Cognitive and personality functioning

Cognitive and personality functioning • What are meaningful ways to integrate these two pieces of information? • What interpretations might one make for high IQ individuals relative to low IQ individuals re: personality? • Overlap with maturity? Less complex presentations? • What PD is associated with extremist thinking (splitting), inability to recognize subtleties? • Other implications? • Ease of use for clients, alternative test format, wider range of responses (variability), alternative approach to detecting pathology, difficult for client to identify socially desirable or undesirable responding, theory based • Defensiveness strategies (see MMPI-2)?

Projective test/technique • MMPI/MMPI-2 is most frequently used test in inpatient settings • Rorschach & TAT are not too far behind • Advantages of projectives? • Disadvantages of projectives? • Administration and scoring is generally less standardized so reliability and validity are compromised

Minimal criteria for a test • Standardized administration • Rorschach has numerous administration procedures (Bleck, Klopfer, Exner, etc.) • Standardized scoring • Rorschach has numerous scoring approaches (Bleck, Klopfer, Exner, etc.) • Standard of comparison for interpretations (norm group) • Minimal information with regard to representative norms

Rorschach – Exner • Exner’s (1987) scoring system involves an attempt to increase validity by objectifying the scoring, increasing the number of responses (14), and standardizing the administration • This has resulted in significant improvements in the test’s reliability and validity • In a meta-analysis, Hiller et al. (1999) found the Rorschach (using Exner’s scoring) to have larger validity coefficients than the MMPI-2 for studies using objective criterion variables

Exner’s scoring system • Location – part of the blot • W, D, d, S, (WS) • How common is the location (normative comparisons from manual) • Determinant – what led to response • Form, Color, FC or CF, Movement, etc. • Evaluate form quality (normative decision based on manual of responses). Low F+% = psychosis/poor reality contact • Content – focus on what specifically • Human or animal, whole or detail, nature, etc. • Populars – determines normative responding

Other projective “tests” • TAT (Thematic apperception test, Murray) • Stimuli are less ambiguous than the ink blots • Tell a story, though little standardization re: which pictures to be used, scoring (typically a content analysis), etc. • Used extensively with less literate pops like children (CAT), geriatric pops (GAT), non-English speaking individuals, etc. • Draw-a-figure test (figure drawings) • Person, family, house, tree, etc. – all are interpreted as you • Minimal standardization for scoring • Sentence completion • Sentence stems like “Mom is”, “Life”, etc. largely scored for a thematic standpoint • Bender-Gestalt (the same test used for neuropsychological screens) • Copying figures and making personality interpretations

Test or technique? • Review articles and come up with an opinion. Come ready to debate/discuss. • On Tuesday/Thursday?

Assessment of malingering • What is malingering? What must it include? • Intentional? Awareness? Personal gain? • Very complex phenomenon that may change over time • e.g., A lie (or lies) that become “real/true” for the individual over time, or a truthful statement that becomes a lie. • Most statements can’t be categorized as one or the other, and typically involve aspects of both • Berry et al (1995) suggest that faking good and faking bad are distinct constructs (not opposite ends of the same continuum) • Harder to detect specific faking vs. general faking • Content nonresponsivity (CNR) – random responding, all true or all false • Content response faking (CRF) – fake good or bad; research suggests that these may be independent dimensions (client may fake good on some parts and fake bad on others) • Should always be considered (in some form) when there are contingencies for the patient

Classifications of Misrepresentation • Are symptoms under conscious control? Are physical/psychological symptoms motivated by internal or external gains? • Factitious Disorders – intentional production of symptoms (feigning) that are motivated by internal gains • Motivation is to assume the “sick role” as there are no external incentives for the behavior (e.g., economic gain, avoiding legal responsibility, etc.) • Somatoform disorder – unintentional (i.e., unconscious) production of symptoms for internal gains • Malingering – intentional production or exaggeration of symptoms (i.e., conscious) motivated by external incentives • Lack of cooperation during the evaluation, presence of ASPD, discrepancy between self-reported data and objective findings, medicolegal context for referral (e.g., attorney, police, etc.) • Note: Exaggeration rather than fabrication makes differential very difficult

Pros and Cons of Malingering Dx • What are the costs of labeling someone a “malingerer” • Questions all present and future clinical presentations • What are the limits of our measures to make this differential? • After weighing the strength of any claim of malingering (relatively weak given the limits of our measures) and the costs of making an erroneous judgment, we need to act very carefully • Use converging, independent evidence to make any determinations • e.g., objective inventories like the MMPI-2, strong contextual factors (i.e., to provide the motive and baserates), interview, low probability baserates for responding (e.g., incorrect on all options when this would be well below chance responding), and response to the evaluator’s feedback (e.g., “Actually, you’re doing quite well” – followed by decrements in performance)

Mind of a murderer – the Bianchi tapes • Identify the circumstances that could be seen as contingencies for malingering (reinforcers for malingering) • Why would that particular malingering behavior be manifested? • How could client have obtained the information necessary to provide the malingering profile? Any evidence that this information was obtained? • Any indications of malingering in his presentation? (Be objective) • What are some reasons why he might not be malingering? • Predict response sets in advance of testing (vs. scoring in hindsight) • What pattern of responses do you predict for the Rorschach? • What pattern of responses would you predict for the MMPI-2? • What’s your call?

Measures of malingering – Berry et al • The pasta strainer and photo copy machine “incident” • MMPI-2: F, F-K (note: these two indices are not independent), VRIN (random), TRIN (all true or all false), and Fb • Also look for discrepancies between some of your subtle and obvious supplemental scales (though this can also just assess sophistication in malingering) • The D scale has also been used with some success, as the items appear to reflect a less sophisticated (popular) view of mental illness • MCMI – evaluates random responding, low frequency responding, willingness to disclose information, debasement (willingness to endorse psychological problems), and desirability (unwilling to endorse psychological problems). Also as with the D scale of the MMPI, the well-being scale can likewise assess psychopathology

Measures of malingering – 2 continued • CPI (Cough, 1957) – intended to assess personality in the normal population • Has 3 validity scales: good impression (faking good), communality (items with either very high or very low endorsement frequency that assesses random responding), well-being (assesses fake bad) • Basic personality inventory (BPI: Jackson, 1989) contains 12 scales each with 20 T/F items. Research is limited on its utility for this. • Deviation scale is comparable to the MMPI-2 F scale • Personality assessment inventory (PAI: Morey, 1991) is a 344 items • 4 validity scales: Inconsistency, infrequency, negative impression management and positive impression management • NEO-PI-R (Costa & McCrae, 1991) – no effective validity index, so should not be used in this context • 16 PF also lacks adequate validity measures and should not be used

Measures to specifically detect malingering • These measures should be administered when the referral question specifically implicates malingering and/or when there are substantial contingencies to suggest that malingering is likely • Structured Interview of reported symptoms (SIRS) • Has shown some promise, though it is susceptible to acquiescence and false positives (claiming malingering when it is not) • The M test is a 33 item T/F test with three scales: genuine symptoms of schizophrenia, atypical attitudes not characteristic of mental illness, and bizarre and unusual symptoms rarely found in mental illness • Showed some ability to differentiate patients from directed malingerers and from suspected malingerers (Note: The problem with using the latter criterion group as there is no definitive knowledge about those individuals)

Measures to specifically detect malinger. - 2 • Test battery approach including WAIS-III and the MMPI-2 – the more tests administered, the harder it is to present a consistent profile • This approach should use baserates for incorrect responses as the primary means of classifying • Provide response options (typically no more than two) such that a chance correct criterion can be calculated (e.g., 50% for a two item version) – this should be no lower than 30% to avoid floor effects • Track responses over at least 30 trials (the more the better as this minimizes chance outcomes). • Calculate the probabilities for deviations from .50 correct and apply it to client’s correct response rate (i.e., what are the odds that they would have missed as many as they did if they were truly guessing) • Evaluate responsiveness to your feedback (e.g., “You’re actually not doing that bad” vs. “Most people with your type of injury do better”) • If less sophisticated malingering there will be an immediate and relatively large response to your comments

Who is your client? • Why is this question important in addressing the malingering issue? • If the suspected malingerer is your client who is undergoing therapy with you (or someone else) to whom is your obligation and what are the costs/benefits of undertaking an evaluation of malingering? • Does it help the therapeutic process? Focus on why one might be deceptive to better understand client’s behavior • If the “client” is the court, then to whom is your obligation and what are the costs/benefits of undertaking an evaluation of malingering? • Question now is to determine if client is being deceptive/evasive.

Assessing psychopathic personality • Psychopathic personality = behavior characterized by remorseful and callous disregard for others and a chronic antisocial lifestyle. Thus, most ASPDs are not necessarily psychopathic. • Drawing data from various sources (at least three) • In person interview • Testing • Independent historical information (anything that is not self report – it is important to note that other official records are not necessarily based on anything other than self-report) • Although all three of the above are important in order to provide converging evidence, the test data will be the strongest tool in court (due to its psychometric strengths)

Assessment (Meloy & Gacono, 1995) • The Psychopathy checklist – revised (Hare, 1991) – 20 item test with a 4-point Likert scale response format. Largely intended for males (little data on females) • To be completed by the clinician after a clinical interview and review of historical data (includes descriptors falling under a single dimension of psychopathy) e.g., impulsive, irresponsible, shallow emotions, etc. • Items must be scored in a particular sequence, with more structured items first, followed by the least structured items (with the former contributing to the latter) • Cutoff score of 30 or greater to define psychopathy, with higher scores denoting more extreme presentations • Adequate reliability and validity, though note the overlap between some of the validity criteria and the info used to determine the score (e.g., extent of criminal record is used for both)

Assessment (Meloy & Gacono, 1995) – p. 2 • The Rorschach – should still pursue the minimum number of responses (14 or more) as suggested by Exner (1986) • Include an assessment of defenses and object relations (both of which appear to have modest reliability) that suggest more narcissism (self-references), violations of boundaries, etc. in the psychopathic personality (specific ratios from Exner’s scoring system are described) • MMPI-2 – primary focus is on scale 4 (also content subscales drawn from 4 – be cautious with the latter) • If administering scale 4 alone, note that you will not have the benefit of the k correction. Thus, scores will be suppressed. • L and F will also predict psychopathy (tendency to be untruthful) • Cognitive abilities (e.g., WAIS-III) are unrelated to the presence of psychopathy, but may be informative as to the nature of the presentation (e.g., level of sophistication, concordance with traditional/normative concepts of intelligence, etc.)

Integrity testing • Evaluating integrity as a trait, whereas such behavior may be situation specific (e.g., someone who would not lie in interpersonal settings might not hesitate to cheat on their taxes). • Characterological view of integrity downplays situational factors • Integrity is a very broad concept that can include diverse responses (e.g., passive vs. active lying, cheating vs. theft, etc.) • Early paper and pencil tests were validated with the polygraph • Employed in low end entry jobs when people have to interact with money (retail, financial services, etc.) • Today, such tests attempt to predict a wide range of behaviors including violations of work rules, fraud, absenteeism, etc.

Integrity testing – p. 2 • Overt integrity tests – evaluate beliefs about the incidence of theft and other counterproductive behaviors, punitive attitudes towards theft, endorsement of common rationalizations for theft, and direct questions about one’s own involvement in such activities. • Personality oriented measures – much broader than integrity tests and tend to have lower face validity (e.g., high conscientiousness on the NEO) • Clinical measures like the MMPI – validity scales • All are difficult to validate because the behavior we are trying to predict goes largely undetected. So if a test score does not predict it could just mean that this is a false positive or someone who was not caught

The polygraph test • Measures physiological arousal that is presumed to be associated with lying. e.g., perspiration as indicated by galvanic skin response, brain activity suggesting arousal, etc. to the question (not answer) • Is this assumption reasonable? • Confounds? • Under what circumstances can lying not be associated with arousal? • Habituation effect from repeated lying? • Lack of awareness of the lying? (issue of conscious vs. unconscious) • What is the best way to quantify arousal? Should we evaluate this normatively or ipsatively? • Control Question Test (CQT) – compares relevant questions to control questions which are intended to elicit a strong physiological response from innocent subjects (e.g., “Prior to 1993, did you ever do anything that was illegal or dishonest?”) • While innocent people know they didn’t commit the crime, they are either uncertain or lying about the CQ. Guilty persons should not respond as much to the CQ

The polygraph test – p. 2 • Criticisms of the CQT • Difficult to develop good control questions that will produce similar responses relative to relevant questions for innocent people. This results in many false positives (Note: Bias for positive outcome is why most of these tests have artificially high success rates in forensic settings – most are guilty) • CQ are designed for each individual, so standardization is compromised • Direct Lie Control Test (DLCT) – if person answers truthfully to a question they are asked the question again and told to lie about it when asked again (a known lie for comparison) • Can be standardized and the power of the DLCT is from the instruction (which is standardized) not the content of the question • Can reduce the rate of false positives and generally does better than the CQT • Initially employed absolute standards for arousal = lying and this was not at all effective

The polygraph test – p. 3 • The guilty knowledge test (GKT) – not designed to detect deception, rather it tries to differentiate between those who have knowledge about a particular event (crime) and those who do not (the innocent) • The concealed information test (CIT) – is similar to the above approach and likewise tries to assess familiarity with specific information as opposed to lying • Both of these approaches have the advantage of asking the exact same questions of all individuals and comparing responses both within and between subjects • Minimal data on these approaches, as the bulk of the research is on the CQT

Does it work? • Honts (1994) reviewed the literature on the effectiveness of the polygraph and found that it does about as well as chance in experimental settings. Most of the reviewed research uses the DLCT • In real life and experimental settings, the majority of errors are false negatives (saying someone is innocent when they are guilty) • Most deceptive individuals (up to 95%) are misclassified • Because the cost of a false positive (saying someone is guilty when really they are innocent) is deemed to be higher in our legal system. Therefore, the cutoff scores (criteria) have been altered so as to make false negatives more likely • Why does it fail? • If high arousal to control questions, then more difficult to discriminate • Idiosyncratic responses to lying

Admissibility of the polygraph (Saxe & Ben-Shakhar, 1999) • Courts have almost universally rejected the polygraph, though this question has been and continues to be litigated extensively • Courts are increasingly being made responsible for evaluating the merits of test data, despite lacking the expertise to do so. • Note: The literature has become increasingly discrepant in its view on the polygraph (disagreement on its validity even in the scientific community) • What criteria should be used to evaluate this information and what should we tell the courts? • History • Marston (1917) used a blood pressure cuff to determine truthfulness (arousal) in a defendant (Frye), based on the assumption that while truth required little or no energy, lies do – rejected by the courts

History of the Polygraph • Note the courts use of the term “experimental” as “not well established evidence” • The Frye ruling adequately reflects the courts treatment of the polygraph even today, though now based on the Federal Rules of Evidence (FRE) which require that the evidence (polygraph or otherwise) be relevant and that it aid the jury (i.e., be valid). • Daubert (1993) was based on the FRE and highlights 4 considerations when ruling on evidence: • Testability or falsifiability (see Popper and the method of science) • Error rate • Peer review and publication • General acceptance • This basically requires juries & judges to evaluate scientific issues

History of the Polygraph – p. 2 • In trials like Daubert, scientists with opposing views on the polygraph present their views and the jury must decide on the merits of their arguments • Generally there has been no legal distinction between the concepts of reliability and validity (you can see where this is go, since, from a scientific standpoint, reliability limits validity) • An additional problem with these concepts is that the data is collected as a series of discrepancy scores and these are then summed to reflect a qualitative assessment of truthful, deceptive, and inconclusive. Thus, very different discrepancy readings might still result in similar qualitative assessments. • Two accepted approaches for reliability are: • Test the same person twice on the same issue using the same polygraph technique with 2 different testers • Test the person once, but have the chart scored by two different people

History of the Polygraph – p. 3 • The latter approach deals on with the error involved in chart scoring and ignores (or equates) administration error • The real issue is whether the procedure as a whole is reliable (e.g., the creation and administration of control questions), thereby getting at internal reliability (do different parts of the test agree), test retest reliability (different administrations of the test agree), inter-rater reliability (different test administrators agree as to the outcome) • Note: There are practical limitations to how often the “same” test could be given to the same individual • What little data exists on reliability focuses only on the between examiners approach (inter-rater reliability), though this reliability is reasonable (not high). Thus, this remains an unevaluated component of the polygraph (major limitation)

History of the Polygraph – p. 4 • Because the courts do not distinguish between reliability and validity, the minimal reliability that does exist carries far more weight than it should. • Modern views of validity highlight the integrative component of validity (recall Messick, 1995), though to evaluate it, it is necessary to consider different aspects separately • Different types of validity are more relevant depending on the question at hand • e.g., predictive validity for integrity testing in job placement/hiring, vs. criterion validity being more relevant for determining truth/lying • Construct validity gets at the theoretical issue of what is a lie. Is it a situational phenomenon or a trait? Can it be represented by physiological responding? Etc. • No theory to explain why a stronger response should occur for lies vs. truth

History of the Polygraph – p. 5 • Similar physiological responses to lying appear to occur for experiences such as surprise/novelty • Note: For the CQT, questions about the crime are expected to be well rehearsed for the criminal • Thus, they have questionable construct validity (not necessarily measuring what they propose to measure) • Under-represents the construct of interest and over-represents irrelevant constructs (surprise, stress, etc.) • What criterion can be used? • Outcome of a trial? If the case is dismissed? • Do either of these assure that we know the client’s status re: lying? • Note also that a true evaluation of the polygraph would mean that the examiner only has access to the polygraph data (that s never the case).

History of the Polygraph – p. 6 • The criterion and predictor are rarely independent. • e.g., if the polygraph is used to get a confession and the confession helps get a conviction, then by definition, the polygraph is part of the criterion (polygraphs are frequently used to get confessions) • Experimental criteria for the polygraph generally lack external validity (is lying in an experiment = to lying in a crime involving yourself? That is, are all types of deception equal?), while real life evaluations of the polygraph lack experimental rigor and control (e.g., only a subset of them will ultimately have a clear outcome regarding deception and this may not be representative of all respondents). • The CQT assumes that you can create similar “control” questions. • Do deceptions involving different types of crime result in the same physiological response?

Issues in assessing alcohol/substance abuse • Recognition of dual diagnosis (vs. assuming all other problems are merely secondary to the addiction) – How can we address this? • Timing of assessment remains an important concern as this can dramatically alter the outcome- When is the optimal time to assess? • Patterns of use/abuse and general categories (e.g., stimulants, sedatives, etc.) of use may be important to assessment and intervention • Also some drugs may be used to offset the deleterious effects of other drugs • Context in which use typically occurs may help in identifying triggers and high risk settings for potential relapse – Examples of assess & tx? • Motivation for seeking treatment is likewise a critical component to evaluating the patient – Why? How would you assess and tx differently? • e.g., legal motivation, social/family pressure, work requirement, etc. • May require different test features to identify those still using as opposed to those who have used before but are not now using • The outcome of research in this area varies greatly as a function of how use is defined (any use, quantity/freq, problem behaviors, combos., etc.) • May identify different pops (e.g., those with liver damage vs. those losing jobs)

Specific measures to assess alcohol and drug abuse • The MMPI-2 has 2 items (264 “I have used alcohol excessively” & 489 “I have a drug or alcohol problem”) that directly assess use, but the small number of items limits their psychometric properties. • These items each appear to identify very different groups • Sensitivity (how well the test identifies those who abuse alcohol) of approx. 80% for males and 75% for women • Specificity (how well the test identifies those who do not abuse alcohol) ranges from 53% to 95% for men and from 76% to 97% for women (varying on the item and race of the respondent) • Because the lifetime prevalence base rates for use in the population are 8% for women and 16% for men, it is difficult to improve on the base rate of non-use (84% or more) • Other measures include the MAST and the CAGE – what do you know about these? • Both have problems identifying female substance abusers (they were developed for and validated on, men)

Specific measures to assess alcohol and drug abuse: MMPI-2 scales – p. 2 • MacAndrew Alcoholism scale – (from the MMPI-2) is best for identifying white males who have a propensity for polydrug abuse. It has a sensitivity of approx. 70-75% and 20% false negatives. • Very high false positive rate for black males, little data on females and adolescents, and lower hit rates for psychiatric patients • Addiction Admission scale (also from the MMPI-2) – acknowledgment or denial of substance abuse problems • Low reliability • Addiction Potential scale (also from the MMPI-2) – personality features associated with use • Low reliability • MMPI-2 profiles associated with use: 2/4, 4/2, 2/7, 7/2, 9/4, 4/9, • Just males: 1/2, 2/1 • Just females: 3/4, 4/3, 6/4, 4/6, 8/4, 4/8 • Code types account for 25-35% of alcoholics & they don’t differ on tx success

Issues in alcohol/drug assessment • Is there any utility in identify substance abusers who are doing so covertly or who don’t believe they have a problem? • Drawbacks: Treatment generally requires the clients willing consent, so why bother identifying anyone other than those who acknowledge use? This is consistent with the most widely used model, AA. • Some benefits: Accuracy of other diagnoses, as use can alter presentation of other symptoms, it can make some medication treatments undesirable due to interaction effects, it could bring a problem to a higher level of awareness for the client, etc. • Utility in administering a measure for some clients as it can serve as a standard (vs. an opinion) to the lay person, that allows for a normative evaluation • * Research suggests that exposure to norms can not only help with assessment, but also recognition of problem drinking • Use, in and of itself is considered problem use for an alcoholic from an AA perspective. What factors are relevant from a CD perspective?

Legal/ethical issues in assessing children • Three components of “consent” for testing • Knowledge – what will be done, why, and how • Voluntariness – absence of coercion; a child alone can’t do this, but they are usually asked for assent • Competence – parents must be legally competent and guardians to give consent for child • Also you are ethically (though not legally) bound to tell the parents of potential risks from testing (e.g., what test scores can be used for – such as being grounds to deny entry to a special education program) • Child is not likely to be the one who asked for testing. So are they the client? If not, who is? • Legal issues abound for intelligence testing, but there have been few precedents for personality assessment. Why?

Demers (1986) on testing • Although there are few legal challenges of personality tests, these measures do tend to have more problems with reliability and validity • Little to no evidence for gender or racial bias in personality testing • Also, most personality tests are administered in a voluntary context • Test validation issues: • Tests must be validated for the purpose for which they are being used • Tests must be reliable for the pop being used, and appropriate norms must exist for that pop. • The tests must be capable of generating appropriate decisions for that pop (i.e., validity)

Providing feedback to clients • APA requires that feedback be provided after testing, but it must be in a form that they can understand (varies depending on the client) • This can be best accomplished through an overview of the findings and then a Q & A session. • The feedback should provide a clear path to treatment goals • Consider anything that is assessed as representing a continuum, such that any characteristic will be shared by some portion of the population • Terminology such as unique and different can be substituted for “abnormal”, “deviant”, or “pathological” • Client need not agree with your feedback. Objections can be used to clarify findings and as a starting point for the intervention • Have client summarize info. Back to you

Providing feedback to clients - p.2 • Feedback should also include information on the tests themselves (validity and reliability) in language that can be understood by the client • General psychometrics can be used to enhance the credibility of the test e.g., “The MMPI has been used for over 50 years by clinicians and it is one of the most widely used tests. Many research studies have been done to show that it is pretty consistent in the scores it produces and that it works pretty well at predicting behaviors.” • This issue may be further complicated when giving feedback to those with limited cognitive abilities, but a more detailed account can be provided to those who have legal guardianship

Providing MMPI-2 feedback to clients • Empirical evaluation of getting MMPI-2 feedback • Compared MMPI-2 feedback of college students relative to attention with no feedback • The former showed increased self-esteem, immediately & after 2 weeks • Decreased symptomatic distress, immediately and after 2 weeks • Why would this occur? • Nature of the client population? (higher functioning, therefore feedback is likely to be generally positive?) • Selective sampling? (Those seeking out personality evaluations are wanting feedback and are more likely to construe it positively?) • When initially meeting with clients and discussing the testing and the eventual feedback you will be able to differentiate those who will be most/least receptive to the feedback • Highlights the importance of having the client arrive at the decision to test

Legal precedents • Griggs v Duke Power Company (1971) – job testing • Hobson v Hansen (1967) – racial disparity (problems with standardization & norms; assessed present skills rather than innate ability) • Larry P. V Riles (1972) – culturally biased IQ tests for EMR determination • PASE v. Hannon (1980) – reversed the Larry P. decision based on the fact that EMR determinations were based on more than just IQ testing (any thoughts on the item by item review by the judge?) • Lora v Board of Education City of New York – use of TAT, Rorschach, & Bender-Gestalt to label minority children as emotionally disturbed (vague def. for latter) • Note: Most personality tests are administered voluntarily. Test validation issues: • Tests must be validated for the purpose for which they are being used • Tests must be reliable for the pop being used, and appropriate norms must exist for that pop. • The tests must be capable of generating appropriate decisions for that pop (i.e., validity) • Note: many personality tests were developed for adults and co-opted for children. Which of the above issues is most affected?

Example DSM-IV codes: Review • The parenthetical term “(provisional)” may follow a diagnosis to indicate a significant degree of diagnostic uncertainty • The phrase “rule out” is used to denote other diagnoses that should be considered and that are still to be ruled out. • The numeric code should follow the AXIS number and then the formal name of the disorder should be listed. • e.g., AXIS I: 295.40 Schizophreniform disorder (Provisional, rule out Organic Delusional Disorder), with(out) good prognostic features. • Numeric codes from the DSM are matched to the ICD (International Classification of Diseases) codes to allow for international compatibility. • Recording procedures: e.g., Major Depressive Disorder • AXIS I: 296.34 - 4th digit is either 2 (single episode) or 3 (multiple) -5th digit is severity: 1 = mild, 2= moderate, 3 = severe without psychotic features, 4= severe with psychotic features, 5= partial remission, 6= full remission • 4th and 5th digits typically apply to most recent or current episode

DSM-IV codes - continued • Recording procedures: e.g., Bipolar I disorder • AXIS I: 296.34 - 4th digit is 0 (single episode). For recurrent episodes, it’s 4 if current or most recent episode is hypomanic or manic, 5 if depressive, 6 if mixed, 7 if unspecified. -5th digit is severity: 1 = mild, 2= moderate, 3 = severe without psychotic features, 4= severe with psychotic features, 5= partial remission, 6= full remission, 0 = unspecified (except for hypomanic where 5th digit is always a 0, and unspecified, where there is no 5th digit). • For Bipolar II, the 4th digit coding is the same, but do not use the 5th digit code as is already specified as 9.

Cognitive and personality functioning