Chapter 3: Clinical Assessment, Diagnosis, and Treatment

• PSYC 168 is an introductory course in clinical assesment, diagnosis, and treatment

Multicultural Perspective

• Race, ethnicity, gender, sexual orientation, ability, socioeconomic status, and religion affect people of diverse backgrounds
• Understand the role of oppression, discrimination, marginalization, injustice, and poverty in mental health
• Apply the lens of intersectionality, to see how multiple identities intersect

Culturally Responsive Therapies

• Therapeutic approaches address unique issues faced by clients from different cultural groups, showing greater sensitivity to cultural issues
• Cultural morals and models are included in treatment, emphasizing the role of cultural humility
• Affirmative therapy is also utilized

Comparing Models of Therapy

• Biological model views the cause of dysfunction as biological malfunction, while the psychodynamic model sees it as underlying conflicts
• Cognitive-behavioral model attributes dysfunction to maladaptive thinking and learning
• Humanistic model blames self-deceit and the existential model blames avoidance of responsibility
• Family-social model focuses on family or social stress, and the multicultural model highlights external pressures or cultural conflicts
• Biological therapy is rooted in biological repair
• Psychodynamic therapy aims for broad psychological change, while cognitive-behavioral seeks functional thoughts and behaviors
• Humanistic therapy facilitates self-actualization, and existential therapy pushes authentic life
• Family social therapy looks for effective family or social system
• Multicultural therapy aims for cultural awareness and comfort

The Developmental Psychopathology Perspective

• Many theorists and clinicians now consider multiple causes, combining techniques from several models
• This leads to the emergence of biopsychosocial theories and identifying as "integrated" or "eclectic"
• Developmental Psychopathology uses a developmental framework to understand how variables and principles from various models account for adaptive and maladaptive functioning
• The two core principles of the developmental psychopathology are equifinality and multifinality
• Equifinality suggests different developmental routes can lead to same psychological disorder
• Multifinality shows persons with similar histories can have different clinical outcomes
• Protective factors are positive variables that offset negative influences

Diagnosis: Classification Systems

• Using all available information, clinicians attempt to paint a cluster of symptoms, or a syndrome, to make a diagnosis
• It's a determination that a person's psychological problems constitute a particular disorder, and are based on an existing classification system

DSM: Diagnostic and Statistical Manual of Mental Disorders

• DSM is the classification system written by the American Psychiatric Association
• The most recent edition of the DSM was published in 2022, named DSM-5-TR
• DSM-5-TR (2022) is an amended version primarily focused on updating background text Information, included the addition of prolonged grief disorder, and offers deeper dicussions on the impact of discrimination.
• It also requires clinicians to provide both categorical and dimensional information on severity of the disorder

The History of the DSM

• DSM-I was published in 1952 with 132 pages and 128 diagnoses and the revenue for the American Psychiatric Association is unknown
• DSM-II was published in 1968 had 119 pages and 193 diagnoses and the revenue for the American Psychiatric Association was $1.27 million
• DSM-III was published in 1980 had 494 pages and 228 diagnoses and the revenue for the American Psychiatric Association was $9.33 million
• DSM-III-R was published in 1987 had 567 pages and 253 diagnoses and the revenue for the American Psychiatric Association was $16.65 million
• DSM-IV was published in 1994 had 886 pages and 383 diagnoses and the revenue for the American Psychiatric Association was $120 million
• DSM-IV-TR was published in 2000 had 943 pages and 383 diagnoses and the revenue for the American Psychiatric Association is unknown
• DSM-5 was published in 2013 had 947 pages and 541 diagnoses and the revenue for the American Psychiatric Association is unknown

ICD and ICD codes

• The International Classification of Diseases (ICD) is designed by the WHO and used for ALL medical disease classifications
• The 6th chapter, consisting of "Mental, behavioral, or neurodevelopmental disorders" are also listed in the DSM, and the two systems compete against each other.
• The ICD is more concise, whereas the DSM are more detailed, with the ICD being used for epidemiology, policy, research, insurance and coding.
• DSM has its own coding system before DSM-IV; starting from DSM-5, ICD codes are used instead

The Structure of a Diagnosis

• A diagnosis constitutes an ICD code, the name of the disorder including a specifier for type or episode, etc, and a severity specifier.
• For example: F32.1, major depressive disorder, single episode, with anxious distress, moderate or F45.21, illness anxiety disorder, care-seeking type, severe

Problems with DSM and Diagnosis

• There are validity and reliability issues in diagnosis
• Some disorders are ill-advised or can be misapplied, and issues of diagnostic labeling can lead to prejudice and a self-fulfilling prophecy
• Issues involving sexual orientation and gender identity caused mistreatment and stigmatization, such as homosexuality being listed in the DSM until 1973/1987, and Gender Identity Disorder being replaced by Gender Dysphoria in 2013

Clinical Assessment

• Assessment involves collecting and interpreting relevant information about a client or research participant.
• Hundreds of clinical assessment tools have been developed and fall into three categories.
• These categories of assessment tools are clinical interviews, clinical tests, and clinical observations

Clinical Interview

• Clinical interviews are often the first contact between client and clinician to collect detailed information about the person’s difficulties, feelings, lifestyle, relationships, and personal history
• May include client expectations of and motives for therapy
• This is the time basic background data is gathered with a specific theoretical focus, such as psychodynamic, cognitive-behavioral, humanistic, or biological.
• This can either involve the clinical doing the assessment in a unstructured or structured format
• It is important to conduct a mental status exam of the patient to test if the individual is alert & oriented x4 (time, place, person, event), as well as an assessment of their appearance, attention, thought process, judgement, insight, or mood.

Clinical Tests

• Clinical tests are used to gather information about psychological functioning from which broader information is later inferred.
• The clinical tests can be further subdivided to include projective tests, personality inventories, response inventories, psychophysiological tests, neuroimaging and neuropsychological tests, and intelligence tests

Projective Tests

• This test requires client interpretation of vague or ambiguous stimuli or open-ended instruction, with a psychodynamic orientation
• Examples of projective assessments, are the Rorschach Inkblot test, Thematic Apperception Test (TAT), sentence completion tests, and drawings

Personality Inventories

• Measure broad personality characteristics
• Most widely used inventory is the Minnesota Multiphasic Personality Inventory
  • The Minnesota Multiphasic Personality Inventory has been used for adults: MMPI (original); MMPI-2 (1989); MMPI-3 (2020) and for adolescents MMPI-A
  • Scores from 0 to 120 are generally created and graphed into a profile and indicate if above 70 is to be considered deviant

Response Inventories

• Response inventories are usually based on self-reported responses and focus on one specific area of functioning
• Affective inventories measure things like Beck Depression Inventory, and it can also focus on Social/Cognitive skills, as well as show DSM assessment measures

Psychophysiological Tests and Neuroimaging

• Psychophysiological tests measure physiological responses, such as heart rate, blood pressure, body temperature, galvanic skin response, or muscle contraction, to indicate psychological problems.
• Use of polygraph (lie detector)
• Techniques like neuroimaging assess brain function by directly assessing brain structure and activity through the measure of EEG, PET scans, CT/CAT scans, MRI, and/or fMRI

Neuropsychological Tests

• This test measures cognitive, perceptual, and motor performance on certain tasks in order to interpret significantly atypical performances, as an indicator of irregularities in the brain.
• Measures the Bender Visual-Motor Gestalt Test, and this test is often used within a battery composed of series of these types of test to target a specific skill area

Intelligence Tests

• Designed to indirectly measure intellectual ability, often consists of a series of tests assessing both verbal and nonverbal skills
• It can hold more than 100 tests, which are all carefully produced and standardized
• the general score for all tests is an intelligence quotient (IQ), but one has to keep in mind cultural biases and misuse in terms of assessment

Clinical Observations

• Naturalistic observations occur in everyday environments made by participant observers reporting to a clinician, but since this is impractical, analog observations are used and conducted in artificial settings
• Self-monitoring of behavior involves people to observe themselves and carefully record the frequency of certain behaviors, feelings, or cognitions as they occur, which measures private thoughts or perception

Treatment

• Treatment decisions begin with assessment information and diagnostic decisions to determine a course and are currently focused on empirically supported, evidence-based care
• People in therapy are usually better off than people with similar problems who receive no treatment, but various therapies do not appear to differ dramatically in their general effectiveness.
• Certain therapies or combinations of therapies appear to be more effective than others for certain disorders

Factors Contributing to Therapy Outcomes

• Specific therapy techniques account for 15%
• Therapist factors account for 10%
• Client-therapist alliance accounts for 20%
• Specific factors of the client account for 10%
• Expectancy of therapy's success accounts for 15%
• Events occuring in the client's life are responsible for 30%