Robert M. Gordon,Ph.D. ABPP

Be informed, open-minded and respectful for accurate and helpful psychodiagnostic reports for treatment recommendations. To be informed, the psychologist needs a good mastery of the current editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the Psychodynamic Diagnostic Manual (PDM). These manuals complement one another. The DSM is more medically oriented and the PDM is more psychotherapy oriented. You will learn diagnostics from integrating them.

Some psychologists feel that giving a diagnosis is iatrogenic. Research disputes this prejudice, as does the rest of health care. Also, third party payers do not define our nosology. An assessment of just symptoms may serve them, but that is not enough to serve the patient. Help starts with an accurate diagnostic formulation of the whole person in a bio-psycho-social context.

The psychologist needs to be open-minded to make treatment recommendations without bias. Recent research indicates that CBT, psychodynamic and interpersonal therapies (or any part or combination) are equally effective for short-term treatment (Cuijpers, van Straten, Andersson, & van Oppen, 2008; Leichsenring, Hiller, Weissberg, & Leibing, 2006). Long-term psychodynamic therapy is effective for complex mental disorders that do not respond well to short-term treatment (Leichsenring and Rabung, 2008).

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It is unethical and incompetent to recommend a treatment because of your bias and not due to the needs of the patient. Have your treatment recommendations clearly follow from the results of your findings. Specify the needs and capacities of the patient and why a particular treatment would be best. Does the patient respond better to interpretations, direct suggestions or to the supportive nature of the relationship? Can the patient form a therapeutic alliance?

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Respectfulness and kindness will help develop a collaborative effort. This includes explanations of the patient’s rights, degree of privilege and purpose of the assessment. Patients are sometimes fearful and confused. They exaggerate to look bad or good, and are defensive. You not only note these in your report, but you want to manage them to obtain the most valid data.

Review the relevant previous assessments and other documents in advance. You want to ask individualized as well as the stock questions. You also want to assess the patients’ explanations of problems to determine the level of insight and defensive functioning.

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Try to use a combination of different methodologies that dovetail, i.e. document review and prior test results, structured mental status interview, a multi-trait personality self-report (ex. MMPI-2), an evaluator generated objective test (ex. the Shedler-Westen Assessment Procedure-200) (Shedler, & Westen, 1998), a quantative or qualitative projective assessment (ex. Rorschach, or the patient’s distortions of the evaluator), a brief neuropsychological screening, a memory and/or intelligence test and perhaps also collateral interviews with family, professionals, etc. If you are unable to give a full battery, then use the most relevant test or tests along with the structured interview.

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Avoid piling up tests of similar methodology, such as combinations of the MMPI-2, PAI, or MCMI. These self-reports are all excellent and they assess the main psychopathologies. But they are all self-reports. Also, avoid self-reports that tap only one domain, such as depression. There are many forms of depression, and depression is often co-morbid with personality disorders.

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Use a structured interview. Search the several free mental status interview forms online. These forms will make sure that you cover: appearance, attitude, activity level, mood and affect, speech and language issues, thought process, thought content and perception, cognition and intelligence, insight and judgment.

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Your report begins with all the necessary identifying Information and then has at least the following sections: presenting complaint, reason for the assessment, mental status findings (see above), precipitating factors, history of the problem, relevant history of the person, test results, diagnoses, prognosis and recommendations. Remember, that the prognosis does not so much depend on the severity of the symptoms, but mental capacities of the patient (self-reflective capacity, curiosity, resiliency, object relations, defensiveness, etc.).

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The DSM has a rarely used but important defense mechanism axis. The person’s favored defenses are one of the best indicators to differentiate between healthy, neurotic, borderline or psychotic personality structures (think first in terms of these major categories). Examples of favored defenses of someone with a healthy personality structure are: humor, anticipation and sublimation. Examples of the favored defenses of a person with a neurotic personality structure are: repression, undoing and reaction formation. People with a borderline personality structure or a psychotic personality structure both favor primitive defenses such as denial, projection, projective identification, idealization/devaluation, withdrawal, reaching for the omnipotent control of others and splitting. One of the main differences between them is that people with a borderline personality structure generally maintain reality testing and those at the psychotic level do not.

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The PDM uses the level of favored defenses along with other criteria (such as reality testing, identity integration, etc.) to determine a personality disorder’s level of severity (ex. depressive personality disorder at the borderline level of severity because the person favors primitive defenses.) The PDM’s concept of the level of severity is largely based on the personality structure (personality disorder at either the neurotic or borderline level of severity). The DSM’s level of severity can be noted with a 0 to 100 GAF scale. Use both methods together.

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Both the DSM and the PDM have a personality disorder axis. The DSM is a symptom check list, while the PDM looks at the contributing constitutional patterns, the central tensions, the central affects, the characteristic pathogenic beliefs about the self, the characteristic pathogenic beliefs about others, favored defense mechanisms and personality subtypes (depressive- introjective or depressive- anaclitic), The PDM also offers treatment recommendations that follow from the diagnoses. For example Sidney Blatt’s research suggests that the depressive- introjective personality responds better to interpretive interventions (CBT or psychodynamic) because they are primarily concerned with self-definition, whereas the depressive- anaclitic personality responds more to the interpersonal aspects of the therapeutic relationship because they are primarily concerned with attachment issues.

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Both the DSM and PDM start with warnings not to use them as cookbooks. Most patients do not fit into simple diagnostic categories. Useful psychodiagnostic formulations are more like an artist’s palette than a cattle chute. Remember that the diagnostic formulations are ways to understand another’s suffering in order to find the best remedies for him or her. Nevertheless, beginners should take every opportunity to give full psychological batteries with structured interviews. Later, only after lots of experience, you may be able to develop the art of psychodiagnostics. Watch a seasoned diagnostician such a Nancy McWilliams (one of the main authors of the PDM). She seems like she is having just a concerned chat and listening intently, while she is systematically working her way through the assessment.

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Fun tip: try role-playing diagnostic interviews with colleagues. Each person takes turns presenting complex diagnoses from both the DSM and PDM. The more people you stump, the more points you win. Review what you had missed and how you could have assessed it. It is a fun way to sharpen your psychodiagnostic skills.   

References:

Cuijpers, P., van Straten, A., Andersson, G., & van Oppen, P. (2008). Psychotherapy for depression in adults: A meta-analysis of comparative outcome studies. Journal of Consulting and Clinical Psychology, 76(6), 909-922.

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Leichsenring, F., Hiller, W., Weissberg, M., & Leibing, E. (2006). Cognitive-Behavioral Therapy and Psychodynamic Psychotherapy: Techniques, Efficacy, and Indications. American Journal of Psychotherapy, 60(3), 233-259.

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Leichsenring, F., Rabung, S., (2008). Effectiveness of Long-term Psychodynamic Psychotherapy: A Meta-analysis JAMA: The Journal of the American Medical Association, 300 (13), 1551-1565.

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Shedler, J., & Westen, D. (1998). Refining the measurement of Axis II: A Q-sort procedure for assessing personality pathology. Assessment, 5(4), 333-353.

CE Questions

1. The best diagnostic manual for learning psychodiagnoses:
a) ICD
b) DSM
c) PDM
d) a and b
e) b and c *

2. Your report should recommendation:
a) Treatments of your orientation 
b) What is best for the patient *
c) Short-term treatment
d) Symptom focused treatment
e) Personality focused treatment

3. Which do you use for a psychodiagnostic assessment?
a) document review
b) structured mental status interview
c) objective self-report test
d) objective evaluator generated test
e) projective test
f) cognitive functioning test
g) collateral interviews
h) all the above *