Clinical Assessment and Diagnosis.pdf

Clinical Assessment and Diagnosis collecting information across a broad range of individual’s functioning. After the Clinical Assessment is the systematic preliminary overall functi...

Clinical Assessment and Diagnosis collecting information across a broad range of individual’s functioning. After the Clinical Assessment is the systematic preliminary overall functioning of the person, evaluation and measurement of the clinician narrows the focus. psychological, biological, and social factors in an individual presenting with a possible Three Basic Concepts to determine the value psychological disorder. of assessments: Diagnosis is the process of determining 1. Reliability whether the particular problem afflicting the - It is the degree to which the individual meets all criteria for a measurement is consistent. psychological disorder as set forth in DSM5. Textbook Example: FRANK You had stomach pain and went to four - Possible treatment of severe distress physicians and got four different and anxiety centering on his diagnoses and four different treatments. marriage. One way to improve reliability is to Note that we always begin by asking a patient ensure that two or more raters will get the to describe for us, in a relatively open- same answer, which is called as minded way. interrater reliability. It allows us to relate details of the patient’s Textbook Example: life revealed later in the interview through the If you got an IQ of 110 on Tuesday, it central problems as seen through the patient’s should be the same answer when you take eyes. the exam again on Thursday. This is - He worked in an auto-repair shop for known as test-retest reliability the past 4 years and that, 9 months 2. Validity after, he had married a 17-year-old - The degree to which a technique woman. measure is designed to measure. - He seemed tense and anxious. He was closing his eyes for a period of 2-3 Textbook Example: seconds and his right leg would twitch. If the results from a standard, but long IQ test were the same as the results from a BRIAN new, brief version, you would conclude that the brief version had concurrent or - He is in another state of evaluation of descriptive validity. sexual problem. - He is homosexual who wanted to be Predictive Validity is how well your straight. assessment tells you what will happen in the future. Key Concepts in Assessments 3. Standardization The process of clinical evaluation is - It is the process in which a certain set compared to a funnel. It begins with of standard of norms is determined  for a technique to make its use - Notes any overt physical behavior, as consistent across different well as dress, general appearance, measurements. posture, and facial expression. Textbook Example: Textbook Example: If you are an African American male, 19 Slow and effortful motor behavior is years old and from a middle-class sometimes referred to as psychomotor background, your score on a retardation or may indicate severe psychological test should be compared depression. with the scores of others like you and not 2. Thought Processes to the scores of different people. - They observe the rate of speech (talk Reliability, Standardization, and Validity quickly or slowly). are all important in forms of psychological - The continuity of speech (make sense assessments. when talking or ideas presented with no apparent connections.) Clinical assessments include procedures such as clinical interview, a mental exam Patients with schizophrenia, a administered, and physical examination; a disorganized speech pattern is referred behavioral observation and assessment and to as loose association or derailment. if needed, psychological tests. - The content of speech. The Clinical Interview Typical Delusions: It is the core of clinical work. The interview Delusion of Grandeur – An individual gathers information on current and past thinks she is all powerful. behaviors, attitudes, emotions, as well as detailed history of the individual’s life and Delusion of Persecution – An individual the presenting problem. thinks that people are after him and about to get him all the time. They also gather information on the patient’s current and past interpersonal and social Ideas of Reference – Everything and history including family make-up, and on everyone else does somehow and relates individual’s upbringing. Aside from this, back to the individual. they also collect information regarding about sexual development, religious attitudes, Textbook Example: cultural concerns, and educational history. Thinking that a conversation between two The Mental Status Exam strangers on the other side of the room must be about you. This involves the systematic observation of an individual’s behavior. In the case of Brian, his negative attitude toward homosexuality is referred to as This can be structured or detailed. homophobia. The exam covers five categories: 3. Mood and Affect - Important part of mental exam. 1. Appearance and Behavior - Mood is a predominant feeling state phrased to elicit information in a of an individual while Affect refers to consistent manner. the feeling state that accompanies The disadvantage of unstructured is it what we say at a given point. robs the interview of some of the - Usually, our affect is appropriate spontaneous quality of people talking. On when our mood and affect match the other hand, if structured applied too while it’s inappropriate when it’s not. rigidly, it inhibits the patient If there’s a mood but with no affect, volunteering useful information. the clinicians would say that it’s blunt or flat. In Frank’s case, he might use the Anxiety 4. Intellectual Functioning Disorders Interview Schedule for - Rough estimate of intellectual DSM5. functioning (vocabulary, abstractions and metaphors, memory) just by Physical Examination talking to them. They require physical exam because 5. Sensorium sometimes, the psychological problem - It refers to our general awareness of might be associated with medical our surroundings. conditions. - When the patients are fully aware of his/her surroundings, the clinicians In toxic state, it could be caused by bad would say that it’s clear and oriented food, wrong amount of medicine, or three times. onset of medical condition. Informal behavioral observations allow Textbook Example: the clinician to assess what behavior, and Thyroid difficulties, particularly condition should be assessed in detail. hyperthyroidism (overactive thyroid In Frank’s case, there is an identification gland) may produce symptoms that mimic of the possible existence of a disorder certain anxiety disorders such as GAD. characterized by intrusive, unwanted Hypothyroidism (underactive thyroid thoughts, and attempt to resist them- in glands) might produce symptoms of other words obsessive compulsive depression. disorder. Behavioral Assessment It is important to conduct clinical Behavioral Assessment uses direct interviews that elicits the patient’s trust observation to assess formally the and empathy. person’s thoughts, feelings, behavior in Semi-structured Clinical Interviews specific situations. Unstructured interviews follow no In direct observation, clinicians would go systematic format. to the person’s home or workplace, or even in the local community to observe Structured interviews are made up of the person and then report the problem questions that have been carefully directly. Some setup role play simulations to see how people behave in His mother lacks a response. similar situations. (Consequence) In behavioral assessment, target The ABC observation might suggest that behaviors are identified and observed the boy was being reinforced for his with the goal of determining the factors violent outburst by not having to clean up that seem to influence them. They his mess. And because there were no sometimes arrange analogues or similar negative consequences for his behavior settings. (his mother didn’t scold or reprimand him) he will probably act violently the Textbook Example: next time he doesn’t want to do In a research study of children who have something. autism spectrum disorder (a disorder The example is in the form of informal characterized by social withdrawal and observation in which it relies on the communication problems), the reason observer’s recollection, as well as for self-hitting (self-injurious) behavior interpretation of the events. are placing the children in a simulated situation, such as sitting alone at home, On the other hand, formal observation playing with sibling, or being asked to involves identifying specific behaviors complete a difficult task. that are observable and measurable called an operational definition. In short words, researchers use a variety of creative techniques to study Textbook Example: psychological disorders. It would be difficult to agree on what The ABC Observation or the “having an attitude” looks like. An Antecedent- Behavior -Consequence operational definition however clarifies Observation that this behavior is specifying that this is “any time that the boy does not comply A = Antecedent (What happened just with his mother’s reasonable requests.” before the behavior). Once the target behavior is selected and C = Consequence (What happened defined, the observer writes down each afterward). time it occurs. The goal of collecting this Textbook Example: information is to see whether there are any obvious patterns of behavior and A violent boy. design treatment based on these patterns. The observer noted the following Self Monitoring sequence of events: It observes their own behavior. His mother asked him to put his glass in the sink. (Antecedent) The goal here is to help clients monitor their behavior more conveniently. When The boy throwing the glass. (Behavior) behavior occurs only in private (such as purging by people with bulimia) self - people who are asked to describe monitoring is essential. what they see. A more formal and structured way to The theory here is that people project observe behavior is through checklist and their own personality and unconscious behavior rating scales which are used as fears onto other people and things – in assessment tools before treatment. this case ambiguous stimulus reveal their unconscious thoughts. The Brief Psychiatric Rating Scale assesses 18 general areas of concern. It Hermann Rorschach developed a includes psychotic disorders, somatic psychological test named Rorschach concern, fear of physical illness, Inkblot Test that studies perceptual hypochondriasis, guilt feelings, and processes. It is one of the early grandiosity. projective tests. Reactivity is a phenomenon that refers to It consists of 10 inkblot pictures and the distorting observational data. Any time examiner presents it one by one to the you observe how people behave; the person and they will respond by telling mere fact of your presence may cause what they see. them to change their behavior. When he died at the age of 38, his test put Clinicians sometimes depend on in controversy because of lack of reactivity of self-monitoring to increase reliability or validity among other the effectiveness of their treatments. things. Psychological Testing John Exner developed a standardized version of the Rorschach Inkblot called This used to assess psychological “Comprehensive System”. Exner’s disorders must meet the strict system of administering and scoring the standards we have noted. Rorschach specifies how cards should Psychological tests include specific tools be presented and what the examiner to determine cognitive, emotional, or should say and how the responses should behavioral responses that might be be recorded. associated with a specific disorder. The Thematic Apperception Test is the Intelligence testing determine the best-known projective test after structure and patterns of cognition. Rorschach. It was developed by Neuropsychological testing determines Christiana Morgan and Henry Murray. the possible contribution of brain It consists of 31 cards- 30 pictures and 1 damage or dysfunction to the patient’s blank card, though 20 cards are condition. Neuroimaging assesses brain typically used during each structure and function. administration. The TAT ask the person Projective Testing to tell a dramatic story about the picture. An ambiguous stimulus such as pictures The TAT is based on the notion that of people or things are presented to people will reveal their unconscious mental processes in their stories about Infrequency Scale measures false the pictures. claims about psychological problems or whether the person answers randomly. Several variations of TAT have been produced such as Children Subtle Defensiveness Scale which Apperception Test (CAT) and Senior assesses whether the person sees herself Apperception Technique (SAT). in unrealistically positive ways. In TAT, they developed formal scoring Textbook Example: systems including Social Cognition and James S. is a 27-year-old man who had a Object Relations scale. criminal record of kidnapping, raping, Unfortunately, TAT and its variants and murdering a middle-aged woman, continue to be used inconsistently. MMPI is the most extensively Personality Inventories researched assessment instrument in Psychology. Face Validity refers to the questions seems to fit the type of information Recent versions of MMPI are MMPI-2 desired. and MMPI- A Paul Meeh presented his study about The other versions of MMPI faced personality inventories (self-reports that problems such as: assess personal traits). His point is not 1. Some questions are sexist. whether the questions necessarily make 2. Other items were criticized as sense on the surface but rather what insensitive to cultural diversity. answers to these questions predict. Reliability of the MMPI is excellent The most widely used personality when it is interpreted according to the inventory is the Minnesota- Multiphasic standardized procedures. Personality Inventory (MMPI). In projective tests, it rely heavily on theory Intelligence Testing for interpretation. On the other hand, in MMPI, it is based on empirical Intelligence Testing were developed to approach. The administration of MMPI predict who would do well in school. is straightforward. It also answers with Alfred Binet and Theodore Simon True or False. developed a test that would identify slow In assessing the responses in MMPI, learners who would benefit from pattern of responses is reviewed remedial help. They include tasks of whether to see if it resembles patterns attention, perception, memory, reasoning, from groups of people who have specific and verbal comprehension. disorder. Lewis Ternan translated a revised Lie Scale indicates that the person may version of it and called it as Stanford be falsifying answers to look good. Binet Test. Intelligence Quotient (IQ) were the person’s ability to perform certain calculated by using children’s mental age. tasks. Deviation IQ refers when a person’s One example test is the Bender Visual score is compared only with the scores of Motor Gestalt. The child is given a series others of the same age. The IQ scores of cards on which are drawn various then, is an estimate of how much a child’s lines and shapes. The task for the child is performance in school deviates from the to copy what is drawn on the card. average performance of others of the If the number of errors exceeds, a same age. certain figure of brain dysfunction is David’s Weschler Test includes versions suspected. for adult (Weschler Adult Intelligence Two of the most popular tests are the Scale or WAIS-III), (Weschler Luria Nebraska Neuropsychological Intelligence Scale for Children or Battery and Halstead Reitan WISC IV) and (Weschler Pre-School Neuropsychological Battery. and Primary Scale of Intelligence or WPPSI-III). For example, in Halstead, it includes the Rhythm Test (ask the person to compare All tests contain verbal scales (measure rhythmic beats, thus sound recognition, vocabulary, knowledge of facts, short- attention, and concentration), Strength term memory, and verbal reasoning.) and of Grip Test (compares the grips of the performance scales (assess psychomotor right and left hands), Tactile abilities and non-verbal reasoning and Performance Test (requires the test taker ability to learn new relationships. to place wooden blocks in a form of board Some theorists think that intelligence while blindfolded, thus learning and involves more, including ability to adapt memory skills). to the environment, ability to generate Research on validity of new ideas, and ability to process neuropsychological tests suggest they information efficiently. may be useful for detecting organic IQ Tests tend to be reliable, and they change. However, it raises the issue of predict academic success, they are valid false positive and false negatives in assessment tools. which there will be times when the test shows a problem when none exists Neuropsychological Testing (false positive) and times when no Neuropsychological Tests measure problem is found even though some abilities in areas such receptive and difficulty is present (false negative). expressive language, attention, and Neuropsychological test can be used as concentration, memory, motor skills, primarily screening devices to improve perceptual abilities, and learning and the likelihood that real problems will be abstraction. In other words, this method found but its downside is it requires of testing assess brain dysfunction on hours to administer and therefore not used unless brain damage is suspected. Neuroimaging: Pictures of the Brain totally enclosed inside a narrow tube with magnetic coil surrounding the head. With the use of neuroimaging, we have People who are somewhat the ability now to look inside the nervous claustrophobic. system and take increasingly accurate pictures of the structure and function of Images of Brain Functioning the brain. Positron Emission Tomography or PET Neuroimaging can be divided into two scan is used for brain functioning. It categories: happens when the subject are injected with a tracer substance attached to 1. Procedures that examine the brain. radioactive isotopes, or groups of atoms. 2. Procedures that examine the actual functioning of the brain by mapping The PET scan is also useful in blood flow and other metabolic supplementing MRI and CT scans when activity. localizing the sites of trauma resulting from head injury or stroke, as well as Images of the Brain Structure when localizing brain tumors. Computerized Axial Tomography or PET scans are also used to look at CT scan is useful in identifying and varying patterns of metabolism that locating abnormalities in the structure might be associated with different or shape of the brain. disorders. It is also useful in locating brain tumors, Textbook Situation: injuries, and other structural and anatomical abnormalities. However, Patients with Alzheimer’s type dementia one difficulty is that all X-rays involve that there is a reduce glucose metabolism repeated x-radiation in which poses in the parietal lobes. some risk cell damage. The second procedure is called Single Magnetic Resonance Imaging or MRI. Photon Emission Computed During MRI, the patient’s head is placed Tomography (SPECT). It works like in a high strength magnetic field PET but with a different tracer through which radio frequency signals substance is used in this procedure; less are transmitted. These signals “excite” accurate and less expensive. Therefore, the brain tissue, altering the protons in SPECT is used often more than PET hydrogen atoms. scans. MRI is more expensive than CT scan. MRI procedures have been developed to work quickly than regular. These Differences: procedures may take to milliseconds and MRI takes 10 minutes. can take pictures of the brain at work, recording changes from one second to the CT scan takes 45 minutes. next. Because these procedures measure Another disadvantage of MRI is the the functioning of the brain, it is called as person undergoing the procedure is Functional MRI. MRI procedures allow researchers to waves. These brain waves are slower and immediate response of the brain, as well more irregular than the alpha waves. as new face such as BOLD- fMRI (Blood If frequent delta wave occurred, it might Oxygen Level Dependent fMRI) is indicate dysfunction of localized areas of currently the most non-common MRI the brain. technique used to study psychological disorders. Physiological assessments include heart rate, respiration, and electrodermal Brain imagery procedures hold responding formerly known as galvanic enormous potential of illuminating the skin response or GAR which measures contribution of biological factors to the sweat gland activity controlled by psychological disorders. the nervous system. Psychophysiological Assessment Importance of Physiological Assessment: It refers to the measurable changes in the 1. Assessing psychophysiological nervous system that reflect emotional or response to emotional stimuli is psychological events. It can be taken important in many disorders, one ither directly to the brain or from other being post-traumatic stress disorder. parts of the body. 2. It is also used with many sexual Measuring electrical activity in the head dysfunction and disorders. related to the firing of a specific group of 3. It is also important in the assessment neurons reveal brain wave activity. A and treatment of conditions such as person’s brain waves can be assessed in headaches and hypertension; they both waking and sleeping states. In form the basis for treatment called electroencephalogram or EEG, biofeedback. electrodes are placed directly on various - In biofeedback, levels of places on the scalp to record different low physiological responding, such as voltage currents. blood pressure readings are fed back to the patient by meters or gauges so When brief period of EEG patterns is that the patient can try to regulate recorded in response to specific events these responses. such as hearing a psychologically meaningful stimulus, the response is Diagnosing Psychological Disorders called evoked potential. Idiographic Strategy refers to the In a normal, healthy, relaxed adult, unique about an individual’s personality, waking activities are characterized by cultural background, or circumstances. regular pattern of changes in voltage To determine the general class of termed alpha waves. The alpha wave problems, we must determine first the pattern is associated with relaxation and nomothetic strategy or the attempt to calmness. name or classify the problem. During the deepest and most relaxed Classification refers to the construct stage, EEG shows a pattern of delta groups or categories to assign objects or people to these categories on the basis of The second strategy is Dimensional their shared attributes or relations – a Approach in which we note variety of nomothetic strategy. cognitions, moods, and behaviors in which the patient presents and quantify In scientific context, it is called them on a scale. taxonomy such as insects or rocks. However, if the subject is psychology- This was labeled as unsatisfactory behaviors, you use the word nosology. because most theories have not been able to agree on how many dimensions are Nomenclature describes the names or required. labels of the disorders that makes up the nosology. The third strategy is a categorical approach with a twist called prototypical Classification Issues approach in which you identifies Within psychopathology, definitions of characteristics of an entity and classify it, normal and abnormal are questioned, as but you allow non-essential variations it is the assumption that a behavior or that do not necessarily change the cognition is part of one disorder and not classification. another. Textbook Example: Categorical and Dimensional If someone were asked you to describe a Approaches dog, you can give general description of The classical categorical approach it, but you might not give exactly originates from the work of Emil describing a specific dog. Kraepelin and from the study of This has the best, fitting with the current biological tradition of psychopathology. state of psychopathology. When using a Each disorder is unique. Because prototypical approach in psychology, disorder is fundamentally different from features are listed, and an individual each other, we only need one set of must meet enough of them to fall into defining criteria in which everybody in that category. the category has to meet. Reliability Textbook Example: The psychological disorder can thus be If the criteria for major depressive identified reliably. If the disorder is not episode are presence of depressed mood, readily apparent to both clinicians, the significant weight loss or gain when not diagnoses might represent bias. eating, diminished ability to think or The more reliable the nosology or concentrate and then seven other system of classification is, the less likely symptoms, an individual would have to bias to creep during diagnosis. meet all the criteria. Validity This approach is clearly inappropriate because of the complexity of the psychological disorders. Construct Validity means the sign and disturbances had the greatest impact on symptoms chosen as criteria for the the development of our nosology. diagnostic category are consistently APA published a second edition of DSM associated. Famillial Aggregation to II. which the disorder would be found among patient’s relative. DSM-III and DSM-III-R Predictive Validity happens when the Under the leadership of Robert Spitz, clinician tells what is likely to happen three changes stood out: with the prototypical patient; may predict the course of disorder. Criterion 1. DSM-III attempted to take a Validity is when the outcome is the theoretical approach to diagnosis, criterion by which we judge the relying on precise description of usefulness of the diagnostic category. disorders rather than on psychoanalytic and biological Finally, the content validity is when you theories of etiology. simply create criteria for diagnosis. In - Rather than classifying phobia under other words, you need to get the label the broad category of “neurosis” right. defined by intrapsychic conflicts and defense mechanisms, it was assigned Diagnosis before 1980 to its own category within a broader Only three out of nine systems were group “anxiety groups”. listed phobic disorder as a separate 2. Specificity and detail which the category. criteria for identifying as disorder were listed to made it possible to Kraepelin first discovered the study their reliability and validity. schizophrenia disorder. His term for the 3. It allows individuals with disorder at the time is Dementia Praecox psychological disorders to be rated that refers to the deterioration of the on five dimensions or axis. brain occurs with advancing age - The schizophrenia or mood disorder (dementia) and develops earlier than it is on the first axis. Enduring chronic supposed to, or prematurely (praecox) disorders of personality is on the The name reflected based on his belief second axis. Physical disorders and that brain pathology is the cause of this condition are on the third axis. The particular disorder. Alongside with amount of psychosocial stress is on schizophrenia, he also described bipolar the fourth axis and on the fifth axis, disorder, then called as manic- it is the level of adaptive depressive disorder. functioning. Multiaxial system Philippine Pinel characterized allowed the clinician to gather psychological disorders including information in a number of areas depression as separate entities but rather than one. Kraepelin’s theorizing that psychological DSM-IV and DSM-IV-TR disorders are basically biological The most substantial change in DSM-IV In DSM-V, it introduces cross-cutting was that the distinction between dimensional symptom measures. This organically based disorders and assessment is not specific to any psychologically based disorders that particular disorder but evaluate in a was present in previous editions were global sense important symptom. eliminated. DSM-5 and Frank The Multiaxial Format in DSM-IV One change in DSM-V is to make Only personality disorders and judgment or severity and impairment intellectual disability were now coded more systematic using dimensional on Axis II. scale. Pervasive developmental disorders, Social and Cultural Considerations in motor skill disorders, and DSM-V communication disorders are on Axis I. Cultural Formulation allows the The new Axis IV is used for reporting disorder to be described from the psychosocial and environmental perspective of patient’s personal problems that might have an impact on experience and in terms of his/her disorder. primary social and cultural group. Axis V was essentially unchanged. Criticisms of DSM-V DSM-V DSM-V is the most advanced, scientifically based systems of nosology DSM-V is largely unchanged from DSM- ever developed. IV, although somehow new disorders are introduced, and other disorders have been Comorbidity is when the patient is reclassified. diagnoses with more than one psychological disorder at the same time. The manual is divided into three sections: A Caution about Labelling and Stigma 1. Introduces the manual and describes how best to use it. Stigma is a combination of stereotypic 2. It presents the disorder themselves. negative beliefs, prejudices, and 3. It includes the descriptions or attitudes resulting in reduce life disorders that need further research. opportunities for the devalue group. The most notable change in multi-axial In DSM-V, the term mental retardation system is the former Axis I, II, and III, is dropped and replaced with intellectual have been combined into the description disability. of the disorders, and clinicians can make Mixed Anxiety Depression notions separately for relevant psychosocial or contextual factors DSM-IV is concerned with these issues (formerly Axis IV) or extent disability for several reasons: (formerly Axis V) associated with diagnosis. 1. Many individuals present with some Pre-Menstrual Dysphoric Disorder minor symptoms of a given disorder. Clinicians had identified a small group of - Threshold means it is the minimum women incapacitating emotional number of criteria required to meet reactions associated with late luteal the definition of a disorder. phase of their menstrual period. 2. Substantial and legal policy implications are contingent on a It was named as late luteal phase diagnosis. dysphoric disorder (LLPDD) and placed on the appendix. However, after The authors of ICD-10 created a category further research, it was changed to pre- of mixed anxiety depression, but they menstrual dysphoric disorder had not defined it or created new (PMDD). criteria for it. Therefore, to possibly explore of creating new diagnostic, the A substantial number of women with no study undertaken three specific goals: psychological disorder meet the criteria for LLPDD. 1. Mental health professionals carefully administered semi structured The accumulating evidence concluded interviews. that PMDD is best considered a mood 2. If mixed anxiety depression did exist, disorder, rather than an endocrine was it more prevalent in medical disorder. Because of this, the support for primary care settings than in PMDD is sufficient and it was included outpatient mental health settings? as a distinct psychological disorder in 3. What set of criteria would best DSM-V in the mood disorders chapter. identify the disorder? Beyond DSM-5: Dimension and Specs The results found out that the people who did not meet criteria for an existing The term spectrum is another way to anxiety or mood disorder were common describe groups of disorder that share in primary care settings. Furthermore, certain biological or psychological they were substantially impaired in qualities or dimensions. their occupational and social Asperger’s syndrome (mild form of functioning and experienced great deal autism) was integrated with autistic of distress. disorder into a new category of “autism Because these people appeared both spectrum disorder.” anxious and depressed, the potential category possessed validity content. The mixed anxiety disorder was placed in the appendix that implies “new disorder under study”.