COMMENTARY
In a earlier article, one in all us (RP) described the rationale behind a diagnostic “prism,” designed to seize the affected person’s psychopathology in seven practical domains.1 On this barely revised model, we present how the Psychopathology Refracted into 7 Modalities (PRiSM) Scale is likely to be utilized in a hypothetical however not unusual scientific presentation. You will need to word that the PRiSM isn’t geared toward yielding a selected DSM prognosis, although we imagine it should show helpful as a prediagnostic information to broad forms of psychopathology. Because the PRiSM has not but been field-tested and validated in scientific populations, there aren’t any exact, quantitative knowledge that may be utilized to scoring. The numbers that seem within the hypothetical train right here are supposed to be heuristic, not definitive, because the PRiSM stays a piece in progress.
Case Vignette
“Jason” is a 17-year-old boy with a 2-year historical past of moderate-to-severe psychiatric signs. His chief grievance on consumption analysis is “feeling scared and confused, like my world is muddled and breaking apart into tiny particles or bones.” Raised in an upper-middle-class, nondenominational household, Jason seems to have had an unremarkable developmental and childhood historical past, till concerning the age of 14, when he started to withdraw from his mates in school, and voiced the idea that “The watchers are spying on me in my bed room…and after I pull the covers over my head, they inform me that I’m a grimy pervert.” At instances, Jason has doubts that the world is “actual,” and typically feels “unreal” himself. His dad and mom report that, at instances, Jason “appears to be misplaced in his personal little world and it’s arduous to interrupt by way of to him.” They state that Jason has gentle problem organizing his day and hassle specializing in psychological duties at house and at school. Jason states that, “my ideas are, like, caught within the mud or some sort of psychological sludge. I really feel like I’m a film in gradual movement.” Throughout these durations, Jason experiences dropping curiosity in most actions and feels “sort of down,” experiencing little pleasure in life, and “largely staying in my room and watching stuff on YouTube.”
PRiSM Evaluation [Completed by Clinician]
In every part, test the field or bins that finest apply, and circle the quantity reflecting severity. Base your responses on the affected person’s psychiatric historical past, psychological standing examination, and your analysis of the particular areas of concern. Inside every subsection (area), point out the full rating.
1=minimal/uncommon 2=gentle/occasional 3=reasonable/typically 4=extreme/frequent
Outcomes of Jason’s Analysis
Disturbances of Actuality Notion Cluster
- Experiences/reveals mounted, clearly false beliefs, equivalent to paranoid, persecutory, or somatic delusions, that aren’t adequately defined by cultural, spiritual, ethnic, or social media influences □ 1 □2 ☒3 □4
- Experiences/reveals auditory, visible, tactile, or different hallucinations, not clearly on account of drug or substance use, not on account of identified medical/neurological situation □1 □2 ☒3 □4
- Experiences/reveals reexperiencing of traumatic occasions (“as if it was occurring proper now”) ☒1 □2 □3 □4
- Experiences/reveals feeling just like the world or self isn’t actual or “like being in a dream” □1 □2 ☒3 □4
- Experiences/reveals durations lasting hours or a number of days of being out of contact with actuality, based mostly on self/different observations □1 □2 □3 ☒4
Whole: 14
Disturbances of Reminiscence, Calculation, Planning, or Consideration Cluster
- Experiences/reveals difficulties recalling current occasions, equivalent to breakfast gadgets consumed that day □1 □2 □3 □4
- Experiences/reveals difficulties balancing checkbook, determining easy percentages, paying payments, and so on □1 □2 □3 □4
- Experiences/reveals difficulties organizing every day actions, planning buying, packing for journeys, and so on □1 ☒2 □3 □4
- Experiences/reveals issues preserving monitor of what was simply mentioned, organizing ideas, specializing in a activity, sustaining practice of thought □1 ☒2 □3 □4
Whole: 4
Disturbances of Self-Integration Cluster
- Experiences/reveals feeling, when beneath stress, like they’re in a “fog” or a “haze” or that issues round them have modified in dimension or form □1 ☒2□3 □4
- Experiences/reveals feeling, when beneath stress, like their physique or part of it was by some means modified or not actual □1 ☒2□3 □4
- Experiences/reveals frequent reminiscence gaps, or historical past of transient blackouts throughout which they’re unable to recall what has occurred □1 □2 □3 □4
- Experiences/reveals feeling indifferent from their physique or as if they’re watching themselves from the surface ☒1 □2 □3 □4
Whole: 5
Disturbances of Temper High quality, Regulation, or Stability Cluster
- Experiences/reveals distinct episodes lasting 2 days or longer of markedly anxious, depressed, or elevated temper, or of extreme temper swings □1 □2 □3 □4
- Experiences/reveals distinct episodes of feeling markedly slowed down in pondering and motion □1 □2 ☒3 □4
- Experiences/reveals distinct episodes of feeling markedly “sped up” in pondering and motion □1 □2 □3 □4
- Experiences/reveals distinct durations of dropping all or most curiosity in pleasurable life actions □1 ☒2 □3 □4
- Experiences/reveals distinct durations of great improve or lower in sleep, urge for food, or weight □1 □2 □3 □4
Whole: 5
Disturbances of Behavioral Self-Regulation Cluster
- Experiences/reveals repetitive acts that they’re pushed to carry out to alleviate anxiousness or stop a dreaded consequence ☒1 □2 □3 □4
- Experiences/reveals continued use of a drug or medicine regardless of clear destructive life penalties □1 □2 □3 □4
- Experiences/reveals a historical past of self-injurious conduct, equivalent to slicing, burning, or different probably harmful actions □1 □2 □3 □4
- Experiences/reveals a historical past of violent or prison conduct □1 □2 □3 □4
Whole: 1
Disturbances of Thought Course of, Group, and Circulate Cluster
- Experiences/reveals disruption within the potential to kind and talk ideas clearly□1 □2 ☒3 □4
- Experiences/reveals an abrupt interruption or cessation of ideas, leading to a short lived incapacity to speak ☒1 □2 □3 □4
- Experiences/reveals a bent to meander away from a given subject and leap to different subjects with or with out returning to the unique subject □1 ☒2 □3 □4
- Experiences/reveals recurrent and chronic ideas, urges, or impulses which are skilled as intrusive and undesirable □1 ☒2 □3 □4
Whole: 8
Disturbances of Interpersonal Relations Cluster
- Experiences/reveals a bent to see self and others as being both “all good” or “all unhealthy” at completely different deadlines, with a restricted potential to combine these perceptions to see issues in “shades of gray” ☒1 □2 □3 □4
- Experiences/reveals vital adjustments in temper and functioning associated straight and predictably to ups and downs in relationships □1 □2 □3 □4
- Experiences/reveals a historical past of aggressive, exploitative, or vindictive conduct within the context of relationships □1 □2 □3 □4
- Experiences/reveals durations of great social withdrawal or decreased motivation/need to socialize □1 □2 ☒3 □4
- Experiences/reveals intense fears of abandonment □1 □2 □3 □4
Whole: 4
Evaluation
When evaluated within the 7 domains, Jason exhibits a diffusely optimistic response sample, with 20 of 31 gadgets reflecting a point of dysfunction in all 7 domains. The best rating (14) is within the Disturbances of Actuality Notion cluster, and the second highest rating (8) is within the Disturbances of Thought Course of, Group, and Circulate cluster. The following largest scores (each 5) are within the domains of Disturbances of Self-Integration and Disturbances of Temper High quality, Regulation, or Stability.
Interpretation of Jason’s Psychopathology Utilizing the PRiSM Scale
The worldwide image suggests some sort of power psychotic course of compromising actuality notion, thought course of, self-integration, and temper, amongst different capabilities. Guided by the best rating of 14 within the Disturbances of Actuality Notion cluster, essentially the most parsimonious interpretation of Jason’s pathology—one of the best diagnostic match with the manifest psychopathology—is to posit schizophrenia or some associated situation, equivalent to a schizoaffective sickness. Schizophrenia is a heterogeneous syndrome most likely composed of a number of pathophysiological subtypes.
Making use of Occam’s Razor, schizophrenia alone may account for almost all essentially the most outstanding signs famous in Jason’s scientific image, together with (however not restricted to) Jason’s disturbances of actuality notion; thought course of; self-integration; temper high quality; and cognitive impairments. Thus, in precept, we don’t must posit one other prognosis, such because the DSM-5 class of depersonalization-derealization dysfunction (DDD)—a dissociative dysfunction—to account adequately for Jason’s scientific image. In a hierarchical sense, schizophrenia would take priority over DDD.2 Nevertheless, a ultimate, formal prognosis would require ruling out medical and neurological causes for Jason’s psychopathology, and contemplating different or further diagnostic potentialities, equivalent to schizoaffective dysfunction. In idea, ample psychosocial and pharmacological remedy of Jason’s putative schizophrenia ought to scale back the sample of diffuse dysfunction by lowering signs in a number of of the 7 domains.
Conclusion and Prospectus
At this stage of its growth, the PRiSM scale is a work-in-progress, not an office-ready psychometric instrument. We’d encourage clinicians to make the most of the PRiSM as part of a broader analysis course of and to not depend on it as a solo diagnostic instrument. When used as a part of a extra complete analysis, a PRiSM rating could possibly help in reaching a proper DSM-5 prognosis by guiding clinicians to a normal sphere of psychopathology. However, figuring out a selected DSM-5 prognosis requires a extra thorough analysis of the affected person’s indicators and signs, in accordance with established diagnostic tips.
It’s our hope that the PRiSM scale will scale back the frequency of misdiagnosis and the issues consequent to misdiagnosis by encouraging clinicians to contemplate how psychopathology affecting 1 area could also be resulting in disturbances in different domains. Assigning a number of psychiatric diagnoses to a single affected person has change into the norm, not the exception, and whereas comorbidity is actually attainable, we imagine that the DSM system as presently constituted could lend itself to inappropriate polydiagnosis.2 As this case demonstrates, main psychopathology can have an effect on varied domains of psychological functioning, however these disturbances don’t all the time warrant further diagnoses.
In time, our purpose is for the PRiSM scale to change into a validated diagnostic instrument to be used in on a regular basis scientific follow by psychiatrists, psychologists, scientific social staff, and different psychological well being professionals to help within the advanced activity of psychiatric prognosis. We encourage you to obtain the size free of charge right here, and we welcome suggestions in your expertise with PRiSM.
Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical College; Scientific Professor of Psychiatry, Tufts College Faculty of Drugs; and Editor in Chief Emeritus of Psychiatric Occasions (2007-2010). Dr Pies is the writer of a number of books. A group of his works could be discovered on Amazon. Dr Ruffalo is an assistant professor of psychiatry on the College of Central Florida School of Drugs in Orlando and adjunct assistant professor of psychiatry at Tufts College Faculty of Drugs in Boston, Massachusetts.
References
1. Pies RW. The prism of psychiatric prognosis: can this potential evaluation software make clear the affected person’s psychopathology? Psychiatric Occasions. February 11, 2025. https://www.psychiatrictimes.com/view/the-prism-of-psychiatric-diagnosis-can-this-potential-assessment-tool-shed-light-on-the-patients-psychpathology
2. Ghaemi SN. After the failure of DSM: scientific analysis on psychiatric prognosis. World Psychiatry. 2018;17(3):301-302.
