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March 11, 2020

Assessment of Psychopathology: Is Asking Questions Good Enough?

Author Affiliations
  • 1Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
  • 2Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
JAMA Psychiatry. 2020;77(6):557-558. doi:10.1001/jamapsychiatry.2020.0108

The evaluation and success of our efforts to prevent, detect, and treat mental illness depend on the assessment of psychopathology. Almost all psychiatric assessments consist of asking questions, through questionnaires or interviews, about behaviors and experiences. We either ask the person being assessed or someone who knows them well. Based on the answers, we diagnose, recommend treatment, and monitor outcome. Regardless of who is reporting, overreporting and underreporting are common. People may overreport or underreport on purpose when they are hoping for benefits associated with a diagnosis (eg, educational support, time off work, or access to medication), or fearing the consequences of diagnosis, including stigma or adverse effects of medication. Beliefs about mental illness not being real, concerns about privacy, health insurance cost, and implications for custody of children are also reasons for underreporting.

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    2 Comments for this article
    How Can I Help You: Response to Pavlova and Uher
    Leon Hoffman, MD | New York Psychoanalytic Society and Institute and Icahn School of Medicine at Mount Sinai
    Pavlova and Uher’s (1) Viewpoint article, “Assessment of Psychopathology: Is Asking Questions Good Enough?,” illustrates the problem with contemporary psychiatry. The authors conclude that diagnostic reliability would be increased by “incorporating objective and unbiased
    assessment in the work flow of research and clinical practice” (page E2).

    Contemporary psychiatry in its goal to becoming a more “scientific” profession has devalued the centrality of the doctor-patient relationship and the value empathic history-taking as a diagnostic tool. Ohm, et al (2) studied how medical students need to learn empathic communication as well as how to ask relevant clinical information during history-taking. In
    their review of the literature, they report a variety of studies that demonstrate that between 75 and 80% of diagnoses can be made with a good history, including citing the experience of Nobel Peace Price laureate Bernard Lown (page 2).

    Unfortunately, psychiatry has devalued the diagnostic role as well as the healing power of the doctor-patient relationship. Instead of asking a patient, before speaking with them, to first fill out a myriad of checklists and undergo a variety of standardized tests, the psychiatrist should first ask, “How can I help you” (3).

    (1) Pavlova B, Uher R. Assessment of Psychopathology: Is Asking Questions Good Enough? JAMA Psychiatry. Published online March 11, 2020. doi:10.1001/jamapsychiatry.2020.0108
    (2) Ohm, F., Vogel, D., Sehner, S. et al. Details acquired from medical history and patients’ experience of empathy – two sides of the same coin. BMC Med Educ 13, 67 (2013). https://doi.org/10.1186/1472-6920-13-67
    (3) Hoffman, L. How Can I Help You? Dimensional versus Categorical Distinctions in the Assessment for Child Analysis and Child Psychotherapy. Journal of Infant, Child, and Adolescent Psychotherapy, 19:1, 1-15, DOI: 10.1080/15289168.2019.1701866
    Comment on Pavlova and Uher (2020). Assessment of psychopathology. Is asking questions good enough?
    Harriette Riese, PhD | University of Groningen, University Medical Centre Groningen, Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion regulation, Groningen, The Netherlands
    Pavlova and Uher1 advocated for more objective methods to improve assessment of psychopathology. We agree with the authors that ecological momentary assessment (EMA) may advance psychopathology diagnostics and treatment. The authors outlined that advantages of EMA are its ecological validity and minimization of memory bias. In this comment we elaborate on two additional advantages of EMA.
    First, traditionally in psychiatric research and practice single psychopathology assessments are used, whereas psychopathology develops dynamically over time. EMA involves intensive repeated questionnaire assessments that offer insight into the dynamic processes of psychopathology. Second, most psychiatric research is group-based (nomothetic), focusing on group averages.
    Although essential for clinical guidelines, group-based findings on psychopathological processes do not necessarily generalize to individual patients.2 This is unfortunate for both research and practice, because this means that individual differences in psychopathological processes are largely overlooked. Therefore, we argue that nomothetic research should be supplemented with single-subject (idiographic) research. In such studies, EMA data of each patient are analyzed separately and a patient is his/her own control. Thus by assessment of EMA data for prolonged periods, we are able to shed light on individual dynamic processes of psychopathology.3,4
    Moreover, additionally to advancing diagnostic accuracy and treatment, EMA may benefit clinical practice directly by enhancing insight in patients’ well-being and pinpointing (social) contexts and activities that trigger or buffer psychopathology. This is particularly the case when EMA is personalized.3 Both EMA monitoring and personalized feedback on EMA data can be used to monitor for relapse5 and serve as starting point for a dialogue between a patient and his/her clinician.3,4 However, to the best of our knowledge, validated practical EMA-tools for large-scale clinical implementation are currently not available. Such implementation requires intuitive, user-friendly technology that is specifically designed for clinical practice. Especially personalized EMA-tools hold a promise for improving patients’ diagnostic accuracy, treatment, and insight in their own well-being.

    Harriëtte Riese PhD, Marij Zuidersma PhD, Fionneke M. Bos MSc

    Financial support
    Foundation VCVGZ (”Stichting tot Steun VCVGZ”, grantno 239 awarded to Riese and Bastiaansen); Innovatiefonds De Friesland (grantno DS81 awarded to Riese and Wichers); and the Rob Giel Research Center.

    1. Pavlova B, Uher R. Assessment of psychopathology. Is asking questions good enough? JAMA Psychiatry. doi:10.1001/jamapsychiatry.2020.0108
    2. Fisher AJ, Medaglia JD, Jeronimus BF. Lack of group-to-individual generalizability is a threat to human subjects research. Proc Natl Acad Sci. 2018;115(27):E6106-E6115.
    3. Bos FM, Snippe E, Bruggeman R, Wichers M, van der Krieke L. Insights of patients and clinicians on the promise of the experience sampling method for psychiatric care. Psychiatr Serv. 2019;70(11):983-991.
    4. Kroeze R, van der Veen DC, Servaas MN, et al. Personalized feedback on symptom dynamics of psychopathology: A proof-of-principle study. Journal of Person-Oriented Research. 2017;3(1):1-10.
    5. Smit AC, Snippe E, Wichers M. Increasing restlessness signals impending increase in depressive symptoms more than 2 months before it happens in individual patients. Psychother Psychosom. 2019;88(4):249-251.