Chapter 3 Clinical Assessment and Diagnosis

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Chapter 3Clinical Assessment and Diagnosis
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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

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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

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Three Concepts Determine the Value of Assessment

• Figure 3.1 Concepts that determine the value of
  clinical assessments.

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Domains of AssessmentThe Clinical Interview and
Physical Exam

• Clinical Interview
• 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

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Mental Status Exam
Figure 3.2 Components of the mental status exam.
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Domains of AssessmentBehavioral Assessment and
Observation

• Behavioral Assessment
• 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

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Domains of AssessmentBehavioral Assessment and
Observation
Figure 3.3 The ABCs of observation.
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Domains of AssessmentPsychological Testing and
Projective Tests

• Psychological Testing
• 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

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Rorschach Test
Figure 3.4 This inkblot resembles the ambiguous
figures presented in the Rorschach test.
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Thematic Apperception Test
Figure 3.5 Example of a picture resembling those
in the Thematic Apperception Test.
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Domains of Assessment PsychologicalTesting and
Objective Tests

• 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

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Domains of Assessment PsychologicalTesting and
Neuropsychology

• Neuropsychological Tests
• Assess broad range of skills and abilities
• Goal is to understand brain-behavior relations
• Used to evaluate a persons 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

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Domains of AssessmentNeuroimaging 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

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Domains of AssessmentNeuroimaging 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

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Domains of AssessmentPsychophysiological
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

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Diagnosing Psychological DisordersFoundations
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)

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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

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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

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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

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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

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Summary of Clinical Assessment and Diagnosis

• 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