank may resemble other people in terms of the problems each presents is also very important, for several reasons. If in the past people came in with similar problems or psychological profiles, we can go back and find a lot of information from their cases that might be applicable to Frank’s case. We can see how the problems began for those other individuals, what factors seemed influential, and how long the problem or disorder lasted. Did the problem in the other cases just go away on its own? If not, what kept it going? Did it need treatment? Most important, what treatments seemed to relieve the problem for those other individuals? These general questions are very useful because they evoke a wealth of clinical and research information that enables the investigator to make certain inferences about what will happen next and what treatments may work. In other words, the clinician can establish a prognosis, a term we discussed in Chapter 1 that refers to the likely future course of a disorder under certain conditions.

Because classification is such an integral part of science and, indeed, of our human experience, we describe its various aspects (Blashfield et al., 2014; Millon, 1991; Widiger & Crego, 2013). The term classification itself is very broad, referring simply to any effort to construct groups or categories and to assign objects or people to these categories on the basis of their shared attributes or relations—a nomothetic strategy.

If the classification is in a scientific context, it is most often called taxonomy, which is the classification of entities for scientific purposes, such as insects or rocks or, if the subject is psychology, behaviours. If you apply a taxonomic system to psychological or medical phenomena or other clinical areas, you use the word nosology. The term nomenclature describes the names or labels of the disorders that make up the nosology (e.g., anxiety or mood disorders). Most mental health professionals in North America use the classification system contained in the Diagnostic and Statistical Manual of Mental Disorders, called the DSM-5, which includes definitions and conceptualizations of mental disorders to assist in diagnosis. It is not the only recognized system, however. Another system, the International Classification of Diseases and Health Related Problems, 10th edition (ICD-10; World Health Organization, 1992), is the most used worldwide. In addition to mental disorders, the ICD-10 is also used to categorize health conditions.

The ICD-10 functions as a public health classification that ensures consistent definitions and conceptualization of diseases such that morbidity and mortality data are comparable throughout the world. Most countries, including Canada, have agreed to report health information to the World Health Organization about their population using this system. A specialist version of the ICD-10 that was developed for mental health professionals is called the ICD-10 Clinical Descriptions and Diagnostic Guidelines, and its format resembles that of the DSM-5.

During the past several years, we have seen enormous changes in how we think about classifying psychopathology. Because these developments affect so much of what we do, we examine carefully the processes of classification and diagnosis as they are used in psychopathology. We look first at different approaches, examine the concepts of reliability and validity as they pertain to diagnosis, and then discuss our current system of classification in North America—the DSM-5.

Question 23

Classification issues

Answer 23

In a biology or geology course, when studying insects or rocks, classification is fundamental. Knowing how one species of insects differs from another allows us to study its functioning and origins. When we are dealing with human behaviour or human behavioural disorders, however, the subject of classification becomes controversial. Some people have questioned whether it is proper or ethical to classify human behaviour. Even among those who recognize the necessity of classification, major controversies have arisen in several areas. Within psychopathology, for example, definitions of “normal” and “abnormal” are questioned and so is the assumption that a behaviour or cognition is part of one category or disorder and not another. Some would prefer to talk about behaviour and feelings on a continuum from happy to sad or fearful to nonfearful, rather than to create such categories as mania, depression, and phobia. Of course, for better or worse, classifying behaviour and people is something we all do. Few of us talk about our own emotions or those of our friends by using a number on a scale (where 0 is totally unhappy and 100 is totally happy), although this approach might be more accurate. (“How do you feel about that?” “About 65.”) Rather, we talk about being happy, sad, angry, depressed, fearful, and so on.

• Categorical, Dimensional, and Prototypical Approaches
• Reliability
• Validity

Question 24

Categorical, Dimensional, and Prototypical Approaches - Classification issues

Answer 24

The pure or classical categorical approach to classification originates in the work of Emil Kraepelin (1856–1926) and the biological tradition in the study of psychopathology. Here we assume that every diagnosis has a clear underlying pathophysiological cause, such as a bacterial infection or a malfunctioning endocrine system, and that each disorder is unique. When diagnoses are thought of in this way, the causes could be psychological or cultural, instead of pathophysiological, but each disorder has only one set of causative factors that do not overlap at all with other disorders. Because each disorder is fundamentally different from every other, we need only one set of defining criteria, which everybody in the category has to meet. If the criteria for a major depressive disorder are: (1) the presence of depressed mood, (2) significant weight gain or weight loss when not dieting, and (3) diminished ability to think or concentrate, and six additional specific symptoms, then, to be diagnosed with depression, an individual would have to meet all nine criteria. In that case, according to the classical categorical approach, the clinician would know the cause of the disorder.

Classical categorical approaches are quite useful in medicine. It is extremely important for a physician to make accurate diagnoses. If a patient has a fever accompanied by stomach pain, the doctor must determine quickly if the cause is food poisoning or an infected appendix. This distinction is not always easy to make, but physicians are trained to examine the signs and symptoms closely, and they usually reach the correct conclusion. To understand the cause of the symptoms (infected appendix) is to know what treat- ment will be effective (surgery). But if someone is depressed or anxious, is there a similar type of underlying cause? As we saw in Chapter 2, probably not. Most psychopathologists believe biological, psychological, and social factors interact in complex ways to produce a disorder. Therefore, despite the beliefs of Kraepelin and other early biological investigators, the mental health field has not adopted a classical categorical model of psychopathology

A second strategy is a dimensional approach, in which we note the variety of cognitions, moods, and behaviours with which the patient presents and quantify them on a scale. For example, on a scale of 1 to 10, a patient might be rated as severely anxious (10), moderately depressed (5), and mildly manic (2) to create a profile of emotional functioning (10, 5, 2). Although dimensional approaches have been applied to psychopathology in the past— particularly to personality disorders (Blashfield et al., 2014; Helzer et al., 2008; Krueger et al., 2014; Widiger & Samuel, 2005), they have been relatively unsatisfactory (Brown & Barlow, 2009; Frances, 2009; Regier et al., 2009; Widiger & Edmundson, 2011). Most theorists can’t agree on how many dimensions are required; some say one dimension is enough; others have identified as many as 33

A third strategy for organizing and classifying behavioural disorders has found increasing support in recent years as an alternative to classical categorical or dimensional approaches. It is a categorical approach but with the twist that it combines some of the features of each of the other approaches. Called a prototypical approach, this alternative identifies certain essential characteristics of an entity so you (and others) can classify it, but it also allows for certain non-essential variations that do not necessarily change the classification. For example, if someone were to ask you to describe a dog, you could very easily give a general description (the essential, categorical characteristics), but you might not exactly describe a specific dog. Dogs come in different colours, sizes, and breeds (the non-essential, dimensional variations), but they all share certain doggish characteristics that allow you to classify them separately from cats. Thus, requiring a certain number of prototypical criteria and only some of an additional number of criteria is adequate. Of course, this system is not perfect because greater blurring happens at the boundaries of categories, and some symptoms apply to more than one disorder. For this reason these categories are often called “fuzzy.” It has the advantage, however, of fitting better with the current state of our knowledge of psychopathology, and it is relatively user friendly.

When this approach is used in classifying a psychological disorder, many of the different possible features or properties of the disorder are listed, and any candidate must meet enough (but not necessarily all) of them to fall into that category. Consider the types of DSM-5 criteria defining a major depressive disorder (see DSM Table 8.1 in Chapter 8). Five or more specific symptoms must be present during the same two-week period and they must represent a change from the individual’s previous functioning. At least one of the symptoms is either depressed mood or loss of interest or pleasure in most or all activities. The other symptoms can include considerable weight gain or loss without dieting, near-daily insomnia or hypersomnia, physical restlessness or extreme difficulty performing physical activities, near-daily fatigue, extreme feelings of worthlessness or needless guilt, the inability to concentrate or make decisions, and recurring thoughts of death

As you can see, the criteria include many non-essential symptoms, but if you have either depressed mood or marked loss of interest or pleasure in most activities and at least four of the remaining eight symptoms, you come close enough to the prototype to meet the criteria for a major depressive disorder. One person might have depressed mood, significant weight loss, insomnia, psychomotor agitation, and loss of energy, whereas another person who also meets the criteria for major depressive disorder might have markedly diminished interest or pleasure in activities, fatigue, feelings of worthlessness, difficulty thinking or concentrating, and suicidal ideation. Although both have the requisite five symptoms that bring them close to the prototype, they look very different because they share only one symptom. This is a good example of a prototypical category. Other examples are the diagnosis of histrionic personality disorder (see DSM Table 13.7 in Chapter 13), in which individuals must meet five of eight criteria; and PTSD (see DSM Table 7.1 in Chapter 7), in which individuals must meet one of four exposure criteria, one of five intrusion symptom criteria, one of two avoidance criteria, two of seven alteration of mood criteria, and two of six alteration of arousal and reactivity criteria. The DSM-5 is based on this prototypical approach.

Diagnosing forms of mental disorders is one very important activity engaged in by clinical psychologists and some other mental health professionals. The importance of establishing an accurate diagnosis cannot be stressed enough since errors in diag- nosis can lead to inappropriate treatments being used with a given client. In part, accurate diagnoses are dependent on the strengths of the diagnostic system being used (e.g., DSM-5, ICD-10), but diagnostic accuracy is also dependent on the skills and training of the individual making the diagnosis. Therefore, only trained indi- viduals are permitted to diagnose mental disorders, and the activ- ity of diagnosis is often regulated to protect the public. For example, in Ontario, diagnosis by psychologists is one activity that falls under the Regulated Health Profes- sions Act (1991). The DSM-5 criteria for major depressive episode, as just illustrated, highlight the importance of the adequate training of the individual making the diagno- sis. At first glance, many university students would meet criteria for major depressive episode since many experience depressed mood, weight gain, insomnia, fatigue, and indecisiveness. However, a well-trained professional would recognize that the DSM-5 also specifies that each of these symptoms must be present all day, every day, for two full weeks in the past month (American Psychiat- ric Association, 2000a), resulting in a much smaller proportion of students actually quali- fying for the diagnosis.

One limitation of the use of a medically derived concept such as diagnosis in psychology is that it relies on an acceptance of a disease model of mental illness drawn from medicine. Some continue to argue that this model is not suitable for the behavioural disorders for a variety of reasons (see reviews by Ausubel, 1971; Gorenstein, 1984; Horwitz, 2002). For example, some contend that psychiatric diagnoses play a very insignificant role in characterizing the kinds of difficulties faced by people seeking help for mental health issues (e.g., life problems such as social isolation, extramarital affairs, marital breakup, financial difficulties). On the other hand, some have argued that no inherent contradiction exists in viewing mental symptoms both as manifestations of illness and as expressions of problems in living (e.g., Ausubel, 1971). This debate has been ongoing for a very long time (Szasz, 1960).
Any classification system, whether it be a system involving the classical categorical approach, one involving the dimensional approach, or one involving the prototype approach, needs to be evaluated for two important characteristics: reliability and validity.

Question 25

Reliability - Classification issues

Answer 25

A system of classification should describe specific subgroups of symptoms that are clearly evident and can be readily identified by experienced clinicians. If two clinicians interview the patient at separate times on the same day (and assuming the patient’s condition does not change during the day), the two clinicians should see, and perhaps measure, the same set of behaviours and emotions. The psychological disorder can thus be identified reliably (Chmielewski et al., 2015; Kraemer, 2014). Obviously, if the disorder is not readily apparent to both clinicians, the resulting diagnoses might represent bias.

One of the most unreliable categories in current classification is the area of personality disorders—chronic, trait-like sets of inappropriate behaviours and emotional reactions that characterize a person’s way of interacting with the world. Although great progress has been made, particularly with certain personality disorders, determining the presence or absence of this type of disorder during one interview is still very difficult (Krueger et al., 2015). In a classic study, Morey and Ochoa (1989) asked 291 mental health professionals to describe an individual with a personality disorder they had recently seen, along with their diagnoses. They also collected from these clinicians detailed information on the actual signs and symptoms present in these patients. In this way, they were able to determine whether the actual diagnosis made by the clinicians matched the objective criteria for the diagnosis as determined by the symptoms. In other words, was the clinician’s diagnosis accurate, based on the presence of symptoms that actually define the diagnosis?

Morey and Ochoa (1989) found substantial bias in making diagnoses. For example, clinicians who were either less experienced or were female diagnosed borderline personality disorder more frequently than the criteria indicated. More experienced clinicians and male clinicians diagnosed the condition less frequently than the criteria indicated. Patients who were white, female, or poor were diagnosed with borderline personality disorder more often than the criteria indicated. Although bias among clinicians is always a potential problem, the more reliable the nosology, or system of classification, the less likely it is to creep in during diagnosis.

Question 26

Validity - Classification issues

Answer 26

In addition to being reliable, a system of nosology must be valid. Earlier we described validity as whether something measures what it is designed to measure. A valid diagnosis tells the clinician what is likely to happen with the prototypical patient; it may predict the course of the disorder and the likely effect of one treatment or another. This type of validity is often called predictive validity and sometimes criterion validity, when the outcome is the criterion by which we judge the usefulness of the category. Content validity simply means that if you create criteria for a diagnosis of, say, social phobia, it should reflect the way most experts in the field think of social phobia, as opposed to, say, depression. In other words, you need to get the label right.

Question 27

diagnosis Before 1980

Answer 27

Observations of depressed, phobic, or psychotic features stretch back to the earliest recorded observations of human behaviour. Many of these observations were so detailed and complete that we could make a diagnosis today of the individuals they described. Nevertheless, only recently have we attempted the very difficult task of creating a formal nosology that would be useful for scientists and clinicians around the world.

As late as 1959, at least nine different systems of varying usefulness were used for classifying psychological disorders worldwide, but only three of the nine systems listed “phobic disorder” as a separate category (Marks, 1969). One reason for this confusion is that creating a useful nosology is easier said than done.

Early efforts to classify psychological disorders arose out of the biological tradition, particularly the work of Emil Kraepelin. Kraepelin first identified what we now know as the disorder of schizophrenia. His term for the disorder at the time was dementia praecox. Dementia praecox refers to deterioration of the brain that sometimes occurs with advancing age (dementia) and develops earlier than it is supposed to, or prematurely (praecox). This label (later changed to schizophrenia) reflected Kraepelin’s belief that brain pathology is the cause of this particular disorder. Kraepelin’s landmark 1913 book, Textbook of Psychiatry, described not only dementia praecox but also bipolar disorder, then called manic depressive psychosis. Kraepelin also described a variety of organic brain syndromes. Other well-known figures in their time, such as French psychiatrist Philippe Pinel, characterized psychological disorders, including depression (melancholia), as separate entities; but Kraepelin’s theorizing that psychological disorders are basically biological disturbances had the greatest impact on the development of our nosology and led to an early emphasis on classical categorical strategies.

It was not until 1948 that the World Health Organization (WHO) added a section classifying mental disorders to the sixth edition of the ICD. This early system did not have much influence, however. Nor did the first Diagnostic and Statistical Manual (DSM-I) published in 1952 by the American Psychiatric Association. Only in the late 1960s did systems of nosology begin to have some real influence on mental health professionals. In 1968, the American Psychiatric Association published DSM-II, the second edition of its manual, in 1969, WHO published the eighth edition of the ICD, which was all but identical to DSM-II, since leaders in mental health began to realize the importance of at least trying to develop a uniform system of classification. Nevertheless, these systems lacked precision, often relying heavily on unproven theories of etiology not widely accepted by all mental health professionals. To make matters worse, the systems had very little reliability. Two mental health practitioners looking at the same patient often came to very different conclusions based on the nosology at that time. Even as late as the 1970s, many countries, such as France and Russia, had their own systems of nosology. In these countries, the same disorders would be labelled and interpreted very differently.

Question 28

DSM-III and DSM-III-R

Answer 28

The year 1980 brought a landmark in the history of nosology: DSM-III, the third edition of the American Psychiatric Association’s manual. Under the leadership of Robert Spitzer, the DSM-III departed radically from its predecessors. Two changes stood out

First, the DSM-III attempted to take an atheoretical approach to diagnosis, relying on precise descriptions of the disorders as they presented to clinicians rather than on psychoanalytic or biological theories of etiology. With this focus, the DSM-III became a tool for clinicians with a variety of points of view. For example, rather than classifying phobia under the broad category “neurosis,” defined by intrapsychic conflicts and defence mechanisms, it was assigned its own category within a new broader group, “anxiety disorders.”

The second major change in the DSM-III was that the specificity and detail with which the criteria for identifying a disorder were listed made it possible to study their reliability and validity. Although not all categories in the DSM-III (and its 1987 revision, DSM-III-R) achieved perfect or even good reliability and validity, this system was a vast improvement over what was available before.

Despite numerous shortcomings, such as low reliability in identifying some disorders and arbitrary decisions on criteria for many disorders, the DSM-III and DSM-III-R had a substantial impact. Maser, Kaelber, and Weise (1991) surveyed the international usage of various diagnostic systems at that time and found that the DSM-III had become popular for a number of reasons. Primary among them were its precise descriptive format and its neutrality with regard to presuming a cause for diagnosis. The multiaxial format, which emphasizes a broad consideration of the whole individual rather than a narrow focus on the disorder alone, was also thought to be useful. Therefore, more clinicians around the world used the DSM-III-R at the beginning of the 1990s than the ICD system, which was designed to be applicable internationally

Question 29

DSM-IV and DSM-IV-TR

Answer 29

The ICD-10 (WHO, 1992) was published in 1992. To make the ICD-10 and the DSM as compatible as possible, work proceeded more or less as a collaboration between the developers of the ICD-10 and the fourth edition of the DSM (DSM-IV) published in 1994. Although the final versions of both classifications share important similarities by virtue of the categories included and their definitions, there were important distinctions (First, 2009). The DSM-IV task force decided to rely as little as possible on a consensus of experts. Any changes in the diagnostic system were to be based on sound scientific data. The revisers attempted to review the voluminous literature in all areas pertaining to the diagnostic system (Widiger et al., 1996, 1998) and to identify large sets of data that might have been collected for other reasons but that, with reanalysis, would be useful to the DSM-IV. Finally, 12 independent studies or field trials examined the reliability and validity of alternative sets of definitions or criteria and, in some cases, the possibility of creating a new diagnosis.

Perhaps the most substantial change in the DSM-IV was that the distinction between organically based disorders and psychologically based disorders that was present in previous editions was eliminated. As you saw in Chapter 2, we now know that even disorders associated with known brain pathology are substantially affected by psychological and social influences. Similarly, disorders previously described as psychological in origin certainly have biological components and, most likely, identifiable brain circuits.

In 2000, a committee updated the text that describes the research literature accompanying the DSM-IV diagnostic category and made minor changes to some of the criteria themselves to improve consistency. This text revision (DSM-IV-TR) helped clarify many issues related to the diagnosis of psychological disorders.

Question 30

DSM-5

Answer 30

he DSM-5 was published in spring 2013. This massive undertaking was also carried out with considerable collaboration with international leaders working simultaneously on ICD-11 such that each workgroup responsible for a set of disorders (e.g., anxiety disorders) had an international expert deeply involved in the work of the committee. Although working group members for the ICD-11 were asked to consider the poten- tial global applicability of the DSM-5, as was the case for ICD-10, the ICD-11 will contain conceptual differences (e.g., the placement of some disorders) and structural differences (e.g., the ICD avoids the use of arbitrary symptom counts to establish a diagno- sis) from DSM-5 (First, Reed, et al., 2015). One motivation for these changes was to make the ICD-11 as clinically useful as possible for clinicians working in vastly varied settings and circumstances, all over the world. The differences, in part, reflect the public health mandate of the ICD as a WHO document, although care was taken in the harmonization process with the DSM-5 to avoid inadvertent differences (First, 2009). University of Ottawa professors Cary Kogan and Sabrina Paterniti have provided a useful analysis of the strengths and weaknesses of DSM-5 and the ICD-11 in the Canadian context

The general consensus is that the DSM-5 is largely unchanged from the DSM-IV, although some new disorders are introduced and other disorders have been reclassified. There have also been some organizational and structural changes in the diagnostic manual itself. For example, the manual is divided into three main sections. The first section introduces the manual and describes how best to use it. The second section presents the disorders themselves, and the third section includes descriptions of disorders or conditions that need further research before they can qualify as official diagnoses.

The use of dimensional axes for rating severity, intensity, frequency, or duration of specific disorders in a relatively uniform manner across all disorders is also a feature of DSM-5. For example, for PTSD, LeBeau et al. (2014) developed the National Stressful Events Survey PTSD Short Scale (NSESSS–PTSD), which is a nine-item self-report scale based on data from a national study of U.S. adults (Kilpatrick et al., 2010). This scale was reviewed and approved by the DSM-5 workgroup to assess the severity of PTSD symptoms over the past seven days.

In addition to dimensional assessments of severity or intensity for individual disorders, the DSM-5 introduces cross-cutting dimensional symptom measures. These assessments are not specific to any particular disorder but rather evaluate, in a global sense, important symptoms that are often present across disorders, in almost all patients. Examples include anxiety, depression, and problems with sleep (Narrow et al., 2014). The idea is to monitor the symptoms, if present, across the course of treatment for the presenting disorder.

Thus one might diagnose bipolar disorder and provide a dimensional rating of the degree of anxiety also present because a greater degree of anxiety seems to predict a poorer response to treatment and thus may require additional treatment (Howland et al., 2009; Deckersbach et al., 2014). The suggested questions in the DSM-5 are: “During the past two weeks how much (or how often) have you been bothered by (1) feeling nervous, anxious, frightened, worried, or on edge? (2) feeling panic or being frightened? or (3) avoiding situations that make you anxious?” (American Psychi- atric Association, 2013, p. 738). The DSM-5 uses a 0 to 4 scale where 0 = no anxiety and 4 = very severe anxiety.

Notice that this revision does not represent a change to the categories of disorders themselves; rather, these dimensions are added on to the categorical diagnoses to provide clinicians with additional information for assessment, treatment planning, and treatment monitoring. Specific changes to diagnostic categories and new diagnoses will be described in subsequent chapters.

Question 31

dsm-5 and Frank

Answer 31

In Frank’s case, initial observations indicate an obsessive-compulsive disorder diagnosis. He might also have long-standing person- ality traits that lead him to systematically avoid social contact. If so, there might also be a diagnosis of schizoid personality disor- der. Job and marital difficulties might be indicated where clini- cians note psychosocial or environmental problems that are not part of the disorder but might make it worse or affect treatment planning. Similarly, overall severity and impairment would be rated in a dimensional fashion periodically, as just described for PTSD, to monitor response to treatment by using a DSM-5 scale devised for that purpose (LeBeau et al., 2013).

It is important to emphasize that impairment is a crucial deter- mination in making any diagnosis. For example, if someone, such as Frank, has all the symptoms of obsessive-compulsive disorder but finds them only mildly annoying because the intrusive thoughts are not severe and don’t occur that often, that person would not meet the criteria for a psychological disorder. It is essential that the various behaviours and cognitions composing the diagnosis interfere with functioning in some substantial manner. Thus, the criteria for disorders include the provision that the disorder must cause clinically significant distress or impairment in social, occupational, or other important areas of function- ing. Individuals who have all the symptoms as noted earlier but do not cross this threshold of impairment could not be diagnosed with a disorder. As noted, one change in the DSM-5 is to make this judgment of severity and impairment more systematic by using a dimensional scale. In one of our own clinics, we have been doing something similar to this for many years (Brown & Barlow, 2014). For instance, we have used a scale of 0 to 8, where 0 is no impairment and 8 is severely disturbing or disabling (usually housebound and barely functional). The disorder must be rated at least a 4 in severity (definitely disturbing or disabling) to meet the criteria for a psychological disorder. Many times, disorders such as obsessive-compulsive disorder would be rated a 2 or 3, meaning that all of the symptoms are there but in too mild a form to impair functioning; in this case, the disorder would be termed subthreshold. Using Frank as an example again, the sever- ity of his obsessive-compulsive disorder would be rated 5.

Question 32

Social and Cultural Considerations in the dsm-5

Answer 32

By emphasizing levels of stress in the environment, the DSM-III and DSM-IV facilitated a more complete picture of the individual. Furthermore, the DSM-IV corrected a previous omission by including a plan for integrating important social and cultural influences on diagnosis, a feature that remains in the DSM-5. “Culture” refers to the values, knowledge, and practices that individuals derive from membership in different ethnic groups, reli- gious groups, or other social groups, as well as how membership in these groups may affect the individual’s perspective on their experience with psychological disorders. The plan, referred to as “cultural formulation,” allows the disorder to be described from the perspective of the patient’s personal experience and in terms of the primary social and cultural group, such as Chinese or Indigenous Peoples. Answering suggested culture-related ques- tions from the DSM-5 Cultural Formulation Interview (American Psychiatric Association, 2013) will help accomplish these goals. The following are suggestions for accomplishing these goals (Mezzich et al., 1993, 1999):

1. What is the primary cultural reference group of the patient? For recent immigrants to the country and other ethnic minorities, how involved are they with their new culture versus their old culture? Have they mastered the language of their new country (e.g., English or French in Canada) or is language a continuing problem?
2. Does the patient use terms and descriptions from his or her old country or culture to describe the disorder? For example, as we will see in Chapter 5, kayak-angst in the Inuit culture is a type of anxiety disorder close to panic disorder with agoraphobia. Does the patient accept Western models of disease or disorder in which treatment is available in health-care systems, or does the patient also have an alternative health- care system in another culture (e.g., traditional herbal doctors in Chinese subcultures)?
3. What does it mean to have a disability? What kinds of disabilities are acceptable in a given culture, and which are not? For example, is it acceptable to be physically ill but not anxious or depressed? What are the typical family, social, and religious supports in the culture? Are they available to the patient? Does the clinician understand the first language of the patient and the cultural significance of the disorder?

These cultural considerations must not be overlooked in making diagnoses and planning treatment, and they are assumed throughout this book. But, as yet, there is no research supporting the use of these cultural formulation guidelines (Aggarwal et al., 2013). The consensus is that we have a lot more work to do in this area to make our nosology truly culturally sensitive.

Question 33

Criticisms of the dsm-5

Answer 33

Because the collaboration among groups creating the ICD-11 and DSM-5 was largely successful, it is clear that the DSM-5 and the closely related ICD-11’s section on mental disorders are the most advanced, scientifically based systems of nosology ever developed. Nevertheless, any nosological system should be considered a work in progress and the DSM-5 has attempted to put operations in place allowing for interim revisions to categories as new information becomes available; for instance, updates are published e online by the American Psychiatric Association

For the time being, we still have fuzzy categories that blur at the edges, making diagnostic decisions difficult at times. As a consequence, individuals are often diagnosed with more than one psychological disorder at the same time, which is called comorbidity. How can we conclude anything definite about the course of a disorder, the response to treatment, or the likelihood of associated problems if we are dealing with combinations of disorders (Allen et al., 2010; Brown & Barlow, 2009; Krueger et al., 2014)? Is there a way to identify essential features of comorbid disorders and, perhaps, rate them dimensionally (Brown & Barlow, 2009; Rosellini et al., 2015)? Resolution of these tough problems simply awaits the long, slow process of science.

Criticisms of the DSM-5 and the forthcoming ICD-11 centre on two other aspects. First, the systems strongly emphasize reliability, sometimes at the expense of validity. This is understandable, because reliability is so difficult to achieve unless you are willing to sacrifice validity. If the sole criterion for establishing depression were to hear the patient say at some point during an interview, “I feel depressed,” the clinician could theoretically achieve perfect reliability. But this achievement would be at the expense of validity because many people with differing psychological disorders, or none, occasionally say they are depressed. Thus, clinicians could agree that the statement occurred, but it would be of little use (Meehl, 1989). Second, as Carson (1996) pointed out, meth- ods of constructing a nosology of mental disorders have a way of perpetuating definitions handed down to us from past decades, even if they might be fundamentally flawed (Lillienfield, 2014). Some (e.g., Markon, 2013) think that it might be better to start fresh once in a while and create a new system of disorders, or several new systems, based on emerging scientific knowledge and see which one turns out to be best rather than to simply fine-tune old definitions. But this is unlikely to happen because of the enormous effort and expense involved and the necessity of discarding the accumulated wisdom of previous versions.

In addition to the daunting complexity of categorizing psychological disorders, systems are subject to misuse, some of which can be dangerous and harmful. Diagnostic categories are just a convenient format for organizing observations that help professionals communicate, study, and plan. But if we reify a category, we literally make it a “thing,” assuming it has a meaning that, in reality, may not exist. Categories may change occasionally with new knowledge, so none can be written in stone. If a case falls on the fuzzy borders between diagnostic categories, we should not expend all our energy attempting to force it into one category or another. It is a mistaken assumption that everything has to fit neatly somewhere.

Question 34

A Caution about Labelling and Stigma

Answer 34

A related problem that occurs any time we categorize people is labelling. You may remember Kermit the Frog from Sesame Street sharing with us that “It’s not easy being green.” Something in human nature causes us to use a label, even one as superficial as skin colour, to characterize the totality of an individual (“He’s green . . . he’s different from me”). We see the same phenomenon among psychological disorders (“He’s a schizo”). Furthermore, if the disorder is associated with an impairment in cognitive or behavioural functioning, the label itself has negative connotations and contributes to stigma, which is a combination of stereotypic negative beliefs, prejudices, and attitudes resulting in reduced life opportunities for the devalued group in question, such as individuals with mental disorders

There have been many attempts over the years to categorize intellectual disability. Most of the categories were based on the severity of the impairment or highest level of developmental ability that the individual could reach. But we have had to change the labels for these categories of cognitive impairment periodically as the stigma associated with them builds up. One early categorization described levels of severity as moron (least severe), imbecile, and idiot (most severe). When these terms were introduced they were rather neutral, simply describing the severity of a person’s cognitive and developmental impairment. But as they began to be used in common language, they picked up negative connotations and were used as insults. As these terms gradually became pejorative, it was necessary to eliminate them as categories and come up with a new set of classifying labels that were less derogatory. One recent development is to categorize intellectual disability functionally in terms of the levels of support needed by these individuals. In other words, a person’s degree of intellectual disability is determined by how much assistance he or she requires (e.g., intermittent, limited, extensive, or pervasive) rather than by his or her IQ score (Lubinski, 2004; Luckasson et al., 1992). In the DSM-5 the term “mental retardation” has been dropped in favour of the more accurate term “intellectual disabil- ity,” which is further described as mild, moderate, severe, or profound (American Psychiatric Association, 2013).

Many efforts have been made in Canada to reduce the stigma
associated with mental disorders. The Mental Health Commission
of Canada has created anti-stigma programs, such as HEAD-STRONG for schools, and initiatives, such as Mental Health First
Aid for the workplace so that coworkers can become more informed about mental illness and better help people struggling

Question 35

Creating a diagnosis

Answer 35

During the extensive deliberations that led to the publication of both the DSM-IV and the DSM-5, several potentially new diagnostic categories were considered. Because one of us was a member of the DSM-IV task force, the final decision-making body overseeing the creation of the DSM, and an adviser to DSM-5, we can offer brief examples to illustrate how diagnostic categories are created. In one case, a potential new diagnosis was not included in the DSM-5; in a second case, a new diagnosis was indeed created. We now briefly describe each case.

• Mixed Anxiety-Depression
• Premenstrual Dysphoric Disorder

Question 36

Mixed Anxiety-Depression

Answer 36

Family physicians’ offices, clinics, hospitals, and so on, are called primary care settings because they are where a person goes first with a problem.

Health-care professionals examining these individuals report that their symptoms of anxiety and depression are classic but not frequent or severe enough to be an existing anxiety or mood disorder

The DSM-IV task force was concerned about issues like this one for several reasons. First, because many individuals present with some minor symptoms of a given disorder, it is important to set thresholds high enough that only people who clearly experience some impairment qualify for the category. (Thresholds are the minimum number of criteria required to meet the definition of a disorder.) The primary reason for this concern is that substantial legal and policy implications are contingent on a diagnosis. That is, someone who presents with a psychological disorder that clearly qualifies for a diagnosis becomes part of the loosely orga- nized medico-legal system and is eligible to ask the government or private insurance companies for financial reimbursement or disability payments.

In Canada, the services provided by a psychologist are covered by provincial health insurance only if the psychologist is employed by a publicly funded institution like a hospital, community health clinic, school, social agency, or correctional facility. In contrast, services provided by a psychologist in private practice are not covered by provincial or territorial health-care plans. These costs are either paid for by the patient or covered partially or in full by health benefits through private insurance plans offered by employers. The services of psychiatrists are covered through provincial health insurance plans regardless of where the psychiatrist is employed (Canadian Psychological Association, 2004). Disability payments are covered by the Canada Pension Plan based on contributions from workers and employers in Canada. The primary role of this plan is to replace a portion of income for contributors who cannot work because of a severe and prolonged disability, such as a severe mental health disorder

Clearly, if the diagnostic system includes people who have only minor symptoms, who are not particularly impaired and just feel down periodically, or who don’t like their job and want disability (an all-too-common request in mental health clinics), the health-care system would be even more strained and have fewer resources to treat the serious impairments. But if people are experiencing considerable problems and impairment in function- ing, they should be covered in any health-care system. For these reasons, minor complaints of dysphoric mood, characterized by vague complaints of anxiety and depression, were not considered sufficiently severe to constitute a formal diagnosis.

In 1989, Klerman and Weissman, reporting on a large study by Wells et al. (1989), found that patients who claimed to be anxious and mildly depressed were impaired in a number of areas when compared with normal controls and with patients with chronic medical conditions. Substantial impairment was present in the areas of physical and social functioning, not only causing patients to miss work but also interfering with their functioning in the home; it was worse than the impairment of many patients with chronic medical conditions. The evidence also suggested that these individuals were already imposing an enormous burden on the health-care system by appearing in large numbers at community health clinics and the offices of family doctors.

Therefore, we concluded that it might be very valuable to identify these people and find out more about the etiology, course, and maintenance of the problem. The authors of the ICD-10, recognizing this phenomenon is prevalent throughout the world, had created a category of mixed anxiety-depression, but they had not defined it or created any criteria that would allow further examination of the potential disorder. Therefore, to explore the possibility of creating a new diagnostic category (Zinbarg & Barlow, 1996; Zinbarg et al., 1994, 1998), a study was undertaken that had three specific goals. First, if mental health professionals carefully administered semistructured interviews (the Anxiety Disorders Interview Schedule), would they find patients who fit the new category? Or would careful examination find the criteria for already existing disorders that had been overlooked by health professionals not well trained in identifying psychological disor- ders? Second, if mixed anxiety-depression did exist, was it really more prevalent in medical primary care settings than in outpatient mental health settings? Third, what set of criteria (e.g., types and number of symptoms) would best identify the disorder?

The study to answer these questions was conducted simultane- ously in seven sites around the world (Zinbarg et al., 1994, 1998). Results indicated that people presenting with several symptoms of anxiety and depression, who did not meet the criteria for an existing anxiety or mood disorder (because they did not have the right mix or severity of anxious or depressed symptoms), were common in primary care settings. Furthermore, they were substan- tially impaired in their occupational and social functioning and experienced a great deal of distress. Additional analysis revealed that such people could be distinguished from people with existing anxiety or mood disorders on the basis of their symptoms with the very careful and detailed assessment procedures used. Because these people appeared both anxious and depressed, the potential new category possessed content validity.

This study also established some of the criteria important in determining construct validity for the new category of mixed anxiety-depression. Because the category is so new, however, we do not have information on additional criteria important in estab- lishing construct validity, such as course, response to treatment, and the extent to which the disorder aggregates in families, and we cannot yet verify the reliability of the diagnosis or anything about predictive validity. Therefore, the decision of the DSM-IV task force was to place this mixed anxiety-depression diagnosis in the appendix, which is reserved for new diagnoses under study. After the publication of the DSM-IV, several studies re-examined this issue to see if mixed anxiety-depression should be included in the DSM-5 (e.g., Weisberg et al., 2005). The general conclusion was that although people do present with these symptoms, it is relatively rare in the absence of a current or previous anxiety or mood disorder, the mixed anxiety-depressive symptoms do not last long, and it was very difficult to identify the condition in a reliable fashion. The findings eliminated further consideration of mixed anxiety-depression as a new and separate diagnosis; in fact, is was not even placed in Section 3 where disorders needing further study are found in DSM-5, and it is unlikely it will be considered in future DSM editions.

Question 37

Premenstrual Dysphoric Disorder

Answer 37

Premenstrual dysphoric disorder (PMDD) evokes a very different issue that must be considered in the creation of any diagnostic category: bias and stigmatization. Evaluation of PMDD as a diag- nostic category actually began well before the publication of DSM-III-R in 1987. Some clinicians had claimed to have identi- fied a small group of women who presented with severe and sometimes incapacitating emotional reactions associated with the late luteal phase of their menstrual cycle (Rivera-Tovar et al., 1992). Subsequently, proposals were made to consider inclusion of this possible disorder in the DSM-III-R. In view of the difficul- ties and impairment associated with this condition, the propo- nents argued, women deserved the attention, care, and financial support that inclusion in a diagnostic category would provide. In addition, as with mixed anxiety-depression, proponents argued that the creation of this category would promote a substantial increase in research into the nature and treatment of the problem. Di Guilio and Reissing (2006) of the University of Ottawa, for example, argue that the accumulated research suggests that PMDD represents a distinct diagnostic entity that is separable from both normal premenstrual symptoms and major depression. They argue that recognition of this problem through formal diag- nostic criteria would serve the important minority of women who suffer from this cyclical mood “disorder.”

Nevertheless, arguments against the category were marshalled along several fronts. First, opponents noted that relatively little scientific information existed in either the clinical or research literature on this topic. The available information was insufficient to warrant the creation of a new diagnostic category. More impor- tant were substantial objections that what could be a normal endocrinological stage experienced by all or most women would be stigmatized as a psychiatric disorder. Some pointed to research showing that women who complain of premenstrual emotional symptoms are significantly more likely than other women to be in distressing life situations (e.g., being battered); thus, to label them as having a mental disorder may mask the real, external (societal) sources of their difficulties (see the review by Offman & Klein- platz, 2004). In addition, the seeming similarities with the once widely accepted category of hysteria described in Chapter 1 were also noted. Questions were raised about whether the disorder would best be described as endocrinological or gynecological rather than psychological. Because premenstrual dysphoric disor- der could occur only in women, should we include a comparable disorder associated with, for example, aggressiveness related to excessive male hormones?

The DSM-III-R task force decided to place this disorder in an appendix in the hope of promoting further study. The task force also wanted to clearly differentiate this syndrome from premen- strual syndrome (PMS), which has less severe and specific premenstrual symptoms. One way of accomplishing this was by naming the condition late luteal phase dysphoric disorder (LLPDD).

After the publication of the DSM-III-R, LLPDD attracted a great deal of research attention. By 1991, Judith Gold, a psychia- trist from Halifax, Nova Scotia, who chaired the DSM-IV work group on this issue, estimated that one research article per month on LLPDD was published (Gold et al., 1996). A variety of scien- tific findings began to accrue that supported the inclusion of this disorder in the DSM-IV. For example, although the rather vague and less severe symptoms of PMS occur in 20 percent to 40 percent of women (Severino & Moline, 1989), only a very small proportion of them—about 5 percent—experience the more severe and incapacitating symptoms associated with LLPDD (Rivera-Tovar & Frank, 1990). In addition, abnormali- ties in several biological systems appear to be associated with clinically significant premenstrual dysphoria (reviewed in Gold et al., 1996), and several different types of treatment showed promise of being effective with LLPDD (e.g., Stone et al., 1991). Hurt and colleagues, in a reanalysis of data from 670 women, recommended a set of criteria for this disorder that were not very different from those proposed in the DSM-III-R (Hurt et al., 1992).

Nevertheless, arguments continued against including this label in the diagnostic system. Most opponents cite the issue of stigma- tization, warning that recognition might confirm the cultural belief that menstruation and resulting disability make women unfit for positions of responsibility. (There have been several cases where accusations of the less severe condition of PMS have been used against a mother in an attempt to win child custody for the father; see Gold et al., 1996.) Those arguing against the disor- der also point out that some of the symptoms outlined in the criteria for LLPDD involve anger, which would not be viewed as inappropriate in a male. Only in a female does society presume that anger signifies something is wrong.

Interestingly, many women who have been given this label say they are quite comfortable with it. Some women presenting with other psychological disorders, such as depression, refuse to accept the suggestion that they have a psychiatric problem, insisting it is really premenstrual syndrome (Rapkin et al., 1989).

Early in 1994, the DSM-IV task force decided to retain the disorder in the appendix as needing further study. The commit- tee wanted to see more epidemiological data using the new criteria and to examine more carefully the data on the relation of this problem to existing mood disorders, among other problems.

Several additional research findings indicated that the name late luteal phase dysphoric disorder was not entirely accurate, because the symptoms may not be exclusively related to the endo- crine state of the late luteal phase. Therefore, the name has been changed to premenstrual dysphoric disorder (PMDD).

Since 1994, research has continued, and even accelerated, on the nature and treatment of PMDD, with thousands of papers published on this general topic (Bloch et al., 2014; Epperson et al., 2012; Hartlage et al., 2012; O’Brien et al., 2011; Pearlstein, 2010; Zachar & Kendler, 2014). Epidemiological studies from around the world supported the existence of disabling premen- strual symptoms in 2 to 5 percent of women, with another 14 to 18 percent experiencing moderate symptoms (Cunningham et al., 2009; Epperson et al., 2012; Gold, 1997a, 1997b; Ko et al., 1996; Pearlstein & Steiner, 2008). The American College of Obstetri- cians and Gynecologists (2002) has published systematic clinical practice guidelines recommending specific treatments, and new information on effective treatment is published frequently (Epperson et al., 2012; Freeman et al., 2009; Jang et al., 2014; Yonkers et al., 2014). One of the difficulties encountered has been distinguishing PMDD from premenstrual exacerbations of other disorders, such as binge eating disorder or mood disorders (Pearlstein et al., 2005). Hartlage et al. (2012) proposed a method that carefully considers the nature and timing of the symptoms to make a valid distinction between PMDD and premenstrual exac- erbations of other disorders. For example, the symptoms of PMDD must be absent or present only mildly postmenstrually. To distinguish it from a mood disorder, at least some symptoms must be different from those associated with a mood disorder, such as certain physical symptoms or anxiety. The accumulating evidence thus far seems to suggest that PMDD is best considered a disorder of mood rather than, for example, an endocrine disor- der and that it should continue to be considered a psychological disorder (Cunningham et al., 2009; Gold, 1999). Support for PMDD is now sufficient that it is now included as a distinct psychological disorder in the DSM-5 in the chapter on mood disorders.

Question 38

Beyond DSM-5: dimensions and spectra

Answer 38

The process of changing the criteria for existing diagnoses and creating new ones will continue as science advances. New find- ings on brain circuits, cognitive processes, and cultural factors that affect our behaviour could date diagnostic criteria relatively quickly.

although some new disorders have been added, and others relocated from one section to another, overall the DSM-5 has not changed substantially from the DSM-IV. Nevertheless, it has been clear to most professionals involved in this process that an exclusive reliance on discrete diagnostic categories has not achieved its objective in achieving a satisfactory system of nosology

In addition to problems noted earlier with comorbidity and the fuzzy boundary between diagnostic categories, little evidence has emerged validating these categories, such as discovering specific underlying causes associated with each (Regier et al., 2009). In fact, not one biological marker, such as a laboratory test, that would clearly distinguish one disorder from another has been discovered (Frances, 2009; Widiger & Cregor, 2013; Widiger & Samuel, 2005). One exception might be narcolepsy, which seems to be associated with specific cerebrospinal biomarkers (e.g., Heier et al., 2014). It is also clear that the current categories lack treatment specificity. That is, certain treatments, such as cogni- tive-behavioural therapies or specific antidepressant drugs, are effective for a large number of diagnostic categories that are not supposed to be all that similar. Therefore, although some progress has been made, many are beginning to assume that the limitations of the current diagnostic system are substantial enough that continued research on these diagnostic categories may never be successful in uncovering their underlying causes or helping us develop new treatments.

It may be time for a new approach. A suggestion strongly supported by the last two directors of the U.S. National Institute of Mental Health (Hyman, 2010; Insel et al., 2010; Insel, 2014). Most people agree that this approach will incorporate a dimen- sional strategy to a much greater extent than in DSM-5 (Krueger & Markon, 2014; Widiger & Cregor, 2013). The term “spectrum” is another way to describe groups of disorders that share certain basic biological or psychological qualities or dimensions. For example, in Chapter 15 you will read about one of the notable advances in the DSM-5 where the term “Asperger’s syndrome” (a mild form of autism) was integrated with autistic disorder into a new category of “autism spectrum disorder.” But it is also clear at this point that research is not sufficiently advanced to attempt a wholesale switch to a dimensional or spectrum approach, so the categories in the DSM-5 for the most part look very much like the categories in the DSM-IV with some updated language and increased precision and clarity. But sparked by research and conceptual advances during the process of creating the DSM-5, more conceptually substantial and consistent dimensional approaches are in development and may be ready for the 6th edition of the DSM in 10 to 20 years.

For example, most investigators have concluded that personal- ity disorders are not qualitatively distinct from the personalities of normal-functioning individuals in community samples (Krueger et al., 2014; Trull et al., 2013). Instead, personality disorders simply represent maladaptive, and perhaps extreme, variants of common personality traits (Widiger & Edmundson, 2011; Widiger et al., 2009). Even the genetic structure of personality is not consistent with discrete categorical personality disorders. That is, personality dispositions more broadly defined, such as being shy and inhibited or outgoing, have a stronger genetic influence (higher genetic loading) than personality disorders as currently defined (First et al., 2002; Livesley & Jang, 2008; Livesley et al., 1998; Rutter et al., 2006; Widiger et al., 2009). For the anxiety and mood disorders, Brown and Barlow (2009) have proposed a new dimensional system of classification based on previous research (Brown et al., 1998) demonstrating that anxiety and depression have more in common than previously thought and may best be represented as points on a continuum of negative affect or a spectrum of emotional disorders (see Barlow, 2002; Brown & Barlow, 2005, 2009; Rosellini et al., 2015). Even for severe disorders with seemingly stronger genetic influences, such as schizophrenia, it appears that dimensional classification strate- gies or spectrum approaches might prove superior

At the same time, exciting new developments from the area of neuroscience relating to brain structure and function will provide enormously important information on the nature of psychological disorders. This information could then be integrated with more psychological, social, and cultural information into a diagnostic system. But even neuroscientists are abandoning the notion that groups of genes or brain circuits will be found that are specifically associated with DSM-5 diagnostic categories, as noted in Chapter 2. Rather, it is now assumed that neurobiological processes will be discovered that are associated with specific cognitive, emotional, and behavioural patterns or traits (e.g., beha- vioural inhibition) that do not necessarily correspond closely with current diagnostic categories.