1. Assessment and Diagnosis
Chapter 3

2. Chapter Outline Clinical Assessment Assessment Instruments
Diagnosis and Classification

3. 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

4. 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

5. 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.

6. Developmental and Cultural Considerations
Age
Developmental status
People involved in testing
Nature of test chosen
Testing environment
Cultural factors
“Cultural fair”
For example elementary school children in China overall perform higher on executive function tasks in comparison to American children.

7. 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.
It is important to note that only using one of these measures is sufficient enough to make a formal psychiatric diagnosis. Only through the use of all these different instruments, a mental health specialist is able to make a differential diagnosis.
Remember a patient’s “perception is their reality” when they report information related to the assessment.

8. Self-Report Measures
Is a type of survey/questionnaire in which patients read the question and select a response by themselves without interviewer interference.
Usually administered at the beginning of treatment, and depending on the treator, throughout the treatment process.
These measures will be useful in determining the patients’ symptoms’ severity. In addition, these measures will be helpful through the course of treatment, evaluating how well the intervention is working.

9. 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)
Unstructured: What brings you here today? – Avoiding “yes”, “no” answers. Inquiring more on the issues that the client is elaborating on, therefore getting to know them and what they are going through better.
Structured: Asking a set of questions, verbatim, in order to capture the presence, or absence or certain symptoms. i.e. SCID

10. 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

11. Validity scales of MMPI
The F scale: “faking good” or “faking bad.” asks questions designed to determine if test-takers are contradicting themselves in their responses.
The L scale: “lie scale,” this validity scale was developed to detect attempts by patients to present themselves in a favorable light.
The K scale: “defensiveness scale,” is a more effective and less obvious way of detecting attempts to present oneself in the best possible way.
TRIN Scale: The True Response Inconsistency Scale - to detect patients who respond inconsistently. This section consists of 23 paired questions that are opposite of each other.
VRIN Scale: The Variable Response Inconsistency Scale - to detect inconsistent responses.
The Fb Scale: This scale is composed of 40 items that less than 10% of normal respondents support. High scores on this scale sometimes indicate that the respondent stopped paying attention and began answering questions randomly.
Number of items unanswered: 30 or more

12. 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

13. Mini Mental State Exam
A brief 30-point questionnaire used to screen for cognitive impairment.
Commonly used to screen for dementia, to estimate the severity of cognitive impairment, and to follow the course of cognitive changes in an individual over time.
It is also used by mental health clinicians at intake, in order to test how oriented or disoriented a patient is, and how their cognition is affected by their symptoms.

14. Wisconsin Card Sorting Task: This instrument measures set shifting or the ability to display flexibility in thinking as the goal of the task changes – requires attention memory, working memory, and visual processing – frontal lobe test (schizophrenia, brain injuries, dementia, Parkinson’s etc.)
-     each card in the deck has 1, 2, 3, or 4 triangles, circles, squares, or crosses that are all red, green, yellow, or blue
  -     the subject is told to sort the cards into four different piles but is not told on what basis the sorting is to be accomplished;
     they are told after each card is placed in a pile whether or not it was correctly placed
-     at first the patient must learn to sort by color, but once she or he has learned this sorting principle, the correct principle changes without warning to form or number
 -     patients with frontal-lobe lesions adapt poorly to rule changes;
     they perseverate (continue to respond in a previously correct fashion long after it has become     incorrect)

15. Figure 3.6 The Bender Visual Motor Gestalt Test
Bender-Gestalt Test Definition
The Bender Visual Motor Gestalt test (or Bender-Gestalt test) is a psychological assessment used to evaluate visual-motor functioning, visual-perceptual skills, neurological impairment, and emotional disturbances in children and adults ages three and older.
Purpose
The Bender-Gestalt is used to evaluate visual-motor maturity and to screen children for developmental delays. The test is also used to assess brain damage and neurological deficits. Individuals who have suffered a traumatic brain injury may be given the Bender-Gestalt as part of a battery of neuropsychological measures, or tests.
The Bender-Gestalt is sometimes used in conjunction with other personality tests to determine the presence of emotional and psychiatric disturbances such as schizophrenia.
Precautions
Psychometric testing requires a clinically trained examiner. The Bender Visual Motor Gestalt Test should be administered and interpreted by a trained psychologist or psychiatrist. The Bender-Gestalt should always be employed as only one element of a complete battery of psychological or developmental tests, and should never be used alone as the sole basis for a diagnosis.
Description
The original Bender Visual Motor Gestalt test was developed in 1938 by psychiatrist Lauretta Bender. There are several different versions of the Bender-Gestalt available today (i.e., the Bender-Gestalt test; Modified Version of the Bender-Gestalt test for Preschool and Primary School Children; the Hutt Adaptation of the Bender-Gestalt test; the Bender Visual Motor Gestalt test for Children; the Bender-Gestalt test for Young Children; the Watkins Bender-Gestalt Scoring System; the Canter Background Interference Procedure for the Bender-Gestalt test). All use the same basic test materials, but vary in their scoring and interpretation methods.
The standard Bender Visual Motor Gestalt test consists of nine figures, each on its own 3 × 5 card. An examiner presents each figure to the test subject one at a time and asks the subject to copy it onto a single piece of blank paper. The only instruction given to the subject is that he or she should make the best reproduction of the figure possible. The test is not timed, although standard administration time is typically minutes. After testing is complete, the results are scored based on accuracy and organization. Interpretation depends on the form of the test in use. Common features considered in evaluating the drawings are rotation, distortion, symmetry, and perseveration. As an example, a patient with frontal lobe injury may reproduce the same pattern over and over (perserveration).
The Bender-Gestalt can also be administered in a group setting. In group testing, the figures are shown to test subjects with a slide projector, in a test booklet, or on larger versions of the individual test cards. Both the individual and group- administered Bender-Gestalt evaluation may take place in either an outpatient or hospital setting. Patients should check with their insurance plans to determine if these or other mental health services are covered.
Normal results
Children normally improve in this test as they age, but, because of the complexity of the scoring process, results for the Bender-Gestalt should only be interpreted by a clinically trained psychologist or psychiatrist.
From Nevid/Rathus/Greene, Abnormal Psychology in a Changing World, 5e, p Copyright © 2008 Pearson/Prentice Hall. Reprinted by permission.
Figure 3.6 The Bender Visual Motor Gestalt Test

16. Intelligence Tests Used to measure intelligence quotient (IQ)
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)
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)
The origin of the IQ test began in France, by Alfred Binet and Theodore Simon, who were commissioned by the French government to create a test to predict academic success. During WWI, the IQ test was used as a way to determine the ranks of soldiers, and who was to become a commander, and who was to fight at enemy lines.
In 1960s, the test developed by David Wechsler, the Wechsler Adult Intelligence Test (WAIS) became more popular, and to this day is the most commonly used IQ test.

17. Wechsler Adult Intelligence Scale (WAIS-IV)
Currently in its fourth edition
Adapted from the tests that the US Army used.
Produces four index scores
Verbal Comprehension Index (VCI)
Working Memory Index (WMI)
Perceptual Reasoning Index (PRI)
Processing Speed Index (PSI)

18. WAIS-IV CONTD. Verbal Comprehension Index Working Memory Index
Vocabulary (timed)
Comprehension (timed)
Why do plants need water?
Similarities
How are an apple and orange similar?
Reading rate (timed)
Working Memory Index
Digit Span
“46”, “583”, “6835”, “79248”
backwards
Arithmetic

19. WAIS-IV CONTD. Perceptual Reasoning Index Visual puzzles
Arrange a set of blocks so that they reproduce a design
Matrix reasoning
Choose which pattern logically follows after a set of patterns

20. WAIS-IV CONTD. Processing Speed Index Trails making (timed)
Making a trail
An easier version of this test, Trails A, only has numbers, and the test taker is supposed to make a trail starting from the smallest number, ending in the largest one. In this example you are seeing, Trails B, the test taker is supposed to make a trail, starting with the smallest number, than going to the first letter of the alphabet, then to the next number. For example, the trail is supposed to start with 1, then go to A, then go to 2, and then go to B.

21. 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.
The way the individual makes sense of these ambiguous images gives us an idea about how they make sense of the world and interpret their observations. The tester is able to get a picture of tendencies that the individual might have according to their interpretations.
It is important to note that an individual’s respond to one card cannot be indicative of a personality type or diagnosis. They only make sense if interpreted together, and alongside other measures.

22. Can you please describe to me what you see? Where do you see it?
Has been known to detect thought disorders (explain what this means) if the person is reluctant or unable to describe what they are seeing.
There are 10 official inkblots
Can you please describe to me what you see? Where do you see it?
Common responses: a wolf, an angel, a bat, an insect, a mask
The nine questions in scoring:
What is the location?
What is the developmental quality
What are the determinants?
What is the form quality?
Is there a pair?
What are the contents?
Is it a popular?
Are there any special scores?
Plate 1

23. The nine questions in scoring:
What is the location?
What is the developmental quality
What are the determinants?
What is the form quality?
Is there a pair?
What are the contents?
Is it a popular?
Are there any special scores?

24. The Rorschach Inkblot Test
Examine the Evidence: It’s important to remember 25% of the CS scores are not considered reliable, “the norms” published by Exner is extremely outdated (from the 1970s and 1980s), and adequate validity only exists for 20 of the 180 CS scores. Conclusion: There continues to be critics and advocates for the utility of the Rorschach; however no sound empirical data exists.
Fact: 75% of the Exner’s Comprehensive System (CS) scores warrant internal validity which is based on sums of individual scores.
Not necessarily a diagnostic tool, but used to gain more insight into individual’ inner world, and thought processes.
Some previous studies found that validity increases when clinicians use their clinical judgment to incorporate the Rorschach results with information gathered from other sources.

25. 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

26. 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)

27. The Historical Roots of Diagnosis…
American Psychiatric Association (APA, 1952)
Diagnostic and Statistical Manual of Mental Disorders (DSM, current edition DSM-V, 2013)
Multiaxial system of diagnosis and classification
International Classification of Diseases (ICD-10, 1992) published by WHO

28. 91-100 Excellent functioning in all aspects of life
Global Assessment of Functioning (GAF) a way for clinician’s to use a rating system to assess one’s functioning.
Excellent functioning in all aspects of life
81-90 Good functioning, only everyday problems like traffic
71-80 Starting to shows slight impairment in Axis IV areas
61-70 Starting to show mild symptoms and social supports still intact
51-60 Starting to show moderate symptoms and an increase in the level of distress and impairment in Axis IV areas
If a patient presents with suicidality (either an attempt or ideation), then their GAF is automatically lower than 50.

29. Global Assessment of Functioning (GAF) continued…
41-50 Symptoms are severe and obvious and there is severe impact on one’s Axis IV areas
31-40 Major difficulties in reality orientation, judgment, and communication, as well as extreme difficulties in Axis IV areas
21-30 One is actively having delusions and hallucinations and an inability to function in all aspects of life
11-20 One is experiencing thoughts of DTO/DTS (e.g., danger to others and danger to self) behaviors and poor hygiene
1-10 Actively suicidal and homicidal with a current plan and continued poor hygiene

30. 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?

31. 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)

32. 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

33. 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

34. 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

35. 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
Same issues are true for DSM-V. Due to lack of research, a true dimensional approach was not able to be adapted.
Changes in trauma, psychosis, asperger’s became a part of autism
A NEW SLIDE ON THE CHANGES OF DSM

36. 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

37. DSM-5: PROPOSED REVISIONS:
Removal of the multiaxial 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
Addiction related disorders for substance abuse or dependence

38. DSM-5: PROPOSED REVISIONS:
Proposal of new disorders
behavioral addictions – gambling; binge eating disorder; temper dysregulation with dysphoria
‘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”.

39. 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

40. DSM-5: PROPOSED REVISIONS:
Proposal of a dimensional system
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.

41. DSM 5
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.