Psychology and Mental Health 2014 Assessment and Diagnosis

Psychology and Mental Health

Assessment & Diagnosis

2013-2014

Overview• Learning outcomes:

• The assessment process• The diagnosis• Individual formulation• Issues

The Assessment Process• Physical examination • History taking• Mental state examination/standardised interview

• Clinical psychology report• Social work report

• last two items not always available but increasingly used as DSM-IV becoming more widespread

Physical Examination• This includes:• checking for medical conditions• PET scans- Positron Emission Tomography

• CAT scans – Computerised Axial Tomography

• EEG - Electroencephalogram• age, apparent health and other factors to be

considered here also

History Taking• Current illness• medical/psychiatric history• family history• personal history• pre-morbid personality• current living circumstances

*the overall picture here will help with other aspects of assessment to give a general picture of the person being assessed

Mental State Examination

• General information• speech• thought• perception• mood• cognitive/intellectual function - memory, attention/concentration/orientation

• Insight into own circumstances etc.• clinician’s reaction to the client/patient to be

recorded as this can be important - reflexive analysis

Standardised Interviews

• Structured interviews• assessment tools e.g. prepared structured questionnaires: General Health Questionnaire, Structured clinical Interview

• Tests/instruments for specific disorders e.g. Beck Depression Inventory or Scale for Assessment of Negative Symptoms

Clinical Psychology Report

• Includes testing in various areas - intelligence, personality including specific tests such as Maudsley OCD Inventory, neurological functioning tests.

• Observation of behaviour in different settings

• Cognitive assessment

Social Work Report• Usually written by a psychiatric social worker

known as Approved Social Worker or ASW:

• Home condition/situation• Family - client’s effect on them & vice-versa;

family support• Other significant relationship(s)• Material/income etc.

Diagnosis

• Used in addition to the assessment outlined or to save time in lengthy processes

• based on the two major systems:• DSM IV-TR or ICD-10

Two Major Systems• International System of Classification of : International Classification of Diseases - also known as ICD - 10 published by World Health Organisation (WHO)

• Diagnostic and Statistical Manual of Mental Disorders (DSM), current version 4 with revised text hence DSM IV-TR, published by American Psychiatric Association

ICD-10• Lists 458 mental disorders• some are discrete disorders others are sub-types of more major psychiatric disorders

• also known as the F scale due to the prefacing of the letter followed by a number denoting a disorder e.g. F-70-F79 for Learning Difficulties

• There are 10 major categories of disorders:

• Organic including symptomatic mental disorders

• mental and behavioural disorders due to psychoactive substance use disorders

• schizophrenia, schizotypal and delusional disorders

• mood disorders• neurotic, stress-related and somatoform disorders

• behavioural syndromes associated with physiological disturbances and physical factors

• abnormalities of adult personality and behaviour

• mental retardation• disorders of psychological development

• behavioural and emotional disorders with onset usually occuring in childhood and adolescence

DSM IV- TR• Different to ICD in that it has some inference of aetiology

• Highly descriptive set of operational criteria

• No psychodynamic terms or inference• More phenomenological • Readily open to accepting new disorders

• Multi-axial

• Axis I - listing of clinical syndromes with their diagnostic criteria, disorders such as schizophrenia and anxiety disorders

• Axis II - contains those conditions which are considered permanent states mainly personality disorders and mental retardation

• Axis-III - list of general medical conditions that may co-occur with and influence mental disorders

• Axis-IV: checklist of environmental and psychosocial stressors which are considered in order of severity

• Axis-V: a rating scale called the Global Assessment of Functioning Scale (GAF scale) giving the patient’s current ability to function and cope with life. Ranges from superior ability to imminent danger to self and others

Individual Formulation• This is a method of integrating comprehensive data regarding a particular individual to reasonably and accurately predict the outcome for the case i.e. a prognosis

• nomothetic pigeon-holing of individual to fixed classificatory category in the patient/client is expected to conform to the general ‘laws’ of that classification

• in contrast the formulation has a more ideographic approach in providing a fuller prescriptive description of the unique case of the individual

• A format for the formulation may be structured with the following headings:

• Demographic data• descriptive formulation• differential diagnosis• aetiology• investigations• treatment• prognosis

• A long history of controversy:

• Diagnostic systems based on the medical model

• Descriptive not explanatory• Problems in earlier versions led to replication of Emile Kraeplin’s problems in classifying disorders - see Rosenhan’s (1973) studies

• Ever-growing list of disorders • Culture-bound to Western ways of life

• unlike general medical conditions there are inherent problems in the presentation of psychiatric illnesses, and psychological distress and the judgements made in their assessment and diagnosis

• the diagnostic process is one of pushing ideographic behaviour into nomothetic categories, that is, assigning individual behaviour patterns to a fixed classifications of behaviour common to all in that category.

• Causes of a disorder can be same in each case but the physical and psychological differences between individuals can produce unique reactions to those same causes

• Many psychiatric disorders are syndromes i.e. they have a range of possible symptoms, a selection of which may be presented by an individual but not all of which occurs in each case

• Boundaries between disorders can also overlap e.g. as in personality disorders. This is known as co-morbidity

• It is then imperative to use differential diagnosis to examine which side of the boundary a particular disorder lies - these can be confounded by medication, self-medication or the long-term effects of institutionalisation or other impoverished environment etc.

• All of these factors can make diagnosis difficult so:

• Training• Clinical experience• Ongoing updating re: continuing professional development (CPD) in skills, knowledge based on research etc

• Knowledge of clients/patients

• Same issues are present in the diagnosis debate as in other forms of assessments:

• Validity• Reliability• Culture• Gender• Class• Home circumstances• Ethics• etc.

Next…• In the 4th seminar we will be unpicking some of the issues and controversies identified, along with focus on culture and culture-bound syndromes. There will be further attention paid to the formulation of an individual presenting with their case and the psychological approach to assessing their distress.