Chapter 3 Clinical Assessment and Diagnosis

1. Chapter 3Clinical Assessment and Diagnosis

2. Outline • Assessing Psychological Disorders • Key Concepts • Assessment Techniques • Diagnosing Psychological Disorders • Classification Issues • History of diagnostic assessment through DSM-5

3. Focus Questions How are psychological disorders assessed with a clinical interview? What are the features of behavioral assessment? What other tests and instruments are available for assessing psychopathology? What is the current diagnostic system, and how has it changed over time?

4. Assessing Psychological Disorders • Clinical assessment • Systematic evaluation and measurement • Psychological • Biological • Social • Diagnosis • Degree of fit between symptoms and diagnostic criteria

5. Assessing Psychological Disorders • Purpose • Understanding the individual • Predicting behavior • Treatment planning • Evaluating outcomes • Funnel analogy • Broad, multidimensional start • Narrows to specific problems

6. Key Concepts in Assessment • Reliability • Degree of consistency of a measurement • Example: “Agreement” between two different testing times or between two different evaluators

7. Key Concepts in Assessment • Validity • Does the test measure what it’s supposed to? • Several types: • Concurrent: Comparison between results of one assessment with another measure known to be valid • Predictive: How well the assessment predicts outcomes • Construct: Degree to which test or item measures the unobservable construct it claims to measure (e.g., “depression”)

8. Key Concepts in Assessment • Standardization • Consistent use of techniques • Provides normative population data • Examples of things that are kept constant • Administration procedures • Scoring • Evaluation of data

9. Key Concepts in Assessment

10. The Clinical Interview • Clinical interview • Assesses multiple domains • Presenting problem • Current and past behavior • Detailed history • Attitudes and emotions

11. The Clinical Interview • Clinical interview • Most common clinical assessment method • Structured or semi-structured • Example of semi-structured interview: Anxiety Disorders Interview Schedule for DSM-5 (ADIS-5) has modules pertaining to anxiety, mood and related disorders, designed to assess DSM-5 criteria

12. Mental Status Exam • Mental status exam • Appearance and behavior • Thought processes • Mood and affect • Intellectual functioning • Sensorium

13. Components of Mental Status Exam

14. Physical Examination • Physical examinations can be helpful in diagnosing mental health problems • Understand out rule out physical etiologies • Toxicities • Medication side effects • Allergic reactions • Metabolic conditions

15. Behavioral Assessment • Behavioral observation • Identification and observation of target behaviors • Target behavior: Behavior of interest (e.g., something that needs to be increased or decreased) • Direct observation conducted by assessor (e.g., therapist) or by individual or loved one • Goal: Determine the factors that are influencing target behaviors

16. Behavioral Assessment • The ABCs of observation • Antecedents • Behavior • Consequences

18. Behavioral Assessment • Behavioral observation • When individual observes self, it is called self-monitoring • May be informal or formal (e.g., using established rating scales) • The problem of reactivity • Simply observing a behavior may cause it to change due to the individual’s knowledge of being observed

19. Psychological Testing • Psychological testing • Specific tools for assessment of: • Cognition • Emotion • Behavior • Include specialized areas like personality and intelligence

20. Psychological Testing: Projective Tests • Projective tests • Rooted in psychoanalytic tradition • Used to assess unconscious processes • Project aspects of personality onto ambiguous test stimuli • Require high degree of inference in scoring and interpretation

21. Projective Tests (continued) • Examples • The Rorschach inkblot test; Thematic Apperception Test • Strengths • May be useful icebreakers • One way to gather qualitative data • Criticisms: • Hard to standardize • Reliability and validity data tend to be mixed

23. Objective Tests and Personality Tests • Objective tests • Roots in empirical tradition • Test stimuli are less ambiguous • Require minimal clinical inference in scoring and interpretation • Personality tests • Minnesota Multiphasic Personality Inventory (MMPI) • Extensive reliability, validity, and normative database

24. Psychological Testing • Minnesota Multiphasic Personality Inventory • 567 items (MMPI-2) • True/false responses • Example item: “I would like to be a singer.” • Interpretation • Individual scales • Profiles

25. Psychological Testing and Objective Tests • Intelligence tests • Nature of intellectual functioning and IQ • Originally developed as a measure of degree to which children’s performance diverged from others in their grade • The deviation IQ • Compare a person’s scores against those of other people who are the same age • Verbal and performance domains

26. Neuropsychological Testing • Purpose and goals • Assess broad range of skills and abilities • Goal is to understand brain-behavior relations • Examples • The Luria-Nebraska and Halstead-Reitan batteries • Designed to assess for brain damage • Test diverse skills ranging from grip strength to sound recognition, attention, concentration

27. Neuropsychological Testing • Problems with neuropsychological tests • False positives: Mistakenly shows a problem where there is none • False negatives: Fails to detect a problem that is present

28. Neuroimaging and Brain Structure • Neuroimaging: Pictures of the brain • Two objectives: • Understand brain structure • Understand brain function

29. Neuroimaging and Brain Structure • Imaging brain structure • Computerized axial tomography (CAT or CT scan) • Utilizes X-rays • Magnetic resonance imaging (MRI) • Utilizes strong magnetic fields • Better resolution than CT scan

30. Neuroimaging and Brain Function • Imaging brain function • Positron emission tomography (PET) • Single photon emission computed tomography (SPECT) • Both involve injection of radioactive isotopes • Isotopes react with oxygen, blood, and glucose in the brain • Functional MRI (fMRI) – brief changes in brain activity

31. Neuroimaging Advantages and Disadvantages • Chief advantage: • Yield detailed information • Lead to better understanding of brain structure and function • Disadvantages: • Still not well understood • Expense • Lack adequate norms • Limited clinical utility

32. Psychophysiological Assessment • Purpose • Assess brain structure, function, and activity of the nervous system • Psychophysiological assessment domains • Electroencephalogram (EEG) – brain wave activity. • ERP – Event related potentials = brain response to a specific experience (e.g., hearing a tone) • Heart rate and respiration – cardiorespiratory activity • Electrodermal response and levels – sweat gland activity

33. Psychophysiological Assessment • Uses of routine psychophysiological assessment • Disorders involving a strong physiological component • Examples • PTSD, sexual dysfunctions, sleep disorders • Headache and hypertension

34. Diagnosing Psychological Disorders: Foundations in Classification • Diagnostic classification • Classification is central to all sciences • Assignment to categories based on shared attributes or relations

35. Diagnosing Psychological Disorders: Foundations in Classification • Idiographic strategy • What is unique about an individual’s personality, cultural background, or circumstances • Nomothetic strategy • Often used when dentifying a specific psychological disorder, to make a diagnosis

36. Diagnosing Psychological Disorders: Foundations in Classification • Terminology of classification systems • Taxonomy – classification in a scientific context • Nosology – taxonomy in psychological/medical phenomena • Nomenclature – labels in a nosological system (e.g., “panic disorder” “depressive disorders”)

37. Issues with Classifying and Diagnosing Psychological Disorders • Categorical and dimensional approaches • Classical (or pure) categorical approach – strict categories (e.g., you either have social anxiety disorder or you don’t) • Dimensional approach – classification along dimensions (e.g., different people have varying amounts of anxiety in social situations) • Prototypical approach – combines classical and dimensional views

38. Issues with Classifying and Diagnosing Psychological Disorders • Widely used classification systems • Diagnostic and Statistical Manual of Mental Disorders (DSM) • Updated every 10-20 years • Current edition (released May 2013): DSM-5 • Previous edition called DSM-IV-TR • ICD-10 • International Classification of Diseases (ICD-10) • Published by the World Health Organization (WHO)

39. History of the DSM • Prior to 1980, diagnoses were made based on biological or psychoanalytic theory • Introduction of DSM-III in 1980 revolutionized classification • Classification newly relied on specific lists of symptoms, improving reliability and validity • Diagnoses classified along five “Axes” describing types of problems (e.g. disorder categories, health problems, life stressors)

40. History of the DSM • DSM-IV introduced in 1994 • Eliminated previous distinction between psychological vs. organic mental disorders • Reflected appreciation that all disorders are influenced by both psychological and biological factors • DSM-IV-TR (“text revision” of DSM-IV) incorporated new research and slightly altered criteria accordingly

41. The DSM-5 • Basic characteristics • Removed axial system • Clear inclusion and exclusion criteria for disorders • Disorders are categorized under broad headings • Empirically-grounded, prototypic approach to classification

42. Adding New Diagnoses • New disorder labels are created when groups of individuals are identified whose symptoms are not adequately explained by existing labels • Example: Premenstrual dysphoric disorder • New disorder in DSM-5 • Relatively rare and severe emotional disturbance present during the majority of premenstrual phases • Example of new disorder that did not make it into the DSM-5: Mixed anxiety-depression • Insufficient research to justify the creation

43. Unresolved Issues in DSM-5 • The problem of comorbidity • Defined as two or more disorders for the same person • High comorbidity is extremely common • Emphasizes reliability, maybe at the expense of validity (i.e., may artificially “split” diagnoses that are very similar)

44. Unresolved Issues in DSM-5 • Dimensional classification: • DSM was intended to move toward a more dimensional approach, but critics say it does not improve much from DSM-IV • Labeling issues and stigmatization • Some labels have negative connotations and may make patients less likely to seek treatment

45. Summary of Clinical Assessment and Diagnosis • Clinical assessment and diagnosis • Aims to fully understand the client • Aids in understanding and ameliorating human suffering • Based on reliable, valid, and standardized information