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. 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?

6. 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.

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

8. 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.

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)

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. 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

12. 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)

13. 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.

14. 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

15. 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)

16. 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

17. 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?

18. 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)

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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.