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Module 3: Clinical Assessment, Diagnosis, and Treatment

3rd edition as of August 2022

 

Module Overview

Module 3 covers the issues of clinical assessment, diagnosis, and treatment. We will define assessment and then describe key issues such as reliability, validity, standardization, and specific methods that are used. In terms of clinical diagnosis, we will discuss the two main classification systems used around the world – the DSM-5-TR and ICD-11. Finally, we discuss the reasons why people may seek treatment and what to expect when doing so.

 

Module Outline

 

Module Learning Outcomes

  • Describe clinical assessment and methods used in it.
  • Clarify how mental health professionals diagnose mental disorders in a standardized way.
  • Discuss reasons to seek treatment and the importance of psychotherapy.

 


3.1. Clinical Assessment of Abnormal Behavior

 

Section Learning Objectives

  • Define clinical assessment.
  • Clarify why clinical assessment is an ongoing process.
  • Define and exemplify reliability.
  • Define and exemplify validity.
  • Define standardization.
  • List and describe seven methods of assessment.

 

3.1.1. What is Clinical Assessment?

For a mental health professional to be able to effectively help treat a client and know that the treatment selected worked (or is working), they first must engage in the clinical assessment of the client, or collecting information and drawing conclusions through the use of observation, psychological tests, neurological tests, and interviews to determine the person’s problem and the presenting symptoms. This collection of information involves learning about the client’s skills, abilities, personality characteristics, cognitive and emotional functioning, the social context in terms of environmental stressors that are faced, and cultural factors particular to them such as their language or ethnicity. Clinical assessment is not just conducted at the beginning of the process of seeking help but throughout the process. Why is that?

Consider this. First, we need to determine if a treatment is even needed. By having a clear accounting of the person’s symptoms and how they affect daily functioning, we can decide to what extent the individual is adversely affected. Assuming a treatment is needed, our second reason to engage in clinical assessment will be to determine what treatment will work best. As you will see later in this module, there are numerous approaches to treatment.  These include Behavior Therapy, Cognitive and Cognitive-Behavioral Therapy (CBT), Humanistic-Experiential Therapies, Psychodynamic Therapies, Couples and Family Therapy, and biological treatments (psychopharmacology). Of course, for any mental disorder, some of the aforementioned therapies will have greater efficacy than others. Even if several can work well, it does not mean a particular therapy will work well for that specific client. Assessment can help figure this out. Finally, we need to know if the treatment we employed worked. This will involve measuring before any treatment is used and then measuring the behavior while the treatment is in place. We will even want to measure after the treatment ends to make sure symptoms of the disorder do not return. Knowing what the person’s baselines are for different aspects of psychological functioning will help us to see when improvement occurs.

In recap, obtaining the baselines happens in the beginning, implementing the treatment plan that is agreed upon happens more so in the middle, and then making sure the treatment produces the desired outcome occurs at the end. It should be clear from this discussion that clinical assessment is an ongoing process.

 

3.1.2. Key Concepts in Assessment

The assessment process involves three critical concepts – reliability, validity, and standardization. These three are important to science in general. First, we want the assessment to be reliable or consistent. Outside of clinical assessment, when our car has an issue and we take it to the mechanic, we want to make sure that what one mechanic says is wrong with our car is the same as what another says, or even two others. If not, the measurement tools they use to assess cars are flawed. The same is true of a patient who is suffering from a mental disorder. If one mental health professional says the person suffers from major depressive disorder and another says the issue is borderline personality disorder, then there is an issue with the assessment tool being used. Ensuring that two different raters are consistent in their assessment of patients is called interrater reliability. Another type of reliability occurs when a person takes a test one day, and then the same test on another day. We would expect the person’s answers to be consistent, which is called test-retest reliability. For example, let’s say the person takes the MMPI on Tuesday and then the same test on Friday. Unless something miraculous or tragic happened over the two days in between tests, the scores on the MMPI should be nearly identical to one another. What does identical mean? The score at test and the score at retest are correlated with one another. If the test is reliable, the correlation should be very high (remember, a correlation goes from -1.00 to +1.00, and positive means as one score goes up, so does the other, so the correlation for the two tests should be high on the positive side).

In addition to reliability, we want to make sure the test measures what it says it measures. This is called validity. Let’s say a new test is developed to measure symptoms of depression. It is compared against an existing and proven test, such as the Beck Depression Inventory (BDI).  If the new test measures depression, then the scores on it should be highly comparable to the ones obtained by the BDI. This is called concurrent or descriptive validity. We might even ask if an assessment tool looks valid. If we answer yes, then it has face validity, though it should be noted that this is not based on any statistical or evidence-based method of assessing validity. An example would be a personality test that asks about how people behave in certain situations. Therefore, it seems to measure personality, or we have an overall feeling that it measures what we expect it to measure.

Predictive validity is when a tool accurately predicts what will happen in the future. Let’s say we want to tell if a high school student will do well in college. We might create a national exam to test needed skills and call it something like the Scholastic Aptitude Test (SAT). We would have high school students take it by their senior year and then wait until they are in college for a few years and see how they are doing. If they did well on the SAT, we would expect that at that point, they should be doing well in college. If so, then the SAT accurately predicts college success. The same would be true of a test such as the Graduate Record Exam (GRE) and its ability to predict graduate school performance.

Finally, we want to make sure that the experience one patient has when taking a test or being assessed is the same as another patient taking the test the same day or on a different day, and with either the same tester or another tester. This is accomplished with the use of clearly laid out rules, norms, and/or procedures, and is called standardization. Equally important is that mental health professionals interpret the results of the testing in the same way, or otherwise, it will be unclear what the meaning of a specific score is.

 

3.1.3. Methods of Assessment

So how do we assess patients in our care? We will discuss observation, psychological tests, neurological tests, the clinical interview, and a few others in this section.

            3.1.3.1. Observation. In Section 1.5.2.1 we talked about two types of observation – naturalistic, or observing the person or animal in their environment, and laboratory, or observing the organism in a more controlled or artificial setting where the experimenter can use sophisticated equipment and videotape the session to examine it later. One-way mirrors can also be used. A limitation of this method is that the process of recording a behavior causes the behavior to change, called reactivity. Have you ever noticed someone staring at you while you sat and ate your lunch? If you have, what did you do? Did you change your behavior? Did you become self-conscious? Likely yes, and this is an example of reactivity. Another issue is that the behavior made in one situation may not be made in other situations, such as your significant other only acting out at the football game and not at home. This form of validity is called cross-sectional validity. We also need our raters to observe and record behavior in the same way or to have high inter-rater reliability.

            3.1.3.2. The clinical interview. A clinical interview is a face-to-face encounter between a mental health professional and a patient in which the former observes the latter and gathers data about the person’s behavior, attitudes, current situation, personality, and life history. The interview may be unstructured in which open-ended questions are asked, structured in which a specific set of questions according to an interview schedule are asked, or semi-structured, in which there is a pre-set list of questions, but clinicians can follow up on specific issues that catch their attention. A mental status examination is used to organize the information collected during the interview and systematically evaluates the patient through a series of questions assessing appearance and behavior. The latter includes grooming and body posture, thought processes and content to include disorganized speech or thought and false beliefs, mood and affect such that whether the person feels hopeless or elated, intellectual functioning to include speech and memory, and awareness of surroundings to include where the person is and what the day and time are. The exam covers areas not normally part of the interview and allows the mental health professional to determine which areas need to be examined further. The limitation of the interview is that it lacks reliability, especially in the case of the unstructured interview.

            3.1.3.3. Psychological tests and inventories. Psychological tests assess the client’s personality, social skills, cognitive abilities, emotions, behavioral responses, or interests. They can be administered either individually or to groups in paper or oral fashion. Projective tests consist of simple ambiguous stimuli that can elicit an unlimited number of responses. They include the Rorschach or inkblot test and the Thematic Apperception Test which asks the individual to write a complete story about each of 20 cards shown to them and give details about what led up to the scene depicted, what the characters are thinking, what they are doing, and what the outcome will be. From the response, the clinician gains perspective on the patient’s worries, needs, emotions, conflicts, and the individual always connects with one of the people on the card.  Another projective test is the sentence completion test and asks individuals to finish an incomplete sentence. Examples include ‘My mother…’ or ‘I hope…’

Personality inventories ask clients to state whether each item in a long list of statements applies to them, and could ask about feelings, behaviors, or beliefs. Examples include the MMPI or Minnesota Multiphasic Personality Inventory and the NEO-PI-R, which is a concise measure of the five major domains of personality – Neuroticism, Extroversion, Openness, Agreeableness, and Conscientiousness. Six facets define each of the five domains, and the measure assesses emotional, interpersonal, experimental, attitudinal, and motivational styles (Costa & McCrae, 1992). These inventories have the advantage of being easy to administer by either a professional or the individual taking it, are standardized, objectively scored, and can be completed electronically or by hand. That said, personality cannot be directly assessed, and so you do not ever completely know the individual.

            3.1.3.4. Neurological tests. Neurological tests are used to diagnose cognitive impairments caused by brain damage due to tumors, infections, or head injuries; or changes in brain activity. Positron Emission Tomography or PET is used to study the brain’s chemistry. It begins by injecting the patient with a radionuclide that collects in the brain and then having them lie on a scanning table while a ring-shaped machine is positioned over their head. Images are produced that yield information about the functioning of the brain. Magnetic Resonance Imaging or MRI provides 3D images of the brain or other body structures using magnetic fields and computers. It can detect brain and spinal cord tumors or nervous system disorders such as multiple sclerosis. Finally, computed tomography or the CT scan involves taking X-rays of the brain at different angles and is used to diagnose brain damage caused by head injuries or brain tumors.

            3.1.3.5. Physical examination. Many mental health professionals recommend the patient see their family physician for a physical examination, which is much like a check-up. Why is that? Some organic conditions, such as hyperthyroidism or hormonal irregularities, manifest behavioral symptoms that are like mental disorders. Ruling out such conditions can save costly therapy or surgery.

            3.1.3.6. Behavioral assessment. Within the realm of behavior modification and applied behavior analysis, we talk about what is called behavioral assessment, which is the measurement of a target behavior. The target behavior is whatever behavior we want to change, and it can be in excess and needing to be reduced, or in a deficit state and needing to be increased. During the behavioral assessment we learn about the ABCs of behavior in which Antecedents are the environmental events or stimuli that trigger a behavior; Behaviors are what the person does, says, thinks/feels; and Consequences are the outcome of a behavior that either encourages it to be made again in the future or discourages its future occurrence. Though we might try to change another person’s behavior using behavior modification, we can also change our own behavior, which is called self-modification. The person does their own measuring and recording of the ABCs, which is called self-monitoring. In the context of psychopathology, behavior modification can be useful in treating phobias, reducing habit disorders, and ridding the person of maladaptive cognitions.

            3.1.3.7. Intelligence tests. Intelligence testing determines the patient’s level of cognitive functioning and consists of a series of tasks asking the patient to use both verbal and nonverbal skills. An example is the Stanford-Binet Intelligence test, which assesses fluid reasoning, knowledge, quantitative reasoning, visual-spatial processing, and working memory. Intelligence tests have been criticized for not predicting future behaviors such as achievement and reflecting social or cultural factors/biases and not actual intelligence. Also, can we really assess intelligence through one dimension, or are there multiple dimensions?

 

Key Takeaways

You should have learned the following in this section:

  • Clinical assessment is the collecting of information and drawing conclusions through the use of observation, psychological tests, neurological tests, and interviews.
  • Reliability refers to consistency in measurement and can take the form of interrater and test-retest reliability.
  • Validity is when we ensure the test measures what it says it measures and takes the forms of concurrent or descriptive, face, and predictive validity.
  • Standardization is all the clearly laid out rules, norms, and/or procedures to ensure the experience each participant has is the same.
  • Patients are assessed through observation, psychological tests, neurological tests, and the clinical interview, all with their own strengths and limitations.

 

Section 3.1 Review Questions

  1. What does it mean that clinical assessment is an ongoing process?
  2. Define and exemplify reliability, validity, and standardization.
  3. For each assessment method, define it and then state its strengths and limitations.

 


3.2. Diagnosing and Classifying Abnormal Behavior

 

Section Learning Objectives

  • Explain what it means to make a clinical diagnosis.
  • Define syndrome.
  • Clarify and exemplify what a classification system does.
  • Identify the two most used classification systems.
  • Outline the history of the DSM.
  • Identify and explain the elements of a diagnosis.
  • Outline the major disorder categories of the DSM-5-TR.
  • Describe the ICD-11.
  • Clarify why the DSM-5-TR and ICD-11 need to be harmonized.

 

3.2.1. Clinical Diagnosis and Classification Systems

Before starting any type of treatment, the client/patient must be clearly diagnosed with a mental disorder. Clinical diagnosis is the process of using assessment data to determine if the pattern of symptoms the person presents with is consistent with the diagnostic criteria for a specific mental disorder outlined in an established classification system such as the DSM-5-TR or ICD-11 (both will be described shortly). Any diagnosis should have clinical utility, meaning it aids the mental health professional in determining prognosis, the treatment plan, and possible outcomes of treatment (APA, 2022). Receiving a diagnosis does not necessarily mean the person requires treatment. This decision is made based upon how severe the symptoms are, level of distress caused by the symptoms, symptom salience such as expressing suicidal ideation, risks and benefits of treatment, disability, and other factors (APA, 2022). Likewise, a patient may not meet the full criteria for a diagnosis but demonstrate a clear need for treatment or care, nonetheless. As stated in the DSM, “The fact that some individuals do not show all symptoms indicative of a diagnosis should not be used to justify limiting their access to appropriate care” (APA, 2022).

Symptoms that cluster together regularly are called a syndrome. If they also follow the same, predictable course, we say that they are characteristic of a specific disorderClassification systems provide mental health professionals with an agreed-upon list of disorders falling into distinct categories for which there are clear descriptions and criteria for making a diagnosis. Distinct is the keyword here. People suffering from delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior, and/or negative symptoms are different from people presenting with a primary clinical deficit in cognitive functioning that is not developmental but acquired (i.e., they have shown a decline in cognitive functioning over time). The former suffers from a schizophrenia spectrum disorder while the latter suffers from a neurocognitive disorder (NCD). The latter can be further distinguished from neurodevelopmental disorders which manifest early in development and involve developmental deficits that cause impairments in social, personal, academic, or occupational functioning (APA, 2022). These three disorder groups or categories can be clearly distinguished from one another. Classification systems also permit the gathering of statistics to determine incidence and prevalence rates and conform to the requirements of insurance companies for the payment of claims.

The most widely used classification system in the United States is the Diagnostic and Statistical Manual of Mental Disorders (DSM) which is a “medical classification of disorders and as such serves as a historically determined cognitive schema imposed on clinical and scientific information to increase its comprehensibility and utility. The classification of disorders (the way in which disorders are grouped) provides a high-level organization for the manual” (APA, 2022, pg. 11). The DSM is currently in its 5th edition Text-Revision (DSM-5-TR) and is produced by the American Psychiatric Association (APA, 2022). Alternatively, the World Health Organization (WHO) publishes the International Statistical Classification of Diseases and Related Health Problems (ICD) currently in its 11th edition. We will begin by discussing the DSM and then move to the ICD.

 

 3.2.2. The DSM Classification System

            3.2.2.1. A brief history of the DSM. The DSM-5 was published in 2013 and took the place of the DSM IV-TR (TR means Text Revision; published in 2000). In March 2022, a Text-Revision was published for the DSM-5, making it the DSM-5-TR.

The history of the DSM goes back to 1952 when the American Psychiatric Association published the first edition of the DSM which was “…the first official manual of mental disorders to contain a glossary of descriptions of the diagnostic categories” (APA, 2022, p. 5). The DSM evolved through four major editions after World War II into a diagnostic classification system to be used by psychiatrists and physicians, but also other mental health professionals. The Herculean task of revising the DSM began in 1999 when the APA embarked upon an evaluation of the strengths and weaknesses of the DSM in coordination with the World Health Organization (WHO) Division of Mental Health, the World Psychiatric Association, and the National Institute of Mental Health (NIMH). This collaboration resulted in the publication of a monograph in 2002 called A Research Agenda for DSM-V. From 2003 to 2008, the APA, WHO, NIMH, the National Institute on Drug Abuse (NIDA), and the National Institute on Alcoholism and Alcohol Abuse (NIAAA) convened 13 international DSM-5 research planning conferences “to review the world literature in specific diagnostic areas to prepare for revisions in developing both DSM-5 and the International Classification of Disease, 11th Revision (ICD-11)” (APA, 2022, pg. 6).

After the naming of a DSM-5 Task Force Chair and Vice-Chair in 2006, task force members were selected and approved by 2007, and workgroup members were approved in 2008. An intensive 6-year process of “conducting literature reviews and secondary analyses, publishing research reports in scientific journals, developing draft diagnostic criteria, posting preliminary drafts on the DSM-5 website for public comment, presenting preliminary findings at professional meetings, performing field trials, and revisiting criteria and text” was undertaken (APA, 2022, pg. 7). The process involved physicians, psychologists, social workers, epidemiologists, neuroscientists, nurses, counselors, and statisticians, all who aided in the development and testing of DSM-5 while individuals with mental disorders, families of those with a mental disorder, consumer groups, lawyers, and advocacy groups provided feedback on the mental disorders contained in the book. Additionally, disorders with low clinical utility and weak validity were considered for deletion while “Conditions for Future Study” were placed in Section 3 and “contingent on the amount of empirical evidence generated on the proposed diagnosis, diagnostic reliability or validity, presence of clear clinical need, and potential benefit in advancing research” (APA, 2022, pg. 7).

            3.2.2.2. The DSM-5 text revision process. In the spring 2019, APA started work on the Text-Revision for the DSM-5. This involved more than 200 experts who were asked to conduct literature reviews of the past 10 years and to review the text to identify any material that was out-of-date. Experts were divided into 20 disorder review groups, each with its own section editor. Four cross-cutting review groups to include Culture, Sex and Gender, Suicide, and Forensic, reviewed each chapter and focused on material involving their specific expertise. The text was also reviewed by an Ethnoracial Equity and Inclusion work group whose task was to “ensure appropriate attention to risk factors such as racism and discrimination and the use of nonstigmatizing language” (APA, 2022, pg. 11).

As such, the DSM-5-TR “is committed to the use of language that challenges the view that races are discrete and natural entities” (APA, 2022, pg. 18). Some of changes include:

  • Use of racialized instead of racial to indicate the socially constructed nature of race
  • Ethnoracial is used to denote U.S. Census categories such as Hispanic, African American, or White
  • Latinx is used in place of Latino or Latina to promote gender-inclusive terminology
  • The term Caucasian is omitted since it is “based on obsolete and erroneous views about the geographic origin of a prototypical pan-European ethnicity” (pg. 18)
  • To avoid perpetuating social hierarchies, the terms minority and non-White are avoided since they describe social groups in relation to a racialized “majority”
  • The terms cultural contexts and cultural backgrounds are preferred to culture which is only used to refer to a “heterogeneity of cultural views and practices within societies” (pg. 18)
  • The inclusion of data on specific ethnoracial groups only when “existing research documented reliable estimates based on representative samples.” This led to limited inclusion of data on Native Americans since data from nonrepresentative samples may be misleading.
  • The use of gender differences or “women and men” or “boys and girls” since much of the information on the expressions of mental disorders in women and men is based on self-identified gender.
  • Inclusion of a new section for each diagnosis providing information about suicidal thoughts or behavior associated with that diagnosis.

            3.2.2.3. Elements of a diagnosis. The DSM-5-TR states that the following make up the key elements of a diagnosis (APA, 2022):

  • Diagnostic Criteria and Descriptors – Diagnostic criteria are the guidelines for making a diagnosis and should be informed by clinical judgment. When the full criteria are met, mental health professionals can add severity and course specifiers to indicate the patient’s current presentation. If the full criteria are not met, designators such as “other specified” or “unspecified” can be used. If applicable, an indication of severity (mild, moderate, severe, or extreme), descriptive features, and course (type of remission – partial or full – or recurrent) can be provided with the diagnosis. The final diagnosis is based on the clinical interview, text descriptions, criteria, and clinical judgment.
  • Subtypes and Specifiers – Subtypes denote “mutually exclusive and jointly exhaustive phenomenological subgroupings within a diagnosis” (APA, 2022, pg. 22). For example, non-rapid eye movement (NREM) sleep arousal disorders can have either a sleepwalking or sleep terror type. Enuresis is nocturnal-only, diurnal-only, or both. Specifiers are not mutually exclusive or jointly exhaustive and so more than one specifier can be given. For instance, binge eating disorder has remission and severity specifiers. Somatic symptom disorder has a specifier for severity, if with predominant pain, and/or if persistent. Again, the fundamental distinction between subtypes and specifiers is that there can be only one subtype but multiple specifiers. As the DSM-5-TR says, “Specifiers and subtypes provide an opportunity to define a more homogeneous subgrouping of individuals with the disorder who share certain features… and to convey information that is relevant to the management of the individual’s disorder” (pg. 22).
  • Principle Diagnosis – A principal diagnosis is used when more than one diagnosis is given for an individual. It is the reason for the admission in an inpatient setting or the basis for a visit resulting in ambulatory care medical services in outpatient settings. The principal diagnosis is generally the focus of attention or treatment.
  • Provisional Diagnosis – If not enough information is available for a mental health professional to make a definitive diagnosis, but there is a strong presumption that the full criteria will be met with additional information or time, then the provisional specifier can be used.           

            3.2.2.4. DSM-5 disorder categories. The DSM-5 includes the following categories of disorders:

 

Table 3.1. DSM-5 Classification System of Mental Disorders

Disorder Category Short Description Module
Neurodevelopmental disorders A group of conditions that arise in the developmental period and include intellectual disability, communication disorders, autism spectrum disorder, specific learning disorder, motor disorders, and ADHD Not covered
Schizophrenia Spectrum Disorders characterized by one or more of the following: delusions, hallucinations, disorganized thinking and speech, disorganized motor behavior, and negative symptoms 12
Bipolar and Related Characterized by mania or hypomania and possibly depressed mood; includes Bipolar I and II and cyclothymic disorder 4
Depressive Characterized by sad, empty, or irritable mood, as well as somatic and cognitive changes that affect functioning; includes major depressive, persistent depressive disorder, mood dysregulation disorder, and premenstrual dysphoric disorder 4
Anxiety Characterized by excessive fear and anxiety and related behavioral disturbances; Includes phobias, separation anxiety, panic disorder, generalized anxiety disorder, social anxiety disorder, agoraphobia 7
Obsessive-Compulsive Characterized by obsessions and compulsions and includes OCD, hoarding, body dysmorphic disorder, trichotillomania, and excoriation 9
Trauma- and Stressor- Related Characterized by exposure to a traumatic or stressful event; PTSD, acute stress disorder, adjustment disorders, and prolonged grief disorder 5
Dissociative Characterized by a disruption or discontinuity in memory, identity, emotion, perception, body representation, consciousness, motor control, or behavior; dissociative identity disorder, dissociative amnesia, and depersonalization/derealization disorder 6
Somatic Symptom Characterized by prominent somatic symptoms and/or illness anxiety associated with significant distress and impairment; includes illness anxiety disorder, somatic symptom disorder, and conversion disorder 8
Feeding and Eating Characterized by a persistent disturbance of eating or eating-related behavior to include bingeing and purging; Includes pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia, bulimia, and binge-eating disorder 10
Elimination Characterized by the inappropriate elimination of urine or feces; usually first diagnosed in childhood or adolescence; Includes enuresis and encopresis Not covered
Sleep-Wake Characterized by sleep-wake complaints about the quality, timing, and amount of sleep; includes insomnia, sleep terrors, narcolepsy, sleep apnea, hypersomnolence disorder, restless leg syndrome, and circadian-rhythm sleep-wake disorders Not covered
Sexual Dysfunctions Characterized by sexual difficulties and include premature or delayed ejaculation, female orgasmic disorder, and erectile disorder (to name a few) Not covered
Gender Dysphoria Characterized by distress associated with the incongruity between one’s experienced or expressed gender and the gender assigned at birth Not covered
Disruptive, Impulse-Control, Conduct Characterized by problems in the self-control of emotions and behavior and involve the violation of the rights of others and cause the individual to violate societal norms; includes oppositional defiant disorder, antisocial personality disorder, kleptomania, intermittent explosive disorder, conduct disorder, and pyromania Not covered
Substance-Related and Addictive Characterized by the continued use of a substance despite significant problems related to its use 11
Neurocognitive Characterized by a decline in cognitive functioning over time and the NCD has not been present since birth or early in life; Includes delirium, major and mild neurocognitive disorder, and Alzheimer’s disease 14
Personality Characterized by a pattern of stable traits which are inflexible, pervasive, and leads to distress or impairment; Includes paranoid, schizoid, borderline, obsessive-compulsive, narcissistic, histrionic, dependent, schizotypal, antisocial, and avoidant personality disorder 13
Paraphilic Characterized by recurrent and intense sexual fantasies that can cause harm to the individual or others; includes exhibitionism, voyeurism, sexual sadism, sexual masochism, pedophilic, and fetishistic disorders Not covered

 

3.2.3. The ICD-11

In 1893, the International Statistical Institute adopted the International List of Causes of Death which was the first international classification edition. The World Health Organization was entrusted with the development of the ICD in 1948 and published the 6th version (ICD-6). The ICD-11 went into effect January 1, 2022, though it was adopted in May 2019. The WHO states:

ICD serves a broad range of uses globally and provides critical knowledge on the extent, causes and consequences of human disease and death worldwide via data that is reported and coded with the ICD. Clinical terms coded with ICD are the main basis for health recording and statistics on disease in primary, secondary and tertiary care, as well as on cause of death certificates. These data and statistics support payment systems, service planning, administration of quality and safety, and health services research. Diagnostic guidance linked to categories of ICD also standardizes data collection and enables large scale research.

As a classification system, it “allows the systematic recording, analysis, interpretation and comparison of mortality and morbidity data collected in different countries or regions and at different times.” As well, it “ensures semantic interoperability and reusability of recorded data for the different use cases beyond mere health statistics, including decision support, resource allocation, reimbursement, guidelines and more.”

Source: http://www.who.int/classifications/icd/en/

The ICD lists many types of diseases and disorders to include Chapter 06: Mental, Behavioral, or Neurodevelopmental Disorders. The list of mental disorders is broken down as follows:

  • Neurodevelopmental disorders
  • Schizophrenia or other primary psychotic disorders
  • Catatonia
  • Mood disorders
  • Anxiety or fear-related disorders
  • Obsessive-compulsive or related disorders
  • Disorders specifically associated with stress
  • Dissociative disorders
  • Feeding or eating disorders
  • Elimination disorders
  • Disorders of bodily distress or bodily experience
  • Disorders due to substance use or addictive behaviours
  • Impulse control disorders
  • Disruptive behaviour or dissocial disorders
  • Personality disorders and related traits
  • Paraphilic disorders
  • Factitious disorders
  • Neurocognitive disorders
  • Mental or behavioural disorders associated with pregnancy, childbirth or the puerperium

It should be noted that Sleep-Wake Disorders are listed in Chapter 07.

To access Chapter 06 of the ICD-11, please visit the following:

https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f334423054

 

3.2.4. Harmonization of DSM-5-TR and ICD-11

According to the DSM-5-TR, there is an effort to harmonize the two classification systems: 1) for a more accurate collection of national health statistics and design of clinical trials aimed at developing new treatments, 2) to increase the ability to replicate scientific findings across national boundaries, and 3) to rectify the issue of DSM-IV and ICD-10 diagnoses not agreeing (APA, 2022, pg. 13). Complete harmonization of the DSM-5 diagnostic criteria with the ICD-11 disorder definitions has not occurred due to differences in timing. The DSM-5 developmental effort was several years ahead of the ICD-11 revision process. Despite this, some improvement in harmonization did occur as many ICD-11 working group members had participated in the development of the DSM-5 diagnostic criteria and all ICD-11 work groups were given instructions to review the DSM-5 criteria sets and make them as similar as possible (unless there was a legitimate reason not to). This has led to the ICD and DSM being closer than at any time since DSM-II and ICD-8 (APA, 2022).

 

Key Takeaways

You should have learned the following in this section:

  • Clinical diagnosis is the process of using assessment data to determine if the pattern of symptoms the person presents with is consistent with the diagnostic criteria for a specific mental disorder outlined in an established classification system such as the DSM-5-TR or ICD-11.
  • Classification systems provide mental health professionals with an agreed-upon list of disorders falling into distinct categories for which there are clear descriptions and criteria for making a diagnosis.
  • Elements of a diagnosis in the DSM include the diagnostic criteria and descriptors, subtypes and specifiers, the principle diagnosis, and a provisional diagnosis.

 

Section 3.2 Review Questions

  1. What is clinical diagnosis?
  2. What is a classification system and what are the two main ones used today?
  3. Outline the diagnostic categories used in the DSM-5-TR.

 


3.3. Treatment of Mental Disorders – An Overview

 

Section Learning Objectives

  • Clarify reasons why an individual may need to seek treatment.
  • Critique myths about psychotherapy.

 

3.3.1. Seeking Treatment

            3.3.1.1. Who seeks treatment? Would you describe the people who seek treatment as being on the brink, crazy, or desperate? Or can the ordinary Joe in need of advice seek out mental health counseling? The answer is that anyone can. David Sack, M.D. (2013) writes in the article 5 Signs Its Time to Seek Therapy, published in Psychology Today, that “most people can benefit from therapy at least some point in their lives,” and though the signs you need to seek help are obvious at times, we often try “to sustain [our] busy life until it sets in that life has become unmanageable.” So, when should we seek help? First, if we feel sad, angry, or not like ourselves. We might be withdrawing from friends and families or sleeping more or less than we usually do. Second, if we are abusing drugs, alcohol, food, or sex to deal with life’s problems. In this case, our coping skills may need some work. Third, in instances when we have lost a loved one or something else important to us, whether due to death or divorce, the grief may be too much to process. Fourth, a traumatic event may have occurred, such as abuse, a crime, an accident, chronic illness, or rape. Finally, if you have stopped doing the things you enjoy the most. Sack (2013) says, “If you decide that therapy is worth a try, it doesn’t mean you’re in for a lifetime of head shrinking.” A 2001 study in the Journal of Counseling Psychology found that most people feel better within seven to 10 visits. In another study, published in 2006 in the Journal of Consulting and Clinical Psychology, 88% of therapy-goers reported improvements after just one session.”

            3.3.1.2. When friends, family, and self-healing are not enough. If you are experiencing any of the aforementioned issues, you should seek help. Instead of facing the potential stigma of talking to a mental health professional, many people think that talking through their problems with friends or family is just as good. Though you will ultimately need these people to see you through your recovery, they do not have the training and years of experience that a psychologist or similar professional has. “Psychologists can recognize behavior or thought patterns objectively, more so than those closest to you who may have stopped noticing — or maybe never noticed. A psychologist might offer remarks or observations similar to those in your existing relationships, but their help may be more effective due to their timing, focus, or your trust in their neutral stance” (http://www.apa.org/helpcenter/psychotherapy-myths.aspx). You also should not wait to recover on your own. It is not a failure to admit you need help, and there could be a biological issue that makes it almost impossible to heal yourself.

            3.3.1.3. What exactly is psychotherapy? According to the APA, in psychotherapy “psychologists apply scientifically validated procedures to help people develop healthier, more effective habits.” Several different approaches can be utilized to include behavior, cognitive and cognitive-behavior, humanistic-experiential, psychodynamic, couples and family, and biological treatments.

            3.3.1.4. The client-therapist relationship. What is the ideal client-therapist relationship? APA says, “Psychotherapy is a collaborative treatment based on the relationship between an individual and a psychologist. Grounded in dialogue, it provides a supportive environment that allows you to talk openly with someone who’s objective, neutral and nonjudgmental. You and your psychologist will work together to identify and change the thought and behavior patterns that are keeping you from feeling your best.” It’s not just about solving the problem you saw the therapist for, but also about learning new skills to help you cope better in the future when faced with the same or similar environmental stressors.

So how do you find a psychotherapist? Several strategies may prove fruitful. You could ask family and friends, your primary care physician (PCP), look online, consult an area community mental health center, your local university’s psychology department, state psychological association, or use APA’s Psychologist Locator Service (https://locator.apa.org/?_ga=2.160567293.1305482682.1516057794-1001575750.1501611950). Once you find a list of psychologists or other practitioners, choose the right one for you by determining if you plan on attending alone or with family, what you wish to get out of your time with a psychotherapist, how much your insurance company pays for and if you have to pay out of pocket how much you can afford, when you can attend sessions, and how far you are willing to travel to see the mental health professional. Once you have done this, make your first appointment.

But what should you bring? APA suggests, “to make the most of your time, make a list of the points you want to cover in your first session and what you want to work on in psychotherapy. Be prepared to share information about what’s bringing you to the psychologist. Even a vague idea of what you want to accomplish can help you and your psychologist proceed efficiently and effectively.” Additionally, they suggest taking report cards, a list of medications, information on the reasons for a referral, a notebook, a calendar to schedule future visits if needed, and a form of payment. What you take depends on the reason for the visit.

In terms of what you should expect, you and your therapist will work to develop a full history which could take several visits. From this, a treatment plan will be developed. “This collaborative goal-setting is important, because both of you need to be invested in achieving your goals. Your psychologist may write down the goals and read them back to you, so you’re both clear about what you’ll be working on. Some psychologists even create a treatment contract that lays out the purpose of treatment, its expected duration and goals, with both the individual’s and psychologist’s responsibilities outlined.”

After the initial visit, the mental health professional may conduct tests to further understand your condition but will continue talking through the issue. He/she may even suggest involving others, especially in cases of relationship issues. Resilience is a skill that will be taught so that you can better handle future situations.

            3.3.1.5. Does it work? APA writes, “Reviews of these studies show that about 75 percent of people who enter psychotherapy show some benefit. Other reviews have found that the average person who engages in psychotherapy is better off by the end of treatment than 80 percent of those who don’t receive treatment at all.” Treatment works due to finding evidence-based treatment that is specific for the person’s problem; the expertise of the therapist; and the characteristics, values, culture, preferences, and personality of the client.

            3.3.1.6. How do you know you are finished? “How long psychotherapy takes depends on several factors: the type of problem or disorder, the patient’s characteristics and history, the patient’s goals, what’s going on in the patient’s life outside psychotherapy and how fast the patient is able to make progress.” It is important to note that psychotherapy is not a lifelong commitment, and it is a joint decision of client and therapist as to when it ends. Once over, expect to have a periodic check-up with your therapist. This might be weeks or even months after your last session. If you need to see him/her sooner, schedule an appointment. APA calls this a “mental health tune up” or a “booster session.”

 

For more on psychotherapy, please see the very interesting APA article on this matter:

http://www.apa.org/helpcenter/understanding-psychotherapy.aspx

 

Key Takeaways

You should have learned the following in this section:

  • Anyone can seek treatment and we all can benefit from it at some point in our lives.
  • Psychotherapy is when psychologists apply scientifically validated procedures to help a person feel better and develop healthy habits.

 

Section 3.3 Review Questions

  1. When should you seek help?
  2. Why should you seek professional help over the advice dispensed by family and friends?
  3. How do you find a therapist and what should you bring to your appointment?
  4. Does psychotherapy work?

 



Module Recap

That’s it. With the conclusion of Module 3, you now have the necessary foundation to understand each of the groups of disorders we discuss beginning in Module 4 and through Module 14.

In Module 3 we reviewed clinical assessment, diagnosis, and treatment. In terms of assessment, we covered key concepts such as reliability, validity, and standardization; and discussed methods of assessment such as observation, the clinical interview, psychological tests, personality inventories, neurological tests, the physical examination, behavioral assessment, and intelligence tests. In terms of diagnosis, we discussed the classification systems of the DSM-5-TR and ICD-11. For treatment, we discussed the reasons why someone may seek treatment, self-treatment, psychotherapy, the client-centered relationship, and how well psychotherapy works.


3rd edition

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