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

4. Three Concepts Determine the Value of Assessment • Reliability • Examples include test-retest, inter-rater reliability • Validity • Examples include content, concurrent, discriminant, construct, and face validity • Standardization and Norms • Examples include administration procedures, scoring, and evaluation of data

5. Domains of Assessment:The Clinical Interview and Physical Exam • Physical Exam – Referral to physician • Rule out medical conditions • 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

6. 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

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

11. 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) • Millon Clinical Multiaxial Inventory • Objective Intelligence Tests • WAIS/WISC – Performance and Verbal Scales • Stanford-Binet – Mental Age/Age = IQ • Raven Progressive Matrices Test – Non-verbal

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

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 • React with oxygen, blood, and glucose in the brain • Functional MRI (fMRI) – Brief changes in brain activity • Used mainly in research

16. 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)

17. 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

18. 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

19. 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

20. 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

21. 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