Clinical Assessment and Diagnosis

1. Clinical Assessment and Diagnosis Chapter 4

2. IntroducTION Human beings have been trying to figure out the origins of personality and behavior since ancient times. The Old Testament states that Gideon relied on observations of men as they trembled with fear around him to decide whether or not they were fit for duty. He also watched how men drank from a stream in order to decide if they were fit for duty. Psychological assessment is one of the oldest and most widely developed branches of contemporary psychology. Psychological assessment – a procedure in which clinicians, usually psychological tests, observations, and interviews, develop a summary of the client’s symptoms and problems. Clinical diagnosis – is the process through which a clinician arrives at a general “summary classification” of the patient’s symptoms by following the DSM-5 or the ICD-10 (International Classifications of Diseases), which was published by the World Health Organization.

3. INtroduction Assessment is an on-going process and needs to be evaluated at every step along the way with treatment. This should not happen just at the beginning of treatment, but all throughout treatment. It is also important to evaluate the treatment and the eventual outcome. In the initial visit, an attempt is made to identify the main dimensions of the client’s problems and predict the course of events. It is at this point that critical decisions need to be made. The treatment needs to be decided, whether or not there will be hospitalization, the role of the family, etc. Sometimes, these decisions have to be made in emergency situations with very little information. Establishing a baseline is very important to see if there is improvement. This will help to determine if therapy has been successful or not.

4. The basic elements in assessment What does the clinician need to know? The presenting problem - What is the major symptom(s) and behavior the client is experiencing? Is it situational (divorce, unemployment, etc.) or is it a long-term disorder? Is there any evidence of cognitive deterioration? What is the duration of the current complaint and how is the person dealing with the problem? What prior help has been sought? Are there indications of self-defeating behavior and personality deterioration or is the individual using available personal and environmental resources in a good effort to cope? How has this affected the person’s social roles? Do the symptoms fit any of the DSM-5’s diagnoses?

5. The relationship between assessment and diagnosis It is very important to have an adequate classification. Knowledge of the person’s type of disorder can help in planning and managing the appropriate treatment. It is also important to know which treatment facilities are available. A formal diagnosis is almost always essential because of insurance claims and covering the costs of the treatment.

6. Taking a Social or behavioral history It is very important to know a person’s behavior history, intellectual functioning, personality characteristics, and environmental pressures and resources. This generally includes much more than a diagnostic label. This overview needs to be objective. How does the person respond to other people’s behaviors? Are there excesses in behavior present, such as eating too much or drinking too much? Are there deficits in social skills? How appropriate are the person’s behaviors? Is the person behaving unresponsively? Are they uncooperative? Excesses, deficits, and appropriateness are key to knowing and understanding the person’s disorder and whether or not they should be brought into the clinic?

7. Personality Factors Assessment should include a description of any long-term personality characteristics. Has the person responded in deviant ways to particular kinds of situations? Are there personality traits that predispose the individual to behave in maladaptive ways? Does the person become enmeshed with others to the point of losing his or her identity, or is he or she so self-absorbed that intimate relationships are not possible? Is the person capable of genuine affection and of accepting appropriate responsibility for the welfare of others.

8. The social context What type of environmental demands are typically placed on this person? What supports does this person have? Is the person a care-taker? Are they experiencing psychological damage? Once all the information is gathered concerning the person’s behaviors, social environment, and stressors…the picture is attempted to be put together. Some clinicians refer to this as “dynamic formulation” because it describes the current situation, but also includes a hypothesis about what is driving the person to be maladaptive. The clinician should attempt to offer an explanation. The clinician should attempt to try and predict the person’s future behavior as well.

9. The social Content What is the likelihood of improvement or deterioration if the person’s problems are left untreated? What behaviors should be the initial focus of change? What treatment methods are likely to be most efficient in producing this change? How much change should be expected from a particular type of treatment? Clinicians attempt to gain the approval of the patient with treatment. Sometimes, clinicians have to make difficult decisions without the consent of the patient or the family members. What qualities does the individual bring to treatment that enhance the chances of improvement? Assessments are only as good as the individual and/or treatment center that are making them available.

10. Ensuring culturally sensitive Assessment procedures Practitioners are increasingly being asked to conduct evaluations with clients from diverse ethnic and language backgrounds. In a clinical setting or court setting, a psychologist may be referred a client who has limited English skills and low exposure to American mores, values, and laws. Psychologists have to be aware of culturally sensitive issues and how this might effect the outcome of the assessment. This increase in minority evaluations has been because of increased immigration and refugees who have had adjustment difficulties. The Hispanic population now makes up 16% of the American population. This population makes up the largest minority population in the U.S. African Americans make up 12.9% of the population, Asians are 4.5%, and Native Americans are 1%. They are often viewed by the majority population as inferior. This often creates problems.

11. Ensuring Culturally Sensitive Assessment procedures The tests that are used by psychologists to assess psychological impact need to take into consideration the population being examined. The test procedures taken also need to be taken into consideration if the person taking the test is a minority. When a Westernized test is administered, users need to take into account the dominant language, SES, ethnicity, and gender of their clients. There may be differences in tests that are provided in another language. The meanings of words can be misinterpreted given various languages. The most widely used personality assessment is the Minnesota Multiphasic Personality Inventory (MMPI-2). This test is available in many languages and in international applications. Resent research has provided support for the use of the MMPI-2 with minorities.

12. The influence of professional orientation How the clinician goes about the assessment process often depends upon their basic treatment orientations. Depending upon the beliefs systems of the psychologist or psychiatrist, they will probably see the outcome of the issue from this perspective. A bio-psychologist will focus on the mind and problems with the brain’s chemistry. A psychoanalyst will look at the person’s childhood. This will also influence what assessment they may use. Most clinicians use a variety of methods and believe in multiple perspectives of psychology.

13. Reliability, Validity, and Standardization An assessment needs to show reliability – a term describing the degree to which an assessment measure produces the same result each time it is used to evaluate the same thing. Validity – is the extent to which the measuring instrument actually measures what it is supposed to measure. This is a degree to which a measure accurately conveys to us something clinically about the person whose behavior fits the category, such as helping to predict the future behavior of the individual. Validity presupposes reliability. If the clinicians cannot agree to the class that the person belongs, the question of validity of a diagnostic classification under consideration becomes irrelevant. Good reliability does not guarantee validity, either. Standardization – is the process by which a psychological test is administered, scored, and interpreted in a “consistent” or standard manner. Standardized tests are considered to be more fair in that they are applied consistently and in the same manner to all persons taking them. Individual scores are often compared to a reference population, often referred to as a normative sample. It can also tell whether the individual’s score is low, average, or high along the distribution of scores.

14. Trust and Rapport between the clinician and the client In order for the client to talk about all their symptoms and issues, they need to feel comfortable with the clinician. This is imperative. When a clinician asks for a test, the client needs to know that it will help the clinician help the client. Clients need to be reassured that their beliefs, values, attitudes, and personal history won’t be used against them or be made to feel guilty. When an evaluation is ordered by a judge in a court, this can be shared with multiple sources. If the client decides to have the tests run, these must remain anonymous. Developing rapport with someone that has been forced by a court to be evaluated will be difficult. In a clinical setting people will be motivated to know the results. When the tests results are given back, this conversation can be very powerful. These individuals will tend to improve just by being aware of what the results are.

15. Assessment of the physical organism A psychologist or psychiatrist may ask the individual to get a physical with a medical doctor first to rule out any physical health problems. It is important for psychological clinicians to take a medical history and make sure that the doctor has completed a physical exam. It is important to know whether this is a physical condition, an addiction, or an organic brain disorder. Hormonal irregularities can produce behavioral symptoms that closely mimic those of mental disorders. Pain can come from emotional disorders.

16. The neurological examination Brain pathology can be involved in mental disorders (unusual memory deficits or motor impairments), a specialized neurological examination can be administered in addition to seeing a doctor. An EEG (electroencephalogram) assesses brain wave patterns in awake and sleeping states. An EEG is a graphical record of the brain’s electrical activity. Electrodes are placed on the scalp and amplify the minute brain wave impulses from various brain areas. These impulses drive oscillating pens whose deviations are traced on a piece of thin paper that keeps moving. Much is known about the sleeping and wake patterns under various conditions of sensory stimulation. Significant divergences from the normal pattern can thus reflect abnormalities of brain function such as might be caused by a brain tumor or another lesion. When an EEG reveals a dysrhythmia, or irregular pattern, in the brain’s electrical activity other specialized techniques may be used in an attempt to arrive at a more precise diagnosis of the problem.

17. Anatomic brain scans A CAT (computerized axial tomography) is a specialized technique and technology that shows parts of the brain. This has provided rapid access (without surgery) to accurate information about the localization and extent of anomalies in the brain’s structural characteristics. The procedure involves the use of computer analysis applied to X-ray beams across sections of a patient’s brain to produce images that a neurologist can than interpret. CAT scans have been increasingly replaced by magnetic resonance imaging (MRI). The MRI is superior in many ways because it can differentiate subtle soft tissue differences. This machine does not subject the patient to ionizing radiation. MRI can make possible (by non-invasive means), visualization of all but the minute abnormalities of brain structure. It is very good with confirming degenerative diseases.

18. Anatomic brain scans MRI machine can be problematic in that some patients are claustrophobic. It is necessary to put the patient in a narrow cylinder of the MRI machine to contain the magnetic field and block out external radio signals. There are many experts that believe the MRI machine does not lead to better outcomes for patients, though. The PET (positron emission tomography) scan allows for an appraisal of how an organ is functioning. It provides metabolic portraits by tracking natural compounds, such as glucose as they are used by the brain and organs. The PET scan helps specialists to pinpoint sites responsible for epileptic seizures, trauma from head injury or stroke, and brain tumors. It may reveal problems that are not immediately apparent anatomically. This may eventually aid in treatment of the disorder. Because there are radioactive atoms required for the procedure, it is very expensive and not used as often.

19. fMRI The functional MRI has been used in psychopathology for years. In the beginning, it could reveal brain structure and not brain activity. Now, fMRI can measure changes in local oxygenation (e.g. blood flow) of specific areas of brain tissue that depend on neuronal activity, such as sensations, images, and thoughts ( which can be mapped) revealing the specific areas of the brain that appear to be involved in their neurophysiological processes. The newer models can even analyze incoming data. One recent study showed that psychological factors or environmental events can affect brain processes as measured by fMRI. The fMRI could even pick up self-critical thinking. Some researchers think the fMRI can help greatly in mental health care. The court systems have already ruled that fMRI machines will not be used as lie detectors.

20. fMRI There are other problems with fMRI. If the patient moves, it could produce the look of something that is there that isn’t there. The error rate is quite high. The results of fMRI are also hard to interpret. fMRI is not effective given an assessment of cognitive processes. Right now, the fMRI is not considered to be a valid or useful diagnostic tool for mental disorders. Many researchers are optimistic that this procedures shows great promise for understanding brain functioning.

21. The neuropsychological examination Neuropsychological assessment – involves the use of various testing devices to measure a person’s cognitive, perceptual, and motor performance as clues to the extent and location of brain damage. Standardized tasks on a test can provide clues to the probable location of the brain damage, although PET scans, MRI’s, and other physical tests may be more effective with this. The Halstead-Reitan battery is composed of several tests and variables from which an “index of impairment” can be computed. It provides specific information about a subject’s functioning in several skill areas.

22. Psychological assessments Halstead Category Test – measures a subject’s ability to learn and remember material and can provide clues as to his or her judgment and impulsivity. A subject is presented with a stimulus on the screen that suggests a number between 1 and 4. The person is either given a loud buzzer for an incorrect response and a nice sounding bell for a correct response. The person is required to determine from the pattern of buzzers and bells what the underlying principle of the correct choice is. Tactual Performance Test – measures a subject’s motor speed, response to the unfamiliar, and ability to learn and use tactile and kinesthetic cues. The test surface is a board that has 10 blocks of varied shapes. The subject is blindfolded and asked to place the blocks into the correct grooves in the board. They are asked later to draw the board and shapes from memory.

23. Psychological assessments Rhythm test – measures attention and sustained concentration through an auditory perception task. It includes 30 pairs of rhythmic beats that are presented on a tape recorder. The subject is asked whether the pairs are the same or different. Speech Sounds Perception Test – determines whether an individual can identify spoken words. Nonsense words are presented on the tape recorder and the subject is asked to identify the presented word in a list of four printed words. His task measures the subject’s concentration, attention, and comprehension. Finger Oscillation Task – measures the speed at which an individual can depress a lever with the index finger. Several trials are given for each hand.

24. Psychosocial interview The psychosocial interview attempts to understand the individual in their social environment. The individual’s personality as well as their resources, stressors, and social supports are included. The clinician listens for the first of many interviews and attempts to put the pieces of the puzzle together. An Assessment Interview – involves face-to-face interaction in which the clinician obtains information about various aspects of the client’s situation, behavior, and personality. The clinician may make moment to moment decisions about their questioning line. They may also choose to conduct a very structured interview. The structured assessment interview yields far more reliable results than the flexible format. Most clinicians think that their own methods are superior to assessment interview testing.

25. Psychosocial interview Structured interviews follow a predetermined set of questions throughout the interview. Questions may include: Have you ever had periods in which you could not sleep lately? Have you experienced feeling very nervous about being in public? The interviewer cannot deviate when asking this line of questioning. The questions are set in a way that they can be quantified (given a score). Unstructured assessment interviews – are typically subjective and do not follow a predetermined set of questions. The questions are generally tailored for their client. The questioner decides which question is next based on the client’s answer to the previous question. Generally, these questions are viewed as more centered on the needs of the client and the client can feel better with an unstructured assessment interview.

26. Psychosocial interview Rating scales – the reliability of the assessment interview may be enhanced by use of a rating scale, which may ask the client to rate a statement using 3, 5, or 7 – with respect to self-esteem, anxiety, or other characteristics. These types interviews may show problems that otherwise may not have been talked about by the clinician. These problems may include: suicidal family members, suicidal ideation, drug dependence, marital difficulties, etc. The DSM pushes that clinicians diagnose based upon observable behavior or acts and use an “operational” definition of items. The DSM helps in that it has certain criteria that has to be met in order for the person to have the disorder.

27. The clinical observation of Behavior One of the most useful tools of clinicians is that they can directly observe the behavior of their clients. By looking at the client’s appearance and the behavior that they are presenting, a clinician can tell much about the person. It is important to note whether or not the client has depression, personal hygiene issues, anxiety, aggression, hallucinations, and/or delusions. An observation should take part in the person’s natural settings, but this rarely is the case. Observations tend to happen in the clinic or at the hospital. Some clinicians will use roleplaying, event reenactment, family interaction assignments, or think-aloud procedures. Clinicians tend to use self-monitoring procedures – self-observation and objective reporting of behavior, thoughts, and feelings as they occur in natural settings. People are excellent sources of information about themselves. If people are honest and want to help themselves, these forms can be important in deciding therapy.

28. Rating Scales Self-report assignments help to both organize information and encourage reliability and objectivity. Observer inferences generally cannot be added to these forms. These forms show whether or not a person has a trait and/or behavior, but also what its prominence is. One of the most used tools for recording observations is the Brief Psychiatric Rating Scale (BPRS) – which provides a structured and quantifiable format for rating clinical symptoms anxiety, emotional withdrawal, guilt feelings, hostility, suspiciousness, and unusual thought patterns. This allows the clinician to rate the behavior of this individual as compared to other psychiatric patients. This scale is really good at assigning patients to treatment groups. The Hamilton Rating Scale for Depression (HRSD) is used for assessing depression and whether or not a treatment has been responsive.

29. Psychological tests Psychological tests are more of an indirect means of assessing psychological characteristics. Scientifically developed psychological tests (not the ones in magazines) are standardized sets of procedures or tasks for obtaining samples of behavior. A subject’s responses to the standardized stimuli are compared with those of other people who have comparable demographic characteristics, usually through established test norms or test score distributions. The clinician can then decide how much the behavior of the person differs from those that may have the same or similar problems. These tests can measure coping patterns, motive patterns, personality characteristics, role behaviors, values, levels of depression, etc. Impressive advances in technology of test development have made it possible to create instruments of acceptability reliability and validity to measure almost any psychological characteristic on which people may vary. They are mostly computer-generated and computer-interpreted format.

30. Psychological tests Psychological tests are more precise and often more reliable than interviews or some observational techniques, they are not perfect. It is generally the competence of the clinician that helps to interpret the test. These tests are generally as useful to the clinician as what a blood test would be to a doctor. Clinicians tend to use intelligence tests and personality tests.

31. Intelligence testing The Wechsler Intelligence Scale for Children (WISC-IV) and a current edition of the Standord-Binet Intelligence Scale – are used quite often in clinical settings to measure the intellectual abilities of children. The most common adult test is the Weschler Adult Intelligence Scale-Revised (WAIS-IV). It includes both verbal and performance material and consists of 15 subtests. It generally takes about 2-3 hours to administer, score, and interpret. There is generally not enough time or money to use the whole test. This testing is imperative given brain damage or a cognitive deficiency. These forms of intelligence testing also tell us how the person will typically deal with a problem. Providing treatment does not mean that these tests always have to be administered.

32. Projected personality tests Personality tests are generally divided into projective and objective measures. Projective personality tests – are unstructured and rely on various stimuli such as inkblots of vague pictures rather than on explicit verbal questions and the answers are not statistically significant. People will reveal much about their personal preoccupations, conflicts, motives, coping techniques, etc. The thought is that individuals project their own problems, motives, and wishes about a situation. These personality tests can tell a lot about past learning and personality structure and how they organize information about their environment. The Rorschach Inkblot Test and the Thematic Apperception Test (TAT) and sentence completion tests are all projective personality tests. Objective Personality Tests – are structured and generally use questionnaires, self-report inventories, or rating scales in which questions or items are carefully phrased and alternative responses are specified as choices.

33. Objective personality tests There are a large number of statistically significant personality tests on the market. The NEO-PI (Neuroticism-Extroversion-Openness-Personality Inventory – provides information on the major dimensions in personality. The Millon Clinical Multiaxial Inventory (MCMI-III) helps to evaluate personality measures in those getting psychological treatment. The most widely used measure of personality is the MMPI (Minnesota Multiphasic Personality Inventory), which is called the MMPI-2 because it was revised in 1989. The MMPI was introduced for use by Starke Hathaway and J.C. McKinley and is used in clinical settings as well as forensic settings to assess psychopathology. It is often the test most often taught in clinical psychology programs across the United States. The original MMPI was a self-reporting questionnaire consisting of 550 questions ranging from psychical conditions to psychological states. Clients are asked to answer the questions either “true or false”. This test also has a malingering category where administrators can tell if someone is being honest or not.