PSYC1003 Lecture 5 on Classification and Assessment in Clinical Psychology 2023 PDF

Classification and Assessment in Clinical Psychology PSYC1003 Lecture 5 Prof. Matt Field Attendance monitoring  What we will be covering today How are psychological disorders classified & diagnosed? – Benefits and disadvantages of the existing approach How a...

Classification and Assessment in Clinical Psychology PSYC1003 Lecture 5 Prof. Matt Field Attendance monitoring  What we will be covering today How are psychological disorders classified & diagnosed? – Benefits and disadvantages of the existing approach How are psychological disorders assessed? – Strengths and limitations of different assessment methods – Cultural bias in assessment Case formulation  Reading for this lecture Davey (2014) chapter 2  Learning outcomes for this lecture 1: Explain the goals of assessment and diagnosis of psychological disorders. 2. Describe and evaluate classification systems of psychological disorders such as DSM 5 and ICD-10. 3. Discuss the strengths and weaknesses of different methods of assessment of psychological disorders.  Recap of most relevant bits of lecture 4 (with Asha Akram) Q: How do we determine that a person has a psychological disorder? A: Not easily! 1. Statistical approach: is this person ‘different’? 2. Normative approach: does their behaviour violate social norms? 3. Functional approach: is this person able to function? 4. Distress-based approach: is this person in distress?  Exercise Watch this short video Exercise on WooClap www.wooclap.com/ZDSEKR  Questions (on WooClap) What symptoms does the client have? What aspects of their life is this affecting? Why is the doctor asking about alcohol and drug use? Why do you think the client’s (deceased) Grandma could be relevant? Why does the Doctor ask about those particular other symptoms (muscle tension, irritability, sleep disturbance etc?)  Diagnostic criteria for Generalized Anxiety Disorder (GAD) DSM-5 ICD-10 A. Excessive anxiety and worry for at A. Prominent tension, worry, and least 6 months feelings of apprehension for at B. Worry is difficult to control least 6 months B. At least four of the following C. Anxiety and worry associated with at symptoms, one of which must be least 3 of the following: from 1. – Restlessness 1. Palpitations or pounding heart; – Easily fatigued sweating; trembling or shaking; dry – Difficulty concentrating mouth – Irritability 2. Difficulty breathing; feeling of choking; chest pain or discomfort; – Muscle tension nausea; feeling dizzy or – Sleep disturbance lightheaded; derealization; depersonalization; fear of losing D. Clinically significant distress or control, going crazy, or passing impairment out. E. Not attributable to any substance or other medical condition Note: similar criteria to DSM F. Not better explained by another criteria D-F are applicable for all psychological disorder ICD-10 diagnoses Note: diagnostic criteria are shortened & paraphrased, see Davey (2014) for complete info  Classification of mental disorders: the taxonomic approach Anxiety Depressive disorders disorders Disruptive Major Persistent Premenstrual Generalized mood Social anxiety depressive depressive dysphoric Others… anxiety Panic disorder Specific phobia Others… dysregulation disorder disorder disorder disorder disorder disorder Scientists classify things (taxonomies)  Taxonomies of mental disorders Anxiety Depressive disorders disorders Disruptive Major Persistent Premenstrual Generalized mood Social anxiety depressive depressive dysphoric Others… anxiety Panic disorder Specific phobia Others… dysregulation disorder disorder disorder disorder disorder disorder  What do classification systems do? Help us understand which things are related to each other AND Help us understand which things are distinct (different) from each other  Why do we classify psychological disorders? Arguably, classification and diagnosis are essential if we hope to… – Understand causes – Identify most appropriate treatment(s) – Determine if treatment has been effective (or not) – Practical consequences, e.g. Is this person fit to stand trial? Does this person deserve compensation?  Objectives of classification systems 1. Provide necessary and sufficient diagnostic criteria for correct differential diagnosis. 2. Permit distinction of ‘true’ psychopathology from non-disordered ‘problems in living’ 3. Diagnostic criteria can be systematically applied, by different clinicians in different settings. 4. Diagnostic criteria should be theoretically neutral  The Diagnostic and Statistical Manual of Mental Disorders (DSM) 1952 ➤ 2013  DSM 5 categories of mental disorders 1. Neurodevelopmental 10. Feeding and eating disorders disorders 2. Schizophrenia spectrum and 11. Elimination disorders other psychotic disorders 12. Sleep-wake disorders 3. Bipolar and related disorders 13. Sexual dysfunctions 4. Depressive disorders 14. Gender dysphoria 5. Anxiety disorders 15. Disruptive, impulse- 6. Obsessive-compulsive and control and conduct related disorders disorders 7. Trauma and stressor-related 16. Substance-related and disorders addictive disorders 8. Dissociative disorders 17. Neurocognitive disorders 9. Somatic symptoms and 18. Personality disorders related disorders 19. Paraphilic disorders  International Classification of Diseases (ICD) rnational List of Causes of Death (1893) ➤ International Classification of Disease -10 (1990), ICD-11 implemented in 2022  Taxonomies of mental disorders Anxiety Depressive disorders disorders Disruptive Major Persistent Premenstrual Generalized mood Social anxiety depressive depressive dysphoric Others… anxiety Panic disorder Specific phobia Others… dysregulation disorder disorder disorder disorder disorder disorder  Example: Generalized Anxiety Disorder (GAD) DSM-5 ICD-10 A. Excessive anxiety and worry for at A. Prominent tension, worry, and least 6 months feelings of apprehension for at B. Worry is difficult to control least 6 months B. At least four of the following C. Anxiety and worry associated with at symptoms, one of which must be least 3 of the following: from 1. – Restlessness 1. Palpitations or pounding heart; – Easily fatigued sweating; trembling or shaking; dry – Difficulty concentrating mouth – Irritability 2. Difficulty breathing; feeling of choking; chest pain or discomfort; – Muscle tension nausea; feeling dizzy or – Sleep disturbance lightheaded; derealization; depersonalization; fear of losing D. Clinically significant distress or control, going crazy, or passing impairment out. E. Not attributable to any substance or other medical condition Note: similar criteria to DSM F. Not better explained by another criteria D-F are applicable for all psychological disorder ICD-10 diagnoses Note: diagnostic criteria are shortened & paraphrased, see Davey (2014) for complete info Problems with classification approaches and diagnostic manuals (1) 1. Describe observable symptoms – (rather than explain causes) 2. Diagnoses (labels) can be stigmatising. 3. Diagnoses are categorical (yes / no) – E.g. you are either depressed, or you are not – However, severity of disorder can be quantified Problems with classification approaches and diagnostic manuals (2) 4. Homogeneity of sufferers – Many different combinations of symptoms could warrant diagnosis of e.g. schizophrenia, or substance use disorder 5. Disorders are distinct from each other – But comorbidity is the norm, e.g. anxiety and depression 6. A ‘hodgepodge’ collection of disorders, with much historical ’baggage’ – Short-term problem vs. life-long personality? – Misery vs. bad behaviour? – Extremely rare vs. very common, slight exaggerations of normal variations in mood or behaviour? – Origins in infancy or old age? – Clear biological origin, or not?  Some specific criticisms of DSM-5 Proliferation of disorders with each revision Gradual lowering of thresholds – favours over- rather than under-diagnosis – ‘medicalising’ normal experiences – overprescription of psychiatric medication. Disproportionately influenced by biological models Most psychological disorders are dimensional, i.e. they have a continuum of severity – DSM 5 does explicitly acknowledge this – However, this means that any cut-off score or threshold is somewhat arbitrary and subjective  Part 2: Assessment of psychological disorders  The goals of assessment 1. What problems does this person have? 2. Which psychological disorder(s) should they be diagnosed with? (not essential; see case formulation) 3. Did our treatment work?  How would we determine if a person should be diagnosed with Generalized Anxiety Disorder (GAD)? DSM-5 ICD-10 A. Excessive anxiety and worry for at A. Prominent tension, worry, and least 6 months feelings of apprehension for at B. Worry is difficult to control least 6 months B. At least four of the following C. Anxiety and worry associated with at symptoms, one of which must be least 3 of the following: from 1. – Restlessness 1. Palpitations or pounding heart; – Easily fatigued sweating; trembling or shaking; dry – Difficulty concentrating mouth – Irritability 2. Difficulty breathing; feeling of choking; chest pain or discomfort; – Muscle tension nausea; feeling dizzy or – Sleep disturbance lightheaded; derealization; depersonalization; fear of losing D. Clinically significant distress or control, going crazy, or passing impairment out. E. Not attributable to any substance or other medical condition Note: similar criteria to DSM F. Not better explained by another criteria D-F are applicable for all psychological disorder ICD-10 diagnoses Note: diagnostic criteria are shortened & paraphrased, see Davey (2014) for complete info  Methods of assessment Clinical interviews Clinical observation Psychological tests – Questionnaires – Projective tests – Intelligence tests Biologically based assessments – Psychophysiology – Neuroimaging  Diagnosis is almost always reliant on subjective judgment Clinical interviews Clinical observation Psychological tests – Questionnaires – Projective tests – Intelligence tests Biologically based assessments – Psychophysiology – Neuroimaging  Reliability and validity Reliability Validity – Test-retest reliability – Concurrent validity – Inter-rater reliability – Face validity – Internal consistency – Predictive validity (cronbach’s ) – Construct validity  Some definitions (1) Test-retest Inter-rater reliability reliability The extent that a test will produce The degree to roughly similar which two results when the test independent is given to the same clinicians agree person several when interpreting weeks or even months apart or scoring a particular test  Some definitions (2) Concurrent Predictive validity validity A measure of how The degree to highly correlated which an scores of one test assessment are with scores method is able to from other types of help the clinician assessment that predict future we know also behaviour and / or measure that symptoms attribute  Clinical interviews Structured Clinical Interview for DSM (SCID) – Questions are predetermined – Client’s response to one question determines the next question to be asked – High inter-rater reliability for many disorders  Limitations of clinical interviews 1. Reliability of unstructured interviews is low, probably because of different skills and personalities of clinicians! 2. Some disorders characterized by poor self- awareness 3. Some clients may intentionally mislead (e.g. some personality disorders) 4. Interviewers prone to biases (e.g. primacy effect)  Clinical observation E.g., in a school context, observer could use ABC chart to identify – What happens before the target behaviour (Antecedents) – What the individual did (Behaviour) – The consequences of that behaviour (Consequences) Uses and advantages: – Can capture frequency of target behaviours – Better ecological validity than self-reports – Can identify practical treatment options  Limitations of clinical observation – Very time-consuming, observers need a lot of training – Observations normally limited to one context – Presence of observer may influence behaviour (could be overcome by video recording) – Inter-observer reliability can be poor unless both are intensively trained  Psychological tests (1) Self-report questionnaires, e.g. personality tests – Assess a specific characteristic or trait – Rigid response requirements so they can be scored objectively, easily and without bias – Many (e.g. Minnesota Multiphasic Personality Inventory; MMPI) have good internal reliability and concurrent validity with diagnostic status, assessments from family members – Statistical norms can be established, which permits standardisation, which in turn enables clinician to estimate if client is likely to meet diagnostic criteria  Limitations of self-report questionnaires 1. Time consuming 2. Can be faked, although some (such as the Minnesota Multiphasic Personality Inventory; MMPI) have ‘lie’ scales and scales that capture social desirability and so on (see Davey, 2014). Projective tests  Psychological tests (2) Projective tests: – Rorschach inkblot Test – Thematic Apperception Test – Sentence Completion Task All have low inter-rater reliability and validity; may not reveal any more than self-report measures or clinical interview. However, may be useful (valid) in some circumstances, such as detection of thought disorder in schizophrenia.  Psychological tests (3) Intelligence tests, e.g. Wechsler Adult Intelligence Scale (WAIS) Can aid diagnosis of intellectual and learning disability Strengths: – Extensively studied and developed over decades. Most are standardised with a mean score of 100, SD of 15. – High internal consistency, test-retest reliability, and predictive validity Limitations: – The underlying construct(s) are still hypothetical. – Culturally biased – They do not capture other, equally important aspects of intelligence such as ‘emotional intelligence’, musical ability, motor skills, etc.  Biologically based assessments Psychophysiology, e.g. – electrodermal responding (’skin conductance’) – Electromyogram (EMG) (muscle activity, can detect ’smiling’ and ‘frowning’) – Electrocardiogram (ECG) (heart activity) – Electroencephalogram (EEG) (brain activity) – Neuroimaging Structural (CAT, MRI) Functional (fMRI, PET, SPECT) Neuroimaging (MR = Magnetic Resonance Imaging) Positron Emission Tomography (PET) Measures brain function (rather than structure)  Clinical implications? https://app.wooclap.com/PYDRAP  Cultural biases in assessment Most tests developed and validated on white European or American populations In the USA, differential rates of diagnosis in different ethnic groups. In the UK, Caribbean immigrants in the 1970s more likely to be diagnosed with schizophrenia. Clinicians tend to view people of lower SES as more ‘disturbed’ than those of higher SES, attributable to influence from stereotypes during unstructured interviews.  Why does this happen and why does it matter? https://app.wooclap.com/YRMLNR  Case formulation Clinicians gather information about clients in order to draw up a psychological explanation of the client’s problems and to develop a plan for therapy Assumes that each client is unique, and therefore an individualised approach is needed. Does not require a psychiatric diagnosis (but not incompatible with diagnostic approach). For example, a CBT formulation identifies – Antecedents (causes) – Beliefs (psychological determinants), and – Consequences (symptoms)  6 components of case formulation 1. Create a list of the client’s problems 2. Identify & describe underlying psychological mechanisms 3. Understand how those mechanisms generate the client’s problems 4. Identify the kinds of events that precipitate the problems 5. Identify how those the underlying psychological mechanisms mediate the antecedent > symptoms link 6. Develop a treatment plan based on the above  Group activity: try out a case formulation! With the people sitting next to you…. Think about an undesirable aspect of your behaviour (nothing too personal, and certainly nothing related to a mental health concern). For example: – Being irritable in the mornings – Forgetting your keys, phone, or money when you leave the house – Not maintaining close friendships With your neighbour(s), try out a case formulation to help you to change this behaviour!  Advantages of case formulation No need for a diagnosis, so reduced stigma Collaborative, and gives the patient input into the best solution Client is treated as unique (not a label), and the solution is tailored to them Based on a theoretical understanding of the causes and consequences of disorder (unlike diagnosis, which is based only on presenting symptoms)  Disadvantages Subjective: explanation of psychological mechanisms will be based on therapist’s background and approach (e.g. psychoanalytic vs. CBT). Relies on a lot of assumptions that are not tested. For example, causes of most disorders are not well understood. How can we share knowledge and learn from ‘what worked’ in similar cases?  Self-test questions from Davey (many more in the book) DSM 5 is not an ideal classification system. Can you describe at least four problems associated with it? What are the main benefits and limitations of the clinical interview? What are the main components of a case formulation?  Lecture summary Psychological disorders are classified in much the same way as other things are classified in science (taxonomies). This serves a purpose, but there are many limitations. Case formulation is an alternative, but it has its own problems. There are many different ways of assessing psychological disorders, each of which has strengths and limitations. There are important cultural differences in assessment and diagnosis of psychological disorders.