Psychiatric Classification and Diagnosis

• Many disorders are ego-dystonic (self-aware, OCD) rather than ego-syntonic (no awareness, OCPD), creating an "unreliable narrator" that is unhelpful in diagnosis
  • Patients being aware of their own experiences can make them harder to treat.
  • Many diagnoses have overlapping criteria.

Diagnostic/Classification Systems

• Lists of terms for conventionally accepted concepts to describe psychopathology, such as DSM-5 and ICD-10, both current classification systems

Classification

• The activity of forming groups

Diagnosis

• The process by which individuals are assigned to already existing groups

Taxonomy

• The study of how groups are formed

Fundamental Problems of Psychiatric Classification

• Unresolved issues concern the nature of the entities being classified while definitions are still being understood and developed.
• This includes defining mental disorders and distinguishing between normality and pathology.
• Controversies surround definitions, logical status, and whether some entities are pathological conditions.

Classifying Defines Boundaries

• Establishing where the discipline ends and begins
• Ultimately defining the field of psychopathology

Purposes of Classification

• Provides nomenclature
  • A list of names or terms for categories within a classification system for practitioners
  • Allows psychologists to "talk to each other" using short-hand terminology.
• Serves as a basis for organizing and retrieving information, helping clinicians retrieve information about etiology, treatment, and prognosis.
• Describes common symptom patterns, establishing a descriptive basis for a science of psychopathology
  • Involves transforming individual cases to principles.
  • Cases within a diagnosis should be similar to other cases that share a diagnosis and different from cases that don't share a diagnosis.
• Provides a basis for making predictions
  • Information about a diagnosis gives the clinician information relevant to the patient's clinical course and response to treatment. Forms the basis for the development of theories
  • Theories about the relationship between diagnoses can be helpful such as the relationship between OCD and OCPD.

Classification of Syndromes, Disorders, or Diseases

• Symptoms: Self-reported issues
• Signs: Issues observed by others
• Syndrome: When signs and symptoms co-occur frequently (only descriptive)
• Scientist has no clue what's wrong with this person = Syndrome
• Disorder: A pattern of symptoms and signs that includes an implied impact on the functioning of an individual
• More descriptive than a syndrome
• Has some causal factors might be understood
• Has unclear or multiply determined etiology
• Disease: Known etiology and known path from causal agent to symptoms and signs
• Classification of Disorders ≠ Classification of Individuals
• Important to avoid stigmatization of individuals
• Categorical Advantages: Easy to use because it's more "black and white”
• Categorical Disadvantages: Results in the loss of some information due to arbitrary or ill-defined boundaries

Assessment

• A common professional activity of clinical psychologists in which clients are evaluated or appraised via clinical interviews, testing, observation, or other means

The Clinical Interview

• A common assessment technique used by clinical psychologists involving a purposeful conversation with clients characterized by questions and answers that must have:
• Validity: Measures what it claims to measure
• Reliability: Yields consistent, repeatable results
• Clinical utility: The extent to which a technique benefits the clinician and ultimately the client in a meaningful way

General Skills

• Quieting yourself: Minimize internal, self-directed thoughts that can preoccupy or distract the interviewer
• Being self-aware: The ability to know how the interviewer might affect others interpersonally and how others tend to relate to him or her
  • Skill interviewers: Are cognizant of their unique traits and consider their effect on the interview process

Developing a Positive Working Relationship

• Many assessments turn into working relationships and come with experience

Specific Behaviors

• Eye contact serves as a delivery receipt/confirmation for the person speaking
  • Important but eye contact that is too long, intense, scarce, or inconsistent can be bad and affected by cultural or sex differences.
• Nonverbal behavior: Should be presentable without distractions like fidgets or yawns
• Vocal Qualities: Talking quietly promotes closeness and using inflections helps to express emotion

Building Rapport

• Rapport: Positive, comfortable relationship between the interviewer and client
  • Engaging in small talk disarms the client.
  • Acknowledge the unique situation of the clinical interview
  • Notice the client's use of language and follow their lead, using their analogy

Directive VS Non-directive Styles

• Directive: Obtains information by specifically asking for it, such as frequency of suicide attempts or hours of sleep
  • Shortcoming: Hard to build rapport and don't know what to look for and ask
• Non-Directive: The interviewer allows clients to determine the course of the interview
  • Provides info the interviewer may not know and allows the client to expand on what they think is essential, which is oftentimes the most important
  • Helpful to start with Non-directive and follow with Directive

Open & Closed Ended Questions

• Open: Allows for individualized and spontaneous responses (non-directive style)
• Closed: Allows for less elaboration and self-expression by the client

Clarification

• Technique designed to ensure the interviewer has an accurate understanding of the client's comments
  • Helps to ensure the client isn't misunderstood
  • Conveys that the clinician is actively listening and processing.
• Confrontation: Used when the interviewer notices discrepancies or inconsistencies in a client's comments
• Paraphrasing: Restates the content of the client's comments using similar but not the same language
• Reflection of feelings echoes the client's emotions, while paraphrasing echoes the client's words
• Summarizing: Ties together statements or topics
  • Identifies themes that have recurred
  • An accurate summarization = Interviewer has a grasp of the “big picture"

Types of Interviews

• Intake Interview: Used to determine whether the client needs treatment
• What form of treatment is needed and whether the current facility can provide treatment
• Ask detailed questions about the presenting complaint
• Diagnostic Interviews: Goal = Confidently and accurately assign a DSM-5 diagnosis to the client's problems
• Structured Interview: Uses a predetermined, planned sequence of questions (A stream of questions) that provides:
• High reliability
• Ease of administration
• Reduced reliance on subjective judgements and biases, but it has a rigid format inhibiting rapport
• Unstructured Interview: No predetermined or planned questions; uses off-the-cuff questions
• Semi-Structured Interview: Unstructured + Structured
• Mental Status Exam: Quickly assesses how the client is functioning at the time of the evaluation at the end of interviews
• Uses brief paragraphs
• Crisis Interview: Assesses a problem demanding urgent attention, like suicide or crisis lines
• Provides immediate and effective intervention for that problem

Lecture 10 Intellectual and Neuropsychological Assessment

• Three types of tests:
  • Intelligence: Assesses aptitude or intellect, including speed of mental processing, imagination, memory, reasoning, etc, measures a client's intellectual abilities
  • Achievement: Measures how much a person has accomplished and how much students have learned in specific and clearly defined content areas
  • Neuropsychological: Focuses on issues of cognitive or brain dysfunction (effects of injuries and illnesses)
• Intelligence: Gottfredson:
  • The ability to direct one's thinking and adapt to one's circumstances, and learn from one's experiences
  • Pinker: The ability to attain goals in the face of obstacles by means of decisions based on rational
• Charles Spearman: Believed intelligence is one thing (single characteristic)
  • General intelligence: “g”, global intellectual ability
  • Specific intelligence, "s", but relatively minor role compared to “g”
• Louis Thurstone: Believed intelligence is distinct with numerous distinct abilities that have little relationship to one another:
• An individual's ability in one skill cannot reliably predict their capability in another skill
• Hierarchical Model of Intelligence: Differences in abilities exist (“s”), but highly correlated to each other to make “g” (Spearman + Thurstone)
• James Cattell:
  • Fluid (Ability to reason when faced with novel problems)
  • Crystallized Intelligence (What one knows after being taught)
• John Carroll: Developed the Three-Stratum Theory of Intelligence, which most psychologists mirror with variations in maybe fewer specific abilities
  • Intelligence operates at three levels:
    • 1 “g”
    • 8 broad factors under "g"
    • 69 specific factors under the 8 broad ones

Wechsler Intelligence Tests

• David Wechsler: The most cited even after being dead for decades in the following three tests that cover a person's entire life (Different prompts for each)
  • WAIS (Adults)
  • WISC (Children)
  • WPPSI (Preschool and Primary)
• Employs a hierarchical model of intelligence
  • A single full-scale intelligence score reflecting “g”
  • Four or five index scores and Subtest scores to reflect "s"
• Administered one-on-one and face-to-face, which is a structured interpersonal interaction requiring extensive training
• Subtest names: Vocabulary, Similarities, Information, Comprehension, Block Design, Picture Completion, Matrix Reasoning, Coding, Symbol Search. test difficulty increases until the test taker gets it wrong.
• Originally only verbal and performance subtests, now four factors:
  • Verbal Comprehension: Verbal concept formation and verbal reasoning
  • Perceptual reasoning: Fluid reasoning, spatial processing, and visual-motor integration
  • Working memory: Capacity to store, transform, and recall incoming information and data in short-term memory
  • Processing speed: The ability to process simple or rote information rapidly and accurately
• Normative data: A sample of test-result data that constitutes a basis for comparison of individuals who take the test in clinical settings
• Approach to Interpret Scores:
  • Consider the full-scale IQ score
  • Interpret each index score in relation to the others (Relative deficiencies)
• Note details of testing (Observable patterns of behavior that may have contributed to performance)

Why have an IQ test:

• Specific contexts: Intellectual disability, developmental delays. Giftedness, educational and vocational planning, school placement
• Broader contexts: Comprehensive assessments of clients presenting with many problems neuropsychological (Alzheimer's), emotional (mood disorders), behavioral (ADHD)

Strengths/Weakness

• Strengths:
• High reliability, harder to measure validity but also great as well
• Feature comprehensive and recent normative data
• Cover an extremely wide age range
• Provide full-scale, index, and subtest scores that have great clinical utility
• Most psychologists are familiar
• Criticized:
• Some subtests may be culturally loaded or biased
• Connection between tests and day-to-day life (ecological validity) may be limited
• Scoring can be complex on some students
• Psychologists recognize the Binet scales as good tests maybe even the best psychological test

Stanford-Binet Intelligence Scales

• Similarities to the Wechsler tests:
  • Administered face-to-face and one-on-one
  • Employs a hierarchical model of intelligence
  • A full-scale IQ for “g”
  • Similarly strong reliability and validity
• Differences from Wechsler:
  • Covers the entire lifespan (ages 2-85+) as a single test (Whereas Wechsler has three)
  • Normative sample: is like Wechsler but even better; Includes normative data from individuals with specific relevant diagnoses
  • Including learning problems, intellectual disability, and ADHD
  • Subsets include extensions on both high and low ends
    • Greater # of very easy and very hard items, more accurately assessing people at the extremes
• Specific factors and subtests: Exactly 5 subtests measured verbally and nonverbally, with exactly 5 subtests
  • Fluid Reasoning: the ability to solve novel problems
    • Knowledge: General info. Accumulated over time via personal experiences
  • Quantitative reasoning: The ability to solve numerical problems
  • Visual-Spatial Processing: The ability to analyze visually presented info.
  • Working Memory: The ability to hold and transform info. In short-term memory

Predictability

• WAIS predicts a variety of important life outcomes:
  • IQ is a better predictor of the amount of education a person will receive than the person's social class
  • Intelligent people spend more time in school and perform better when they're there (r = .50 for IQ and academic performance)
• Intelligent people aren't just wealthier, but also healthier
  • Less likely to smoke or drink alcohol
    • More likely to exercise and eat well
    • Live longer
    • Have more satisfying relationships and better mental health
    • Less racist, less sexist, less likely to commit crimes
    • More attentive to the benefits of long-term cooperation and less tempted to exploit others
• Also only one bad traits associated with high IQ: eyesight

Achievement Testing

• What one has accomplished
  • “Learning disability” is now called Specific Learning Disorder: A diagnosis based primarily on the level of academic achievement falling significantly below expected levels of achievement for people of the same age
  • Subtests: The Woodcock Johnson Tests of Achievement (WJ) or The Wide Range Achievement Test (WRAT) or The Kaufman Test of Educational Achievement (KTEA) or The Wechsler Individual Achievement Test (WIAT)

Neuropsychological Testing

• Measures cognitive functioning or impairment of the brain and its specific components or structures
  • Medical procedures such as CR, MRI, PET scans can indicate the part of the brain that looks abnormal
  • Neuropsychological tests show how that part of the brain is actually functioning useful for targeted assessment of problems

Lecture 11 Personality Assessment and Behavioral Assessment

• Three Overarching Themes: Multimethod, Evidence-Based, Culturally competent

  • Multimethod Assessment: Personality is best assessed by using multiple methods, such as tests of different types, interview data, observations, and other sources
    • Evidence-Based Assessment: Clinical psychologists who practice this use only methods with strong psychometrics (reliability, validity, clinical utility)
    • Target assessment strategies toward a particular diagnosis or problem

• Highly recommend instruments: The Structured clinical interview for DSM-5 or The Beck Depression Inventory-II

• How to decide “what works”? Some strengths or weaknesses can be assessed quantitatively in: - Test-retest reliability: Measures the extent to which the method yields similar results at different time points (correlation coefficient ranging from -1 to +1)

• Adequate correlation is at least .70 over a period of several days to several weeks

• Good correlation is at least .70 over a period of several months

• Excellent correlation is at least .70 over a period of a year or longer

Culturally Competent Assessment

• Every culture has its own perception of “normal” and "abnormal" → A personality - Assessment conducted w/o knowledge or sensitivity to these cultural specifics can be dangerous
• Overpathologizing: Viewing as abnormal that which is culturally abnormal

Objective vs Projective Personality Tests:

• Objective: Personality best assessed by directly asking people to describe themselves
  • Uses unambiguous test items, limited range of response objectively scored, typically questionnaires, or questionnaires which are a series of direct, brief statements or questions with either T/F or multiple choice responses
• Projective: Based on the assumption that clients reveal their personalities by the way they make sense of vaguely defined objects or situations that uses:
  • Unambiguous stimuli and an open-ended range of responses
• Objective: MMPI-2: most popular, psychometrically sound objective personality test, used by clinical psychologists with:
  • 567 T/F questions
  • Created by Starke Hathaway and J.C. McKinley, who created a list of items that empirically elicit different responses from people in these normal and abnormal groups by using: - Empirical Criterion Keying: Keeping items only if it “does” and not “should” differentiate between normal and abnormal people → Might lead to low face validity - Test-Taking attitudes: Self-report instruments are vulnerable to insincerity
    • MMPI and MMPI-2 contain questions to “catch” someone faking
    • Validity Scales: Informs the psychologist about the client's approach to the test such as: - L - Lying, faking good - K - Defensiveness, faking good
      • F - Infrequency, faking bad

Millon Clinical Multiaxial Inventory - IV (MCMI-IV)

• Focused on personality disorders similar to the MMPI-2, but shorter since it's only on personality disorders

NEO Personality Inventory - Revised

• by Paul Costa and Robert McCrae
• Based on the five-factor model of personality:
• Neuroticism
• Extraversion
• Openness
• Agreeableness
• Conscientiousness Projective Personality Tests: People will “project” their personalities if presented with unstructured, ambiguous stimuli & an unrestricted opportunity to respond

Criticisms

• Lack of objectivity in scoring and interpreting, far too inferential to be empirically sound because someone's answer may not fall into any category; each client produces a unique - Response, where T/F questions provide definitive answers for objective tests and
• The validity and reliability are insufficient to justify

Rorschach Inkblot Method

• Developed by Hermann Rorschach and uses: - 10 inkblots in
  • Administration that occurs in two phases:
• Free association phase/Response: The psychologist asks “What might this be" and writes down the client's responses verbatim.
• Inquiry phase: After client responds to all 10 cards, the psychologist reads the client's responses aloud and asks them to describe their reasoning

Scoring system

• Location: Does the response involve the whole inkblot, a large portion, or small?

  • Determinants: What aspect of the inkblot such as form, color, and shading, etc caused the client to make a particular response?

  • Form Quality: Is the response easily identifiable and conventional or is it unique or distorted?

    - Popular: How often does the client offer these popular responses?
    - Content: What kinds of objects appear with unusual frequency in the client's response?
    

Thematic Apperception Test (TAT)

• by Henry Murray and Christia Morgan - Presenting a series of cards interpersonal scenes with an ambiguous stimulus - The client is asked to create a story to go along with each scene

Rotter Incomplete Sentences Blank (RISB)

• Most widely known and commonly used with: - 40 written sentence “stems” referring to various aspects of the client's life