Clinical Assessment and Diagnosis Chapter 3 Clinical Assessment and Diagnosis

Outline Assessing Psychological Disorders Diagnosing Psychological Disorders Research in Psychopathology Types of research methods Genetic and Cultural Research Research Ethics

Assessing Psychological Disorders Purposes of clinical assessment To understand the individual To predict behavior To plan treatment To evaluate treatment outcome

Assessing Psychological Disorders Analogous to a funnel Starts broad Multidimensional in approach Considers psychological, biological,, and social factors Narrow to specific problem areas

Key Concepts in Assessment Reliability Consistency in measurement Examples include test-retest and inter-rater reliability Validity What an assessment approach measures and how well it does so Examples include concurrent, discriminant, and predictive validity

Key Concepts in Assessment Standardization Ensures consistency in the use of a technique Provides population benchmarks for comparison Examples include appropriate norms, structured administration, scoring, and evaluation procedures

Key Concepts in Assessment FIGURE 3.1  Concepts that determine the value of clinical assessments.

The Clinical Interview Most common clinical assessment method Structured or semi-structured

The Clinical Interview Mental status exam Appearance and behavior Thought processes Mood and affect Intellectual functioning Sensorium Semistructured clinical interviews {Physical exam}

The Clinical Interview FIGURE 3.2  Components of the mental status exam.

Behavioral Assessment and Observation Focus on the present – here and now Direct observation of behavior-environment relations Purpose is to identify problematic behaviors and situations ABCs – Identify antecedents, behaviors, and consequences

Behavioral Assessment and Observation FIGURE 3.3  The ABCs of observation.

Behavioral Assessment and Observation Behavioral observation and behavioral assessment Can be either formal or informal Self-monitoring vs. being observed by others Problem of memory (and self-honesty) using self-monitoring Problem of reactivity using direct observation

Psychological Testing and Projective Tests Must be reliable and valid 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

Psychological Testing and Projective Tests Examples The Rorschach inkblot test Thematic Apperception Test Reliability and validity data tends to be very poor

Psychological Testing and Projective Tests - RORSCHACH “What might this be?” FIGURE 3.4  This inkblot resembles the ambiguous figures presented in the Rorschach test.

Rorschach Inkblot

Thematic Apperception Test

Psychological Testing and Projective Tests - RORSCHACH Criticisms Poor agreement (i.e., poor inter-rater reliability) Does not consistently detect many disorders Poor evidence that it works to assess what it is often used for Tends to produce false positives for schizophrenia 1 in 6 who are identified with schizophrenia do not actually have the disorder Misleading results for minorities Not scientific! FIGURE 3.4  This inkblot resembles the ambiguous figures presented in the Rorschach test.

Psychological Testing and 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-2) Extensive reliability, validity, and normative database

Psychological Testing and Objective Tests – MMPI-2 MMPI-2 - designed to detect abnormal personality. 10 original scales Hypochondriasis Depression Hysteria Psychopathic Deviate Masculinity-Femininity Paranoia Psychasthenia Schizophrenia Hypomania Social Introversion

Psychological Testing and Objective Tests Intelligence tests The deviation IQ Assumption of normal distribution (M=100; SD=15) Performance compared with peers of the same age Most commonly used – Wechsler Scales For children/adolescents to adults Provide four index scores Verbal comprehension Perceptual reasoning Working memory Processing speed

Normal Distribution

Neuropsychological Testing Purpose and goals Assess broad range of skills and abilities Goal is to understand brain-behavior relations; possible brain dysfunction Neuroimaging CAT Scan (f)MRI PET

Psychophysiological Assessment Purpose and goals Assess brain structure, function, and activity of the nervous system Domains Electroencephalogram (EEG) – brain wave activity Heart rate and respiration – cardiorespiratory activity Electrodermal response and levels – sweat gland activity

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

Diagnosing Psychological Disorders: Foundations in Classification Idiographic strategy What is unique about an individual’s personality, cultural background, or circumstances Nomothetic strategy Identifying a specific psychological disorder to make a diagnosis

Issues with Classifying and Diagnosing Psychological Disorders Categorical and dimensional approaches Classical (or pure) categorical approach – strict categories (e.g., you either have a social anxiety disorder or you don’t) Dimensional approach – classification along dimensions (e.g., people have varying amounts of anxiety in social situations) Prototypical approach – combines classical and dimensional views Current DSM-5 classification system

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)

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)

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

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

The DSM-5 Previously, psychopathology was categorized along five axes. Axis I = Clinical syndromes (most psychological disorders). Axis II = personality disorders and mental retardation (more pervasive), Axis III = relevant medical conditions. Axis IV = Relevant life stressors. Axis V = Global assessment of functioning (0-100 rating). DSM-5 no longer uses the axis system. This information is still taken into account by clinicians, but it’s not discussed in terms of axes.

Unresolved Issues in DSM-5 The problem of comorbidity Defined as two or more disorders for the same person High comorbidity is the rule, clinically Threatens the validity of separate diagnoses (i.e., may artificially “split” diagnoses that are very similar)

Unresolved Issues in DSM-5 Dimensional classification DSM-5 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 May not be sensitive enough to diversity in culture and ethnicity; and women Some argue that context is not given enough consideration

Summary of Clinical Assessment and Diagnosis Aims to fully understand the client Aids in understanding and ameliorating human suffering Identifies problems, informs treatment goals and interventions, and desired outcomes Based on reliable, valid, and standardized information

Conducting Research in Psychopathology Questions driving a science of psychopathology What problems cause distress or impair functioning? Why do people behave in unusual ways? How can we help people behave in more adaptive ways?

Basic Components of Research Starts with a hypothesis or “educated guess” Not all hypotheses are testable Hypotheses in science are formulated so that they are testable

Basic Components of Research Research design A method to test hypotheses Independent variable The variable that causes or influences behavior Dependent variable The behavior influenced by the independent variable

Considerations in Research Design Internal validity vs. external validity Internal validity – extent to which results of a study are due to the independent variable External validity – extent to which results of a study are generalizable to the larger population being studied Ways to increase internal validity by minimizing confounds Use of control groups Use of random assignment procedures Use of analog models (i.e., laboratory conditions)

Statistical versus Clinical Significance Statistical methods – branch of mathematics Helps to protect against biases in evaluating data Statistical vs. clinical significance Statistical significance – are results due to chance? Clinical significance – are results clinically meaningful? Statistical significance does not imply clinical meaningfulness Consider: Effect size = how much the treated people in the experimental group are “better” than the people in the control group Effect size helps determine clinical significance Generalizability (recall external validity)

Studying Individual Cases Case study method Extensive observation and detailed description of a client Foundation of early historic developments in psychopathology Limitations Lacks scientific rigor and suitable controls Internal validity is typically weak Often entails numerous confounds

Research by Correlation The nature of correlation Statistical relation between two or more variables No independent variable is manipulated Range from –1.0 to 0 to +1.0 Negative vs. positive correlation Limitations Does not imply causation Problem of directionality Discussion Tip: Have students generate situations in which a correlational design is necessary and cannot be avoided due to natural or ethical constraints.

Research by Correlation FIGURE 3.6  These three graphs represent hypothetical correlations between age and sleep problems.

Research by Correlation

Correlation and Causation Correlation does not mean causation! or

Research by Experiment Nature of experimental research Manipulation of independent variables Attempt to establish causal relationships Group experimental designs Control groups Placebo: Some participants are given an inactive treatment (e.g., sugar pill), but participants don’t know which treatment they are getting Double-blind: Participants and assessors are unaware of what kind of treatment participants are getting Compare different forms of treatment in similar persons Address treatment process and outcome

Genetic Research Strategies Behavioral genetics Interaction between genes, experience, and behavior Phenotype vs. genotype Genotype: Genetic makeup Phenotype: Observable characteristics (e.g., eye color, degree of shyness)

Genetic Research Strategies Strategies used in genetic research Family studies – behaviors/emotional traits in family members Adoptee studies – separate environmental from genetic factors Twin studies – psychopathology in fraternal vs. identical twins Genetic linkage and association studies – sites of defective genes

Studying Behavior Over Time Rationale and overview How does the problem or behavior change over time? Important in prevention and treatment research

Studying Behavior Over Time Longitudinal design – research design in which one participant or group of participants is studied over a long period of time Advantage: looking at real age-related changes as those changes occur in the same individuals Disadvantages: lengthy amount of time, money, and effort involved in following participants over the years as well as the loss of participants when they move away, lose interest, or die

Studying Behavior Over Time Cross-sectional design – research design in which several different age groups of participants are studied at one particular point in time Advantages: done quickly, relatively inexpensive, and easier to accomplish than the longitudinal design Disadvantages: no longer comparing an individual to the same individual as he/she ages – instead individuals at different ages are being compared to one another Cross-sequential design – combination of longitudinal and cross-sectional designs

Studying Behavior Over Time FIGURE 3.8  Two research designs, longitudinal & cross-sectional: Same people followed across time; people of different ages viewed at the same time.

Studying Behavior Over Time Longitudinal Design Tested at 1 year (Time 1) Again at 4 years (Time 2) Again at 7 years (Time 3)

Studying Behavior Over Time Longitudinal Design Compare Compare Tested at 1 year (Time 1) Again at 4 years (Time 2) Again at 7 years (Time 3) Same Participants Different Times

Cross-Sectional Design Studying Behavior Over Time Cross-Sectional Design Same Time Compare Compare 1-year-olds 4-year-olds 7-year-olds Same Time Different Participants

Studying Behavior Across Cultures Value of cross-cultural research Overcoming ethnocentric research Clarify how psychopathology manifests in different ethnic groups Obstacles – fewer available measures and often more time intensive and expensive

Research Ethics Institutional review boards (IRBs) & the APA ethics code Oversee the rights of human subjects participating in research e.g., informed consent (full information and comprehension), competence (able to provide consent), voluntarism (not coerced) Make sure research and data are handled responsibly

Summary of Research Methods Abnormal psychology is founded in the scientific method Understand the nature of abnormality and human suffering Understand the causes of psychological disorders Understand the course of psychological disorders Understand how to prevent and treat psychological disorders

Summary of Research Methods Replication is the cornerstone of science and programmatic research Research must occur in the context of ethical considerations and values