Use of the PRiSM Diagnostic Instrument in Clinical Practice

Kathy/AdobeStock

COMMENTARY

In a previous article, one of us (RP) described the rationale behind a diagnostic “prism,” designed to capture the patient’s psychopathology in seven functional domains.¹ In this slightly revised version, we show how the Psychopathology Refracted into 7 Modalities (PRiSM) Scale might be used in a hypothetical but not uncommon clinical presentation. It is important to note that the PRiSM is not aimed at yielding a specific DSM diagnosis, though we believe it will prove useful as a prediagnostic guide to broad types of psychopathology. As the PRiSM has not yet been field-tested and validated in clinical populations, there are no precise, quantitative data that can be applied to scoring. The numbers that appear in the hypothetical exercise here are meant to be heuristic, not definitive, as the PRiSM remains a work in progress.

Case Vignette

“Jason” is a 17-year-old boy with a 2-year history of moderate-to-severe psychiatric symptoms. His chief complaint on intake evaluation is “feeling scared and confused, like my world is muddled and breaking up into tiny particles or bones.” Raised in an upper-middle-class, nondenominational family, Jason appears to have had an unremarkable developmental and childhood history, until about the age of 14, when he began to withdraw from his friends at school, and voiced the belief that “The watchers are spying on me in my bedroom…and when I pull the covers over my head, they tell me that I’m a filthy pervert.” At times, Jason has doubts that the world is “real,” and sometimes feels “unreal” himself. His parents report that, at times, Jason “seems to be lost in his own little world and it is hard to break through to him.” They state that Jason has mild difficulty organizing his day and trouble focusing on mental tasks at home and in school. Jason states that, “my thoughts are, like, stuck in the mud or some kind of mental sludge. I feel like I’m a movie in slow motion.” During these periods, Jason reports losing interest in most activities and feels “kind of down,” experiencing little pleasure in life, and “mostly staying in my room and watching stuff on YouTube.”

PRiSM Assessment [Completed by Clinician]

In each section, check the box or boxes that best apply, and circle the number reflecting severity. Base your responses on the patient’s psychiatric history, mental status exam, and your evaluation of the specific areas of concern. Within each subsection (domain), indicate the total score.

1=minimal/rare 2=mild/occasional 3=moderate/often 4=severe/frequent

Results of Jason’s Evaluation

Disturbances of Reality Perception Cluster

• Reports/exhibits fixed, clearly false beliefs, such as paranoid, persecutory, or somatic delusions, that are not adequately explained by cultural, religious, ethnic, or social media influences □ 1 □2 ☒3 □4
• Reports/exhibits auditory, visual, tactile, or other hallucinations, not clearly due to drug or substance use, not due to known medical/neurological condition □1 □2 ☒3 □4
• Reports/exhibits reexperiencing of traumatic events (“as if it was happening right now”) ☒1 □2 □3 □4
• Reports/exhibits feeling like the world or self is not real or “like being in a dream” □1 □2 ☒3 □4
• Reports/exhibits periods lasting hours or a few days of being out of touch with reality, based on self/other observations □1 □2 □3 ☒4

Total: 14

Disturbances of Memory, Calculation, Planning, or Attention Cluster

• Reports/exhibits difficulties recalling recent events, such as breakfast items consumed that day □1 □2 □3 □4
• Reports/exhibits difficulties balancing checkbook, figuring out simple percentages, paying bills, etc □1 □2 □3 □4
• Reports/exhibits difficulties organizing daily activities, planning shopping, packing for trips, etc □1 ☒2 □3 □4
• Reports/exhibits problems keeping track of what was just said, organizing thoughts, focusing on a task, maintaining train of thought □1 ☒2 □3 □4

Total: 4

Disturbances of Self-Integration Cluster

• Reports/exhibits feeling, when under stress, like they are in a “fog” or a “haze” or that things around them have changed in size or shape □1 ☒2□3 □4
• Reports/exhibits feeling, when under stress, like their body or a part of it was somehow changed or not real □1 ☒2□3 □4
• Reports/exhibits frequent memory gaps, or history of brief blackouts during which they are unable to recall what has happened □1 □2 □3 □4
• Reports/exhibits feeling detached from their body or as if they are watching themselves from the outside ☒1 □2 □3 □4

Total: 5

Disturbances of Mood Quality, Regulation, or Stability Cluster

• Reports/exhibits distinct episodes lasting 2 days or longer of markedly anxious, depressed, or elevated mood, or of severe mood swings □1 □2 □3 □4
• Reports/exhibits distinct episodes of feeling markedly slowed down in thinking and movement □1 □2 ☒3 □4
• Reports/exhibits distinct episodes of feeling markedly “sped up” in thinking and movement □1 □2 □3 □4
• Reports/exhibits distinct periods of losing all or most interest in pleasurable life activities □1 ☒2 □3 □4
• Reports/exhibits distinct periods of significant increase or decrease in sleep, appetite, or weight □1 □2 □3 □4

Total: 5

Disturbances of Behavioral Self-Regulation Cluster

• Reports/exhibits repetitive acts that they are driven to perform to alleviate anxiety or prevent a dreaded outcome ☒1 □2 □3 □4
• Reports/exhibits continued use of a drug or drugs despite clear negative life consequences □1 □2 □3 □4
• Reports/exhibits a history of self-injurious behavior, such as cutting, burning, or other potentially dangerous actions □1 □2 □3 □4
• Reports/exhibits a history of violent or criminal behavior □1 □2 □3 □4

Total: 1

Disturbances of Thought Process, Organization, and Flow Cluster

• Reports/exhibits disruption in the ability to form and communicate thoughts clearly□1 □2 ☒3 □4
• Reports/exhibits an abrupt interruption or cessation of thoughts, resulting in a temporary inability to communicate ☒1 □2 □3 □4
• Reports/exhibits a tendency to meander away from a given topic and jump to other topics with or without returning to the original topic □1 ☒2 □3 □4
• Reports/exhibits recurrent and persistent thoughts, urges, or impulses that are experienced as intrusive and unwanted □1 ☒2 □3 □4

Total: 8

Disturbances of Interpersonal Relations Cluster

• Reports/exhibits a tendency to see self and others as being either “all good” or “all bad” at different points in time, with a limited ability to integrate these perceptions to see things in “shades of grey” ☒1 □2 □3 □4
• Reports/exhibits significant changes in mood and functioning related directly and predictably to ups and downs in relationships □1 □2 □3 □4
• Reports/exhibits a history of aggressive, exploitative, or vindictive behavior in the context of relationships □1 □2 □3 □4
• Reports/exhibits periods of significant social withdrawal or decreased motivation/desire to socialize □1 □2 ☒3 □4
• Reports/exhibits intense fears of abandonment □1 □2 □3 □4

Total: 4

Analysis

When evaluated in the 7 domains, Jason shows a diffusely positive response pattern, with 20 of 31 items reflecting some degree of dysfunction in all 7 domains. The highest score (14) is in the Disturbances of Reality Perception cluster, and the second highest score (8) is in the Disturbances of Thought Process, Organization, and Flow cluster. The next largest scores (both 5) are in the domains of Disturbances of Self-Integration and Disturbances of Mood Quality, Regulation, or Stability.

Interpretation of Jason’s Psychopathology Using the PRiSM Scale

The global picture suggests some type of chronic psychotic process compromising reality perception, thought process, self-integration, and mood, among other functions. Guided by the highest score of 14 in the Disturbances of Reality Perception cluster, the most parsimonious interpretation of Jason’s pathology—the best diagnostic fit with the manifest psychopathology—is to posit schizophrenia or some related condition, such as a schizoaffective illness. Schizophrenia is a heterogeneous syndrome probably composed of several pathophysiological subtypes.

Applying Occam’s Razor, schizophrenia alone could account for nearly all the most prominent symptoms noted in Jason’s clinical picture, including (but not limited to) Jason’s disturbances of reality perception; thought process; self-integration; mood quality; and cognitive impairments. Thus, in principle, we do not need to posit another diagnosis, such as the DSM-5 category of depersonalization-derealization disorder (DDD)—a dissociative disorder—to account adequately for Jason’s clinical picture. In a hierarchical sense, schizophrenia would take precedence over DDD.² However, a final, formal diagnosis will require ruling out medical and neurological causes for Jason’s psychopathology, and considering other or additional diagnostic possibilities, such as schizoaffective disorder. In theory, adequate psychosocial and pharmacological treatment of Jason’s putative schizophrenia should reduce the pattern of diffuse dysfunction by reducing symptoms in several of the 7 domains.

Conclusion and Prospectus

At this stage of its development, the PRiSM scale is a work-in-progress, not an office-ready psychometric instrument. We would encourage clinicians to utilize the PRiSM as a part of a broader evaluation process and not to rely on it as a solo diagnostic instrument. When used as part of a more comprehensive evaluation, a PRiSM score may be able to assist in reaching a formal DSM-5 diagnosis by guiding clinicians to a general sphere of psychopathology. Nevertheless, determining a specific DSM-5 diagnosis requires a more thorough evaluation of the patient’s signs and symptoms, in accordance with established diagnostic guidelines.

It is our hope that the PRiSM scale will reduce the frequency of misdiagnosis and the problems consequent to misdiagnosis by encouraging clinicians to consider how psychopathology affecting 1 domain may be leading to disturbances in other domains. Assigning multiple psychiatric diagnoses to a single patient has become the norm, not the exception, and while comorbidity is certainly possible, we believe that the DSM system as currently constituted may lend itself to inappropriate polydiagnosis.² As this case demonstrates, major psychopathology can affect various domains of psychological functioning, but these disturbances do not always warrant additional diagnoses.

In time, our aim is for the PRiSM scale to become a validated diagnostic instrument for use in everyday clinical practice by psychiatrists, psychologists, clinical social workers, and other mental health professionals to aid in the complex task of psychiatric diagnosis. We encourage you to download the scale for free here, and we welcome feedback on your experience with PRiSM.

Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of Psychiatric Times (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on Amazon. Dr Ruffalo is an assistant professor of psychiatry at the University of Central Florida College of Medicine in Orlando and adjunct assistant professor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts.

References

1. Pies RW. The prism of psychiatric diagnosis: can this potential assessment tool shed light on the patient’s psychopathology? Psychiatric Times. 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: clinical research on psychiatric diagnosis. World Psychiatry. 2018;17(3):301-302.