Lesson-3-Clinical-Assessment-and-Diagnosis.pdf

Clinical Assessment and Diagnosis Prepared by: Prof. Gerald M. Llanes, RPm, LPT Assessing Psychological Disorders  Assessing Psychological Disorders ▪ Diagnosis- act of identifying and naming a disorder or disease using a system of categorization. ▪ Clinical assessment- The process clin...

Clinical Assessment and Diagnosis Prepared by: Prof. Gerald M. Llanes, RPm, LPT Assessing Psychological Disorders  Assessing Psychological Disorders ▪ Diagnosis- act of identifying and naming a disorder or disease using a system of categorization. ▪ Clinical assessment- The process clinicians use to gather the information they need to diagnose, determine causes, plan treatment, and predict future course of a disorder. ▪ The process of classification is based on an accurate assessment of past and present signs and symptoms. ▪ Sign- a characteristic feature of a disorder that may be recognized by the clinician, but not the patient. ▪ Symptoms- a characteristic that the patient recognizes.  Assessing Psychological Disorders Diagnosis is the process of determining whether the particular problem afflicting the individual meets all criteria for a psychological disorder, as set forth in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5 (American Psychiatric Association, 2013). In abnormal Psychology the most common classification system is the Diagnostic Statistical Manual of Mental Disorders (DSM). Three (3) issues are important in evaluating the usefulness of any diagnostic system.  Assessing Psychological Disorders 1. Diagnostic Reliability- refers to the extent with which clinicians agree on which signs and symptoms signal a specific disorder. 2. Diagnostic Validity- The capacity of a diagnostic system to identify and predict behavioral and psychiatric disorders. Concurrent Validity- diagnostic system’s ability to categorize current disorders accurately. Predictive Validity- diagnostic system’s capacity to predict future conditions. Key Concepts in Assessment ▪ Assessment techniques are subject to a number of strict requirements, not the least of which is some evidence (research) that they actually do what they are designed to do ▪ Reliability is the degree to which a measurement is consistent. ▪ One way psychologists improve their reliability is by carefully designing their assessment devices and then conducting research on them to ensure that two or more raters will get the same answers Key Concepts in Assessment ▪ Validity is whether something measures what it is designed to measure—in this case, whether a technique assesses what it is supposed to. ▪ Comparing the results of an assessment measure under consideration with the results of others that are better known allows you to begin to determine the validity of the first measure. ▪ Standardization is the process by which a certain set of standards or norms is determined for a technique to make its use consistent across different measurements. Key Concepts in Assessment The Clinical Interview The Clinical Interview ▪ The Clinical interview gathers information on current and past. ▪ Clinicians determine when the specific problem started and identify other events (for example, life stress, trauma, or physical illness) that might have occurred about the same time. The Clinical Interview ▪ In addition, most clinicians gather at least some information on the patient’s current and past interpersonal and social history, including family makeup (for example, marital status, number of children, or college student currently living with parents). ▪ Information on sexual development, religious attitudes (current and past), relevant cultural concerns (such as stress induced by discrimination), and educational history are also routinely collected. Mental Status Examination Mental Status Examination ▪ In essence, the mental status exam involves the systematic observation of an individual’s behavior. This type of observation occurs when any one person interacts with another. ▪ The exam covers five categories 1. Appearance and behavior ▪ The clinician notes any overt physical behaviors as well as the individual’s dress, general appearance, posture, and facial expression ▪ For example, slow and effortful motor behavior, sometimes referred to as psychomotor retardation, may indicate severe depression. 1. Appearance and behavior Item Presentation in psychomotor retardation Decreased and/or slowed movement Gross movement of hands, legs, torso, head Posture Slumped while sitting or standing Increased self-touching, especially Self-touching face Facial expression Flat expression 2. Thought processes. ▪ Clinicians might look for several things here. For example, ▪ What is the rate or flow of speech? Does the person talk quickly or slowly? ▪ What about continuity of speech? In other words, does the patient make sense when talking, or are ideas presented with no apparent connection? ▪ In some patients with schizophrenia, a disorganized speech pattern, referred to as loose association or derailment, is quite noticeable. 2. Thought processes. ▪ Content of the speech: Is there any evidence of delusions? ▪ Delusions of Persecution, in which someone thinks people are after him and out to get him all the time ▪ Delusions of grandeur, in which an individual thinks she is all-powerful in some way ▪ The individual might also have ideas of reference, in which everything everyone else does somehow relates back to the individual. ▪ Hallucinations are things a person sees or hears when those things really aren’t there. 3. Mood and affect. ▪ Mood is the predominant feeling state of the individual ▪ Does the person appear to be down in the dumps or continually elated? ▪ Does the individual talk in a depressed or hopeless fashion? ▪ How pervasive is this mood? ▪ Are there times when the depression seems to go away? ▪ Affect, by contrast, refers to the feeling state that accompanies what we say at a given point. 4. Intellectual Functioning ▪ Clinicians make a rough estimate of others’ intellectual functioning just by talking to them. 5. Sensorium The term sensorium refers to our general awareness of our surroundings. If the patient knows who he is and who the clinician is and has a good idea of the time and place, the clinician would say that the patient’s sensorium is “clear” and is “oriented times three” (to person, place, and time). Physical Examination Physical Examination Many patients with problems first go to a family physician For example, thyroid difficulties, particularly hyperthyroidism (overactive thyroid gland), may produce symptoms that mimic certain anxiety disorders, such as generalized anxiety disorder. Hypothyroidism (underactive thyroid gland) might produce symptoms consistent with depression. Personality Assessment Personality Assessment Personality Assessment attempts to measure enduring traits of character, skills, ability, and competence that makes on person different from another. Divided into Projective methods and Personality inventories. A. Projective Tests- ask respondents to impose their own structure and meaning on unstructured, ambiguous test stimuli. 1. Rorschach Inkblot test- consist of 10 inkblots, some black and white, some color, but all sufficiently ambiguous. Personality Assessment Rorschach Developed by Hermann Rorschach who called it a “form interpretation test” because it uses inkblots as forms to be interpreted. Consists of 10 bilaterally symmetrical inkblots printed on separate cards. No manuals though many researchers have put forward manuals for interpretation, the most comprehensive of which was Exner’s. Personality Assessment PROCEDURE Presenting the inkblots “What might this be?” Inquiry: second administration where examiner attempts to determine what features of the inkblots played a role in the testtaker’s percept. “What made it look like…?” Testing the limits: asking specific questions that provide additional information about the personality. Personality Assessment Personality Assessment Thematic Apperception Test It assumes that behaviors and feelings respondents attribute to the main character in a story represent their own tendencies. Developed by Christina Morgan and Henry Murray Originally designed to elicit material as an aid to eliciting fantasy material from patients in psychoanalysis. Consists of 31 pictures one of which is blank. Goal is to measure apperception, from the root word apperceive: perceive in terms of past perceptions. Personality Assessment Thematic Apperception Test Personality Assessment Other projective tests include: 1. Sentence-completion tests- ask respondents to complete sentences beginning with such open-ended phrases Ex. My mother was…, The happiest time was… 2. Projective drawings- Ask people to draw familiar objects or people. Personality Assessment The theory here is that people project their own personality and unconscious fears onto other people and things—in this case, the ambiguous stimuli—and, without realizing it, reveal their unconscious thoughts to the therapist. Personality Assessment B. Personality inventories Personality inventories (self-report questionnaires that assess personal traits) (Meehl, 1945). The Minnesota Multiphasic Personality Inventory (MMPI) is the most widely used and researched clinical assessment tool used by mental health professionals to help diagnose mental health disorders. The MMPI-2 consists of 567 true-false questions and takes approximately 60 to 90 minutes to complete Personality Assessment 2. Personality inventories The Minnesota Multiphasic Personality Inventory (MMPI) was developed in 1937 by clinical psychologist Starke R. Hathaway and neuropsychiatrist J. Charnley McKinley at the University of Minnesota Personality Assessment 10 Clinical Scales of MMPI Scale 1—Hypochondriasis This scale was designed to assess a neurotic concern over bodily functioning. The items on this scale concern physical symptoms and well- being. It was originally developed to identify people displaying the symptoms of hypochondria, or a tendency to believe that one has an undiagnosed medical condition. Personality Assessment Scale 2—Depression This scale was originally designed to identify depression, characterized by poor morale, lack of hope in the future, and general dissatisfaction with one's own life situation. Very high scores may indicate depression, while moderate scores tend to reveal a general dissatisfaction with one’s life. Personality Assessment A Scale 3—Hysteria The third scale was originally designed to identify those who display hysteria or physical complaints in stressful situations. Those who are well-educated and of a high social class tend to score higher on this scale. Women also tend to score higher than men on this scale. Personality Assessment Scale 4—Psychopathic Deviate Originally developed to identify psychopathic individuals, this scale measures social deviation, lack of acceptance of authority, and amorality (a disregard for morality). This scale can be thought of as a measure of disobedience and antisocial behavior. Personality Assessment Scale 5—Masculinity-Femininity This scale was designed by the original authors to identify what they referred to as "homosexual tendencies," for which it was largely ineffective. Today, it is used to assess how much or how little a person identifies how rigidly an individual identifies with stereotypical male and female gender roles. Personality Assessment Scale 6—Paranoia This scale was originally developed to identify individuals with paranoid symptoms such as suspiciousness, feelings of persecution, grandiose self-concepts, excessive sensitivity, and rigid attitudes. Those who score high on this scale tend to have paranoid or psychotic symptoms. Personality Assessment Scale 7—Psychasthenia This diagnostic label is no longer used today and the symptoms described on this scale are more reflective of anxiety, depression, and obsessive-compulsive disorder. This scale was originally used to measure excessive doubts, compulsions, obsessions, and unreasonable fears. Personality Assessment Scale 8—Schizophrenia This scale was originally developed to identify individuals with schizophrenia. It reflects a wide variety of areas including bizarre thought processes and peculiar perceptions, social alienation, poor familial relationships, difficulties in concentration and impulse control, lack of deep interests, disturbing questions of self-worth and self-identity, and sexual difficulties. Personality Assessment Scale 9—Hypomania This scale was developed to identify characteristics of hypomania such as elevated mood, hallucinations, delusions of grandeur, accelerated speech and motor activity, irritability, flight of ideas, and brief periods of depression. Personality Assessment Scale 0—Social Introversion This scale was developed later than the other nine scales. It's designed to assess a person’s shyness and tendency to withdraw from social contacts and responsibilities Intelligence Measures Intelligence Quotient (IQ) was an estimate of intelligence developed by Alfred Binet by calculating a mental age and dividing this by the child’s chronological age. The scale originally developed by Binet is known today as Stanford-Binet Test. Intelligence Measures TESTS OF INTELLIGENCE 1. Stanford-Binet Intelligence Scale The first published intelligence test to provide detailed administration and scoring instructions. It creates a test composite: test score or index derived from the combination of and/or a mathematical transformation of one or more subtest scores 5th edition can be administered to examinees as young as 2 and as old as 85. Intelligence Measures Measured IQ Range Category 145 - 160 Very Gifted or Highly Advanced 130 - 144 Gifted or Very Advanced 120 - 129 Superior 110 - 119 High Average 90 - 109 Average 80 - 89 Low Average 70 - 79 Borderline Impaired or Delayed 55 - 69 Mildly Impaired or Delayed 40 - 54 Moderately Impaired or Delayed Intelligence Measures TESTS OF INTELLIGENCE 2. Wechsler Tests Individually administered intelligence tests to assess the intellectual abilities of people from preschool to adulthood. Items may be presented orally The Weschsler Tests are all point scales that yield deviation IQs with a mean of 100 (interpreted as average) and a standard deviation of 15. Intelligence Measures Subtests are designated as either core or supplemental. Core subtest is administered to obtain a composite score. Supplemental subtest (also called optional subtest) is used to provide additional clinical information or extending the number of abilities or processes sampled. Intelligence Measures Intelligence Measures Intelligence Measures TESTS OF INTELLIGENCE 3 Wechsler Intelligence Tests: Wechsler Adult Intelligence Scale – Fourth Edition (WAIS – IV) for ages 16 to 90 years 11 months. Wechsler Intelligence Scale for Children – Fifth Edition (WISC – V) for ages 6 through 16 years 11 months. Wechsler Preschool and Primary Scale of Intelligence – Third Edition (WPPSI- III) for ages 3 years to 7 years 3 months. Assessment of Brain Disorders Neuropsychological Tests Brain damage is a general reference to any physical or functional impairment that results in sensory, motor, and cognitive, emotional, and/or related deficit. Organicity came from the research of German neurologist Kurt Goldstein of brain-injured soldiers he diagnosed as having organic brain syndrome or organicity for short. Psychological Testing Neuropsychological Tests Signs signaling the need for a more thorough neuropsychological work-up can be classified as being hard or soft. A Hard Sign may be defined as a definite indicator of neurological deficit. Example: abnormal reflex performance. A Soft Sign is an indicator merely suggestive of neurological deficit. An example is the apparent inability to copy a stimulus figure while attempting to draw it. Psychological Testing Neuropsychological Tests Clock Drawing Test (CDT) The task in this test is to draw the face of the clock usually with the hands of the clock indicating a particular time. Observed abnormalities in the patient’s drawing may be reflective of cognitive dysfunction resulting from dementia or other neurological or psychiatric procedures. Psychological Testing Clock Drawing Test (CDT) Psychological Testing Neuropsychological Tests Confrontation Naming Naming each stimulus presented. This seemingly simple task entails 3 component operations: a perceptual component (perceiving the visual features of the stimulus), a semantic component (accessing the underlying conceptual representation or core meaning of whatever is pictured), and a lexical component (accessing and expressing the appropriate name). Psychological Testing Neuropsychological Tests Confrontation Naming Psychological Testing Neuropsychological Tests Picture Absurdity Item Task is to identify what is wrong or silly about the picture. It can provide insight into the test taker’s social comprehension and reasoning abilities. (Similar to Picture Absurdity items on the Stanford-Binet Intelligence Test) Psychological Testing Neuropsychological Tests Picture Absurdity Item Behavioral Assessment Behavioral Assessment Behavioral assessment- direct observation to assess formally an individual’s thoughts, feelings, and behavior in specific situations or contexts. Behavioral assessment may be more appropriate than an interview in terms of assessing individuals. Behavioral Assessment Focuses on those specific aspects of a person’s behavior that led to the person to seek treatment. Detailed information is sought for: (ABC Model) Antecedents- events, and circumstances that typically precede the target behavior. Behavior (Target behavior)- are the disturbed and disturbing behaviors as well as the thoughts and feelings that accompany them. Consequences- events, and circumstances that typically follow the target behaviors. Self-Monitoring People can also observe their own behavior to find patterns, a technique known as self-monitoring or self-observation (Haynes, O’Brien, & Kaholokula, 2011). When behaviors occur only in private (such as purging by people with bulimia), self-monitoring is essential. A more formal and structured way to observe behavior is through checklists and behavior rating scales.