Chapter 3 Clinical Assessment and Diagnosis

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

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

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

Mental Status Exam

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

Domains of Assessment: Behavioral Assessment and Observation

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

Rorschach Test

Thematic Apperception Test

 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 Domains of Assessment: Psychological Testing and Objective Tests

 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 Domains of Assessment: Psychological Testing and Neuropsychology

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

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

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)

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

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

 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 The DSM-IV

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

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