PRACTICAL FILE OF

UNDERSTANDING MENTAL
DISORDERS

Submitted by:

HIMANSHI BEHL

B.A. (HONORS) PSYCHOLOGY

2nd YEAR

4 SEMESTER

2452820
INDEX
 INTRODUCTION

Abnormality

Defining mental disorders also known as “abnormality” is not an easy task. There is no single
or universal answer. Cultural relativism plays an important part in this, as behaviors
considered abnormal in one culture might be perfectly acceptable in another. Additionally,
the concept of madness itself has evolved throughout history while constantly being shaped
by the prevailing social, profitable, and political forces. Even the idea of psychological
normality is rather vague, lacking a well-defined standard against which to measure
deviations. Thus, definitions of ‘abnormality’ and ‘disorder’ lack universal consensus.
Achieving a satisfying definition is challenging (Stein et al., 2010). However, there is
consensus on which conditions qualify as disorders (Spitzer, 1999). Despite these challenges,
efforts have been made to establish criteria for identifying abnormality and these various
criteria form the basis for our understanding of mental disorders
Five Ds of abnormality:

Deviance

Deviance refers to behavior, thoughts or -emotions that differ remarkably from societal or
statistical norms. Abnormality is often conceptualized as being “away from the norm”.
Statistical deviance refers to something which is not very easily seen. Psychometric
assessments are often used to establish norms and individuals scoring at the extreme end
(very high or very low) are considered statistically deviant. However, not all rare behaviors,
for example exceptional talent or high intelligence, are rare but desirable (Barlow & Durand,
2015).

Cultural deviance: abnormality is also defined in relation to cultural expectations. Behaviours

which violate the cultural norms, values or moral standards may be labeled as abnormal.
However these kinds of judgements are subjective and also vary across societies and time
periods. For example, behaviours considered unacceptable in collectivistic cultures may not
be seen similarly in individualistic societies (Butcher, Mineka, & Hooley, 2017). Thus,
deviance is influenced by both statistical and cultural context, making it a subjective concept
rather than an objective one.

Dysfunctional or maladaptive behaviour

Dysfunctional living is an essential criteria to define psychological disorders. It refers to

impairment in an individual’s ability of daily functioning, as Maladaptive behavior interferes
with well-being, relationships and academic or occupational functioning.
Role-related dysfunction: an individual may fail to perform designated social roles (e.g.
student, parent, employee) and indicate psychological disturbance. psychological
dysfunctions manifest as cognitive, emotional or behavioral breakdowns often in relation to
one's expected roles.
Age-related dysfunction: in terms of age, it refers to what is expected of a person at a
particular age. Behaviour that is inappropriate for one's developmental stage may also signal
abnormality such as highly dependent behaviour in adulthood. For example a child who is
suffering from mental retardation may be unable to achieve the age appropriate development
milestones like walking, talking, crawling etc.

Maladaptive behaviour is a key indicator because it directly affects the quality of life.
However also not all disorders include obvious dysfunction (e.g. some individuals with
antisocial traits may function perfectly in society) emphasising the limitation of this criterion
(Barlow & Durand, 2015).

Distress

Distress indicating psychological suffering is often deemed abnormal whether experienced

personally or causing discomfort to others. It is the subjective experience of psychological
pain, suffering or discomfort. Individuals with disorders such as anxiety or depression often
report high levels of distress. Distress is also said to be a layman criteria to define
psychopathology.

Personal distress: a psychological disorder which creates distress or agony for the individual.
The individual experiences internal suffering, uneasiness or emotional pain. This aligns with
diagnostic consideration and has been acknowledged by DSM-5 which includes it as an
important criterion.

Social distress: a psychological disorder which causes distress and agony for people around
for example antisocial personality disorder. However, distress is neither enough nor
necessary for defining abnormality as for example individuals who suffer from manic
episodes they may feel euphoric rather than distressed (Lilienfeld et al., 2013).

Dangerousness

It refers to a behaviour which is injurious to safety and body integrity is psychopathological.

This involves self harm, suicidal tendencies, aggression, or harmful impulsive behaviours.
Although dangerousness is an essential clinical concern, it is not a conclusive indicator of
abnormality. Not all the individuals who suffer from mental disorders are dangerous and not
all dangerous behaviours come from mental illness. Research has shown that dangerousness
is relatively uncommon among individuals with psychological disorders (Corrigan & Watson,
2005).

Duration

For a behaviour to be determined abnormal it must persist over a significant period rather
than temporarily for a short period of time. Duration helps in differentiating between normal
changes in behaviour and clinically significant disorders. For example, to diagnose major
depressive disorder the symptoms of it should persist for at least two weeks. Similarly other
disorders like schizophrenia involve symptoms over a long duration. Thus, consistency and
persistence of symptoms are two important components for diagnosis of a disorder (American
Psychological Association, 2013).

Additional indicators of abnormality

Apart from the 5Ds there are several other indicators which help to identify abnormality:

Violation of social norms: behaviour that breaks societal norms or moral standards
Social discomfort: behaviour that makes others uncomfortable or uneasy
Irrationality: illogical thinking or distorted sense of reality for example hallucinations and
delusions.
Unpredictability: sudden, unexpected or inconsistent changes in behaviour.

These indicators additionally emphasise that abnormality is also socially constructed and is
context dependent (Lilienfeld et al, 2013).

Modern clinical practice integrates these indicators with the standardised diagnostic system
such as the DSM-5 and ICD to ensure reliable and accurate understanding of mental
disorders.

Causal Factors

There are different views or approaches through which psychologists try to determine the
causes of abnormal behavior. However in recent years, many theorists have mentioned the
need for a more integrative and inclusive approach which acknowledges all the biological,
psychological and social factors with their interaction as they may play an essential role in
psychopathology and treatment.

A) The biological perspective: Mental disorders are seen as disorders of the central nervous
system, the automatic nervous system and or endocrine system that are either inherited or
caused by some pathological process (Barlow et al., 2018). The Four classes of biological
factors which are appropriate to the development of maladaptive behavior are Genetic
vulnerabilities, brain dysfunction and neural plasticity, neurotransmitter, and hormonal
abnormalities. Each of these classes include many conditions that affect the quality and
functioning of one's body and our behaviour.

Genetic vulnerabilities: Genes can be described as long molecules of DNA (deoxyribonucleic

acid) which are there on different locations in chromosomes as they are often termed as the
carriers or messengers of information that one inherits from one's parents. Genes do not fully
determine whether a person develops a mental disorder, however there is substantial evidence
that most mental disorders show at least some genetic influence (Plomin et al., 2013; Rutter,
2006a). Each human cell has 23 pairs of chromosomes (46 in total) containing genetic
material which decides the hereditary plan for each individual. At least one replica of each
chromosome comes from both of the parents. Research has shown that abnormalities which
occur in the structure of chromosomes can be associated with major disorders. For example,
Down syndrome is one kind of intellectual disability in which there is trisomy which refers to
having a set of three chromosomes rather than two in chromosomes 21. The extra
chromosomes are the main reason for the disorder.

Fragile X syndrome can be explained as a genetic condition which occurs due to the mutation
of the FMR1 gene on the X chromosome and often results in intellectual disability. Mental
disorders are usually not caused by chromosomal abnormalities alone. Instead, they are often
influenced by abnormal genes or variations in genes. Instead, they are often influenced by
abnormal genes or variations in genes. These normal gene variations are called Genetic
Polymorphisms. Most psychological disorders are Polygenic Inheritance (Kendler, 2005;
Plomin et al., 2013). This means that different kinds of genes are responsible for vulnerability
of a disorder as it is said that each gene generally has only a minor individual effect. These
genes interact and work in ways which collectively may lead to structural abnormalities in the
central nervous system as changes in gene activity can lead to increased vulnerability to
psychological disorders. An individual's complete genetic endowment is known as genotype
and except for the case of identical twins there are no two individuals who have the same
genetic makeup. The interaction of the genotype and the environment is known as the
individual’s phenotype.

Interaction of Genotype & Environment: it generally happens when genetic factors are not
necessary or sufficient to result in mental disorders rather can lead to vulnerability to develop
psychopathology which only happens when there are impactful stressful life events (genetic
vulnerability and environmental factors work together leading to disorder). For example
Phenylketonuria (PKU) and intellectual disability. Phenylalanine accumulation in the body
damages the brain leading to intellectual disability. However, the disorder can be prevented
by providing a phenylalanine- free diet early in life.

Genotype environment correlations: it happens when an individual's genes affect the type of
environment they tend to experience. Similarly, genetic traits can shape environmental
experiences. For example a child who is genetically more inclined towards aggressive
behavior may face rejection by peers. This kind of early rejection may lead the child to
become part of aggressive groups and therefore in turn increasing the risk of delinquent
behavior in adolescence.

Three types of genotype environment correlations: Passive effect occurs because parents pass
both genes and environments to their children. The environment naturally matches the
parents genetic characteristics. For example well educated parents may provide a nurturing
learning environment Conversely, Parents with antisocial behavior may create unstable or
dysfunctional family environments, increasing risk of mental problems in their children
(Rutter, 2006b). Second is the Evocative effect which is a child's genetic traits leading to
activate certain forms of reactions from others. For example, active and cheerful babies
receive more positive reactions from caregivers (Lytton, 1980). Similarly, musically talented
children may receive special training and encouragement from teachers (Plomin et al., 2013).
Third is the Active effect, where the child seeks an environment that matches their genetic
tendencies or plays a more vigilant role in shaping the environment. For example extraverted
children may be more inclined towards social activities and friendships, this further
strengthens their sociability. Lastly, The Methods for studying genetic influences are family
studies, twin studies, adoption studies, linkage studies and association studies (Baumrind,
1991; Plomin wt al, 2013).

Dysfunction in Brain and Neural Plasticity: brain lesions rarely cause Major psychiatric
disorders instead, many disorders involve subtle abnormalities in brain structure or
functioning. Modern neuroimaging techniques have helped scientists study these brain
changes. Research shows that genetic factors influence brain development, which may
increase vulnerability to mental disorders (Hiber et al., 2015). For example, dysfunction in
the prefrontal cortex leading to poor decision making and impulse control (seen in ADHD
and schizophrenia). Abnormal activity in the Amygdala leads to excessive fear and emotional
responses (seen in anxiety disorder). Reduced activity in Hippocamous leading to memory
and emotional regulation problems (seen in depression). Neural Plasticity can be described as
the brain's ability to change, adapt and reorganise its structure and functions. It allows the
brain to learn from experience, recover from injury, and form new connections between
neurons. Sometimes negative experiences, trauma or chronic stress change brain connections
in harmful ways. This can strengthen maladaptive patterns of thinking and behavior seen in
mental disorders. For example, long term stress may alter connections in the hippocampus,
increasing risk of depression. Repeated fear learning may strengthen pathways in the
amygdala, contributing to anxiety disorders. Neural plasticity continues throughout the life
span, although it is stronger in early development.

Imbalances of neurotransmitters and hormones: For the brain to function properly the
neurons or nerve cells have to communicate effectively with each other which is done
through the transmission of electrical nerve impulses. Nerve impulses travel from dendrites
of one neuron down the axon and axons have branches at their ends known as axon endings.
Here neurotransmitter substances are released into the synapse. Synapse is a small fluid filled
space between the axon endings of one neuron (presynaptic neuron) and dendrites or cell
body of another neuron (post synaptic neuron). The neurotransmitter substances released into
the synapse then act on the postsynaptic membrane of the dendrite of the receiving neuron
which has specialised receptor sites where the neurotransmitter substances pass on their
message. The neurotransmitters can activate postsynaptic neurons to either initiate an impulse
or inhibit impulse transmission. After sending the signal the neurotransmitter must be
removed from the synapse. Otherwise, the receiving neuron would keep firing continuously.
Some neurotransmitters are broken down by enzymes. The brain has many types of
neurotransmitters. Some increase the chance that the next neuron will activate (excitatory)
while others reduce or stop the impulse (inhibitory). Successful transmission of the signal
depends on the concentration of neurotransmitters in the synapse as too much or little can
affect neural communication.
Hormones can be described as the chemical messengers which are secreted by a set of
endocrine glands. The endocrine glands produce and release its own set of hormones directly
into the bloodstream and then they travel and directly affect the target cells influencing
different events like fight or flight reactions, sexual responses, physical growth and many
other physical expressions. An extremely major set of interaction occurs in the hypothalamic-
pituitary-adrenal (HPA) axis where the activation of this includes messages in the form of
corticotropin-releasing hormone which travel from the hypothalamus to the pituitary. In
response to CRH, the pituitary releases adrenocorticotropin hormone which activates the
adrenal gland to produce epinephrine which is then released into the general circulation.
Cortisol mobilises the body which helps to deal with stress and in turn also provides negative
feedback to the hypothalamus and pituitary to reduce their release of CRH and ACTH which
also helps to reduce the release of adrenaline and cortisol. This negative feedback system
works as a thermostat in regulation of the temperature. Malfunctioning of this has resulted in
various forms of psychopathology like depression and PTSD.

Temperament: Temperament can be explained as a child's reaction and characteristic ways of

self-regulation which is said to be biologically performed. Infants differ in temperament
which means that they show differences in their characteristics, emotional and arousal
responses to distinct stimuli and in their tendency to initiate, withdraw, or attend to different
kinds of situations (Rothbart, Derryberry, & Hershey, 2000). Personality starts to develop at
about 2 to 3 months of age on the basis of temperament and five dimensions of temperament
can be identified which are fearfulness, irritability, positive affect, activity level and
attentional persistence. These are in correlation to the three important dimensions of adult
personality which are neuroticism or negative emotionality, extraversion or positive
emotionality and lastly constraint (Tellegen & Waller, 1985). The infant dimensions of
fearfulness and irritability also correlate to the adult dimension of neuroticism while the
disposition correlates to experience negative affect. The infant dimensions of positive affect
and plausible activity level can also be related to the adult dimension of extraversion and the
infant dimension of attentional persistence related to the adult dimension of constraint or
control (Else-Quest et al., 2006). A child with a fearful temperament has many opportunities
for the classical conditioning of fear to situations in which fear is provoked; later the child
may learn to avoid entering those feared situations, and evidence suggests that he or she may
be especially likely to learn to fear social situations (Fox et al., 2010; Kagan, 2003). In
addition, children with high levels of positive affect and activity are more likely to show high
levels of mastery motivation, whereas children with high levels of fear and sadness are likely
to show mastery motivation (Posner & Rothbart, 2007).

B) The psychological perspective: This perspective includes three approaches on human

nature and behavior that have been extremely influential which are psychodynamic,
behavioral and cognitive behavioral. They all emphasise the same concept which is the
importance of early experience and awareness of psychological processes within oneself..
The psychodynamic perspective: Sigmund Freud was the one who founded the
psychoanalytic school which highlighted the role of individuals' unconscious motives,
thoughts and their changing interrelationship to determine both normal and abnormal
behavior.

Structure of personality: Freud proposed that behavior results from the interaction of three
main components of the personality which are the Id, ego and superego. The id is considered
to be the prime source of instinctual drives and also which appears first in an infant. Id
operates on the pleasure principle by engaging in completely selfish and pleasure oriented
behavior which is concerned only with the immediate gratification of needs without paying
any heed to reality. Second is Ego which develops after the first few months after the birth.
The ego balances between the wishes of the id and the reality of the external world. One of
the most rudimentary functions of the ego is to meet its demands or wishes, but that too in
such a way that it ensures the well being and survival of the individual and that is the reason
it is said that ego works on the reality principle. The third and last part of the personality is
superego which is the moral values or rules and regulations of society concerning what is
right and wrong. As superego develops, it tends to become an inner control system that deals
with the desires of id. Superego works on the moral principle.

Anxiety and defense mechanisms: anxiety can be described as a generalised feeling of fear
and apprehension which is essential in the psychoanalytic viewpoint because it plays a major
role in most forms of psychopathology. According to Freud, when anxiety exists only in the
unconscious and one is not aware of it, it cannot be faced with rational measures. In these
types of cases the ego deploys the irrational protective measures that are known as ego-
defense mechanisms. These defense mechanisms reduce anxiety by helping a person to push
painful ideas out of consciousness rather than by dealing directly with the problem:-

Repression- An active shielding process which pushes anxiety provoking thoughts, impulses,
and memories into the unconscious mind.
Denial- one refuses to acknowledge the anxiety provoking factors of the environment or to
accept the reality of the external world.
Displacement- An unacceptable and harmful impulse or thought which is repressed and then
directed at a safer replaced target.
Projection- An unacceptable impulse or thought which is repressed and then attributed to
other people.
Rationalisation- one tends to construct a false but possible explanation or excuse for an
anxiety provoking behavior or event that has already happened.
Reaction formation- An anxiety provoking impulse or thought is repressed and then released
in an exaggerated expression of behaviour which is opposite to one's true self.
Sublimation- A repressed impulse or thought is released in the form of a socially acceptable
or admired behavior towards someone.

Psychosexual stages of development: freud has proposed total five sexual or psychosexual
stages of development that the individual pass through from infancy to puberty:-
Oral Stage – The first stage in which the infant is from birth to eighteen months of age. The
main focus is the mouth which is the pleasure-seeking centre. Oral stimulation is crucial
during this stage as if the infant's needs are not met during this time frame he or she will be
fixated in the oral stage and Fixation in this stage can lead to adult habits such as thumb-
sucking, smoking, over-eating, and nail-biting. Personality traits can also be affected and may
develop later during adulthood that are linked to oral fixation such as optimism or pessimism
or hostility.
Anal Stage – The second stage which lasts from eighteen months to three years of age.
During this stage, the infant's pleasure-seeking centers are located in the bowels and bladder.
Parents stress on toilet training and bowel control during this time period and Fixation in the
anal stage can lead to anal-retention or anal-expulsion in a child. Anal retentive
characteristics include being overly neat, precise, and orderly while anal expulsive
personality involves being disorganized, messy, and destructive.
Phallic Stage – The third stage begins at the age of three and continues until the age of six. In
this stage sensitivity becomes associated with the genitals which becomes a new source of
pleasure. The child becomes vigilant of anatomical sex differences which starts the motion of
conflict of jealousy and fear which he called the Oedipus complex for boys and later Freudian
scholars added the term Electra complex for girls.
Latency Stage – The fourth stage begins at the age of six and continues until the age of
eleven. During this stage there is no such pleasure-seeking region of the body; instead, all
sexual feelings are repressed. Thus children focus to develop social skills, find comfort
through peer and family interaction.
Genital Stage – The final stage of psychosexual development which starts at age of eleven
onwards, lasts throughout puberty, and ends when one reaches adulthood at the age of
eighteen. The onset of puberty reflects strong interest from one person to another of the
opposite sex. If one does not experience fixation in any of the psychosexual stages and
successfully overcome all the stages, he or she will grow into a well-balanced human being in
life.

Newer psychodynamic perspective: Later theorists who came, they developed few of Freud’s
basic ideas in particularly three different ways. Ego psychology was proposed by Anna
Freud, who was much more concerned with how the ego carries out its basic functions as the
executive of personality. Anna Freud and some of the other second generation psychoanalytic
theorists refined and elaborated the ego defense mechanisms and made the ego the central
figure, giving it a major role to play in personality development. This school of thought
proposes that the development of psychopathology results from the ego’s failure to perform
its functions properly to control or delay impulse gratification in the face of internal conflict.
Object relations theory emphasises the role of individual interactions with real and imaginary
people (external and internal objects), and the relationships between real and imaginary
objects. An object can be explained as the symbolic representation of another person in the
infant world (usually a parent). By a process known as introjection, the child symbolically
absorbs the other person into his or her personality (through images). From the point of view
of interpersonal relations, “we are social beings and much of what we are is a product of our
relationships with others” (Mead & Cooley, 1934). Psychopathology is a reflection of this
reality that psychopathology is based on the unfortunate tendencies that we have developed in
our relations with others. This is the main point of the interpersonal perspective, which was
initiated in 1911 by Alfred Adler. Erik Erikson also developed the interpersonal aspects of
psychoanalytical theory and extended Freud's stages of psychosexuality to more social ones
as he saw conflicts occurring in eight stages of life.

Behavioral perspective: it was developed in the early twentieth century as a response to the
unscientific practices of psychoanalysts. Behavioral psychologists believed that an
individual's subjective experiences did not contain acceptable scientific data because they
were not available for verification by other scientists. According to them, only those features
of human behavior which were directly observable are acceptable as a foundation for
understanding human behavior that is both normal and abnormal. The behavioral perspective
was developed in the context of laboratory rather than clinical work with patients and as an
extension of Pavlov's study of classical conditioning and Thorndike's study of instrumental
conditioning, which was later renamed by Skinner as operant conditioning. Learning can be
defined as the modification of the behavior function of experience. Since most human
behavior is learned, the question of how it is learned is of major interest to behavioral
psychologists.

Classical conditioning: Pavlov found this in his experiment in 1927. The presentation of food
is an unconditioned stimulus because it is always accompanied by salivations. Salivations in
response to presentation of food is an unconditioned response (Pavlov, 1927). The stimulus
that is presented before the presentation of food and elicits salivations is called the
conditioned stimulus. The conditioning of this stimulus is said to take place when it alone
elicits salivations, called conditioned response. The same is true in situations where an
electric shock is applied. Classical conditioned responses are long lasting; that is, they do not
get forgotten even after long periods of time. However, it is also possible that if the
conditioned stimulus is repeatedly presented without unconditioned stimulus, it leads to
extinction. This is not to be confused with unlearning because it is known that this response
will reappear in the future. This is called spontaneous recovery by Pavlov. Thus, any
extinction of fear that has taken place in a therapist's office may not necessarily generalise
completely and automatically to other contexts outside the therapist's office. Classical
conditioning is termed or seen essential in abnormal psychology because many physiological,
emotional responses including those which are related to fear, anxiety or sexual arousal and
of those stimulated by drugs of abuse can be conditioned.

Operant conditioning: it is also known as instrumental conditioning. In this conditioning, the

individual learns how to achieve a desired goal (can be rewarding or to escape from
something). The main concept in this is reinforcement, which can be described as either the
delivery of a reward or pleasant stimulus, or the removal or escape from an aversive stimulus.
New responses are learned and tend to stay if they are reinforced. In the starting a high rate of
reinforcement may be necessary or required to establish an instrumental response, but lesser
rates are usually enough to maintain it. However, when reinforcement is consistently not
given over time, the conditioned response, whether it is classical or instrumental, gradually
extinguishes.

Observational learning: whether human or nonhuman primates, both are capable of

observational learning which is learning through observation alone and without directly
experiencing an unconditioned stimulus (for classical conditioning) or a reinforcement (for
instrumental conditioning). Children can acquire new fears by observing a parent or peer
behaving fearfully with some object or situation. In this case, they tend to experience the fear
of the parent or peer vicariously, and that fear then becomes attached to the neutral object.
For observational instrumental learning, Bandura did a classic series of experiments in the
1960s on how children observationally learned various kinds of responses toward a large
Bobo doll.. Although the children themselves were never directly reinforced for showing
these responses, they nonetheless showed them when given the opportunity to interact with
the Bobo doll themselves. The possibilities for observational conditioning of both classical
and instrumental responses greatly expand our opportunities for learning both adaptive and
maladaptive behavior (Bandura, 1961).

The Cognitive-Behavioral Approach: Albert Bandura (b. 1925) who was a learning theorist
developed an early cognitive behavioral perspective and emphasised on the cognitive aspects
of learning. Bandura highlighted that human beings regulate behavior by internal symbolic
processes (thoughts) that are learned through internal reinforcement. Bandura developed a
theory of self-efficacy which is the belief that one can achieve their desired goals. One major
construct of this view is the concept of schema which can be explained as an underlying
representation of knowledge that guides the current processing of information and often leads
to distortment in attention, memory and comprehension. People tend to vary in developing
different schemas on the basis of their temperament, abilities and experiences. One important
schema is a self- schema which includes views on who one is, what one might become and
what is important to oneself. Schemas about the world and self-schemas are vital to one's
ability to engage in effective behavior because they enable one to focus on the relevant bits of
information that are available to one's senses. However, schemas are also sources of
psychological vulnerabilities because some of the schemas may be distorted or inaccurate as .
they may lead to the distortions in thinking which is characteristic of certain disorders such as
anxiety, depression and personality disorders. Another important feature of information
processing is that much of information is processed unconsciously or outside of one's
awareness.
Attribution theory has also majorly contributed to the cognitive behavioral approach.
Attribution is the process of assigning causes to things that happen, which is one may
attribute behavior to external events such as rewards or punishments, or one may tend to
assume that the causes are internal and are derived from traits within ourselves or others. For
example, people suffering from depression may tend to attribute bad events to internal causes
while non-depressed people may tend to have what is known as a self-serving bias in which
they are more likely to make internal and stable attributions for positive rather than negative
events or situations.
C) The social perspective: The past experiences teaches people to face challenges effectively
and to be resilient even in difficult situations. Social factors are environmental influences,
often unpredictable and uncontrollable negative [Link] various uncontrollable and
unpredictable fearful situations is likely to leave a person vulnerable to anxiety and negative
affect, a central problem in a number of mental disorders such as anxiety and depression.
Exposure to the negative events of the same frequency which seems to be predictable and
controllable produces less negative affect. Social factors can be various like early deprivation
or trauma, problems in parenting style, marital discord and divorce, low socioeconomic status
and unemployment, maladaptive peer relationships, and prejudice and discrimination.

Early deprivation or trauma: children who are deprived of resources usually provided by
parents experience deep and irreversible trauma .The most severe depiction of deprivation is
usually seen among abandoned or orphaned children, who may be either institutionalized or
placed in a succession of unwholesome and inadequate foster homes. Current estimates are
that worldwide up to 8 million children live in orphanages (Bos et al., 2011). Significant
reductions in both gray and white matter volume is found among children living in
institutions from a very young age. Long-lasting negative effects are often associated with
institutionalisation. Parental abuse of children whether physical or sexual has been associated
with many negative effects on their physical,emotional or mental development. The children
who are abused I'm a very young age are more likely to be overly aggressive (both verbally
and physically), they can even engage in bullying. Researchers also found difficulties in
linguistic development and behavioral,affective and social components in children who were
poorly treated. Children who face any kind of abuse typically show an unhealthy attachment
pattern which often involves insecurity and inconsistency in behavior towards the primary
caregiver. Children with these types of attachment styles may sometimes show confusion
when met with the caregiver and sometimes actually approach the caregiver followed by
immediate rejection or ignorance. Maltreated children show signs of improvement when the
external caregiving environment improves. Separation has both short and long term effects,
ranging from immediate distress caused by separation to unhealthy or insecure attachment
styles . A person who has experienced some kind of separation in early life is more likely to
show psychiatric symptoms.

Parenting Style problems: the relationship of a parent-child is always bidirectional which is

the behavior of one person affects the behavior of the other. Children who have an anxious,
irritable and impulsive personality may be more difficult to care for and can elicit anxiety,
irritability and impulsiveness in their parents as well. Parental psychopathology is that
parents who have different forms of psychopathology (including schizophrenia, depression,
antisocial personality disorder) tend to have children who are at risk for a wide range of
developmental difficulties. Some of these effects also have a genetic component, however
many researchers have proposed that genetic influences cannot account for all of the effects
that parental psychopathology can have on children. Parenting styles show attitude and values
that are expressed towards children across a wide range of settings. There are Four types of
parenting styles that are related to different development outcomes for children:-
Authoritative parenting is one of the parenting styles in which the parents are both warm and
careful to set clear standards and limits on certain kinds of behaviors while also allowing
considerable freedom within these limitations. This style of parenting is in correlation with
the most positive early social development. They also tend to have secure attachment
relationships and show high levels of overall well being.
Authoritarian parenting, in this parenting style, the parents are high on control but low in
providing warmth. They often tend to appear quiet, cold, demanding, and favoring
punishments if their children disobey. Their children tend to become conflicted, irritable and
moody and later in adolescence, these children tend to be lower in social and academic
competence than children of authoritative parents, especially with boys doing particularly
poorly in social and cognitive skills.
Permissive parenting is one of the parenting styles in which the parents are high in providing
warmth but low on discipline and control. This lenient style of parenting is correlated to
impulsive and aggressive behavior in childhood and adolescence. Overly indulged children
characteristically tend to become spoiled, selfish, impatient, inconsiderate, demanding and in
adolescence they may show more antisocial behaviors.
Neglectful or uninvolved parenting, the parents who are low on both warmth and control
show neglectful or ignorant behaviour towards their children. This style of parenting is
associated with disruptions in attachment during early childhood with low self-esteem and
conduct problems later in adulthood.

Marital discord: all couples have their fair share of arguments but when these arguments are
taken to an extreme it leads to marital discord which can have damaging psychological
effects on both adults and especially on their children. Many severe cases of marital discord
may expose children to one or more of stressors like child abuse or neglect, But even less
severe cases of marital discord also have negative and serious effects on children.
Longitudinal studies have shown that the damaging effects of serious marital discord on
children continue into adulthood as well . These individuals who face this their own
marriages are more likely to be marked by discord. Nearly 20 percent of marriages end in
divorce around the world and separated persons are overrepresented among psychiatric
patients. The negative effects are often temporary, with most people being able to adapt
within 2 or 3 years, but some adults never fully recover. Delinquency and a wide range of
other psychological problems such as anxiety and depression are much more frequent among
children and adolescents from divorced and disputed families than among those from intact
and close knitted families. Nonetheless there are also many children who adjust quite well to
the divorce of their parents with support from others.

Low socioeconomic status and unemployment: The full picture of the society highlights that
lower the socioeconomic class, the higher the cases of mental and physical disorders. This
inverse correlation varies for different disorders . For example, antisocial personality
disorder is strongly related to socioeconomic status, occurring about 3 times as often in the
lowest income category as in the highest income category. Several factors play a role in this
general inverse [Link] major factor can be their lack of resources which does not
allow them to reach out to the necessary treatment or the stigma attached to mental illness can
disrupt their chance of [Link] factor is the higher frequency of stressors in
their lives . Children and adolescents from lower Social economic status families are also
more likely to have more psychological problems but also, many children from lower social
economic status homes do very well, especially those with higher IQs. Studies show
psychopathology is highly linked with factors like financial issues,unemployment and
emotional stressors. There is a noticeable increase in the rates of depression, marital problems
and physical complaints increase during periods of unemployment but usually decreases
when the employment rate recovers.

Maladaptive peer relationships: many children and adolescents tend to develop healthy and
strong peer connections with no major difficulties. However, some may still experience
different types of problems and challenges such as bullying or the victim of intentional
exclusion or aggression. Such problems in peer relationships are correlated with an increased
risk of developing psychological disorders. Most children report having negative attitudes
toward bullying. One of the kinds is Cyberbullying which includes sending offensive,
harassing or intimidating messages over the internet or spreading ugly rumours on certain
internet sites or leaking someone's personal information without consent. Data has predicted
that one third of teenagers who use the internet engage in cyberbullying and the
psychological consequences of cyberbullying on the victims can be serious including,
anxiety, school phobia, lower self esteem, suicidal tendencies and occasional cases of suicide.
There are two types of popular children which are the prosocial and the antisocial types.
Prosocial popular children communicate with their peers in friendly, positive and cooperative
ways while Antisocial popular children (usually boys) tend to be tough who may be
athletically skilled but perform poorly in academics.

Prejudice and discrimination in race, gender and ethnicity: Many members of the society
have faced prejudice and discrimination at some point in their lives. Prejudice is an
unreasonable judgement based on personal characteristics while discrimination unjust or
unfair treatment of others based on perceived group membership, based on their gender, race
and ethnicity. Prejudice and discrimination can take place at different places like college,
school, neighbourhood etc. The prejudice minority groups are one of the major reasons
behind the increased prevalence of certain mental disorders in these groups.

D) The cultural perspective: To understand the factors responsible for dysfunctional behavior
the professionals first need to understand the cultural context of the behavior. Different places
in the world have different understanding or explanation of what is normal and what is
abnormal for them. Studies show that most mental disturbances among both children and
adults are universal and repeated in almost every culture study. A test which is free of
biasedness both in terms of culture and language is to be used. Translation of tests into the
languages prominent in different cultures is important so that they can be considered
appropriate for the new cultural context.

The Minnesota Multiphasic Personality Inventory (MMPI-2) is a widely used test for
different [Link] psychological symptoms are consistently found among many other
[Link] example, Butcher (1996a) found that psychiatric patients from Italy,
Switzerland, Chile,India, Greece and US who were diagnosed with paranoid schizophrenia
produced similar general personality and symptom patterns on MMPI. A commonly emerged
phenomenon called Hikikomori has impacted around 700,000 individuals. This is a disorder
focusing on people who show complete social withdrawal and are prone to staying in their
room ranging from 6 months to several years. The cause of Hikikomori can be attributed to a
mixture of shy temperament, parental rejection, poor parental attachment and social exclusion
by peers. The causal factors are similar but the signs and symptoms differ in different
cultures. Two cross-national studies (Weisz et al., 1987), confirmed that Thai children and
adolescents do indeed have a greater prevalence of overcontrolled problems than do
American children. The cultural differences may also be influenced or caused by the different
perceptions regarding the kind of parent-child relationship.

Clinical Assessment

Clinical assessment refers to the systematic evaluation and measurement of psychological,

biological and social factors in an individual exhibiting a possible psychological disorder
(Barlow & Durand,2015). It is a procedure through which psychologists develop an
understanding of the problems and signs. Assessment is not stagnant but an ongoing process
which holds importance not just at the beginning but even while examining the client’s
progress in treatment or to evaluate the outcome (Hooley, Butcher, Nock, and Mineka,2020).
Pretreatment assessment plays a crucial role in setting up reference levels of a client’s
psychological functioning. These baselines act as a standard point, allowing clinicians to
assess the impact of treatment by evaluating pre- and post-treatment results(Harwood &
Beutler,2009). Research by Kamphaus, Reynolds, and Diver (2014) emphasizes the
importance of initial assessment, especially in children, for recognizing behavioral and
emotional risks and aiding better adjustment and performance in the future.

Purpose: Psychological assessment is a multi-purpose tool serving diagnostic, research and

administrative purposes. The main goal of diagnostic assessment is to understand mental
health, cognitive impairments and behavioral disorders in order to guide treatment. It serves
research purposes as well by providing data necessary for scientific understanding of mental
illness and human behavior. The administrative purpose of assessment entails using
psychological tests and analyses to make applied, formal, or legal decisions rather than just
for clinical diagnosis or treatment.

Basic elements

Relationship between assessment and diagnosis: Diagnosis and assessment are two very
closely connected terms but not exactly the same. An adequate label or classification for a
presenting problem is essential for a variety of reasons. From a clinical perspective, a clear
label of an individual's disorder helps in planning for the suitable treatment. Administratively,
it is considered important as it allows hospitals and clinics to arrange their staff and services
and provide proper treatment. For example, if a clinic mostly manages patients with anxiety-
related issues, it should be prepared with suitable treatment programs and trained
professionals to handle those demands. Moreover, a standardized diagnosis is required for
insurance approval and compensation (Hooley, Butcher, Nock and Mineka,2020).

Social and Behavioral History: For most clinical purposes merely providing a diagnostic label
is less significant than truly understanding an individual. An appropriate assessment is the
one which emphasizes on behavioral history, mental skills, traits of an individual and the
external factors, it goes beyond just labelling disorders. An efficient assessment should
contain an objective explanation of behavior, the focus of the clinician should be on how the
client usually engages with others and whether there are excesses or deficits in the behavior
Assessment should include examining long term personality traits. The therapist evaluates
whether a person behaves in an abnormal or dysfunctional manner in a specific situation. For
instance, does the person withdraw from social situations, rely excessively on others for
decision making. The clinician also considers whether an individual is able to accept
assistance and assume responsibility, it is crucial for understanding the overall functioning of
a person. Clinicians evaluate the social environment a person lives in including the
expectations, stress and support systems. For instance, coping with persistent economic
difficulties can be highly stressful and may cause mental health problems, particularly when
there is limited assistance from family or society. Clinicians usually focus on a “dynamic
formulation “which is an integration of an individual's personality traits, behavior patterns,
and environmental demands as it not only about the current situation but also about the
probable reason behind the maladaptive behavior. It helps in planning the treatment by
anticipating future outcomes, prioritizing the issues and focusing on the interventions which
will be the most effective. Whenever possible the treatment decisions should include the
perspectives of both the therapist and the individual but in severe mental health cases it may
not be feasible and the conclusion may have to be made without client's participation.
Moreover, the nature and thoroughness of the assessment differs from situation to situation,
such as emergency situations compared to long-term treatment planning (Hooley, Butcher,
Nock and Mineka).

Culturally Sensitive Assessment Procedures

Culturally appropriate assessment is becoming more significant as clinicians deal with

individuals from diverse ethnic and language backgrounds. Professionals must be aware of
distinctions in language, principles, customs especially with clients who have limited
exposure to mainstream culture. Clinicians should be informed about the issues involved in
multicultural assessment, that is they should be culturally competent in order to use the
assessment tools which are appropriate for different groups (Butcher et al., 2015).
Psychological assessment of individuals with diverse backgrounds has rises over years
because of the rising number of immigrants or refugees, the significance of culture specific
assessment has also increased with it. To fairly and efficiently deal with such people, the
ethics code of American Psychological Association (APA) advises professionals to remember
various test related factors, individual's performance skills and some other personal traits
such as linguistic or cultural differences which might affect his or her interpretation or
performance. Thus, psychologists using culturally sensitive assessment tools must bear in
mind various factors and issues associated with culturally and linguistically diverse clients. It
is important to make sure that the tools used for assessment are suitable for various cultures
and that the possible sources of unfairness do not interfere with the analyses of individuals.
The challenges of understanding clients when performing multicultural assessments entails
both the characteristics of assessment tools and sociocultural factors like the link between
culture, behavior and mental health (Butcher et al.,2006). Psychologists need to make sure
that the test process they use is appropriate for the particular client. For instance, it is
essential to verify that the test has the same psychological meaning for individuals from
different cultures (Butcher & Han,1996). The cultural relevance of the rest items should be
equal and the standards or norms used should be significant and comparable. When applying
tests developed in Western context, test administrators need to keep in mind the dominant or
primary language, socioeconomic status, sex and cultural background of individuals. For
instance, clients from non-English speaking nations may not have sufficient English-speaking
skills which might affect their performance in the test as well. When employing a translated
version of a test, test users should be mindful of all the differences that can occur when using
an adapted version. Therefore, it is necessary for professionals to be informed of the existing
research on the assessment tool's use with the intended group in order to evaluate whether the
translated version assesses the same factors or variables across different cultures. Lastly,
practitioners should be mindful of the influence and impartiality of the tools they use with
individuals from varied backgrounds, as if there is any potential variation in performance on
the scales among groups.
The MMPI-2 is one of the most popular personality tests which has been extensively studied
in different countries and among diverse populations in the United States (Butcher
&Williams,2009). Adapted versions including Spanish are available and recent research
indicates that it is effective for use with minority groups.

Professional Orientation

How professionals conduct assessment is based on their basic treatment orientation. For
illustration, a practitioner with biological orientation would focus more on biological
assessment techniques to identify any possible organic malfunctioning that may be causing
maladaptive behavior. On the other hand, psychodynamic or psychoanalytic clinicians may
opt for less structured and unstructured personality assessment tools like Rorschach Inkblot
Test to examine unconscious conflicts. At times they may start therapy directly assuming
these conflicts to surface during the therapeutic process. A behaviorally oriented therapist
concentrates more on identifying the association between external factors and maladaptive
factors. They usually use techniques like behavioral observation and self-tracking to reveal
acquired dysfunctional responses. When applying a Cognitive behavioral approach, the focus
moves towards identifying irrational thoughts that affect these behaviors. Practitioners do not
limit themselves to a single technique nor are evaluation methods confined to a single
theoretical approach. Rather various perspectives emphasize certain techniques because they
are more suitable in uncovering underlying causes or signs related to the interpretation and
treatment of a disorder. Both physiological and psychosocial data can be highly significant in
gaining insight into a patient (Butcher et al.,2015).

Reliability, validity and Standardization

Reliability, validity and standardization are three main principles of practical value of
[Link] in research and measurement refers to the consistency, stability, and
repeatability of results. Nunnally (1978) defined reliability as the "stability of measurement
over a variety of conditions in which the results should be obtained". For example, a
stopwatch recorded varying times across a time period, it will not be a true reliable measure
of time. Reliability measures the extent to which an instrument can agree that a person's
behavior fits a given diagnostic class, in the context of assessment. The psychological tool
must be valid as well. “A test is valid if it measures what it claims to measure “(Kelly ,1927).
Validity is the degree to which a measure accurately conveys to us something clinically
significant about the individual whose behavior fits the category, such as helping to decide
the future course of the disorder. Normally, the validity of a mental health measure or
classification assumes reliability. If clinicians can't reach consensus on the category an
individual's behavior fits in, then the matter of validity of clinical classifications being
evaluated is no longer meaningful. “Standardization is the process of administering a test to a
large, representative sample under uniform conditions in order to establish norms for
interpreting individual scores.” (Anastasi & Urbina, 1997). Standardization ensures that a
psychological test is administered, scored and interpreted in a consistent or “standard”
manner. Generally, standardized tests are considered fairer than the no standardized tests as
they are applied in the same manner to all persons taking them. Several psychological
assessments are standardized to enable the test user to evaluate against a specific individual's
test score with a reference population usually known as “normative sample” (Butcher et al.,
2015).

Trust and rapport

For psychological assessment to be conducted effectively and to provide better understanding

of behavior, the individual being evaluated must feel at ease with the clinician. In an
evaluation setting, a client must feel that the testing will enable the practitioner to gain insight
into the problems of the individual and they should be clear about the test procedure and how
the clinician will incorporate them into the clinical evaluation. Clients should be assured
about the confidentiality of the data and information they are providing to the clinician and
that it will be available only to the therapists. The test results are to be released to a third
party only if an appropriate release form is signed by the client. People who are tested in a
clinical setting are generally highly interested to be evaluated and are keen to know the test
results. Clients typically hope for some explanation for their distress. Offering test feedback
in a clinical setting can be a great help in the overall treatment process(Harwood & Buttler).
Research shows that individuals who are provided with feedback by their clinician shows a
significant decline in reported symptoms and an increase in self-esteem levels.

A)Biological assessment: A medical evaluation is necessary to rule out the physiological

abnormalities that might contribute to the mint problem (Swartz,2014).

General Physical Examination

In situations where physical symptoms are part of the showing clinical picture, a medical
evaluation is recommended. A physical assessment includes standardized procedures similar
to the ones experienced during a medical checkup. Typically, a patient's medical record is
obtained and the key physiological systems are assessed (leBlond et al.,2004;Swartz,2014).
This part of the assessment holds greater significance for the disorder involving bodily issues
such as addictive disorders or neurological disorders. In addition, a variety of physiological
disorders like hormonal disruptions can trigger behavioral symptoms that closely resemble
those seen in mental disorders. Although some long-lasting pain may be associated with
genuine physical conditions, others can be solely due to emotional factors. Misdiagnosing at
times can lead to unnecessary or wrong treatment, which makes it important to obtain a
medical report before planning intervention or treatment.

Neurological Examination

Neurological abnormalities sometimes contribute to mental disorders such as motor

impairments, a targeted or focused neurological assessment can be performed alongside
standard physical assessment. An electroencephalogram (EEG) can be used to measure brain
wave patterns or neural activity patterns in awake and sleeping states. An EEG is a graphical
or plotted record of neural electrical signals (Yamada & Meng,2011). It is recorded by
positioning electrodes on the scalp of an individual and intensifying the tiny neural signals,
from different regions of the brain. These strengthened signals control the moving pen and its
fluctuations or deviations are traced down on a strip of paper, advancing steadily. The typical
neural activity of the brain and the sensory stimulation of an individual when he or she is
awake or asleep is understood. Irregularities in the normal patterns can suggest abnormalities
like tumors or brain injuries. EEG’s can detect these abnormal neural patterns very well,
which can be associated with conditions like mood disorders and anxiety disorders. If
irregularities are identified further targeted assessments can help in achieving a precise
diagnosis. Imaging technology or radiological methods such as Computerized axial
tomography (CAT), are among the advanced techniques of Anatomical Brain Scans(Mishra
& Singh,2010). Using X-rays, a CAT scan generates scans or images of parts of the brain that
may be impaired. This procedure has enhanced neuroscience research by enabling quick, non
-invasive insight into the reliable information about the site and magnitude of anatomical
abnormalities in the brain. The procedure operates by employing computerized assessment to
X-ray beams over sections of the brain producing visuals for neurologists to examine. MRI
has increasingly replaced CAT scans offering clearer and sharper visuals of the inner part of
the brain, superior differentiation of soft tissue and a less complex, non-radiative method.
MRI detects fluctuations in electromagnetic fields resulting from variations in hydration,
allowing precise and noninvasive images of brain structure. It is beneficial for identifying
progressive abnormalities and examining neurological irregularities associated with
conditions like schizophrenia. However, MRI has shortcomings, like some patients
experience claustrophobia and critics argue that social, cultural and procedural factors can
impact its use, meaning MRI scans do not always secure enhanced recovery. Positron
Emission Tomography (PET) is an alternative imaging approach. PET scans allow for an
assessment of how an organism is functioning(Meyer et al.,2012). The PET scans offer
functional images by monitoring biological molecules such as sugar molecules as they are
converted by the cerebral tissue or other body organs. By detecting regions of varying
biochemical activity, the PET scan facilitates a clinician to achieve more precise evaluations
of neurological disorders or brain diseases for egg locating sites responsible for epileptic
seizures, cranial trauma and neoplasms. Thus, the PET scan can reveal issues that are not
immediately visible anatomically. Also, using PET scans in research in significant conditions
like Alzheimer’s disease may lead to useful discoveries which may help in the aid of
dementia (Saykin et al.,2006). However, a PET scan faces limitations due to low – fidelity
pictures and their cost. Their use in forensic evaluation is also debated (Moriarty et al.,2013).

The functional MRI commonly known as FMRI has been used in psychopathology for a long
time now. It came into use because MRI could only reveal brain structure but failed to
provide any insight into brain activity. FMRI often measures changes in local oxygenation of
specific areas of brain tissue. Persistent mental processes such as sensory experiences,
visualizations and cognitions can thus be chartered theoretically. Uncovering particular brain
regions that are associated with neural activities. The emergence of FMRI required the
development of high-speed devices for its recording processes due to the measurement of
change being highly time dependent. Some people believe that FMRI is a more reliable
technique for depicting brain abnormalities than any other procedure. Many research studies
support the implementation of FMRI in exploring underline mental processes (MacDonald &
Jones,2009). While FMRI shows potential for mental health research, its use as a lie detector
has been disputed legally. Some methodological limitations influence FMRI results, like both
FMRI & MRI are highly reactive to physical movement and equipment inaccuracies while
group discussions can be observed they often provide minimal information into defined
mental operations. Currently FMRI is not recognized as a valid assessment method but it
remains useful for research on brain functions with potential for later utilization (Davidson et.
Al., 2003; Buckholts & Fairman , 2014).

The Neuropsychological Examination

Neuroimaging methods can recognize irregularities associated with cognitive and behavioral
impairments but such impairments might arise before damaged areas are detectable. Reliable
techniques are therefore used to assess changes in behavior or cognition due to a neurological
disorder. This issue is addressed by an increasing number of neuropsychology experts which
includes assessment tools to measure an individual’s thinking, sensory and movement
abilities as indicators of the severity and area of brain impairment (Snyder et al.,2006). In
cases where neuroanatomical involvement is suspected a neuropsychologist administers a test
battery. The individual’s performance on the task, especially perceptual motor task, can give
significant clues about any cognitive and intellectual impairment. The Halstead-Reitan
battery is made up of a variety of tests and parameters from which indication of impairment
can be derived (Horton,2008; Lezal et al., 2004; Reitan & Wolfson, 1985). It also offers
detailed data about a participant’s abilities in several functional areas. The Halstead-Reitan
battery for adults consists of a set of assessments such as the Halstead category test measures
an individual’s ability to learn and remember material. While Tactual performance test,
Rhythm test, Speech sounds perception test and finger oscillation task measures a subject’s
motor speed, response to novel stimuli, ability to learn and use tactical as well as kinesthetic
cues, attention and sustained concentration through an auditory perception task, ability to
identify spoken words and speed at which an individual can depress a lever, respectively.

B) Psychosocial assessment: Psychosocial assessment emphasizes on providing a complete

picture of a person in association with his or her social surroundings. This picture includes
significant information like the personality traits of a person, the present level of functioning
as well as the available sources in his or her life. Psychosocial assessment emphasizes on
providing a complete picture of a person in association with his or her social surroundings.
This picture includes significant information like the personality traits of a person, the present
level of functioning as well as the available sources in his or her life.

Assessment Interviews

It is considered a central part in the process of assessment. Usually it involves face to face
interactions ranging from a simple set of questions to a more elaborated format. Although
clinicians prefer the freedom to explore, the structured interviews produce far more reliable
results than the unstructured ones. Structured interviews follow a predetermined set of
questions with little or no flexibility. The interviewer is not allowed to make many changes
and the questions are designed in a manner that makes it possible for the responses to be
quantified. Sometimes, structured interviews can feel like a trap especially when the
interviewer feels that probing is necessary. Unstructured interviews on the other hand are
highly subjective and do not follow a predetermined set of questions. The content of an
interview is often influenced by the theoretical perspective of the interviewer and the
questions asked by the interviewer highly depend on the previous responses of an individual.
But this unplanned manner of asking questions might skip the important criteria of DSM-5
diagnosis. This makes the use of unstructured interviews very limited in mental health
research. At the same time the clients might feel that an unstructured interview emphasizes
more on their needs and it may provide valuable information to the clinician that might be
missed in structured interviews. The reliability of a clinical interview maybe enhanced with
evaluation scales that evaluate features like self-esteem and anxiety, helping create a
complete and detailed profile and recognize pressing matters such as marital problems or
suicidal thought. Assessment interviews, however, are likely to be inaccurate as it is based on
subjective evaluation, often resulting in inaccurate diagnoses. To deal with this, the DSM
underscores a standardized procedure with quantifiable standard and explicit protocols,
strengthening diagnostic reliability.

The Clinical Observation of Behavior

Direct observation of behavior is one of the earliest and most useful tools of assessment, the
aim of which is to gain more insight into an individual's psychological functioning(Hartmann
et al.,2004). An objective description of behavior is provided by the professional about a
person's appearance and behavior including his or her personal hygiene, emotional responses
and any signs of depression, anxiety, aggression, hallucinations or delusions. Preferably,
behavioral observation is done in a real life setting but it more frequently occurs after hospital
admission(Leichtman,2009). Some professionals and researchers use a more controlled
setting rather than a naturalistic behavioral setting where observation is made in an artificial
environment. These analogue situations aimed at generating data about coping strategies
might involve various tasks such as scripted role play, family-based tasks or cognitive verbal
protocols(Haynes et al.,2009). In addition, clinicians ask the clients to self- monitor their own
behavior which occurs in different natural settings. The client reports his or her thoughts,
emotions and behavior which helps the clinician to understand in which situations a
maladaptive behavior is more likely to take place. Alternatively, the client may be requested
to complete a self-report questionnaire which is relatively more structured and provides detail
about the problematic reactions experienced in various situations. These approaches
emphasize that individuals are the best source to gather information about themselves.

Rating scales in clinical observation organizes information and increases reliability as well as
objectivity(Aiken,1996;Garb,2007). That is the structured design of a rating scale tends to
limit an observer's interpretations to the lowest level. The most efficient scales allow the
individual to not only indicate the absence or presence of a behavior but the intensity as well.
One of the rating scales most widely used for recording observations in clinical practice and
in psychiatric research is the Brief Psychiatric Rating Scale (BPRS) (Leucht, 2014; Overall &
Hollister, 1982). The BPRS offers a structured and measurable framework for rating clinic
symptoms such as anxiety, emotional withdrawal, guilty feelings, suspiciousness and
hostility. It contains 24 subscales that are scored from ratings made by a clinician after
conducting an interview with the client. The Hamilton Rating Scale for Depression (HRSD),
a similar but more specifically targeted instrument, is one of the most widely used procedures
for selecting research subjects who are clinically depressed and also for assessing the
response of such subjects to various treatments The DSM-V offers several rating scales called
“Cross-Cutting Symptom Measures,” that clinicians can use to gather the symptom reports of
an individual and for subsequent assessments of symptoms over time. The rating scales are
generally completed by the client but if the client is a child or adolescent the parents are
asked to complete it. The WHO provides a widely used rating scale for mental health and
health problems, called the WHODAS 2.0 (WHO, 2014).

Psychological tools
Psychological tests are a more indirect way of assessing psychological characteristics in
comparison to observation and interviews. The Scientifically developed psychological tests
are standardized sets of procedures or tasks for obtaining samples of behavior(Kolen &
Hendrickson,2013). The scores of individuals are compared with the scores of people who
have similar demographic characteristics, which is usually decided by the established test
norms or standards. These established references help clinicians to understand how the
responses deviate from the reference group. Significant improvement or development in
technology test designing has allowed forming tools with adequate reliability and validity to
assess almost any possible mental trait on which people may differ. Even though
psychological tests are far more reliable, they are still not perfect as it is highly influenced by
the competence of the test administrator. There are two broad categories of psychological
tests including intelligence and personality tests (Butcher et al.,2015).

There are several established intelligence tests but the two most popular intelligence tests
used for measuring intelligence in children are the Wechsler Intelligence Scale for Children–
Revised (WISC-IV) (see Weiss et al., 2006) and the current edition of the Stanford-Binet
Intelligence Scale (Kamphaus & Kroncke, 2004). While for measuring intelligence in adults
the Adult Intelligence Scale–Revised (WAIS-IV) is most commonly used(Lichtenberger &
Kaufman,2009). The test has both verbal and performance components and has 15 subsets in
total. The verbal subset of this test comprises a list of words which are verbally presented to
the individual and are asked to define that word. It focuses on the assessment of vocabulary
which is related to general intelligence. On the other hand, the performance subset has two
parts. First, they are asked to say aloud the number in the exact sequence they were verbally
given and second part is where they have to say it backwards. In cases where some kind of
brain damage is suspected, intelligence tests become a very important part of assessment as
well as diagnostic procedure.

Projective personality tests are unstructured and based on vague stimuli such as inkblots or
obscure pictures. The responses are not limited to the right, wrong or cannot say category in
these tests. The responses of projective tests reveal a lot about a person's conflict, emotions,
thoughts, coping strategies and personality characteristics. Projective tests work on the
assumption that while trying to interpret the vague stimuli, individuals project their own
thoughts or emotions which help the practitioner to understand the psychological behavior.
The most prominent projective tests are the Rorschach Inkblot Test, the Thematic
Apperception Test (TAT), and sentence completion tests.

The Rorschach Inkblot test is named after the Swiss psychiatrist Hermann Rorschach (1884–
1922). He started the use of inkblots in personality assessment in 1911, it is still widely used
today. The test includes ten inkblots in total. The administration of Rorschach needs
considerable training and the methods may vary, some might take a long time as well. It is
also considered unreliable due the underlying subjective interpretations. In the hands of a
trained professional, however, Rorschach can be valuable in identifying underlying
psychological conflicts. Furthermore, attempts have been made to objectify Rorschach
interpretations by clearly specifying test variables and empirically exploring their relationship
to external criteria such as clinical diagnoses (Exner, 1995). However, some researchers have
raised questions on the reliability and scoring of Rorschach, claiming that Rorschach over-
paths people taking the test. The use of Rorschach has diminished in recent times as
insurance companies do not provide adequate time needed to administer, score, and interpret
the test. But Rorschach still continues to be one of the most used personality assessment tests.

The Thematic Apperception Test (TAT) was introduced in 1935 by its authors, C. D. Morgan
and Henry Murray of the Harvard Psychological Clinic. It is a widely used test which consists
of some representative and some vague pictures, the client is asked to form stories in the
context of these pictures. Individuals tend to project their own inner feelings and thoughts
while making stories about vague pictures. Several scoring and interpretation systems have
been developed to focus on different aspects of a subject’s stories such as expressions of
needs, the person’s perception of reality and the person’s fantasies. Practitioners often rely on
informal procedure by making a qualitative and subjective determination of how the story
content reflects the person’s underlying traits, motives, and preoccupations, this relies on
science and arts both. Thus, TAT has been criticized by researchers for its scope of error and
the pictures, developed in the 1930s appear quaint to many contemporary subjects.

Sentence completion test is another useful test in personality assessment which was
developed by Hermann Ebbinghaus in 1897. A number of such tests are designed for
children, adolescents and adults as well. Sentence completion test contains the initial part of a
sentence and the other part is supposed to be answered or completed by the test taker. The
test which is linked with free association is more structured than the Rorschach test, but the
scoring is subjective and unreliable. Even though the test stimuli are standardized, the
interpretation usually carried out in an informal manner misses out on the support from
normative comparisons.

Objective personality tests are structured and use questionnaires, self-report inventories or
rating scales which have a predetermined set of questions making them more quantifiable.
Several personality assessment tests are available which can be used in clinical assessment.
Paul Costa & Robert McCrae introduced NEO-PI in 1985 which provides information on the
major dimensions of personality including neuroticism, extraversion and openness. One of
the major structured inventories is Minnesota Multiphasic Personality Inventory (MMPI).
MMPI was introduced for general use in 1943 by Starke Hathaway and J. C. McKinley and
today it is one of the most used inventories for clinical, forensic and research purposes. The
translated versions of the inventory are also widely used for assessment with around 32
translations being made and used. The revised version of MMPI is also available, known as
MMPI-2, published in 1989. The MMPI-2 (Minnesota Multiphasic Personality Inventory-2)
consists of 567 true/false items and generally takes 60–90 minutes to complete. It is a
commonly used personality test, but it has key limitations, like extended duration which often
causes fatigue, difficult language level, reliance on outdated norms which may lower the
validity of the test.
Ethical issues with assessment
An assessment can have a great impact on the lives of individuals which makes assessment a
lot more than just a theoretical concept. Practitioners involved in the process must keep
certain factors in mind: -

Possible cultural bias: Several tests may not be able to fairly measure the behavior of an
individual from a minority group or the practitioner may not be able to assess the behavior of
an individual from a different background objectively. Thus, this factor makes it important to
have culture neutral tests which can be fairly administered across different populations
similar to the MMPI-2.
Theoretical orientation of the clinician: The influence of the perspectives and theoretical
orientations of practitioners cannot be removed. A psychoanalyst will view or assess the
behavior in the context of underlying motives while a behaviorist tends to assess the behavior
in the context of preceding stimulus situations.
Overemphasis on personality traits: Many clinicians overemphasize on the personality traits
as the cause of the issues faced by an individual while ignoring the external factors
completely. It is important to consider environmental or external factors as a potential cause
for the problems in an individual's life.
Insufficient validation: Some of the assessment techniques in use today lack empirical
support. The validity of a test ensures that the test is measuring what it claims to measure and
lack of validation makes the test less reliable.
Inaccurate data: There is always a chance of placing an inaccurate label on an individual as
there is a high risk involved in making predictions based on the group averages. Inaccurate
data leads to a misunderstood picture of a person's problem and also limits the further
information which could have proven to be useful.

Classification

Classification refers to the process by which complexity of a phenomena is reduced by

arranging them into categories based on shared characteristics according to an established
criteria for one or more purposes. In the arena of psychology, the term “classification” in the
context of mental disorders refers to the systematic organisation or categorisation of various
psychological conditions based on their similarities in symptoms, characteristics and
sometimes even etiology. This process of classification is also termed as psychiatric nosology
or taxonomy which has developed over time through the contributions of clinicians and
researchers to improve understanding and treatment of mental health conditions (Butcher,
Mineka, & Hooley, 2017). In the current scientific world there are two official classification
systems: World Health Organisation’s International Classification of Diseases (ICD) and the
American Psychological Association’s Diagnostic and Statistical Manual of Mental Health
Disorders (DSM).

Features of classification:
Atheoretical with regard to causation: modern classification systems of mental health
disorders like ICD and DSM do not claim to be based on causes but primarily for describing
symptoms. These systems focus largely on grouping disorders based on shared symptoms and
not on what causes them. They are considered largely atheoretical as they do not believe or
commit to a single explanation (biological, psychological, or social). However there may be a
slight emphasis on biological perspective due to psychiatry’s medical background (American
Psychiatric Association, 2013; Barlow & Durand, 2015).

Polythetic approach: diagnosis is made according to how close the individual meets a certain
number of criteria from a list of symptoms rather than requiring all the features to be there.
This means the individuals with the same diagnosis may show different combinations of
symptoms (Butcher et al., 2017).

Largely categorical but increasingly hybrid: from traditional approach disorders were
classified categorically (present or absent) however modern approaches incorporate
dimensional aspects by recognising variations in severity and symptom expression.

Comprehensive description of disorders: the classification system provides detailed

description of disorders including their signs, symptoms, course, prognosis, epidemiology,
differential diagnosis, and associated biological or psychological features. This provides a
holistic understanding of disorders (Barlow & Durand, 2015).

Need and Purpose of Classification

Communication: most sciences rely on classification for example the periodic table in
chemistry similarly Classification system in psychology provides a common language for
clinicians and researchers. For example, using the term “schizophrenia” allows professionals
to understand and communicate about the complex clinical information of the disorder
efficiently without lengthy explanations (Butcher et al., 2017).

Structures information: classification system helps to structure information in a more

organised manner. It groups mental disorders by organising the scattered knowledge which in
turn makes it easier to understand between conditions. For example anxiety disorders are
grouped based on shared characteristics like fear and anxiety.

Facilitate research: organising information within a classification system also allows

researchers to study disorders more effectively which in turn leads to better understanding of
causes, progression, and treatment methods (Barlow & Durand, 2015).

Facilitates diagnosis: classification systems play a crucial role in providing standardised

diagnostic criteria (symptoms, duration, severity) which makes diagnosis more reliable and
consistent across clinicians (American Psychiatric Association, 2013).
Facilitates management and treatment: by categorising and identifying disorders based on
their symptoms and characteristics as it helps clinicians to plan appropriate interventions,
predict outcomes, and follow established treatment guidelines.

Social and Political implications: the classification of mental disorders has social and political
implications which helps to determine what is considered a mental disorder, influencing
access to treatment, insurance coverage, and societal attitudes toward mental illness (Stein et
al., 2010).

Types of Classification Systems

Categorical classification: psychiatric disorders have traditionally been classified by dividing

them into categories that are supposed to represent discrete clinical entities where a disorder
is either present or absent. It also assumes that there are boundaries between normality and
abnormality. If the criteria is met, the disorder is diagnosed otherwise it is not. When an
individual also meets criteria for multiple disorders simultaneously it is referred to as
comorbidity or comorbid condition. (Barlow & Durand, 2015).

Dimensional approach: according to this approach, it views mental disorders on a continuum

which ranges from normal to severe where symptoms are assessed based on their number and
severity. For example disorders may be classified as mild, moderate and severe with tools
like rating scales which are used to measure symptom intensity. This approach highlights that
symptoms can be there in both normal and clinical populations (Butcher et al.).

Multiaxial approach: this approach was used in earlier versions of DSM to assess individuals
across multiple dimensions such as personality factors, clinical disorder, medical conditions
and overall functioning. It was also based on the biopsychosocial model and aimed to provide
a comprehensive understanding of the individual. However due to its complex nature and
limited clinical use, it was removed in the DSM-5 and replaced with a more efficient
approach (American Psychiatric Association, 2013).

Historical Development of a Major Classification System- DSM

The historical evolution of psychiatric classification witnessed a significant milestone with

the emergence of the first edition of the Diagnostic and Statistical Manual (DSM) in 1952
which included 106 disorders categorised into conditions with and without organic brain
involvement. However prior to this early attempts at classification was done in 1918 when
the American Medico-Psychological Association introduced the Statistical Manual for the
Use of Institutions for the Insane, which included 22 categories with respect to biological
perspectives. The first edition of DSM was strongly made with respect to psychoanalytic
theory and classified disorders into broad groups such as psychoses, psychoneuroses, and
personality disorders (Butcher, MIneka, & Hooley, 2017).
A pivotal shift occurred with the introduction of DSM-III in 1980 and led to a shift from the
psychoanalytic paradigm towards a focus on inter-diagnostician reliability which emphasised
the significance of signs and symptoms in diagnosis. It also introduced specific and detailed
diagnostic criteria which in turn enhanced reliability and allowed more organised research.
One of its most remarkable contributions was the multiaxial system which allowed clinicians
to assess individuals across multiple dimensions involving clinical disorder, medical
conditions, personality traits and overall functioning. A revised version DSM-III-R came in
1987 which further refined these criteria to ameliorate reliability and validity but some
criticisms remained regarding the ambiguous nature of certain diagnostic thresholds (Barlow
& Durand, 2005).

Further advancement took place with DSM-IV in 1994 and DSM-IV-TR in 2000 which
placed a larger emphasis on empirical research and data driven revisions. To enhance
diagnostic accuracy and clinical use large scale studies and field trials were incorporated in
these editions. Additionally the distinction between organic and psychological disorders was
removed for more integrated understanding of mental illness. Although the multiaxial system
was retained, it went through many modifications and special attention was provided to
cultural and social factors through the introduction of cultural formulation guidelines. These
editions also gave comprehensive descriptions of disorders including information about
prevalence, course and differential diagnosis. However challenges like high comorbidity
rates, heterogeneity within diagnostic categories and difficulty in deciphering normal from
abnormal behaviour persisted (Davison, Neale, & Kring, 2004).

Continued efforts to improve DSM led to the emergence of DSM-5 in 2013 which marked
another important step in the evolution of psychiatric classification. It introduced a
reorganisation of disorders on the basis of shared characteristics like genetic factors,
neurobiological mechanisms, and clinical presentation. Focusing largely on categorical
framework it also incorporated dimensional elements such as severity ratings, specifiers, and
cross-cutting symptom measures to capture variations in symptoms more efficiently. One of
the most prominent modifications was the removal of the multiaxial system to simplify
diagnosis and clinical utility. Additionally DSm-5also introduced new disorders, combined
existing disorders into broader spectra, and upgraded the terminology to be more culturally
sensitive like replacing the term “mental retardation” with "intellectual disability". It also
highlighted cultural context by tools like the cultural formulation interview and aimed for
effective alignment with the global systems such as the International Classification of
Diseases (ICD-11) (American Psychiatric Association, 2013; Stein et al., 2010).

Historical Development of a Major Classification System- ICD

The International Classification of Diseases (ICD), developed by the World Health

Organisation (WHO) has undergone significant evolution since its inception in the late 19th
century. The journey began in 1893 when the International List of Causes of Death was first
introduced to systematically classify causes of morality. This classification focuses largely on
physical illness and external causes of death, highlighting the beginning of standardised
global health reporting. The system evolved because of several revisions with ICD-1 formally
introduced in 1901, followed by ICD-2 in 1909 which further expanded its scope to include
causes of sickness in relation to morality. Subsequent revisions such as ICD-3 in 1920, ICD-4
in 1929 and later versions continued to upgrade the classification system. A major
achievement happened with ICD-6 in 1949 which for the very first time included a distinct
section on mental, psychoneurotic, and personality disorders. This noted a significant turning
point as mental health was formally recognised with an international classification system
(World Health Organisation, 2019). Further revisions including ICD-7 in 1955, ICD-8 in
1965 and ICD-9 in 1975 gradually improved diagnostic categories and clinical applicability.
A major development occurred with ICD-10 in 1990 which included a dedicated chapter
(chapter V) on mental and behavioural disorders. It led to growing recognition of the
importance of mental health and improved diagnostic guidelines.

The most recent version ICD-11 represents a remarkable evolution in the classification of
mental disorders. The chapter 6 of ICD-11 is dedicated to mental, behavioural and
neurodevelopmental disorders which reflects a more integrated and comprehensive view.
Unlike the earlier versions, ICD-11 includes both categorical and dimensional elements
which in turn allows clinicians to consider severity and variation in symptoms. It also focuses
on grouping disorders on the basis of shared etiology and clinical features which aligns more
closely with contemporary research in neuroscience and psychology. Additionally ICD-11
also includes more powerful cultural considerations by acknowledging that mental disorders
are expressed differently across cultural contexts. Another important feature of ICD-11 is that
it has been designed for use in both clinical and research settings with adjustments for
primary health care to help early identification and intervention. The system is also
multilingual so that there is effective accessibility across diverse populations worldwide.
Furthermore it has moved away from the complex nature of multiaxial systems to a more
simplified single-axis structure to facilitate clinicians .

Limitations of Psychiatric Classification Systems

Even though psychiatric classification systems like DSM-5 and ICD have improved the
diagnosis and organisation of mental disorders, they still have several limitations. One
primary concern is that classification shifts attention away from understanding the nature of
psychopathology and instead pay emphasis to the categorisation and distinction between
disorders by prioritising typology over conceptual clarity (Butcher, Mineka, & Hooley,
2017).
These systems are also primarily atheoretical with regard to causation as they rely on
symptom-based descriptions rather than inherent mechanisms. Although recent approaches
attempt to include biological factors, explanations of causes remain limited (American
Psychiatric Association, 2013; Barlow & Durand, 2015). Additionally, they give limited
insight into the subjective experiences of individuals while paying more attention to
observable symptoms than on lived experiences and personal meanings.
Another limitation is the medicalisation of psychological suffering where the complexity of
social and emotions are reduced to diagnostic categories and treated medically. This may
neglect the interaction of biological, psychological, and social factors. Similarly there is a risk
of pathologising everyday life, where simple variations in behaviour may be labeled as
disorders which may lead to over-diagnosis (Fraces, 2013). One key conceptual issue is
circular reasoning where the diagnostic labels both explain and decipher symptoms. For
example, symptoms like hallucinations are used to diagnose schizophrenia and the same
diagnosis is then used to explain those particular symptoms in turn limiting explanatory value
(Kendler, 2016).

Reliability concerns are also present including low inter-diagnostician agreement and lack of
long-term diagnostic stability. The problem of comorbidity where multiple disorders are
diagnosed in the same individual also questions the differentiation of categories (Barlow &
Durand, 2015). Validity problems also emerge due to the categorical nature of classification.
High comorbidity and overlapping occur because boundaries between disorders are often
unclear. Additionally many diagnoses have low predictive validity as they do not consistently
show the course, prognosis or treatment outcomes (Kendler, 2016). Finally, there is an over
usage of residual categories such as ‘not otherwise specified” (NOS) which tend to be used
when individuals do not fully meet criteria given for specific disorders. These categories lack
evident defining features and also reflect the rigidity of classification systems.

In conclusion “classification” in the context of mental disorders refers to the systematic

categorisation of various psychological conditions on the basis of their shared characteristics,
symptoms and sometimes even etiology. It facilitates communication, diagnosis and further
research. DSM and ICD are two famous classification systems in the field of psychology.
Classification, thus is an important component of clinical psychology.