Chapter 3 Clinical Assessment and Diagnosis. Assessing Psychological Disorders Purposes of clinical assessment –T–To understand the individual –T–To predict.

Chapter 3

Clinical Assessment and Diagnosis

Assessing Psychological Disorders

• Purposes of clinical assessment– To understand the individual– To predict behavior– To plan treatment– To evaluate treatment outcome

• Diagnosis – the process of determining whether the individual meets the criteria for a psychological disorder

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

Key Concepts in Assessment

• Standardization– Ensures consistency in the use of

a technique– Provides population benchmarks

for comparison– Examples include structured

administration, scoring, and evaluation procedures

The Clinical Interview and Physical Exam

• Clinical interview– Most common clinical assessment method– Structured or semi-structured

The Clinical Interview and Physical Exam

• Mental status exam– Appearance and behavior– Thought processes– Mood and affect– Intellectual functioning– Sensorium

• Semistructured clinical interviews (DICA, ADIS - IV)• Physical exam

Behavioral Assessment and Observation

• Behavioral assessment– 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

ABC Chart

Behavioral Assessment and Observation

• Behavioral observation and behavioral assessment– Can be either formal or informal– Self-monitoring vs. being observed by others– Problem of reactivity using direct observation

• Behavior Rating Scales– Expanded Brief Psychiatric Rating Scale

12

Rorschach Inkblot Test

10 inkblots - designed by Hermann Rorschach.

1884-1922

13

Thematic Apperception Test (TAT)

Developed by Henry Murray (1893-1988),

Psychological Testing and Objective Tests

• 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)– Extensive reliability, validity, and normative

database

Psychological Testing and Objective Tests

• Intelligence tests– Nature of intellectual functioning and IQ– The deviation IQ– Verbal and performance domains

• Stanford-Binet V• WPPSI – III• WISC – IV• WAIS - III

Neuropsychological Testing

• Purpose and goals– Assess broad range of skills and abilities– Goal is to understand brain-behavior relations

• Examples– NEPSY– The Delis-Kaplan Executive Function System

• Problems– False positives – False negatives

Peeking Inside the Brain

Electroencephalograph(EEG)

Computed tomography(CT) Magnetic resonance Imaging (MRI)

Positron emissiontomography(PET)

The EEG has been admitted in court as another method of lie detection, alternately referred to as “brain fingerprinting.”

fMRI

Psychophysiological Assessment

• Uses of routine psychophysiological assessment– Disorders involving a strong emotional component

• Examples– PTSD, sexual dysfunctions, sleep disorders– Headache and hypertension

Diagnosing Psychological Disorders: Foundations in Classification

• Diagnostic classification– Classification is central to all sciences– Assignment to categories based on shared

attributes or relations

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

Diagnosing Psychological Disorders: Foundations in Classification

• Terminology of classification systems– Taxonomy – classification in a scientific context– Nosology – taxonomy in psychological/medical

phenomena– Nomenclature – nosological labels (e.g., panic

disorder)

Issues with Classifying and Diagnosing Psychological Disorders

• Categorical and dimensional approaches– Classical (or pure) categorical approach – strict

categories– Dimensional approach – classification along

dimensions– Prototypical approach – combines classical and

dimensional views

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) LO 14.3 What are the different types of psychological disorders?

Axis VGlobal Function

Axis VGlobal Function

Level of functioning in daily living

Axis IIPersonality & Retardation

Axis IIPersonality & Retardation

Maladaptive personality traits and brain development issues

Axis IIIGeneral Medical

Axis IIIGeneral Medical

Medical conditions

that affect a mental

disorder

Social & environmental problems impacting treatment

Axis IVPsychosocial& Environment

Axis IVPsychosocial& Environment

Report disorders/conditions requiring clinical attention

Axis IClinical Disorders

Axis IClinical Disorders

DSM-IV-TR Axes

Axis I Disorders

Unresolved Issues in the DSM-IV-TR

• 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

• Labeling issues and stigmatization• DSM-5 – Due out May 2013

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.

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

Considerations in Research Design

• Internal validity vs. external validity– What is internal validity? – What is external validity?

• Ways to increase internal validity by minimizing confounds– Use of control groups– Use of random assignment procedures

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

Statistical versus Clinical Significance

• Balancing statistical versus clinical significance– Evaluate effect size– Evaluate social validity

• Generalizability and the patient uniformity myth

• The “average” client

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

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

Research by Correlation

• Limitations– Does not imply causation– Problem of directionality

• Epidemiological research – an example of the correlational method– Incidence, prevalence, and course of disorders– Examples – AIDS, trauma following disaster

Research by Experiment

• Epidemiology– the study of the incidence, distribution, and

consequences of a particular problem or set of problems in one or more populations

Research by Experiment

• Nature of experimental research– Manipulation of independent variables– Attempt to establish causal relations

• Group experimental designs– Control groups– Placebo vs. double-blind controls

Research by Experiment

• Comparative treatment designs– Type of group design– Compare different forms of treatment in similar

persons– Addresses treatment process and outcome

Single-Case Experimental Designs

• Nature of single subject design– Rigorous study of single cases– Varied experimental conditions and time– Repeated measurement– Evaluation of variability, level, and trend– Premium on internal validity

• Types of single-subject design– Withdrawal designs– Multiple baseline designs

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

Studying Behavior Over Time

• Time-based research strategies– Cross-sectional designs and the cohort effect – Longitudinal designs and the

cross-generational effect– Sequential designs – combine both strategies

• Assets and liabilities of time-based research strategies

Figure 1.6

The Nature of Programmatic Research and Research Ethics

• Research ethics: institutional review boards (IRB) & the APA ethics code – Informed consent –Competence – ability to

provide consent– Voluntarism – lack of coercion – Full information – necessary information to make

an informed decision– Comprehension – understanding about benefits

and risks of participation