ASSESSMENT & CLASSIFICATION

1. ASSESSMENT & CLASSIFICATION PSY 208F PSYCHOPATHOLOGY Dr. Chiwoza Bandawe

2. INTERVENTION PROCESS • 1. Assessment: Information gathering of symptoms and their possible causes • 2. Diagnosis: “A label we attach to set of symptoms that tend to occur with one another” (Nolen-Hoeksema, 2004, p.96) • 3. Treatment Plan: Addressing the problem

3. ASSESSMENT

4. Assessment Tools • Clinical Interview: Unstructured. Structured (e.g. Maudsley; Diagnostic Interview Schedule) • Symptom Questionnaire: ADHD checklist. Beck’s Depression Inventory. Dependent on client’s honesty & cooperation. • Collateral Interview: Info from parents, significant others. Custody battles.

5. Psychological Tests • Intelligence Tests (IQ) • Neuropsychological Tests (Memory, Attention, Motor skills) • Projective Tests (Drawings, Rorschach, Thematic Apperception Test) • Personality Inventories (MMPI; Myers-Briggs)

6. Check lists • Behavioural Observation • Self Monitoring

7. Information gathered in interview • 1. Symptoms and their history • 2. Physiological & neurophysiological factors • 3. Sociocultural factors

8. Current symptoms • What are the symptoms? Describe what you are experiencing in detail • How severe are the symptoms? • When did you begin experiencing them? • How much are they interfering with normal functioning? (Work?, family roles?)

9. Does anything make the symptoms worse? Context. Time. Alone? • What is its duration? • What changes have symptoms brought to your normal life? • How have the symptoms affected client’s life areas?

10. Coping style • How is the client coping with the symptoms? • (Assess whether the coping is adaptive or maladaptive) • What have you done to handle them so far? (Assess motivation to get rid of symptoms) • How does client cope generally with stressful situations?

11. Self-concept & concept of symptoms • Does client have a strong sense of self? • Does s/he have a strong or weak sense of ability to handle & overcome symptoms? • What does the client believe is wrong? • What does the client feel is the best treatment for the problem?

12. Recent Events • Have their been any positive or negative recent events in the client’s life. (Look for indicators of changes to life: moving, loss of loved one, new job etc) • Are there ongoing stressors in client’s life?

13. History of psychological disorders • Has client ever experienced symptoms similar to current symptoms? • Does family have history of any psychological disorder or symptom?

14. Medical & cognitive factors • Are the symptoms due to any medical explanation? • Is there any use of drugs that could cause symptoms? • Is the client taking drugs that could interact with the medication? • Are there any neurological shortcomings that could be contributing to the problem?

15. Socio-cultural factors • What social resources are available to the client?: Family & friends who can support. • Are client’s work relationships supportive? • In what culture was client raised? • If immigrant: How long here? Why came here? Connections with home? What social position at home? Here? Acculturation level?

16. Mental State Examination • The MSE is your evaluation of the client’s current mental functioning (Morrison, 1995). • Behavioural aspects: Observations from speech and behaviour during MSE. • Cognitive aspects: Thoughts your client has.

17. Aspects of the Mental State Examination • Behavioural • Appearance. (Client presentation) • Rapport & connection. Alertness • ThoughtFlow (Association, flight, rate) • Speech (Rapid?,Dragging?, Flat, Tone?) • Motor activity (Relaxed, twitching?) • Mood & Affect (facial expression, labile)

18. Aspects of the Mental State Examination • Cognitive • Structured routine questions • Orientation: Time, person & place • Attention & concentration (Exercises) • Memory: Immediate, short & long term • Content of thought delusions. • Perception: Hallucinations • Insight and Judgment

19. DIAGNOSIS

20. Classification • Diagnosis: Label attached to combination of symptoms (syndrome) • Complexity of combination of syndromes leads to classification systems • 4th century BC Hippocrates: Mania, Melancholia, paranoia & Epilepsy • ICD-10 • DSM

21. ICD-10 • International Classification of Diseases (World Health Organisation) • Endorsed May 1990. In use since 1994 • International Std diagnostic classification for physical & mental health • Mental & behavioural disorders (F00-F99) • Also used for epidemiological info of member states

22. The DSM • Diagnostic & Statistical Manual of Mental Disorders (DSM) Classification system of the American Psychiatric Association • 1952: DSM-I. Vague descriptions based on psychoanalytic theory e.g. anxiety neurosis. Abstract • 1968: DSM-II: Similar to DSM-I, included new disorders. Very unreliable diagnoses

23. DSM III-- IV-TR • 1980: DSM-III: Vague descriptions of disorders replaced with specific and atheoretical concrete criteria for each disorder. Diagnosis based. • 1987: DSM III-R • 1994: DSM IV • 2000: DSM IV-TR

24. Features of DSM III – IV-TR • Specify how long symptoms must be present. • Diagnosis requires interference with occupational and social functioning • Differential diagnoses provided • Course of disorder spelt out. Relapse • Prevalence • Incidence

25. Example: 313.23 Selective Mutism • Diagnostic feature: Failure to speak • Interference with social functioning • Duration (1 month) • Differential diagnosis: Stuttering, Social phobia, Communication Disorder • Associated features: Shyness • Prevalence: >1% • Course: Onset 5yrs, lasts few months

26. DSM Multi-axial system • Dimensions of assessment • AXIS I Clinical disorders • AXIS II Personality disorders Mental Retardation • AXIS III General medical conditions • AXIS IV Psychosocial & environment • AXIS V Global assessment of functioning (G.A.F)

27. AXIS I • Clinical disorders • All mental health conditions except personality disorders & mental retardation. • V71.09 There is no Axis I diagnosis • All Axis I disorders are listed • Other conditions that may be a focus of clinical attention

28. Axis I Clinical Disorders • Disorders first diagnosed in infancy, childhood or adolescence • Dementia, Delirium, Amnestic, Cognitive • Substance-Related Disorders • Schizophrenia & other psychotic disorder • Mood Disorders • Anxiety Disorders

29. Axis I Clinical Disorders… cont • Somatoform Disorders • Dissociative Disorders • Sexual & Gender Identity Disorders • Eating Disorders • Sleep Disorders • Impulse Control Disorders • Adjustment Disorders

30. AXIS II • Personality Disorders and Mental Retardation • Can also indicate maladaptive personality features that do not meet the full diagnostic criteria.

31. Axis II: Personality Disorders • Cluster A • (Odd or eccentric) • Paranoid Personality Disorder • Schizoid Personality Disorder • Schizotypal Personality Disorder

32. Axis II: Personality Disorders • Cluster B • (Dramatic, emotional, erratic) • Antisocial Personality Disorder • Borderline Personality Disorder • Histrionic Personality Disorder • Narcissistic Personality Disorder

33. Axis II: Personality Disorder • Cluster C • (Anxious or fearful) • Avoidant Personality Disorder • Dependent Personality Disorder • Obsessive- Compulsive Personality Disorder

34. Axis II: Mental Retardation • Subaverage intellectual functioning (IQ <70) before 18yrs & adaptive functioning deficits • Mild MR IQ 50/55 – 70 • Moderate MR IQ 35/40 – 50/55 • Severe MR IQ 20/25 – 35/40 • Profound MR IQ Below 20/25

35. AXIS III • General Medical Conditions • E.g. Hypothyroidism causing depression. List Axis I & Axis III • Infectious & parasitic disease • Diseases of the nervous, respiratory, digestive & genitourinary systems etc. • Pregnancy & deliver complications etc

36. AXIS IV • Psychosocial & Environmental Problems • Negative Life event • Educational problems • Occupational problems • Economic problems • Access to health care service • Legal system/crime

37. Axis IV Continued….. • Disasters (e.g. earthquakes, Tsunami) • War, hostilities • Note the ones that are relevant to presenting problem. • Focus on psychosocial stressors of the past year • Primary focus problems noted on Axis I

38. AXIS V • Global Assessment of Functioning (GAF) • Clinician’s judgement on individual’s level of functioning. For treatment planning. • Use of GAF Scale.

39. Examples of Diagnosis schedule • Axis I 296.21 Major Depressive Disorder • Axis I 303.90 Alcohol Dependence • Axis II Dependent Personality Disorder • Axis III None • Axis IV Recent divorce, unemployment • Axis V 58

40. Example 2 of Diagnosis • Axis I 300.4 Dysthymic Disorder • Axis I 315.0 Reading Disorder • Axis II V71.09 No diagnosis • Axis III 382.9 Otitis media, recurrent • Axis IV Victim of child neglect • Axis V 53 (current)

41. Example 3 of Diagnosis • Axis I v61.1 Partner relational problem • Axis II V71.09 No diagnosis • Axis III None • Axis IV Unemployment • Axis V GAF = 83 (highest level past year)

42. Criticisms of DSM • Reflects Western, masculine ideals for a healthy person and pathologises other cultures • Labelling can lead to pathologising and stigma & power abuse. Rosenhan 1973 • Szasz, get rid of mental disorders • However, std diag system aids research

43. The Formulation • This is the explanation, your making sense of what is going on. • Clear and succinct description of the way in which physical, social, emotional, family and school and community events have resulted in the presenting diagnosis.

44. The Formulation • What factors predispose the client to the diagnosis? • What are the factors that precipitated the symptoms? • What factors maintain the symptoms?

45. TREATMENTPLAN

46. Management • Based on the diagnosis you draw up an intervention plan. This plan will be informed by theory: psychodynamic, behavioural, cognitive, systems etc. • If there is need for further information you state the tests to be done, collateral • Set the number of sessions