Clinical Assessment and Diagnosis
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Ritika SenClinical Assessment and Diagnosis
Uploaded by
Ritika SenClinical Assessment and Diagnosis
What is Clinical Assessment?
• Clinical Assessment is the first step towards making decisions to resolve the
psychosocial problem of the client.
• Clinical assessment refers to collecting information and drawing conclusions
through the use of observation, psychological tests, neurological tests, and
interviews to determine what the person’s problem is and what symptoms
he/she is presenting with.
• This collection of information involves learning about the client’s skills,
abilities, personality characteristics, cognitive and emotional functioning,
social context (e.g., environmental stressors), 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 all throughout the process.
Clinical Assessment as an Ongoing Process
1. Obtaining the Baselines:
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 determine to what extent the individual is adversely
affected.
2. Implementing the Treatment Plan:
Assuming treatment is needed, our second reason to engage in clinical
assessment is to determine what treatment will work best
There are numerous approaches to treatment, these include
i. Behavior Therapy,
ii. Cognitive and Cognitive-Behavioral Therapy (CBT),
iii. Humanistic-Experiential Therapies,
iv. Psychodynamic Therapies,
v. Couples and Family Therapy, and
vi. Biological treatments (psychopharmacology).
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.
3. Producing the Desired Outcome:
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.
Key Concepts in Assessment
Reliability
Validity
Standardization
i. Reliability means that an experiment or test reports the same results
after a repeated number of trials. Independent researchers must be able
to replicate experiments using the same controls as the original
researchers, making the research generalizable.
ii. Validity determines if the experiment measures exactly what the
researchers attempted to measure - or the specific concept under study.
iii. Standardization is the process of trying out a new test or treatment,
getting feedback and making changes to improve it.
A standardized test includes reliable methods, accurate content,
administration instructions, and average population scores to compare with a
sample’s scores.
Clinical Diagnosis
• 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).
Classification Systems
• 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.
i. DSM-5-TR
ii. ICD-11
DSM-5-TR
• The Diagnostic and Statistical Manual of Mental Illnesses is the latest edition of the
American Psychiatric Association’s professional reference book on mental health and
brain-related conditions.
• Also known as the DSM-5, this is the main guide for mental health providers in the U.S.
The latest version, the DSM-5-TR, was published in 2022.
• The first step in treating any health condition — physical or mental — is accurately
diagnosing the condition. That’s where the DSM-5 comes in.
• It provides clear, highly detailed definitions of mental health and brain-related
conditions. It also provides details and examples of the signs and symptoms of those
conditions.
• In addition to defining and explaining conditions, the DSM-5 organizes those conditions
into groups. That makes it easier for healthcare providers to accurately diagnose
conditions and tell them apart from conditions with similar signs and symptoms.
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.
• 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.
• 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.
Harmonization of DSM-5-TR and ICD-11
• According to the DSM-5-TR, there is an effort to harmonize the two
classification systems:
i. for a more accurate collection of national health statistics and
design of clinical trials aimed at developing new treatments,
ii. to increase the ability to replicate scientific findings across national
boundaries, and
iii. to rectify the issue of DSM-IV and ICD-10 diagnoses not agreeing
(APA, 2022, pg. 13).
The works must be conceived with fire in the soul but executed
with clinical coolness.
Joan Miro
