Chapter 3 Clinical Assessment and Diagnosis

1. Chapter 3Clinical Assessment and Diagnosis

2. Assessing Psychological Disorders • Purposes of Clinical Assessment • To understand the individual • To predict behavior • To plan treatment • To evaluate treatment outcome • Analogous to a Funnel • Starts broad • Multidimensional in approach • Narrow to specific problem areas

3. Three Concepts Determine the Value of Assessment • Reliability • Consistency in measurement • Examples include test-retest, inter-rater reliability • Validity • What the test measures and how well it does so • Examples include content, concurrent, discriminant, construct, and face validity • Standardization and Norms • Foster consistent use of techniques • Provide population benchmarks for comparison • Examples include administration procedures, scoring, and evaluation of data

4. Three Concepts Determine the Value of Assessment Figure 3.1 Concepts that determine the value of clinical assessments.

5. Domains of Assessment:The Clinical Interview and Physical Exam • Clinical Interview • Most common clinical assessment method • Structured or semi-structured • Mental Status Exam • Appearance and behavior • Thought processes • Mood and affect • Intellectual functioning • Sensorium • Physical Exam

6. Mental Status Exam Figure 3.2 Components of the mental status exam.

7. Domains of Assessment:Behavioral Assessment and Observation • Behavioral Assessment • Focus on here and now • Tends to be direct and minimally inferential • Target behaviors are identified and observed • Focus on antecedents, behaviors, and consequences • Behavioral Observation and Behavioral Assessment • Can be either formal or informal • Self-monitoring vs. others observing • Problem of reactivity using direct observation

8. Domains of Assessment:Behavioral Assessment and Observation Figure 3.3 The ABCs of observation.

9. Domains of Assessment:Psychological Testing and Projective Tests • Psychological Testing • Must be reliable and valid • Projective Tests • Project aspects of personality onto ambiguous stimuli • Roots in psychoanalytic tradition • High degree of inference in scoring and interpretation • Examples include the Rorschach Inkblot Test, Thematic Apperception Test • Reliability and validity data tend to be mixed

10. Rorschach Test Figure 3.4 This inkblot resembles the ambiguous figures presented in the Rorschach test.

11. Thematic Apperception Test Figure 3.5 Example of a picture resembling those in the Thematic Apperception Test.

12. Domains of Assessment: PsychologicalTesting and Objective Tests • Objective Tests • Test stimuli are minimally ambiguous • Roots in empirical tradition • Require minimal inference in scoring and interpretation • Objective Personality Tests • Minnesota Multiphasic Personality Inventory (MMPI, MMPI-2, MMPI-A) • Over 549 true or false items • Extensive reliability, validity, and normative database • Objective Intelligence Tests • Nature of intellectual functioning and IQ • The deviation IQ • Verbal and performance domains

13. Domains of Assessment: PsychologicalTesting and Neuropsychology • Neuropsychological Tests • Assess broad range of skills and abilities • Goal is to understand brain-behavior relations • Used to evaluate a person’s assets and deficits • Examples include the Luria-Nebraska and Halstead-Reitan Batteries • Overlap with intelligence tests • Problems with Neuropsychological Tests • False Positives – Saying “you have a brain problem, but you do not” • False Negatives – Saying “you do not have a brain problem, but you do”

14. Domains of Assessment:Neuroimaging and Brain Structure • Neuroimaging: Pictures of the Brain • Allows examination of brain structure and function • Imaging Brain Structure • Computerized axial tomography (CAT or CT scan) • CAT utilizes X-rays of brain; pictures in slices • Magnetic resonance imaging (MRI) • MRI has better resolution than CAT scan • MRI operates via strong magnetic field around head

15. Domains of Assessment:Neuroimaging and Brain Function (cont.) • Imaging Brain Function • Positron emission tomography (PET) • Single photon emission computed tomography (SPECT) • Both involve injection of radioactive isotopes • Radioactive isotopes react with oxygen, blood, and glucose in the brain • Functional MRI (fMRI) – Brief changes in brain activity • Advantages and Limitations • Provide detailed information regarding brain function • Procedures are expensive, lack adequate norms • Procedures have limited clinical utility

16. Domains of Assessment:Psychophysiological Assessment • Psychophysiological Assessment • Methods used to assess brain structure, function, and activity of the nervous system • Psychophysiological Assessment Domains • Electroencephalogram (EEG) – Brain wave activity • Heart rate and respiration – Cardiorespiratory activity • Electrodermal response and levels – Sweat gland activity • Electromyography (EMG) – Muscle tension • Uses of Routine Psychophysiological Assessment • Disorders involving a strong emotional component • Examples include PTSD, sexual dysfunctions, sleep disorders, headache, and hypertension

17. Diagnosing Psychological Disorders:Foundations in Classification • Clinical Assessment vs. Psychiatric Diagnosis • Assessment – Idiographic approach • Diagnosis – Nomothetic approach • Both are important in treatment planning and intervention • Diagnostic Classification • Classification is central to all sciences • Develop categories based on shared attributes • Terminology of Classification Systems • Taxonomy – Classification in a scientific context • Nosology – Taxonomy in psychological / medical contexts • Nomenclature – Nosological labels (e.g., panic disorder)

18. Diagnosing and Classifying Psychological Disorders • The Nature and Forms of Classification Systems • Classical (or pure) categorical approach – Categories • Dimensional approach – Classification along dimensions • Prototypical approach – Both classical and dimensional • Two Widely Used Classification Systems • International Classification of Diseases and Health Related Problems (ICD-10); published by the World Health Organization • Diagnostic and Statistical Manual of Mental Disorders (DSM); published by the American Psychiatric Association; currently the DSM-IV and DSM-IV-TR

19. Purposes and Evolution of the DSM • Purposes of the DSM System • Aid communication • Evaluate prognosis and need for treatment • Treatment planning • DSM-I (1952) and DSM-II (1968) • Both relied on unproven theories and were unreliable • DSM-III (1980) and DSM-III-R • Were atheoretical, emphasizing clinical description • Multiaxial system with detailed criterion sets for disorders • Problems included low reliability, and reliance on committee consensus

20. The DSM-IV • Basic Characteristics • Five axes describing full clinical presentation • Clear inclusion and exclusion criteria for disorders • Disorders are categorized under broad headings • Empircally grounded prototypic approach to classification • The Five DSM-IV Axes • Axis I – Most major disorders • Axis II – Stable, enduring problems (e.g., personality disorders, mental retardation) • Axis III – Medical conditions related to abnormal behavior • Axis IV – Psychosocial problems • Axis V – Global clinician rating of adaptive functioning • Other Unique Features of the DSM-IV

21. Unresolved Issues in the DSM-IV • What Are the Optimal Thresholds for Diagnosis? • Examples include level or distress, impairment, number of required symptoms • Arbitrary Time Periods in the Definitions of Diagnoses • Should Other Axes Be Included? • Examples include premorbid history, treatment response, family functioning • Is the DSM-IV System Optimal for Treatment or Research? • The Problem of Comorbidity • Defined as two or more disorders for the same person • High comorbidity is the rule clinically • Comorbidity threatens the validity of separate diagnoses

22. Summary of Clinical Assessment and Diagnosis • Clinical Assessment and Diagnosis • To provide a complete picture of the client • To aid understanding and ameliorating human suffering • Require reliable, valid, and standardized information • Dangers of Diagnosis • Problem of reification • Problem of stigmatization • Assessment and Diagnosis • The core of abnormal psychology • Requires a multidimensional perspective