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

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

The Clinical Interview 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

Behavioral Assessment and Observation Behavioral assessment – 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

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 Psychological testing – Must be reliable and valid Projective tests – roots in psychoanalytic tradition – 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?”

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!

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

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 – MMPI-2

Psychological Testing and Objective Tests Intelligence tests – Nature of intellectual functioning and IQ – 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 – EEG 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 – Dimensional approach – classification along dimensions – Prototypical approach – combines classical and dimensional views Current DSM-IV-TR classification system

Issues with Classifying and Diagnosing Psychological Disorders Widely used classification systems – ICD-10 International Classification of Diseases (ICD-10) Published by the World Health Organization (WHO) – DSM-II and DSM-IIIR Used before 1980 – DSM-IV & DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders (DSM-IV and DSM-IV-TR)

DSM-IV-TR Diagnostic and Statistical Manual, Version IV, Text Revision (DSM-IV-TR) is a manual of psychological disorders and their symptoms. DSM-V due out Summer 2013

DSM-IV-TR There are five axes in the DSM-IV-TR, which include clinical disorders, personality disorders, general medical conditions, psychosocial and environmental problems, and a global assessment of functioning. Over one-fifth of all adults over age 18 suffer from a mental disorder in any given year. Major depression is one of the most common psychological disorders worldwide.

The DSM-IV-TR Basic characteristics – Five axes – full clinical presentation – Clear inclusion and exclusion criteria for disorders – Disorders are categorized under broad headings – Empirically-grounded, prototypic approach to classification

DSM-IV-TR

Five Axes Example Axis Major Depressive Disorder, Single Episode, Severe Without Psychotic Features Alcohol Abuse Axis Dependent Personality Disorder Axis Infarction, myocardial, acute Axis 4Threat of job loss Axis 5GAF = 45 (on admission) GAF = 65 (at discharge)

Types of psychological disorders

Unresolved Issues in the DSM-IV-TR 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 Labeling issues and stigmatization May not be sensitive enough to diversity in culture and ethnicity; and women Some argue that context is not given enough consideration Some object to the presence or absence of a disorder based on a cutoff

Summary of Clinical Assessment and Diagnosis 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 – What is internal validity? – What is external validity? Relation between internal and external validity

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 and untreated person in the study changes – Generalizability

Clinical Research Methods

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

Research by Correlation

or Correlation and Causation Correlation does not mean causation!

Research by Experiment Nature of experimental research – Manipulation of independent variables – Attempt to establish cause-and-effect relationships Group experimental designs – Control groups – Placebo vs. double-blind controls

Genetic Research Strategies Behavioral genetics – Interaction between genes, experience, and behavior – Phenotype vs. genotype

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 - research design in which participants are first studied by means of a cross-sectional design but also followed and assessed for a period of no more than six years.

Studying Behavior Over Time

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

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

1-year-olds4-year-olds7-year-olds Compare Same Time Different Participants Same Time Studying Behavior Over Time Cross-Sectional Design

The Nature of Programmatic Research and Research Ethics Research ethics: institutional review boards & the APA ethics code – Role of institutional review boards – Informed consent – historical evolution post WWII – Competence – ability to provide consent – Voluntarism – lack of coercion – Full information – necessary information to make an informed decision – Comprehension – understanding about benefits and risks of participation

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

Assessing Psychological Disorders Diagnosing Psychological Disorders – How is psychiatric diagnosis carried out? Conducting Research in Psychopathology – What are the basic components of research in psychopathology?

Assessing Psychological Disorders Types of Research Methods – What methods are used to conduct research on the causes of behavior? Genetics and Behavior Across Time and Cultures – How do researchers study the interaction between environment and genetics?