Clinical Assessment & Diagnosis PDF

Clinical Assessment & Diagnosis LESSON 3 Question What is Clinical Assessment and Diagnosis? Assessing Psychological Disorders Clinical assessment is the systematic evaluation and measurement of psychological, biological, and social factors in an individual presenting with a possible psychological...

Clinical Assessment & Diagnosis LESSON 3 Question What is Clinical Assessment and Diagnosis? Assessing Psychological Disorders Clinical assessment is the systematic evaluation and measurement of psychological, biological, and social factors in an individual presenting with a possible psychological disorder. 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). ◦ The classification of disorders by symptoms and signs Question What is the advantages of diagnosis? Assessing Psychological Disorders Advantages of diagnosis: 1. Facilitates communication among professionals 2. Advances the search for causes and treatments 3. Cornerstone of clinical care Key Concepts in Assessment Reliability Consistency of measurement Interrater Observer agreement  Test-retest Similarity of scores across repeated test administrations or observations  Alternate Forms Similarity of scores on tests that are similar but not identical Internal Consistency Extent to which test items are related to one another  Validity  Howwell does a test measure what it is supposed to measure?  Content validity Extent to which a measure adequately samples the domain of interest, e.g., all of the symptoms of a disorder  Criterion validity Extent to which a measure is associated with another measure (the criterion) Concurrent - Two measures administered at the same point in time  Predictive - Ability of the measure to predict another variable measured at some future point in time Validity  Construct validity (Cronbach & Meehl, 1955) A construct is an abstract concept or inferred attribute Involves correlating multiple indirect measures of the attribute o e.g., self-report of anxiety correlated with increased HR, shallow breathing, racing thoughts Important for validating our theoretical understanding of psychopathology Method for evaluating diagnostic categories Standardization 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.  The standards might apply to the procedures of testing, scoring, and evaluating data.  For example, the assessment might be given to large numbers of people who differ on important factors such as age, race, gender, socioeconomic status, and diagnosis; their scores would be pooled with other individuals like them and then be used as a standard, or norm, for comparison purposes. For example, if you are an African American male, 19 years old, and from a middle- class background, your score on a psychological test should be compared with the scores of others like you and not to the scores of different people, such as a group of women of Asian descent in their 60s from working-class backgrounds. Reliability, validity, and standardization are important to all forms of psychological assessment The Clinical Interview INFORMAL/LESS STRUCTURED INTERVIEWS STRUCTURED INTERVIEWS Interviewer attends to how questions are All interviewers ask the same questions in answered a predetermined order Is response accompanied by appropriate Structured Clinical Interview for Axis I of emotion? DSM (SCID) Does client fail to answer question? Good interrater reliability for most diagnostic categories Good rapport essential to earn trust Empathy and accepting attitude necessary Reliability lower than for structured interviews The Mental Status Exam The mental status exam involves the systematic observation of an individual’s behavior. The exam covers five categories: 1. Appearance and Behavior 2. Thought Processes 3. Mood and Affect 4. Intellectual Functioning 5. Sensorium Physical Examination  Many problems presenting as disorders of behavior, cognition, or mood may, on careful physical examination, have a clear relationship to a temporary toxic state. This toxic state could be caused by bad food, the wrong amount or type of medicine, or onset of a medical condition.  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.  Certain psychotic symptoms, including delusions or hallucinations, might be associated with the development of a brain tumor. Withdrawal from cocaine often produces panic attacks, but many patients presenting with panic attacks are reluctant to volunteer information about their addiction, which may lead to an inappropriate diagnosis and improper treatment. Behavioral Assessment Behavioral assessment - takes this process one step further by using 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 who are not old enough or skilled enough to report their problems and experiences  Observational assessment is usually focused on the here and now. Therefore, the clinician’s attention is usually directed to the immediate behavior, its antecedents (what happened just before the behavior), and its consequences (what happened afterward) (Haynes et al., 2009). Behavioral Assessment Behavioral Assessment To use the example of the violent boy, an observer would note that the sequence of events was (1) his mother asking him to put his glass in the sink (antecedent), (2) the boy throwing the glass (behavior), and (3) his mother’s lack of response (consequence).  This antecedent–behavior–consequence sequence (the ABCs) might suggest that the boy was being reinforced for his violent outburst by not having to clean up his mess. And because there was no negative consequence for his behavior (his mother didn’t scold or reprimand him), he will probably act violently the next time he doesn’t want to do something. Behavioral and Cognitive Assessment  Focus on aspects of environment  Characteristics of the person  Frequency and form of problematic behaviors  Consequences of problem behaviors Behavioral and Cognitive Assessment Observe behavior as it occurs Sequence of behavior divided into segments Antecedents and consequences Behavioral assessments often conducted in lab setting e.g., mother and child interact in a lab living room Interaction observed through one-way mirror or videotaped for later coding Self-Monitoring or Self-observation People can also observe their own behavior to find patterns, a technique known as self-monitoring or self-observation (Haynes, O’Brien, & Kaholokula, 2011).  Self-monitoring – Individuals observe and record their own behavior e.g., moods, stressful events, thoughts, etc. Ecological Momentary Assessment (EMA) – Collection of data in real time using diaries or smart phones Reactivity – The act of observing one’s behavior may alter it Desirable behaviors tend to increase whereas undesirable behaviors decrease Cognitive-Style Questionnaires Use to help plan treatment targets  Format often similar to personality tests  Dysfunctional Attitude Scale (DAS) Identifies maladaptive thought patterns “People will think less of me if I make mistakes” Psychological Testing  Psychological tests include specific tools to determine cognitive, emotional, or behavioral responses that might be associated with a specific disorder and more general tools that assess longstanding personality features, such as a tendency to be suspicious. Psychological Testing  Personality Tests Self-reported Personality Inventories Minnesota Multiphasic Personality Inventory (MMPI) Yields profile of psychological functioning Specific subscales to detect lying and faking “good” or “bad” Projective Tests - include a variety of methods in which ambiguous stimuli, such as pictures of people or things, are presented to people who are asked to describe what they see Rorshach Inkblot Test and Thematic Apperception Test (TAT) Projective hypothesis Responses to ambiguous stimuli reflect unconscious processes Underreporting of Stigmatized Behaviors Face-to-face interviews can have low validity for stigmatized and illegal behaviors E.g., drug use, sexual behavior, violence Respondents are more likely to endorse behavior on a computer questionnaire Psychological Tests Intelligence tests (IQ tests) – Stanford-Binet, 5th ed. (SB5) – Assess current mental ability – Used to predict school performance, diagnose learning disabilities or intellectual – Wechsler Scales developmental disorder (mental Wechsler Adult Intelligence Scale, 4th ed. retardation), identify gifted children, as part (WAIS-IV) of a neuropsychological examination Wechsler Intelligence Scale for Children, 4th – Mean IQ = 100, SD = 15 (Wechsler) or ed. (WISC-IV) SD = 16 (SB) Wechsler Preschool and Primary Scale for - Lower IQs associated with higher Children, 3rd ed. (WPPSI-III) psychopathology and mortality – Performance on IQ tests impacted by Stereotype Threat Neuropsychological Testing Neuropsychological tests measure abilities in areas such as receptive and expressive language, attention and concentration, memory, motor skills, perceptual abilities, and learning and abstraction in such a way that the clinician can make educated guesses about the person’s performance and the possible existence of brain impairment. Example: Bender Visual-Motor Gestalt test  A child is given a series of cards on which are drawn various lines and shapes. The task is for the child to copy what is drawn on the card. The errors on the test are compared with test results of other children of the same age; if the number of errors exceeds a certain figure, then brain dysfunction is suspected Neurobiological Assessment: Brain Imaging  Computerized Axial Tomography (CT or CAT scan) – e.g., enlarged ventricles  Magnetic Resonance Imaging (MRI) – Similar to CT but higher quality  fMRI (functional MRI)  Images reveal function as well as structure  Measures blood flow in the brain (BOLD=blood oxygenation level dependent)  Positron Emission Tomography (PET scan) – Brain function Neurobiological Assessment: Neuropsychological Assessment Neuropsychologist – Studies how brain abnormalities affect thinking, feeling, and behavior Neuropsychological Tests Reveal performance deficits that can indicate areas of brain malfunction Halstead-Reitan battery Tactile Performance Test-Time Tactile Performance Test-Memory Speech Sounds Perception Test Luria-Nebraska battery Assesses motor skills, tactile and kinesthetic skills, verbal and spatial skills, expressive and receptive speech, etc. Psychophysiological Assessment Psychophysiology – Study of bodily changes that accompany psychological characteristics or events Electrocardiogram (EKG) – Heart rate measured by electrodes placed on chest Electrodermal responding (skin conductance) – Sweat-gland activity measured by electrodes placed on hand Electroencephalogram (EEG) – Brain’s electrical activity measured by electrodes placed on scalp Classification and Diagnosis Diagnostic and Statistical Manual of Mental Disorders (DSM) published by American Psychiatric Association – First edition published in 1952 Previous edition: DSM-IV-TR (fourth edition, revised) – Published in 1994, text revised in 2000 – Many texts and research articles will continue to use DSM-IV terminology for a period of time Current edition: DSM-5 – Published summer of 2013 Changes in DSM-5 Changes in multiaxial system Five axes in DSM-IV-TR changed to two axes in DSM-5 Clinical Syndromes Psychosocial and Environmental Problems Changes in organization of diagnoses DSM-IV-TR clusters diagnoses on similarity of symptoms DSM-5 diagnoses are reorganized to reflect new knowledge of comorbidity and shared etiology OCD moved from anxiety cluster to new cluster that also includes hoarding and body dysmorphic disorder Changes in DSM-5 Personality Disorder Renaming of Diagnoses Diagnoses oMental retardation to intellectual oRemain unchanged from DSM- disability IV oDysthymia to persistent oProposed revisions included in depressive disorder Section III Combining Diagnoses oFor further study oSubstance use disorder replaces New Diagnoses substance abuse and substance oDisruptive mood dysregulation, dependence, etc. premenstrual dysphoric Clearer Criteria disorder, etc. Ethnic and Cultural Considerations Mental illness universal Culture can influence: Risk factors Types of symptoms experienced Willingness to seek help Availability of treatment Cultural Concepts of Distress  Cultural Formulation  9 Concepts of Distress Replaces 25 separate diagnoses E.g., Amok, Drat, Koru, Taijin kyofusho, Hikikomori, etc.  Focus on influence of culture on disorder presentation Criticisms of the DSM  Too many diagnoses? Should relatively common reactions be pathologized? Comorbidity Presence of a second diagnosis 45% of people diagnosed with one disorder will meet criteria for a second disorder Reliability in everyday practice Construct Validity of Diagnostic Categories Construct validity of highest concern Diagnoses are constructs For most disorders, no lab test available to diagnose with certainty Strong construct validity predicts wide range of characteristics Possible etiological causes (past) Clinical characteristics (current) Predict treatment response (future) Criticisms of Classification Stigma against mental illness. Treated differently by others  Difficulty finding a job  Categories do not capture the uniqueness of a person. The disorder does not define the person. She is an individual with schizophrenia, not a “schizophrenic”  Classification may emphasize trivial similarities Relevant information may be overlooked. Questions? Answer Assignment #2– Submission date Sept 27. 1 whole yellow pad QUIZ – SEPT 27. CHAPTER 1-3 REFERENCES Kring, Johnson, Davison, and Neale, Abnormal Psychology, 12th edition, 2014 Barlow & Durrand, Abnormal Psychology, 7th Edition Thank you for listening! PREPARED BY: MA. APRIL F. ARCILLA, MAPSY LA CONSOLACION COLLEGE MANILA