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Diagnosis and Classification Issues
● Defining abnormality has been a primary task
of clinical psychologists since the inception of
the field.
o What defines abnormality?
o Who defines abnormality?
o Why is the definition of abnormality
important?
What Defines Abnormality?
● Various theories have suggested:
o Personal distress
o Deviance from cultural norms
o Statistical infrequency
o Impaired social functioning
o Others
● Harmful Dysfunction- a theory
o Jerome Wakefield
o Consider both scientific data
(dysfunction) and social context
(harmful).
● Can behaviors be culturally typical yet also
abnormal?
Who Defines Abnormality?
● In DSM-5, mental disorders are defined as a
“clinically significant disturbance” in
“cognition, emotion regulation, or behavior”
that indicate a “dysfunctional” in “mental
functioning” that are “usually associated with
significant distress of disability”, in work,
relationships, or other areas of functioning.
● Authors of DSM make the official definitions of
disorders.
● Leading researchers in psychopathology
● Many of these authors have been psychiatrists
(DSM published by American Psychiatric
Association).
o Medical model of psychopathology
■ Categorical definitions with
specific symptoms.
o Increasing cultural diversity among
these authors in more recent editions
of DSM.
Why is the Definition Abnormality Important?
● Labeling an experience as a disorder can affect
professionals and clients.
o Professionals
■ Facilitate research, awareness,
and treatment.
○ Clients
■ Demystify difficult experience
■ Feel like “not the only one”
■ Acknowledge significance of
problem
■ Access treatment
● Stigma damages self-image.
● Stereotyping by those who know the client.
● Legal consequences
Before the DSM
● Abnormal behavior was recognized and studied
in ancient civilizations.
● In the 19th century, asylums in Europe and the
U.S. arose.
● Around 1900, Emil Kraepelin put forth some of
the first specific categories of mental illness.
● Some early categorical systems were for
statistical/census purposes.
DSM-I and DSM-II
● DSM-I - Published in 1952.
● DSM-II - Published in 1968.
● Similar to each other, but different from later
editions.
● Not scientifically or empirically based.
o Based on “clinical wisdom” of leading
psychiatrists.
● Psychoanalytic/Freudian influence.
● Contained three broad categories of disorders:
o Psychoses, neuroses, character
disorders
■ Psychoses - Schizophrenia
■ Neuroses - Major Depression,
Bipolar Disorder, and Anxiety
Disorders
■ Character Disorders -
Personality Disorder
● No specific criteria; just paragraphs with
somewhat vague descriptions.
DSM-III
● Published in 1980.
● Very different from DSM-I and DSM-II.
o More reliant on empirical data.
o Specific criteria defined disorders.
o Atheoretical (no
psychoanalytic/Freudian influence)
o Multiaxial assessment (5 axes) - MD,
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PD & MR, GEN, PSYCHOSOCIAL, o Dimensional approach for personality
GLOBAL disorders.
o DSM-IV-TR o Remove five of the 10 personality
o Much longer- included many more disorders.
disorders. o Proposed disorders
● DSM-III-R (minor changes from DSM-III) was ■ Attenuated Psychosis
published in 1987. Syndrome
■ Mixed Anxiety-Depressive
DSM-IV Disorder
● Published in 1994. ■ Internet Gaming Disorder
● DSM-IV-TR was published in 2000- 16 broad ● New Features:
categories. ○ Naming shifts from Roman numerals
o TR stands for “text revision”. (e.g. DSM-IV) to Arabic numerals (e.g.
o Only text, not diagnostic criteria, differ DSM-5).
between DSM-IV and DSM-IV-TR. ■ Minor updates will be denoted
■ So, these two editions are as new versions (e.g.
essentially similar. DSM-5.1, DSM-5.2, etc.)
● Pervasive Developmental Disorder/Autism ○ Elimination of the multiaxial
Spectrum Disorder assessment system.
○ Autistic Disorder ● New Disorders:
○ Rett Syndrome ○ Premenstrual Dysphoric Disorder,
○ Childhood Disintegrative Disorder Disruptive Mood Dysregulation
○ Asperger’s Syndrome Disorder, Binge Eating Disorder, Mild
○ PDD-Not Otherwise Specified Neurocognitive Disorder, Somatic
● DSM-IV included significant cultural advances. Symptom Disorder, Hoarding Disorder
○ Text describing disorders often ● Revised Disorders in DSM-5
included culturally specific information. ○ Major Depressive Episode
○ Culture-Bound Syndromes were listed ■ “Bereavement exclusion”
■ Not official diagnostic dropped
categories, but experiences ○ Autism Spectrum Disorder (New scope
common in some cultural in DSM-5).
groups. ■ Encompasses autistic
○ Outline for Cultural Formulation disorder, Asperger’s disorder,
■ Helped clinicians appreciate and related developmental
the impact of culture on disorders from DSM- IV, CDD,
symptoms. RETT’S, PDD-NOS.
○ Attention-Deficit/Hyperactivity Disorder
DSM-5 ■ Age at which symptoms must
● Published in 2013. first appear raised from 7 to
● Task Force led Work Groups, each focusing on 12.
a particular area of mental disorders. ○ Bulimia Nervosa
● Attempted greater consistency between DSM ■ Frequency of binge eating
and International Classification of Diseases decreased from twice to once
(ICD). per week.
● Changes that DSM-5 didn’t make: ○ Anorexia Nervosa
o Paradigm shift to emphasize ■ Removed requirement that
neuropsychology/biological roots of menstrual periods stop.
mental disorder. ■ “Low body weight” changed
o Dimensional definition of all mental from a numeric definition to a
disorders. less specific description.

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○ Substance Use Disorder (New scope in
DSM-5)
■ Encompasses substance
abuse and substance
dependence disorders from
DSM-IV.
○ Intellectual Disability Disorder
■ Mental retardation from
DSM-IV.
○ Specific Learning Disorder/LD
■ Covers separate learning
disorders in reading, writing,
and math from DSM-IV.
● DSM-5 Controversy:
○ Allen France’s criticisms
■ DSM-5 features changes that
“seem clearly unsafe and
scientifically unsound”.
■ DSM-5 “will mislabel normal
people, promote diagnostic
inflation, and encourage
inappropriate medication use”.
○ Key areas of criticism
■ Diagnostic overexpansion
■ Questionable transparency of
the revision process.
■ Work Groups predominantly
composed of researchers, not
clinicians.
Criticisms of Recent DSMs
● Despite advances (e.g. empiricism, diagnostic
criteria), some have criticized recent DSMs:
o Breadth of coverage
■ Too many disorders? Some not
actually forms of mental
illness? Too many people
stigmatized? Concept
mental illness becoming
trivialized?
○ Controversial cutoffs
■ How many symptoms should
be necessary for a particular
disorder? What constitutes
“significant distress
impairment?”
○ Cultural issues
■ Some progress, but still
dominated by non-minority
authors and traditional
Western values?
○ Gender bias
■ Do some diagnostic categories
pathologize one gender more
than the other? Consider
premenstrual dysphoric
disorder
○ Nonempirical influences
■ Despite increased empiricism,
do other non-empirical factors
(e.g. politics, finances)
influence decisions about
abnormality?
○ Limitations on objectivity
■ Even with increased
empiricism, do opinion and
judgment still play significant
roles in decisions about
abnormality?
Alternate Directions in Diagnosis and Classification
● Categorical Approach
o The DSM’s approach
o An individual falls in the “yes” or “no”
category for having a particular
disorder.
o “Black and white” approach- no
“shades of gray”.
o May correspond well with human
tendency to think categorically.
o Facilitates communication.
● Dimensional Approach
o “Shades of gray” rather than “black
and white”.
o Place clients’ symptoms on a
continuum rather than into discrete
diagnostic categories.
o Five-factor model of personality could
of
provide the dimensions.
■ Neuroticism, Extraversion,
Openness,
Conscientiousness, and
Agreeableness.
o More difficult to efficiently
communicate, but more thorough
and
description of clients?
o May be better suited for some
disorders (e.g. personality disorders)
Attention to Culture, Racism, and Discrimination in
DSM-5-TR
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● Racialized, Ethnoracial, Latinx ● General skills
o Quieting yourself
DSM-5-TR and Diagnoses for Children o Being self-aware
● More Precise Criteria ■ Know how you tend to affect
o Existing criteria have been updated in others interpersonally, and
DSM-5-TR to provide more precise how others tend to relate to
descriptions and reflect the scientific you.
advances and clinical experience of ○ Develop positive working relationships
the last decade. ● Specific behaviors
● Autism Spectrum Disorder ○ Listening - The primary task of the
● Disruptive Mood Dysregulation Disorder interviewer, consisting of numerous
● Posttraumatic Stress Disorder building blocks.
● Prolonged Grief Disorder ■ Eye contact, Body language,
Vocal qualities
Clinical Interview ■ Verbal tracking - Flow of
● Assessment is closely linked with the identity thoughts
of clinical psychologists. ■ Referring to client by proper
o No other mental health profession name
incorporates assessment into their
work as clinical psychologists do. Components of the Interview
● Clinical interviews are the most frequent ● Rapport
assessment tool. o Positive, comfortable relationship
o More than any specific test. between interviewer and client.
o Vast majority of practicing clinical o How an interviewer is with clients.
psychologists use interviews. ● Technique
o What an interviewer does with clients.
Essential Qualities of Assessment Techniques o Directive vs. nondirective styles.
● All assessment techniques (including
interviews) should have adequate: Specific Interviewer Responses
o Validity - Measures what it claims to ● Open-ended and closed-ended questions
measure. o Open-ended questions
■ Content Validity, Convergent ■ Allow individualized and
Validity, Discriminant Validity. spontaneous responses from
o Reliability - Yields consistency, clients.
repeatable results. ■ Elicit long answers that may or
■ Test-retest Reliability, may not provide necessary
Interrater Reliability, Internal info.
Reliability. ○ Closed-ended questions
o Clinical Utility - Benefits the clinician ■ Allow less elaboration and
and ultimately the client. self-expression by the client.
■ Yield quick and precise
Feedback answers.
● Common to all kinds of psychological ● Clarification
assessment. ○ Question to make sure the interviewer
● Provide results of tests or interviews accurately understands the client’s
● May be face-to-face, a report, etc. comments.
● Sandwich feedback - Positive, negative, ● Confrontation
positive; most common feedback Filipino ○ For discrepancies or inconsistencies in
psychologists use. a client’s comments.
The Interviewer ● Paraphrasing

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○ Restatement of client’s comments to
show they have been heard.
● Reflection of feeling
○ Echo client’s emotions, even if not
explicitly mentioned.
● Summarizing
○ Tie together various topics, connect
statements that may have been made
at different points, and identify
themes.
Pragmatics of the Interview
● Note-taking
o Little consensus about note-taking.
o Provide a reliable written record, but
can be distracting to client and
interviewer.
● Audio- and Video-recording
o Also provide a reliable record, but can
be inhibiting to clients.
o Must obtain permission.
● The Interview Room
o Professional yet comfortable.
● Confidentiality
o Explain confidentiality and its limits to
clients (e.g. child abuse, intention to
harm).
Types of Interview
● Intake Interviews
o To determine whether to “intake” the
client into the agency or refer
elsewhere.
● Diagnostic Interviews
o To provide DSM diagnosis-DSM5-TR
o Structured interviews often used
■ Minimize subjectivity, enhance
reliability
■ SCID is an example
● Currently being revised
for DSM-5-TR
■ Semi-structured interviews
include some structure but
also some flexibility or
opportunities to improvise.
● Mental Status Exam
o Typically used in medical settings
o To quickly assess how a client is
functioning at that time.
● Crisis Interviews
o Assess problems and provide
immediate intervention.
o Clients are often considering suicide or
other harmful act.
Cultural Components
● Appreciating the cultural context
o Knowledge of the client’s culture, as
well as the interviewer’s own culture.
o For behavior described or exhibited
during the interview.
● Acknowledging cultural differences
o Wise to discuss cultural differences
rather than ignore.
o Sensitive inquiry about a client’s
cultural experiences can be helpful.
Intellectual and Neuropsychological Assessment
Assessment Overview
● Tests described in this chapter are related to
cognitive functioning in some way.
o Intelligence tests measure intellectual
abilities.
o Achievement tests measure
accomplishments in academic areas.
o Neuropsychological tests focus on
cognitive dysfunction, often from brain
injury or illness.
Intelligence Testing
● In general, intelligence tests measure a wide
variety of human behaviors better than any
other measure that has been developed.
● They allow professionals to have a uniform way
of comparing a person’s performance with that
of other people who are similar in age.
● These tests also provide information on
cultural and biological differences among
people.
● Intelligence tests are excellent predictors of
academic achievement and provide an outline
of a person’s mental strengths and
weaknesses.
● Many times the scores have revealed talents in
many people, which have led to an
improvement in their educational opportunities.
● Teachers, parents, and psychologists are able
to devise individual curricula that match a
person’s level of development and
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expectations.
● Theories of Intelligence
o Is intelligence one thing or many
things?
■ Charles Spearman - “G” for
general (single) intelligence.
■ Louis Thrustone - Intelligence is
plural abilities that may not
relate to each other.
● More Contemporary Theories of Intelligence
○ James Cattell - Two separate
intelligences.
■ Fluid intelligence - Ability to
reason when faced with novel
problems.
■ Crystallized intelligence - Body
of knowledge accumulated
through life experiences.
○ John Carroll - Three-stratum theory
■ “g”, 8 broad factors, 60
specific abilities
Wechsler Intelligence Tests
● Originally created by David Wechsler in the
early 1900s.
● “The global capacity of a person to act
purposefully, to think rationally, and to deal
effectively with his/her environment.”
● Currently, there are three Wechsler IQ tests:
o Wechsler Adult Intelligence Scale-
Fourth Edition (WAIS-IV) - Age 16-89
o Wechsler Intelligence Scale for
Children- Fourth Edition (WISC-IV) - Age
6.0-16.11
o Wechsler Preschool and Primary Scale
of Intelligence- Third Edition (WPPSI-III) -
Age 2.6-7
● Similarities among the three Wechsler IQ tests:
o Yield a single full-scale intelligence
score.
■ Also yield 4 index scores:
Verbal Comprehension,
Perceptual Reasoning, Working
Memory, Processing Speed.
■ Also yield about a dozen
specific subtests scores.
○ One-to-one, face-to-face administration.
○ Share a core of subtests: Vocabulary,
similarities, information,
comprehension, block design, picture
completion, matrix reasoning, coding,
symbol search.
○ Mean of 100 for full scale and index
scores, and 10 for subtests.
○ Large sets of normative data.
○ Impressive psychometric data to
support reliability and validity.
○ Approach to interpretation: full scale IQ
first, followed by increasingly specific
scores and patterns.
Stanford-Binet Intelligence Scales- 5th edition (SB5)
● Dominated in the early 1900s until Wechsler’s
tests began to complete.
● Like Wechsler tests in many ways.
o Face-to-face, one-to-one administration.
o Single overall IQ score, 5 factor
scores, many more subset scores.
o Mean score is 100.
o Age 2-85
● Unlike Wechsler tests in some ways:
o One test covers the whole lifespan
(ages 2-85+).
o Subtests include extensions at high
and low end (useful for assessing
giftedness or mental retardation).
o DIfferent subsets and factors.
o Has become less commonly used than
Wechsler tests, but still highly
regarded and used.
Culture Fairness in Intelligence Tests
● Some subsets may place people from minority
cultural groups at a disadvantage.
o Verbal subtests especially.
o Both Wechsler and Stanford-Binet have
made improvements in recent editions.
● Universal Nonverbal Intelligence Test (UNIT) -
Created in 1996.
o Entirely language free.
o No speaking necessary for test
administrator or test taker.
■ All instructions are hand
gestures.
■ All responses are manual, nor
verbal.
○ Some drawbacks: only for kids age
5-17, limited psychometric data, more
limited range.
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Achievement Testing
● Intelligence is what a person can accomplish
intellectually.
● Achievement is what a person has
accomplished, especially reading, spelling,
writing, or math.
● Achievement tests typically produce standard
scores that can be easily compared to scores
from intelligence tests (e.g., mean = 100).
o A significant discrepancy between a
person’s achievement and expected
levels of achievement is the basis for
specific learning disorder.
● They also typically produce age- or grade-
equivalency scores.
● Some achievement tests are specific to math,
reading, or other abilities.
● Others are more global
o Wechsler Individual Achievement Test-
Third Edition (WIAT-III) - For ages
4-50:11
■ Administered face-to-face and
one-on-one.
■ Reading, math, written
language, oral language.
Neuropsychological Testing
● Measure cognitive functioning or impairment of
the brain and its specific components or
structures.
● Additional purposes: to make prognosis, plan
rehab, determine eligibility for
accommodations, etc.
Halstead-Reitan Neuropsychological Battery (HRB)
● Comprehensive battery of 8 neuropsychological
tests.
● Primary purpose is to identify people with brain
damage and, to the extent possible, provide
detailed information or hypotheses about any
brain damage identified.
● 15-above
● Some of 8 tests involve sight, hearing, touch,
motor skills, and pencil & paper tasks.
● A similar comprehensive battery of tests is the
Luria-Nebraska Neuropsychological Battery
(LNNB).
o Similarly long and comprehensive.
o Emphasizes qualitative data in addition
to quantitative data.
Brief Neuropsychological Measures
● Bender Visual-Motor Gestalt Test- Second
Edition
o Most commonly used
neuropsychological screen among
clinical psychologists.
o 6 minutes to administer
o Simple copying test using 9 geometric
designs.
o A quick “check”, followed by more
tests as necessary.
o Can suggest brain damage in a
diffuse, but not specific way.
● Rey-Osterrieth Complex Figure Test
o Brief pencil-and-paper drawing task,
but unlike Bender-Gestalt, involves just
a single, more complex figure.
o Also includes a memory component
(recall figure and draw it again from
memory).
o Copy, Recall (immediate or delayed).
● Repeatable Battery for the Assessment of
Neuropsychological Status (RBANS)
o Neuropsych screen focusing on a
broader range of abilities than
Bender-Gestalt or Rey-Osterrieth.
o 12.0-89.11
o 12 subtests in less than half hour.
● Wechsler Memory Scale- Fourth Edition
(WMS-IV)
o Assess memory problems due to brain
injury, dementia, substance abuse,
etc.
o Ages 16-90
o Assess visual and auditory memory,
immediate and delayed recall.
Personality and Behavioral Assessment
Multimethod Assessment
● No measure of personality or behavior is
perfect.
● It is best to use multiple methods: Tests,
Interviews, Observations, Other sources
● Convergent conclusions can be made with
more confidence.
Evidence-Based Assessment
● Assessment based on “what works”
empirically.
● Similar to movement regarding “what works” in
therapy, but data is not quite as abundant yet.
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● Typically tied to particular disorders.
o Ex: SCID and BDI-II for assessing
depression.
Culturally Competent Assessment
● Every culture has its own definitions of
“normal” and “abnormal”.
● Culturally competent clinical psychologists are
aware of this, and of the influence of their own
cultural perspective.
● Especially important not to overpathologize.
o View as abnormal what is culturally
normal.
Objective Personality Tests
● Include unambiguous test items, offer clients a
limited range of responses, and are objectively
scored.
● Typically self-report questionnaires.
Minnesota Multiphasic Personality Inventory-2
(MMPI-2)
● Most popular and most psychometrically sound
objective personality test.
o Used worldwide; translated into dozens
of languages.
● Pencil & paper format.
● 567 self-descriptive sentences.
● Client marks true or false for each.
● Original MMPI was published in 1943.
o Primary authors were Starke Hathaway
and J.C. McKinley.
o Empirical criterion keying was used as
a test construction method.
● Revised edition, MMPI-2, was published in
1989.
o Better norms
o Less outdated wording of items.
● MMPI and MMPI-2 feature 10 clinical scales.
o 1- Hypochondriasis, 2- Depression, 3-
Hysteria, 4- Psychopathic Deviate, 5-
Masculinity/femininity, 6- Paranoia, 7-
Psychasthenia, 8- Schizophrenia, 9-
Mania, 0- Social Introversion
● Also feature supplemental scales and content
scales for additional clinical information.
● MMPI and MMPI-2 also feature validity scales
o To measure test-taking attitudes.
o Can identify clients who “fake good” or
“fake bad,” or clients who respond
randomly.
● MMPI-A (for adolescents, age 14-18) was
published in 1992
o Similar clinical scales, validity scales,
and administration.
● MMPI-2-RF- most recent edition- briefer, less
overlap between clinical scales.
● Strengths include psychometrics (established
reliability and validity) and comprehensiveness.
● Limitations include length, reading
requirement, attention requirement, and
emphasis on pathology/abnormality.
● Therapeutic Assessment
o Interesting use of MMPI-2, developed
by Stephen Finn and colleagues.
● MMPI-2 feedback used as a brief therapeutic
intervention.
Millon Clinical Multiaxial Inventory (MCMI-III)
● Originally created by Theodore Millon.
● Like the MMPI-2 in some ways
o Comprehensive objective personality
test.
o Self-report, pencil & paper format- 175
items.
NEO Personality Inventory- Revised (NEO-PI-R)
● Originally created by Paul Costa and Robert
McCrae.
● Another objective personality test.
o Pencil & paper, self-report format
● Main distinction: measures “normal”
personality traits (not pathologies).
California Psychological Inventory-III (CPI-III)
● Another objective personality test
o Pencil & paper, self-report
● Like NEO-PI-R, it doesn't emphasize pathology.
● Emphasizes positive attributes of personality-
strengths, assets, internal resources.
● Consistent with the recent positive psychology
movement.
● Also goes by the name CPI-434 (434 items).
● 20 scales
Beck Depression Inventory-II (BDI-II)
● Not a comprehensive test of personality, but a
brief, targeted measure of one characteristic
(depression symptoms).
● 21 items; takes 5-10 minutes to complete.
● Pencil & paper, self-report format
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● Lacks validity scales, and much more limited
scope than other tests discussed to this point.
Projective Personality Tests
● Based on the assumption that clients will
“project” their personalities when presented
with unstructured, ambiguous stimuli and an
unrestricted opportunity to respond.
● Lack of objectivity in scoring and interpretation.
o Considered by many to be empirically
inferior to objective tests.
o Usage has declined in recent decades.
● Advocates claim they are less “fake-able”.
Rorschach Inkblot Method
● Created in 1921 by Hermman Rorschach.
● 10 inkblots (5 in color, 5 black & white) are
presented.
● Scoring emphasizes how the client perceives
the blot as well as what the client sees.
● Scoring variables include:
o Location (Whole blot, large part, or
small detail?)
o Determinants (Form, color, or shading
of blot?)
o Form Quality (Conventional?
Distorted?)
o Popular (What others see?
Idiosyncratic?)
o Content (What kinds of objects appear
frequently?)
Thematic Apperception Test (TAT)
● Published in 1943 by Henry Murray and
Christiana Morgan.
● Like Rorschach in that it involves a series of
cards with ambiguous stimuli.
● Cards feature interpersonal scenes rather than
inkblots.
Tell-Me-a-Story (TEMAS)
● Recent TAT-style apperception test.
● Greater emphasis on cultural sensitivity (via
portrayal of diverse individuals in cards).
Sentence Completion Tests
● The ambiguous stimuli are not inkblots or
interpersonal scenes, but beginnings of
sentences.
● Rotter Incomplete Sentence Blank (RISB) is
most widely used.
● Not often formally or empirically scored.
● Reliability and validity are questionable.
Behavioral Assessment
● Assumes that client behaviors are not signs of
underlying issues or problems; instead, those
behaviors are the problems.
● Techniques of Behavioral Assessment
o Behavioral observation is the most
essential technique.
■ Direct, systematic observation
of a client’s behavior in the
natural environment.
■ Also known as naturalistic
observation.
o When naturalistic observation is not
possible, analogue observation is
used.
■ Replicate situation in clinic.
○ Recording of behaviors is crucial.
■ This functionality is a key
concept in behavioral
assessment.
● Technology in Behavioral Assessment
○ Laptop computers or handheld devices
can be used to record observed
behaviors.
○ Numerous software programs have
been created for this purpose.
Prepared and arranged by:
Allaiah Rhae Garcia
Psychological Society QC, Educational Committee