Download Axis V Global Assessment of Functioning

Department of Applied Psychology
School of Social Sciences
Beaconhouse National University
October, 2008
Hand out number: 3
Psychopathology I
Course code: PSY 205 / PSY 520
Course instructor: Madiha Anas
Clinical Assessment and Diagnosis (DSM)
 Clinical Assessment
 A procedure in which a clinician evaluates a person in terms of the psychological,
physical, and social factors that influence the individual's functioning.
 A - Clinical Interviews
 Interview formats
 Mental Status Examination
 B - Clinical Tests
 Characteristics of tests (standardization etc.)
 Projective Tests (Rorschach, TAT)
 Objective Tests (self-report inventories,
 Neuropsychological tests
 Psychophysiological tests
 C - Clinical Observations
----------------------------------------------------------------------------------------------------------- A - Clinical Interview
 most commonly used assessment tool for developing an understanding of
 The client
 Nature of the client's current problems
 History and future aspirations
 Family history
 covers major events in the lives of the client’s relatives
 Personal history
 includes important events and relationships in the client’s life.
 Unstructured interview involves
 a series of open-ended questions.
 Structured interview consists of
 a standardized series of questions with predetermined wording and order.
 Information sought through interviews:
 Reasons for being in treatment
 Symptoms
 Health status
 Family background
 Life history
 Expectations from treatment
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 Limitations of clinical interviews
 Information pre-selected by client
 Distorted perception of client (due to health reasons)
 Interviewer’s subjectivity
 Different client ---- different interviewer
 Mental Status Exam
 A term used by clinicians to describe what the client talks and thinks about and
how he/she acts.
 Clinicians use the mental status examination to assess a client's behavior and
functioning, with particular attention to the symptoms associated with
psychological disturbance.
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Department of Applied Psychology
School of Social Sciences
Beaconhouse National University
B - Clinical Tests
Devices used for gathering information about a few aspects of a person’s psychological
functioning, from which broader information about the person can be inferred.
 1 - Characteristics of Tests
 Reliability
 Consistency in measurement
 Validity
 What the test measures and how well it does so
 Accuracy
 Standardization
 A test should go through the Standardization process
 Has to be administered to a large group of subjects whose performance then
serves as a common standard, or norm, against which any individual’s score
can be measured
 2 - Projective Tests
 Project aspects of personality onto ambiguous stimuli
 Have roots in psychoanalytic tradition
 2a. Inkblot Tests - Rorschach Inkblot Tests
 1911 – Herman Rorschach
 People with schizophrenia saw different images from people with anxiety
disorders
 1921 - Set of ten inkblots
 5 black and white
 5 colored
 Stages of assessment: Rorschach Inkblot
 Free association/Performance phase
 Say it!
 Inquiry phase
 Why did you say it?
 Testing the limits
 Others said it, do you agree?
 Rorschach Interpretation
Normal people
- Whole designs
- But focus on details in at least ½ inkblots
Depressed people
- Give few responses
- Do not mention color at all
Impulsive people
- Respond intensely to color
 2b. Thematic Apperception Test (TAT
 1935 – Henry A. Murray
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–30 black and white pictures
–Clinicians choose appropriate ones
–CAT – children’s apperception test
 2c. Sentence-Completion Test
“I wish ___________________________”
“My father ________________________”
“A home is ________________________”
Sample #1: Assessment of a sentence-completion test
Familial Attitudes
The client appears to be well-adjusted with her family and her perceptions about
her parents appear to be secure. To the stimulus of “The happiest time”, the client
responded with “sitting near the heater in winters with family” (Item # 2). Hence, it may
be assumed her contact with the parental figures and even the siblings is a source of
comfort for her. This assumption can further be substantiated by her response to the
stimulus of “A mother”, to which the client said, “is the most reliable thing you can get
on the face of the earth” (Item # 11). In addition, to “My father”, the client said, “is a
soft, nice guy” (Item # 35). However, there is conflict regarding the death of parental
figures. In two places, the client identified her greatest worry and fear as her parents
“dying on” her (Items # 13 and 39).
 2d. Drawings
 “Draw a person” (DTP)
 “HTP” (House-Tree Person)
 Evaluations of drawing
Quality and shape of drawing
Solidity of the pencil line
Location of the drawing on the paper
Size of the figures
Use of background
Comments made by the respondent
 Sample analysis of HTP
“…The client’s need for intellectual achievement and physical
achievement were noted with the drawing of the tree’s branches
going upward and outward. The long and muscular arms of the
human figures, which are out of proportion to the rest of the body,
substantiate this need.
The omission of the male figure’s foot, as it appears to be
extended in imagination off the bottom of the page reflects the
client’s need for autonomy and achievement. The ground-line upon
which the house rests and the absolute symmetry of the house are
reflective of the client’s need for inner balance and security…”
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Department of Applied Psychology
School of Social Sciences
Beaconhouse National University
3. Objective Tests
3a. Objective Tests
3b. Objective Personality Tests/Self-report inventories
–MMPI and
MMPI-2
–Q-sort
–BDI
3c. Objective Intelligence Tests
–Nature
of intellectual functioning and IQ
3a. Objective Tests
–Test
stimuli are minimally ambiguous
–Roots
in empirical tradition
3b. Objective Personality Tests: MMPI
Original instrument developed in late 1930s
Most widely used and extensively researched of all psychological tests
Revised in 1989 – MMPI-2
MMPI CLINICAL SCALE DEVELOPMENT
Hathaway and McKinely, University of Minnesota
Selected a pool of over 1000 items from a variety of sources, psychology tests,
interviews, and their own clinical experience
Deleted duplicate items and eliminated those not useful for their purposes,
leaving a pool of 504 items.
MMPI-2
Original items obsolete, politically incorrect or offensive
Eliminated and/or reworded items, added items such as
substance abuse and
marital relationships
Final version consists of 567 items
3b. Self-report inventory: Q- Sort
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A method Carl Rogers employed to study the changes in client’s concept of
him/herself before during and after therapy.
Assumption:
–At start of therapy there will be a large difference between clients
perception of what they are like (the self) and
–what they feel they should be or want to be.
Q-sort
Q-sort measures this difference.
–Client asked to sort 100 or so statements on cards (I am lazy, I feel guilty a lot)
into piles ranging along a continuum “very characteristic of me”…”not at all
characteristic of me.”
Correspondence between two sorts can be computed statistically.
Any discrepancy should decrease as client-centered therapy progresses.
3b. Self-report inventory: Beck Depression Inventory (BDI-II)
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The Beck Depression Inventory is a self-report measure of the presence and severity
of depressive symptoms.
Trait vs. State
A personality trait is a durable disposition to behave in a particular way in a variety of
situations. A state is a temporary condition that an individual is in at a particular point in
time, and can respond well to psychotherapy
3c. Intelligence Testing
Intelligence Quotient:
A method of quantifying performance on an intelligence test.
Originally:
Intelligence Testing
First intelligence test by Binet.
Revised as the Stanford-Binet.
Wechsler scales now more widely used.
Wechsler introduced deviation IQ to replace mental/chronological age ratio.
I.Q =
.
Mental Age
Chronological Age
X 100
Psychological Testing and Neuropsychology
Neuropsychological Tests
–Assess
broad range of skills and abilities
–Goal
is to understand brain-behavior relations
–Used
to evaluate a person’s assets and deficits
–Examples
include
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•Luria-Nebraska
•Halstead-Reitan
Batteries
Clinical Test: Bender Visual-Motor Gestalt Test
Neuroimaging and Brain Structure
Neuroimaging:
–Pictures
•Allows
of the Brain
examination of brain structure and function
–Imaging
Brain Structure
•Computerized
•Magnetic
•Positron
axial tomography (CAT or CT scan)
resonance imaging (MRI)
emission tomography (PET)
•Functional
MRI (fMRI)
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Advantages and Limitations
–Provide detailed information regarding brain function
–Procedures are expensive
–Procedures have limited clinical utility (especially for therapist)
Diagnosis
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Diagnosis is an important step in the process of identifying and classifying
a clinical condition.
It is a label that we attach to a set of symptoms that tend to occur together
and this set of symptoms is referred to as a syndrome.
Classification
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For centuries, humans have tried to organize the confusing array of
psychological symptoms into a limited set of syndromes.
This set of syndromes and the rules for determining whether an
individual’s symptoms are part of one of these syndromes are called a
classification system.
One of the first classification systems for psychological symptoms was
proposed by Hippocrates which was based on the categories like mania,
melancholia, paranoia and epilepsy.
In 1939, the World Health Organization added mental disorders to the
International List of Causes of Death which was later expanded to
become the International Statistical Classification of Diseases, Injuries,
and Causes of Death (ICD).
Although this nomenclature was unanimously adopted but mental health
section failed to be widely accepted. Ultimately in 1952, American
Psychiatric Association published its own Diagnostic and Statistical
Manual.
The Diagnostic and Statistical Manual of Mental Disorders
Brief History
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DSM I was published in 1952 and had about 60 different disorders.
DSM II was published in 1968. Both of these editions were strongly influenced
by the psychodynamic approach.
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In 1980, with DSM-III, the psychodynamic view was abandoned and the
biomedical model became the primary approach, introducing a clear distinction
between normal and abnormal.

In 1987 the DSM-III-R appeared as a revision of DSM-III. Many criteria were
changed.
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
In 1994, it evolved into DSM-IV. This work is currently in its fourth edition.
Some new syndromes are presented for future inclusion. List of defense
mechainsms is given for making it an additional axis.

The most recent version is the 'Text Revision' of the DSM-IV, also known as the
DSM-IV-TR, published in 2000. The vast majority of the criteria for the diagoses
were not changed from DSM-IV.
Basic Features of DSM IV
A Multiaxial Approach
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Today practitioners make use of a multiaxial classification system which
is designed to summarize the diverse information relevant to an individual
case rather than to provide a single label.By using this approach clinicians
can describe an individual in terms of a set of clinically important factors,
or axes. The first multiaxial system was presented in 1980 in DSM III.
A multiaxial system is primarily concerned with the description of clinical
problems. Its categories take note of the etiology, or cause, of the disorder
as well as the subjective experiences of the client and their assests and
liabilities. DSM IV Provides information about the context in which
abnormal behavior occurs as well as the description of the behavior.
The axis of DSM IV provide information about the biological,
psychological, and social aspects of a person’s situation.
Axis I: Clinical Syndromes
Axis I reports most of the disorders or conditions in the classification system
except personality disorders and mental retardation. When necessary to accurately
describe a given individual, more than one disorder can be listed on Axis I. In such a
case, the principal diagnosis is listed first.
Disorders listed on Axis I
Disorders usually diagnosed in infancy, childhood, or
adolescence:
Attention –deficit hyperactivity disorder
Conduct and oppositional disorder
Separation anxiety disorder
Pervasive developmental disorders
Learning disorders
Feeding, tic, and elimination disorders
Delirium, dementia,and amnestic or other cognotive disorders
Substance related disorders
Schizophrenia and other psychotic disorders
Mood disorders
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Anxiety disorders
Somatoform disorders
Factitious disorders
Dissociative disorders
Sexual and gender anxiety disorders
Eating disorders
Sleep disorders
Adjustment disorders
Other conditions that may be focus of clinical attention
Axis II: Developmental and Personality Disorders
Axis II deals with lifelong disorders that pervade every area of the person’s life.
Personality disorders and mental retardation, both of which begin in childhood or
adolescence and usually persist into adult life are reported on Axis II.
Disorders Listed on Axis II
Mental Retardation
Personality disorders
Paranoid Personality disorder
Schizoid Personality disorder
Schizotypal Personality disorder
Antisocial Personality disorder
Boderline Personality disorder
Histrionic Personality disorder
Narcissistic Personality disorder
Avoidant Personality disorder
Dependent Personality disorder
Obsessive-compulsive
Personality
disorder
Axis III: Physical Conditions
Axis III describes general medical conditions that may or may not directly related
to the psychological problems of the individual.
Axis IV: Psychosocial Stressors
Axis IV describes psychosocial and environmental problems (eg housing
problems, a negative life event, or family stress). In some cases, these problems may stem
from adjustment difficulties created by the disorder.
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Axis IV Psychosocial and Environmental
Problems to Note
Problems with primary support group
Problems related to the social environment
Educational Problems
Occupational Problems
Housing Problems
Economic Problems
Problems with access to health care services
Problems related to interaction with the legal
system and to crime.
Axis V: Global Assessment Functioning
Axis V is a global assessment of the individual’s psychological, social, and
occupational functioning. The clinician makes a global assessment of functioning on a
rating scale from 1 to 100. Low ratings indicate that individuals pose dangers to
themselves and to others. High ratings indicate good or superior functioning.
Code
100
90
80
70
60
50
40
30
20
10
Axis V Global Assessment of Functioning
Superior functioning in a wide range of areas
Absence or minimal symptoms; good functioningin all areas.
If symptoms present, they are transient and expectable reactions to psychosocial
stressors; only slight impairment in functioning.
Some mild symptoms or difficulty in functioning.
Moderate symptoms and difficulty in functioning.
Serious symptoms and difficulty in functioning.
Some impairement in reality testing or communication or major impairment in
several domains.
Considerable delusions and hallucinations
or serious impairment in
communication and judgment.
Some danger of hurting self or others or gross impairment in communication.
Persistent danger of severely hurting self or others.
The Major Diagnostic Categories
This section provides us with a brief description of the major diagnostic
categories of Axis I and II.
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Beaconhouse National University

Disorders Usually First Diagnosed In Infancy, Childhood, Or Adolescence
Within this broad-ranging category are the intellectual, emotional, and physical
disorders that usually begin in infancy, childhood, or adolescence. Disorders in this
category include:
 Attention deficit hyperactivity Disorder.
 Conduct and Oppositional Defiant.
 Pervasive Developmental Disorder.
 Learning Disorders.
 Separation Anxiety Disorder.
 Feeding, Tic and Elimination Disorder.
 Motor Skills Disorder.
 Communication Disorders.

Substance-Related Disorders
Conditions marked by adverse social, behavioral, psychological, and
physiological effects caused by seeking or using one or more substances, for example
alcohol, cocaine and amphetamines. Disorders in this category include:
 Alcohol-Related Disorder.
 Amphetamine-Related Disorders.
 Caffeine-Related Disorders.
 Cannabis-Related Disorders.
 Cocaine-Related Disorders
 Hallucinogen-Related Disorders.
 Inhalant-Related Disorders.
 Nicotine-Related Disorders
 Opioid-Related Disorders.
 Phencyclidine-Related Disorders.
 Sedative-,Hypnotic-, or Anxiolytic-Related Disorders
 Other Substance-Related Disorders
 Schizophrenia and Other Psychotic Disorders
Significant distortion in the perception of the reality; impaired capacity to reason,
speak and behave rationally and spontaneously with appropriate affect. Disorders in this
category include:
 Schizophrenia (Paranoid, Disorganized, Catatonic, Undifferentiated and Residual)
 Schizophreniform Disorder.
 Schizoaffective Disorder.
 Delusional Disorder
 Brief Psychotic Disorder
 Shared Psychotic Disorder
 Psychotic Disorder due To General Medical condition.
 Shared Psychotic Disorder
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Department of Applied Psychology
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
Psychotic Disorder NOS
Mood Disorders
Abnormal mood characterized by depression, mania, or both symptoms in an
alternating fashion. Disorders in this category include:
 Depressive Disorders(Major Depressive, Dysthymic Disorder, Depressive
Disorder NOS)
 Bipolar Disorders(Bipolar I, Bipolar II, Cyclothymic, Bipolar NOS)
 Other Mood Disorders(General Medical Condition, Substance Induced, NOS)

Anxiety Disorders
High levels os anxiety, tension and worry over extended periods of time that may
be accompanied by avoidance of feared situations, ritual acts or repetitive thoughts.
Disorders in this category include:
 Panic Disorders(with and without agoraphobia)
 Phobias.(Specific and Social)
 Obsessive-Compulsive Disorders.
 Generalized Anxiety Disorder.
 Post Traumatic Stress Disorder.
 Acute Stress Disorder.
 Substance Induced Anxiety Disorder
 Anxiety Disorder Due to General Medical Conditions.
 Anxiety Disorder NOS

Somatoform Disorders
Characterized by physical symptoms for which no medical cause can be found;
persistent worry abiout having a physical illness; exaggerated concern about minor or
imagined physical defects in an otherwisw normally appearing person. This Category
includes:
 Somatization Disorder
 Conversion Disorder
 Pain Disorder
 Hypochondriasis
 Body Dysmorphic Disorder
 Somatoform Disorder NOS

Factitious Disorders
Physical or behavioral symptoms that are voluntarily produced by the individual,
apparently in order to play the role of patient. Disorder includes:
 Factitious Disorder
 Factitious Disorder NOS.

Dissociative Disorders
Temporary, often sudden disruptions in the normal functions of Consciousness
and this category includes:
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Dissociative Amnesia
Dissociative Fuge
Dissociative Identity Disorder
Delirium
Dementia
Dissociative Disorder NOS
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Mental Disorders Due to General medical Conditions Not Elsewhere
Classified
Catatonic Disorder due to a general medical condition
Personality Change Due to a General Medical Condition
Mental Disorders NOS to a General Medical Condition
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Sexual And Gender Identity Disorders:
Difficulty in the expression of normal sexuality. This category includes following
disorders:
 Sexual Desire Disorders
 Sexual Arousal Disorders.
 Orgasmic Disorders
 Sexual Pain Disorders
 Paraphilias
 Gender Identity Disorders.
 Other Sexual Disorders.

Eating Disorders
This category is characterized by significant disturbances in eating patterns and
include:
 Anorexia Nervosa
 Bulimia Nervosa
 Eating Disorder NOS
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Sleep Disorders
Disturbances in sleep process e.g., difficulty in going to sleep , excessive day time
sleep and disturbances of sleep-wake cycle. This category includes:
 Dyssomnias
 Parasomnias
 Sleep Disorders Related to Another Mental Disorders
 Other Sleep Disorders.

Impulse-Control Disorders Not Elsewhere Classified
Repeated expression of impulsive acts that lead to physical or financial damage to
the individual or another person and often result in a sense of relief or release of tension.
Disorders include:
 Intermittent Explosive Disorder
 Kleptomania
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Department of Applied Psychology
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Pyromania
Pathological Gambling
Trichotillomania
Impulse-Control Disorder NOS
Adjustment Disorders
Persistent emotional or behavioralreactions in response to an identifiable stressor.
The reactions may be dominated by anxiety, depression or withdrawal. Disorders in this
category includes:
 Adjustment Disorder
 With Depressed Mood
 With Anxiety
 With Disturbance of Conduct

Personality Disorders
Pervasive and enduring patterns of maladaptive behavior and thought that begin
by early adulthood, often interfers with normal relationships and rerduce personal
effectiveness. Subjective distress may or may not be present. Personality disorders
specified in DSM IV include:
 Paranoid Personality Disorder
 Schizoid Personality Disorder
 Schizotypal Personality Disorder
 Antisocial Personality Disorder
 Boderline Personality Disorder
 Histrionic Personality Disorder
 Narcissitic Personality Disorder
 Avoidant Personality Disorder
 Dependent Personality Disorder
 Obsessive-Compulsive Personality Disorder
 Personality Disorder NOS

Mental Retardation
Disorders marked by delays in development in many areas. These disorders are
predominantly characterized by pervasive impaired intellectual functioning as well as
specific learning problems. Retadation levels rane from mild to profound.

Other Conditions That may be focus of Clinical Attention
Thios category comprises of conditions that are not regarded as menta disorders
but still may be a focus of attention or treatment. This category includes :
 Psychological factors Affecting a medical condition
 Problems related to Abuse or Neglect
 Relational Problems
Some other conditions may include, Noncompliance with Treatment, Malingering,
Antisocial Behavior, Boderline Intellectual Functioning, Age related Cognitive Decline,
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Bereavement, Academic Problem, Occupational Problems, Identity Problems, Religious
or Spiritual Problems, Acculturation Problem and Phase of Life Problems.
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Issues And Possible Categories In Need Of Further Study
One of Dsm-IV’s appendix is entitled “Criteria Sets and Axes Provided for
Further Study”. It contains several proposals for new categories that the DSM-IV task
force considers promising but not sufficiently established by data as to merit inclusion on
DSM-IV. By listing and describing these categories of disorders, the DSM task forces
encourages professionals to consider whether a future DSM contains any of these
syndromes or axes as official ways of classifying mental disorders. Possible new
syndromes are:
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Caffeine Withdrawal
Mixed Anxiety-Depressive Disorder
Pervasive-Aggressive Personality Disorder
Depressive Personality Disorder
References
American Psychiatrist Association: Diagnostic and Statistical Manual of Mental
Disorders, Ed 4. American Psychiatric Association, Washington, 1994.
Carson, R.C, Butcher, J.N & Coleman, J.C. (1998) . Abnormal psychology and modern
Life. USA: Scott Foresman and Company.
Davison, G.C & Neal, J.M. (1998). Abnormal Psychology (7th ed). New York: John
Wiley & Sons, Inc.
Nolen-Hoeksema,S. (2001). Abnormal Psychology. New York: McGraw Hills
Companies, Inc.
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