Assessment and Diagnosis Chapter 3

Chapter Outline Clinical Assessment Assessment Instruments Diagnosis and Classification

Clinical Assessment Process of gathering information about a person and his/her environment to make decisions about the nature, status, and treatment of psychological problems -Begins with a set of referral questions -Questions determine goals of assessment -Selection of appropriate psychological tests and measurements

Differential diagnosis is a process in which a clinician weighs how likely it is that a person has one diagnosis instead of another. Goals of Assessment Deciding what assessment procedures and instruments to administer When conducting an assessment, it is important to take into consideration the age, developmental level, and cultural implications of the test- taker. Screening (identify psychological problems or predict the risk for future problems) Diagnosis (identification of illness) Description Treatment plan (individual’s plan of care to meet mental health needs) Outcome evaluation

Cases of Misdiagnosis Deaf or mental retardation? Epilepsy or schizophrenia? Narcolepsy or schizophrenia? Medication reation or depression? Brain tumor or anorexia nervosa? Bipolar disorder or schizophrenia? The major reason one is misdiagnosed is because of insufficient assessment and inaccurate diagnosis which leads to inappropriate treatment. What is the difference between misdiagnosis and comorbidity? How might misdiagnosis affect not only the patients in the future, but the clinician as well? What precautions should one take to make sure this does not happen?

The Usual Properties of Assessment Instruments Are… Standardization Normative comparisons Self-referent comparisons Reliability -Test-retest reliability -Interrater agreement Validity -Construct, criterion, concurrent, predictive These are important in reviewing the psychometric properties of instruments to ensure a clinician’s confidence in the testing results.

Developmental and Cultural Considerations Age Developmental status People involved in testing Nature of test chosen Testing environment Cultural factors “Cultural fair”

Assessment Instruments – Informed Consent prior to any type of assessment Self-report measures (ask patients to evaluate their own symptoms) Clinician-rated measures (clinician rates symptoms) Subjective responses vs. objective responses Types of assessments -Clinical interviews -Psychological tests -Behavioral Assessments -Psychophysiological Assessments Assessment instruments measure the patient’s perception of the problem and what the clinician observes. Fact or fiction? Yes, the subjective responses are based on the patient’s perception based off of self-report measures that ask patients to evaluate their own symptoms and clinician-rated measures that require the clinician to rate the behaviors, cognitions, and affect. Remember a patient’s “perception is their reality” when they report information related to the assessment.

Clinical Interviews Conversation between an interviewer and a patient, the purpose of which is to gather information and make judgments related to assessment goals Purpose of interviews (screening, diagnosis, treatment planning, or outcome evaluation) Types of interviews -Unstructured (open-ended questions that allow flexibility and close ended questions) -Structured (asking a standard set of questions, typically for diagnostic purposes)

Psychological Tests Personality tests (psychological test that measures personality characteristics) Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1943) – over 500 items Nine clinical subscales: hypochondriasis, depression, hysteria, psychopathic deviance, masculinity-femininity, paranoia, psychasthenia, schizophrenia, & hypomania The Million Clinical Multiaxial Inventory (MCMI) Tests for specific symptoms

Neuropsychological Testing Used to detect impairment in cognitive functioning Measures: memory, attention and attention, motor skills, perception, abstraction, and learning abilities Halstead-Reitan Neuropsychological Battery (Reitan & Davidson, 1974) Wisconsin Card Sorting Test (WCST) Bender Visual Motor Gestalt Test

Intelligence Tests Stanford-Binet Intelligence Scale The average IQ is 100 (mean) and the standard deviation is 15. So if someone has an IQ of 130 that means their IQ is two standard deviations above the mean. Used to measure intelligence quotient (IQ) Intelligence Quotient (a source of cognitive functioning that compares a person’s performance to his or her age-matched peers) Attention Perception Memory Verbal and Perceptual Reasoning Verbal comprehension Stanford-Binet Intelligence Scale Wechsler Adult Intelligence Scale (WAIS-IV; Wechsler, 2008) Wechsler Intelligence Scale for Children (WISC-IV, 7-16 years) Wechsler Preschool and Primary Scale of Intelligence (WPPS-III, 2½-7 years)

Projective Tests Tests derived from psychoanalytic theory in which people are asked to respond to ambiguous stimuli Rorschach Inkblot Test (Rorschach, 1921) Thematic Apperception Test (TAT; 1935) -Consists of 31 black-and-white pictorial cards and the patient is asked to make up a story about the image -The patient is exposed to ambiguous stimuli and then projects a unique interpretation onto them that reflects his/her underlying unconscious processes and conflicts.

Behavioral Assessment The goal of behavioral assessments is to understand behavior within the context of learning, “learned behavior.” Behavioral Assessment Functional analysis – where a clinician identifies causal links between behavior and environment Self-monitoring – a patient records and observes his or her own behavior (advantage: not retrospective) Behavioral observation – measurement of behavior by a trained observer. (event recording or interval recording in a natural or analogue fashion) Behavioral avoidance tests – strategies used to assess avoidance behavior

Psychophysiological Assessment Assessment strategies that measure brain and nervous system activity Electroencephalography (EEG, a noninvasive procedure that measures and records brainwaves) sleep, comatose, and relaxation states Electrodermal activity (EDA, measures changes in electrical conductance produced by increased or decreased sweat gland activity) formerly called Galvanic Skin Response Biofeedback (trains patients to recognize and modify physiological signals)

The Historical Roots of Diagnosis… American Psychiatric Association (APA, 1952) Diagnostic and Statistical Manual of Mental Disorders (DSM, current edition DSM- IV-TR) Multiaxial system of diagnosis and classification International Classification of Diseases (ICD-10, 1992) published by WHO

Comorbidity The presence of more than one disorder 50% of people who meet diagnostic criteria for one mental disorder meet criteria for at least one other disorder With each new edition of the DSM new diagnostic categories arise The DSM has tripled in size since the 1st edition Why do you think so many individuals meet diagnostic criteria for more than one mental disorder? How do you feel about the increasing number of disorders with each new DSM?

Developmental and Cultural Considerations Diagnostic criteria may need to vary across the life span Differences in prevalence (men vs. women) -Women and depression vs. men and substance abuse disorders Differences in symptoms and disorders (based on ethnicity and race) Culture-bound syndrome (sets of symptoms that occur together uniquely in certain ethnic or racial groups)

When is a diagnostic system harmful? Stereotypes & labels Premature or inaccurate assumptions by clinicians Self-fulfilling prophecies Prevention of a thorough evaluation or comprehensive treatment plan Stigma DSM (limited knowledge of an era and too many disorders) Over-medicalization

Common issues related to DSM Distinction between what is normal and not normal or mental disorder and problem of living Mind-body dualism (mental vs. physical disorders) Limited understanding of mental disorders Mostly descriptive rather than explanatory Categorical and prototypical approach vs. dimensional approach Gender biases and too much emphasis on culturally accepted norms

Dimensional Systems vs. Categorical Systems Dimensional (suggests that people with disorder are not qualitatively distinct from people without disorders) -Psychiatric illness conceptualized as dimensions of functioning versus discrete clinical conditioning Features that support the value of dimensional approaches -High frequency of comorbidity and within category variability -“Common language” of classification Cons of dimensional system

Issues with the DSM-IV-TR: Criticism Lacks an overarching conceptual base (theory) No consistent rationale for different diagnoses Emphasis on reliability over validity No vision for a better society Lacks treatment specificity Comorbidity still an issue Complex, long, and not user-friendly

Issues with the DSM-IV-TR Support Based on empirical data – empirical review carefully done and further tests are on their way Complex due to the inherent nature of mental disorders Gender biases have been a concern, but the differences in ratio may just reflect differences in men and women traits

DSM-5: PROPOSED REVISIONS: Removal of multi-axial system Changes in the names of certain disorders Autism-related disorders changed to Autism- spectrum disorders, Asperger’s deleted; Mental retardation may be changed to intellectual disability Substance abuse and dependence categories are now combined and symptom list strenghtened

DSM-5: PROPOSED REVISIONS: Proposal of new ones Binge eating disorder Disruptive mood dysregulation disorder’ to “diagnose children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year”. Hoarding disorder Skin-picking disorder

DSM-5: PROPOSED REVISIONS: Risk syndromes category To identify risk of cognitive impairment earlier in the progression of psychotic and neurocognitive/neurodegenerative disorders (like dementia) New suicide and self-harm assessment criteria seperately for children and adults Changes to the diagnosis of certain disorders Bereavement exclusion is not included in the diagnosis of depressive episode anymore Posttraumatic stress disorder – more attention to behavioral symptoms and more diagnostic clusters, appropriate for children and adults

DSM-5: PROPOSED REVISIONS: Proposal of a dimensional system (Are suggested for future research) Severity ratings (mild, moderate, severe, very severe) for disorders Quantitative cross-cutting measures of the presence of symptoms that cut across the boundaries of any specific diagnoses or disorders– stepwise evaluation Level 1 assessment: cross-cutting symptoms on a 4-rating scale (none, slight, mild, moderate, severe) Level 2 assessment: for those symptoms that are scored higher than a certain cutoff – in a clinically significant range http://www.medscape.com/viewarticle/716807

DSM-5: PROPOSED REVISIONS: Proposal of a dimensional system Personality disorders Keep the categorical system and suggest dimensional system for further study in section 3: Levels of personality functioning: Self (empathy, self-direction) and interpersonal (empathy, intimacy) on a scale of 0 (no impairment), 1 (mild), …, 4 (extreme impairment). Degree of match to personality disorder types Degree of descriptiveness of personality domains Trait domains: Negative emotionality, detachment, antagonism, disinhibition, compulsivity, schizotypy http://www.medscape.com/viewarticle/716807

DSM 5 DSM 5 is to be published in May 2013 The DSM-V Task Force: 27 members, including a chair and vice chair, collectively represent research scientists from psychiatry and other disciplines. Scientists experienced in research, clinical care, biology, genetics, statistics, epidemiology, public health and consumer advocacy.