1. Clinical Assessment and Diagnosis
Chapter 3
Clinical Assessment and Diagnosis

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

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

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

5. 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

6. 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

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

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

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

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

11. 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

12. Behavioral Assessment and Observation
FIGURE 3.3  The ABCs of observation.

13. 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

14. 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

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

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

17. Rorschach Inkblot

18. Thematic Apperception Test

19. 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.

20. 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

21. 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

22. 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

23. Normal Distribution

24. 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

25. 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

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

27. 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

28. 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

29. Issues with Classifying and Diagnosing Psychological Disorders
Widely used classification systems
Diagnostic and Statistical Manual of Mental Disorders (DSM)
Updated every 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)

30. 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)

31. 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

32. 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

33. 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.

34. 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)

35. 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

36. 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

37. 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?

38. 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

39. 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

40. 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)

41. 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)

42. 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

43. 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.

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

45. Research by Correlation

46. Correlation and Causation
Correlation does not mean causation! or

47. 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

48. 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)

49. 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

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

51. 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

52. 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

53. 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.

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

55. 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

56. 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

57. 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

58. 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

59. 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

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