10 Criteria for Clinical Observation Based on DSM + SCID-5 Protocol

In addition to the concepts and diagnostic logic proposed by APA in DSM, its use must follow a specific structure and framework. DSM-5 places particular emphasis on how diagnostic criteria are used and distinguishes between symptoms with clinical significance and symptoms without clinical significance.

In this Blogpost, we will learn how to determine the clinical significance of a symptom, how to make a diagnosis, and overall, how to use the DSM correctly.

Clinical Significance

Clinical significance, in simple terms, means determining which signs are meaningful and which are meaningless or irrelevant. In most cases, clinical significance is used as a relative concept. Identifying, differentiating, and explaining clinically significant symptoms requires specific experience and subtle judgment, and professionals may need years of practice and training.

For example, imagine a person undergoing chemotherapy to fight cancer. During follow-up, the physician notices decreased mood and depression symptoms in the patient and requests a psychiatric evaluation. After the initial interview, the psychiatrist identifies the main and significant symptoms of depression in the patient but faces three different possibilities: 1- Diagnosis of major depressive disorder (without specifier) 2- Diagnosis of major depressive disorder caused by a severe or chronic illness 3- Considering depression as a symptom of cancer recurrence In this equation, the presence of cancer has clinical significance; therefore, the diagnosis of major depressive disorder is ruled out.

At this stage, the psychiatrist must determine whether the effect of cancer (on the body and the psyche) have "caused" the depression or whether the return of cancer, through direct effects on metabolism, has "led" to depression. To make this distinction, clinical significance depends on the continuity and pattern of occurrence. If a metabolic abnormality has caused depression, the symptom begins at a specific point and is experienced throughout the person’s life, whereas if it results from cancer-related complications (indirect), it will have less continuity across different areas of life.

In simpler terms, the extent to which depression "spreads" across different aspects of an individual’s life has clinical significance.

Continuing this example, consider that the patient also reports anxiety. Anxiety and depression can co-occur, but metabolic abnormalities caused by cancer do not create anxiety; therefore, the presence of anxiety makes cancer recurrence less likely as the explanation. On the other hand, anxiety may have developed independently before or after this event and may coincidentally coincide with cancer recurrence.

Differentiating these possibilities is the responsibility of the mental health professional and occurs during the clinical interview by considering diagnostic criteria and clinically significant symptoms.

SCID-5

The handbook "Structured Clinical Interview for DSM-5 Disorders", is one of the manuals published within the DSM library framework. It provides specific information and methods for conducting clinical interviews based on the latest version of the DSM.

This handbook provides diagnostic information such as diagnostic codes, diagnostic criteria, standardized reporting forms, standardized statements for insurance purposes, diagnosis based on the dimensional classification system, and more. Much of the information in this Blogpost is based on this handbook.

Interview and Diagnosis Based on DSM

Generally, an interviewer evaluates two categories of information before considering any diagnosis:

1- Psychological Evaluation:

The person’s history, current condition, and characteristics, including age, gender, religion, educational history, history of medical and psychiatric illnesses, general lifestyle patterns, sleep patterns, and so on.

2- Mental Status Evaluation:

The person’s current problems (chief complaint), abilities and skills such as memory and orientation, appearance including facial and clothing hygiene, personal hygiene, and so on.

Most of the information related to psychological evaluation is obtained through standardized clinical interview questionnaires, while additional information is collected during the clinical interview session.

All information related to the mental status evaluation is obtained during the session. Sometimes, certain aspects such as orientation ability may not always be important and the professional may skip them.

Mental Status Evaluation

The clinical significance of information related to psychological evaluation, especially personal history and background, is assessed through the mental status evaluation. According to the sequence of examination during the diagnostic interview, the mental status evaluation includes the following:

1- Appearance

Physical and visible characteristics such as height and weight, personal hygiene, grooming, appropriateness of clothing (in regard to mental state and social norms), and so on are examined at the beginning of the session and during the first meeting. These details are important because they may contain implicit information. For example, disorders such as depression may result in neglect of hygiene and grooming, or inappropriate clothing in relation to the reported mental state may provide information about emotional congruence.

Factors such as speaking speed and walking speed may provide information related to catatonia, catalepsy, cataplexy, epilepsy, and so on. Additionally, some neurological abnormalities have clear physical manifestations.

For example, a patient with focal epilepsy may occasionally lose control of eye movements or experience involuntary movements in parts of the body. However, these cases are less commonly observed in psychological interviews and are more relevant to psychiatrists.

2- Affect

Emotion has two aspects:

Affect: Observable externally and inferred from facial expressions, tone of voice, and so on.

Feeling: Internal and not directly observable.

A mismatch between affect and feeling provides significant information about the person. Many disorders can lead to inconsistency between them. Exaggeration, denial, or affective inhibition can also result from many disorders.

Two important possibilities must be identified by the professional:

Flat affect: Lack of emotional response to positive and negative events or memories.

Inappropriate affect: An opposite or incongruent emotional response (such as laughing about death of a loved one).

3- Mood

In operational and clinical terms, mood is a relatively stable emotional state. Throughout the day, we experience different emotions, but mood has relative stability and changes continuously.

Mood and emotion must be distinguished in three ways:

Emotion is caused by events, whereas mood does not necessarily depend on events. (Falling down may make us upset, but we can fall down, be hurt and joke about it) Emotion affects and is affected by behavior, whereas mood affects and is affected by behavior and cognition. Mood is long-lasting, while emotion is short-term.

When a person’s mood is not caused by or influencing life events, we describe it as a mood disorder. In mood disorders, brain dysfunction or structural abnormalities determine mood, and events and cognition are essentially unrelated.

4- Psychomotor Activity

The form and speed of muscle movement are largely influenced by brain function; therefore, they are referred to as psychomotor activity.

For example, chorea in Huntington’s disease results from increased glutamate, and hand tremors in Parkinson’s disease result from dopamine deficiency in certain brain areas. Similarly, psychomotor agitation or psychomotor retardation may indicate mania, depression, anxiety, and so on.

Abnormalities in psychomotor activity are clear and noticeable in psychiatric disorders but are much subtle in psychological disorders and require greater attention for diagnosis. An important point is that mild slowing or acceleration of psychomotor activity is not always clinically significant because no universal level exists.

5- Speech

Many disorders affect speech in different ways. Part of speech production may be influenced by psychomotor activity, but an important part is influenced by thought. Regardless of these factors, (sudden or unprecedented) stuttering and different types of aphasia may independently be considered diagnoses or may be symptoms of another disorder.

6- Thought

Disruption in thought is the most important diagnostic criterion for many disorders. Since direct access to a patient’s thoughts is impossible, part of thought processes can be inferred through behavior and most through speech. Magical thinking, delusions, hallucinations, and similar phenomena are all forms of thought disturbance.

To accurately examine possible thought disturbances, thought must be defined in a way that allows it to be inferred through behavior and speech. Based on this, types of thought disturbance include:

6-1- Disorders of Thought Flow

Thought flow disorder means that something disrupts the natural pathway of thinking. This type of thought problem can only be inferred from speech and includes:

Flight of ideas: Rapid and continuous expression of words that may resemble wordplay (repeating similar or rhyming words), resulting in frequent shifts from one topic to another.

Thought blocking: Sudden interruption of the thought process. When examining it through speech, pauses used for thinking should not be considered this condition. A person with thought blocking suddenly stops speaking as if the statement has ended, while it remains unfinished and the person cannot continue.

Thought broadcasting: The person believes others can understand their thoughts. This is not a paranoid thought disorder; the person has simply lost the distinction between thoughts and speech.

Thought control: The person believes their thoughts or speech are controlled by others. This type of thought disorder has a paranoid quality.

Clanging: Instead of semantic associations, the person’s speech follows sound-based associations. In normal speech, words are connected and convey meaning; this is based on semantic association. In clanging, words are selected based on similar sounds or rhythms. Speech is often rhythmic but lacks meaningful content.

Circumstantiality: Thinking is indirect and the beginning and destination of speech are unclear. A healthy person speaks with a purpose and communicates meaning. A person with circumstantial thought disturbance begins speaking, chooses the next word or sentence based on the previous one, and continues without interruption; the speech has no specific goal and does not communicate a clear concept.

Perseveration: The person becomes stuck on a stimulus or statement and responds to a new stimulus or question with a previous repeated response. Perseveration is usually caused by TBI or trauma resulting from brain injury.

6-2- Disorders of Thought Form

Simply stated, thought flow disorders affect the pathway and expression of thought, while thought form disorders affect the structure and basis of thought formation and expression. Some thought form disorders include:

Word salad: Due to the structured nature of the human brain, people normally produce meaningful sequences of words. Even with significant effort and concentration, we cannot produce sequences of words that have no relationship to one another. In word salad, individuals produce words that have absolutely no connection.

Echolalia: Simply means repeating what one hears. If asked a question, the person repeats the question. Importantly, in some cases echolalia is a compensatory mechanism. For example, individuals with severe damage to expressive language areas know they should provide an answer but cannot produce an appropriate response, so they repeat the question as compensation. In these individuals, tone or facial expression may serve as the answer. For example, when asked “Are you sad?”, they repeat the question with a sad tone. In psychosis, however, echolalia usually has no specific reason or purpose and is often accompanied by repetition.

Palilalia: The person repeatedly repeats a phrase or sentence that has been said to them or has come to their mind. It is mainly observed during recovery periods of catatonia or catatonia-like conditions. Simply put, during the acute phase, catatonia affects behavior, and during recovery, it affects speech.

Neologism: This disorder causes the person to create new words. These words usually contain syllables or letters similar to meaningful words or may even follow language rules, but they lack meaning. Neologisms in young children learning their native language indicate language development, but in individuals with disorders, especially psychosis, have clinical significance.

Agrammatism: The person uses appropriate words and has a specific intention, but language rules are not followed. For example, imagine someone speaking German but with English grammar while choosing and pronouncing all German words correctly. This phenomenon is very rare and is seen in individuals with traumatic brain injury (TBI).

7- Disturbances of Perception

Three perception disturbances have significant clinical importance:

Illusion: A sensory stimulus exists, but processing and interpretation are impaired. (For example, a person far away appears to be very small; but our perception takes the distance into account and we perceive them as a person; this context driven disruption can be impaired.)

Hallucination: No sensory stimulus exists, but something is processed and perceived. Hallucinations can independently occur in any of the five senses: hearing, vision, smell, taste, or touch.

Delusion: A belief or interpretation formed based on perceptual errors or hallucinations. (For example, in the previous example, the person develops the delusion that the person far away has changed their height, or believes a heard voice is the voice of God.)

Some substances, illegal drugs, can cause any of these. Excessive use of caffeine, alcohol, and other safe substances can lead to them too. Severe sleep deprivation may also cause them. Also, People without any disorder or any substance abuse may experience them. (whether it is clinically significant depends on rates and quality of them; alongside person's history)

8- Cognitive Disturbances

Cognition includes memory, attention, concentration, orientation, insight, and judgment.

8-1- Memory

Three types of memory have clinical importance:

Immediate memory: Related to a few seconds ago

Recent memory: Related to minutes, hours, and days ago

Remote memory: Related to days, months, and years ago

Memory can be impaired in two ways:

Amnesia: Complete or partial inability to recall experiences, which may result from emotional factors or functional impairment of memory-related structures. Includes:

Anterograde amnesia: Amnesia beginning after an accident, event, or incident (such as brain surgery), where memories before the event remain intact but new memories are not recorded or recalled.

Retrograde amnesia: Amnesia affecting memories before an accident, event, or incident, while new memories can still be recorded and recalled.

Memory distortion: Changes in components and aspects of an event, which may be widespread and involve multiple memories or may be limited to one memory. Includes:

Confabulation: Filling gaps between memories with imaginary experiences.

Déjà vu: A sensory recognition error in which a new situation is perceived as a repetition of a previous experience.

Jamais vu: A sensory recognition error in which a repeated and familiar situation is perceived as a new experience.

8-2- Attention

Attention levels can be influenced by various factors. Due to natural individual differences, to assess normal attention, the professional may say a word and ask how many letters it contains or ask the person to count the number of words in a paragraph, which is usually sufficient.

8-3- Concentration

Similar to attention, assessment of concentration is generally based on working memory tests. The professional asks the person to choose a random number and subtract or add by intervals of 7 or 11.

8-4- Orientation

Orientation refers to awareness of time, place, and Identity. Some disorders (especially degenerative disorders) severely impair orientation. To assess orientation, the person is asked simple question like: Do you know what year, month and day it is? Do you know where you are? Do you recognize me and yourself?

An important clinically significant point is the sequence in which orientation abilities are impaired. Which component of time, place, and personhood is lost has clinical significance. For example, someone may not know the exact date or time, but it is unlikely that they will forget which city they are in or who they are. Time is affected first, followed by place, and then personhood.

For example, individuals with Alzheimer’s disease in early stages may give an incorrect date or time but know their city of residence and do not forget their name. This is because brain tissue deterioration in Alzheimer’s progresses from recent memory toward remote memory. As deterioration progresses, the person may forget their city and eventually, in severe stages, forget their name and identity.

8-5- Insight

Within a diagnostic framework, insight refers to a person’s awareness of their own psychological condition. Individuals with schizophrenia often have severely impaired insight and do not recognize problems in themselves, accepting their thoughts as reality. Therefore, the first factor is awareness of the existence of a problem. The second factor is awareness of possible causes. Individuals with OCD recognize that they have a problem, but often attribute its cause to others or external events. The highest level of insight in a person with a mental disorder is being aware of the problem and providing an appropriate explanation for its possible causes.

8-6- Judgment

The degree of impairment in judgment differs among various disorders. For example, if a person experiencing a severe disorder is asked what they would do if their house caught fire while they were inside, they may answer that they would like to watch television at home. A person with a milder impairment may answer that they would escape or put out the fire. A person without impaired judgment would answer that they would assess the situation, contact firefighters if necessary, leave the house, and help others evacuate. Though distress can heavily but temporarily affect judgement, severe or long-standing impairment in judgment, is rare in psychological disorders and is generally seen in psychosis, degenerative disorders, or TBI.

9- Impulse Control

The ability to control different impulses is an important criterion in clinical interviews. We all experience many impulses throughout the day (sexual, aggressive). However, these thoughts should not necessarily be considered symptoms of a disorder. For example, a person with OCD may have strong impulses to perform certain behaviors, but as long as they can control these impulses and they do not create distress or dysfunction, the person does not meet diagnostic criteria. The level of inability to control impulses may also have implications for the pathology of a disorder. For example, one person may have no control over impulses, with every thought becoming speech or behavior, while another person may be overwhelmed by negative and harmful thoughts but only occasionally acts on them. (what we observe from these two will be totally contrary to their pathology)

10- Reliability

The final point that should be examined during a diagnostic session, usually after the patient leaves, is the reliability of the information provided. In most cases, the only available information about a client is limited to their own statements, with no source available to confirm or deny them. In such situations, distinguishing which statements are exaggerated, completely imagined, or accurate requires evaluation of reliability. For example, imagine a client claims during a diagnostic session that their phone is being tapped, people are constantly watching them through surveillance cameras, and others are always following them. This claim is supported by evidence such as hearing sounds during phone calls that indicate a surveillance device, followers quickly finding them even after losing track, and the followers generally being the same individuals. Evaluating the reliability of such claims is both very important and very difficult. On one hand, the person may be at serious risk of harm, and on the other hand, they may be experiencing paranoid delusions. Given the limitations of diagnostic interviews, reliability can only be examined based on the information provided. In this example, if the client has a history of journalism, political activity, or security-related employment, these factors should be considered; or if there is a history of psychotic disorders such as paranoid personality disorder or schizophrenia, the claim may be considered a paranoid delusion. Additionally, consistency among different pieces of information provides useful insights.

For example, if paranoid thoughts related to harm exist across different areas of a person’s life, the possibility of paranoid delusion is greater than the possibility of actual danger. If the client also reports suspicion about their spouse’s fidelity alongside these claims, there are two signs from two areas of life that are clinically consistent. Finally, in such examples, the manner of expression, coherence of information, contradictions, or signs of deception should be considered. To a large extent, reliability should be assessed based on the information itself and its surrounding context. Note that this example and explanation are highly simplified, and in real cases it is not possible to distinguish real and unreal information in this manner.

The APA emphasizes that any possibility of actual danger must be reported to legal authorities.

Finalizing a Diagnosis

To confirm the diagnosis, all information mentioned in previous sections must be written sequentially and within a specific framework called a clinical report. Then, clinically significant symptoms must be separated, combined, and a possible diagnosis determined.

The APA, alongside the latest version of DSM and based on its ethical principles, has established a universal format and framework for clinical case reports. In this format, after separating clinically significant symptoms and recording a possible diagnosis, the interviewer must independently compare symptoms with DSM diagnostic criteria and scales, identify differential diagnoses, and explain the reasons for ruling each one out. After this, at least one another professional (if the interviewer is a psychologist, a supervising psychiatrist, and vice versa) must review and confirm the notes, diagnosis, and differential diagnoses.

Finally, professionals must specify treatment recommendations and explain the reasons behind them. Ultimately, APA recommends that, for greater validity of a clinical report, at least one psychologist, one psychiatrist, and one physician should review and approve the entire process.

Final Words

The APA provides explanations about the use of DSM diagnostic criteria in the introductory sections of the DSM and the SCID-5 manual. In this Blogpost, we reviewed clinical and diagnostic interviewing based on DSM by summarizing this information. As mentioned previously, APA warns against the misuse of DSM and considers legal consequences for it. Additionally, ignoring these principles reduces diagnostic validity and accuracy.