Rating Scales and Alternative Diagnostic Systems



Rating Scales and Alternative Diagnostic Systems

THERE are many ways to describe and measure distress. For example, a person may speak of having an ataque de nervios, whereas a practitioner may describe him as having a panic attack. Although the person and the practitioner may be describing the same experience, they are accounting for it in different ways. Typically, practitioners account for distress as a symptom of disease—that is, a pathological abnormality in the structure and function of body organs and systems—whereas patients account for distress as illness—that is, their personal experience of abnormality. Psychiatrists and other mental health practitioners currently account for mental distress as neither illness nor disease but rather as disorder. To name a collection of distressing symptoms as a disorder is an attempt to account for both pathological abnormalities and the effects of those abnormalities on a particular patient.

DSM-5 (American Psychiatric Association 2013) mental disorders are diagnostic labels rather than discrete biological phenomena. These diagnoses are provisional formulas for helping a person effect a change he could not make on his own. Within a particular diagnosis, there are very different experiences of symptoms and functional impairment. One older adult with panic attacks may need only to be taught breathing techniques, whereas another may need hospitalization and an extended course of therapy. One way to account for these differences in a patient’s experience of a mental disorder is to use rating scales. Another is to use alternative diagnostic systems to describe the distress differently.

Rating Scales

Because we cannot yet diagnose and monitor most mental illnesses through physical means such as functional imaging, genetic testing, or blood serum tests, rating scales are important clinical aids to mental health care. Individual item responses on a standardized rating scale can be used to guide a clinical conversation (e.g., “You indicated that you sometimes have thoughts that you would be better off dead. Can you tell me more about that?”). Numerical scores on rating scales identify symptoms, guide diagnostic assessments, establish the severity of a disorder, and track the progress of patient care. Collecting these scale results over time will also enable measurement-based care, which refers to adjusting a patient’s treatment plan until a measurable symptom target is reached.

We follow a few principles when considering how to use rating scales:

  • Select scales that are research validated for age, condition, language, and (ideally) culture.
  • Use broad-based screening scales to detect the likelihood of any disorder being present.
  • Use a more specific rating scale to investigate a particular problem.
  • Select brief rating scales to enhance patient cooperation and ease of implementation.
  • Reserve longer rating scales for specialty settings.
  • Remember that rating scales cannot make diagnoses—they are aids, not replacements, for clinician assessment.
  • Recall that rating scale results depend on the reliability of the reporter and his interpretation.

There are hundreds of rating scales available; to assist your practice, we have listed in Table 12–1 the scales that we find especially helpful in the evaluation and care of older persons with mental distress. Many of these rating scales are (or can be) built into an electronic health record, which allows you to follow a patient’s condition more objectively.

TABLE 12–1. Select brief rating scales for use with older adults

Scale (common abbreviation)


Number of items


Neurocognitive disorders

Clock Drawing Test (CDT)

Assesses executive and visuospatial function


Shulman 2000

Confusion Assessment Method (CAM)

Assesses presence of delirium


Inouye et al. 1990


Frontal Assessment Battery (FAB)

Detects executive dysfunction affecting cognition and motor behavior


Dubois et al. 2000

Neuropsychiatric Inventory (NPI)

Assesses dementia-related behavioral symptoms

10, 12

Cummings et al. 1994



Geriatric Depression Scale (GDS)

Self-reporting depression screen


Yesavage et al. 1982–1983


Patient Health Questionnaire (PHQ-9)

Self-reporting depression screen


Kroenke et al. 2001


Executive functioning

Executive Interview (EXIT)

Assesses executive function


Royall et al. 1992

Quick Executive Interview (Quick EXIT)

Assesses executive function


Larson and Heinemann 2010

Global mental status

Mini-Mental State Examination (MMSE)

Assesses cognitive function and screens for dementia


Folstein et al. 1975

Montreal Cognitive Assessment (MoCA)

Detects mild cognitive impairment


Nasreddine et al. 2005


Psychotic disorders

Brief Psychiatric Rating Scale (BPRS)

Assesses presence and severity of psychotic symptoms


Overall and Gorham 1962

Substance use

Alcohol-Related Problems Survey (ARPS)

Assesses alcohol use


Fink et al. 2002

Alcohol Use Disorders Identification Test (AUDIT)

Identifies problematic alcohol use


Babor et al. 1989


Short Michigan Alcoholism Screening Test—Geriatric Version (SMAST-G)

Screens for and detects problematic alcohol use


Blow et al. 1992

In addition, DSM-5 provides severity rating scales for many disorders. Most are specific to a particular disorder, and some include a narrative description to indicate that a particular disorder is mild, moderate, or severe. For some diagnoses, such as alcohol use disorder, severity depends on the number of criteria endorsed by a patient. For other diagnoses, such as a neurocognitive disorder, severity is measured by the degree to which a patient requires support. When appropriate, the severity ratings refer to specific measurements external to the mental status examination. For example, grading the severity of central sleep apnea depends, in part, on the extent of associated oxygen desaturation.

Alternative Diagnostic Systems

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Sep 1, 2019 | Posted by in PSYCHOLOGY | Comments Off on Rating Scales and Alternative Diagnostic Systems
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