1. Chapter 3 Clinical Assessment and Diagnosis

2. 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

3. Three Concepts Determine the Value of Assessment
Reliability
Consistency in measurement
Examples include test-retest, inter-rater reliability
Validity
What the test measures and how well it does so
Examples include content, concurrent, discriminant, construct, and face validity
Standardization and Norms
Foster consistent use of techniques
Provide population benchmarks for comparison
Examples include administration procedures, scoring, and evaluation of data

4. Three Concepts Determine the Value of Assessment
Figure 3.1 Concepts that determine the value of clinical assessments.

5. Domains of Assessment: The Clinical Interview and Physical Exam
Most common clinical assessment method
Structured or semi-structured
Mental Status Exam
Appearance and behavior
Thought processes
Mood and affect
Intellectual functioning
Sensorium
Physical Exam

6. Mental Status Exam
Figure 3.2 Components of the mental status exam.

7. Domains of Assessment: Behavioral Assessment and Observation
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

8. Domains of Assessment: Behavioral Assessment and Observation
Figure 3.3 The ABCs of observation.

9. Domains of Assessment: Psychological Testing and Projective Tests
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

10. Rorschach Test
Figure 3.4 This inkblot resembles the ambiguous figures presented in the Rorschach test.

11. Thematic Apperception Test
Figure 3.5 Example of a picture resembling those in the Thematic Apperception Test.

12. Domains of Assessment: Psychological Testing and 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)
Over 549 true or false items
Extensive reliability, validity, and normative database
Objective Intelligence Tests
Nature of intellectual functioning and IQ
The deviation IQ
Verbal and performance domains

13. Domains of Assessment: Psychological Testing and Neuropsychology
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
Problems with Neuropsychological Tests
False Positives – Saying “you have a brain problem, but you do not”
False Negatives – Saying “you do not have a brain problem, but you do”

14. 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

15. 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
Radioactive isotopes react with oxygen, blood, and glucose in the brain
Functional MRI (fMRI) – Brief changes in brain activity
Advantages and Limitations
Provide detailed information regarding brain function
Procedures are expensive, lack adequate norms
Procedures have limited clinical utility

16. Domains of Assessment: Psychophysiological Assessment
Methods used to assess brain structure, function, and activity of the nervous system
Psychophysiological Assessment Domains
Electroencephalogram (EEG) – Brain wave activity
Heart rate and respiration – Cardiorespiratory activity
Electrodermal response and levels – Sweat gland activity
Electromyography (EMG) – Muscle tension
Uses of Routine Psychophysiological Assessment
Disorders involving a strong emotional component
Examples include PTSD, sexual dysfunctions, sleep disorders, headache, and hypertension

17. 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)

18. 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

19. 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

20. The DSM-IV 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

21. 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

22. Summary of 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