LECTURE 2

Clinical Assessment and

Diagnosis

Assessing Psychological Disorders

Purpose
Understanding the individual
Predicting behavior
Treatment planning
Evaluating outcomes
Funnel Analogy
Broad, multidimensional start
Narrows to specific problems

Assessing Psychological Disorders

Clinical Assessment
Systematic evaluation and measurement
Psychological
Biological
Social
Diagnosis
Degree of fit between symptoms and
diagnostic criteria

Key Concepts in Assessment

Reliability
Measurement consistency
Agreement
Several types:
Test-retest
Inter-rater

Key Concepts in Assessment

Validity
Does the test measure what its supposed to?
Several types:
content
concurrent
discriminant
construct
predictive
face validity

Key Concepts in Assessment

Standardization
Consistent use of techniques
Provides normative population data
Examples
Administration procedures
Scoring
Evaluation of data

Three Concepts Determine the Value of Assessment

The Clinical Interview

Clinical Interview
Clinical core
Structured
Assesses multiple domains
Current and past behavior
Attitudes
Emotions
Detailed history
Presenting problem

The Clinical Interview

Mental Status Exam
Appearance
Behavior
Thought processes
Mood and affect
Intellectual functioning
Sensorium

Mental Status Exam

The Clinical Interview

Other Interviews
Unstructured
Semi structured
Assess most critical items
Departures from format

The Clinical Interview

Physical Examinations
Diagnose or rule out physical etiologies
Toxicities
Medication side effects
Allergic reactions
Metabolic conditions

Assessing Psychological Disorders

Behavioral Assessment
Identification and observation of target
behaviors
Here and now focus
Direct observations
Minimally inferential

Behavioral Assessment

Focus on interactions between events

Assessing Psychological Disorders

Behavioral Observation
Formal vs. informal
Self-monitoring vs. others observing
Reactivity

Assessing Psychological Disorders

Psychological Testing
Reliability
Validity
Specific tools for assessment
Cognition
Emotion
Personality
Behavior

Psychological Testing
Projective Tests
Presentation of ambiguous stimuli
Projection of personality and the
unconscious
Psychoanalytic roots
Examples
Rorschach Inkblot Test
Thematic Apperception Test

Rorschach Test

Psychological Testing
Projective Tests
Criticisms and controversies
Scoring and interpretation
Reliability and validity

Strengths
Qualitative data
Standardization efforts

Psychological Testing
Personality Inventories
Face vs. construct validity
Empirically-based
Minimally ambiguous stimuli
Minimal inference
Scoring
Interpretation

Psychological Testing
Minnesota Multiphasic Personality Inventory
567 items (MMPI-2)
True/false responses
Adolescent version
Extensive normative data
Reliability and validity
Interpretation
Individual scales
Profiles

Psychological Testing

Assessment: Intelligence Testing

Initial purpose: academic prediction
Intelligence quotient (IQ)
Mental vs. chronological age
Deviation IQ
Domains
Verbal
Performance
IQ versus intelligence

Psychological Testing and Neuropsychology

Neuropsychological tests assess
Broad base of skills and abilities
Brain-behavior relations
Assets and deficits
Methods
Fixed versus flexible batteries
Concerns
False Positives
False Negatives

Neuroimaging: Pictures of the Brain

Images of Brain Structure
Computerized axial tomography (CAT/CT)
X-rays of brain
Pictures in slices
Magnetic resonance imaging (MRI)
Strong magnetic field
Improved resolution

Utility: locating tumors, injuries, structural

or anatomical abnormalities

Neuroimaging: Pictures of the Brain

Neuroimaging: Images of Brain Function

PET and SPECT
Injection of radioactive isotopes
React with brain oxygen, blood, and glucose
Reveal metabolic deficiencies

Neuroimaging: Images of Brain Function

Functional MRI (fMRI)
Brief changes in brain activity
Diffuse optical imaging
Infrared light
Less expensive
Improved accuracy

Neuroimaging
Advantages and Limitations
Yield detailed information
Expense
Lack adequate norms
Limited clinical utility

Assessing Psychological Disorders

Psychophysiological Assessment
Emotional or psychological events reflected by
changes in the nervous system
EEG
Brain wave activity
Evoked potentials
Alpha and delta waves
Ex. Nocturnal panic attacks

Psychophysiological Assessment
Other bodily responses
Cardiorespiratory
Heart rate and respiration
Electrodermal
Galvanic skin response
Electromyography
Muscle tension

Psychophysiological Assessment
Assessing response to stimuli is useful in disorders
strong emotional component
PTSD
Sexual dysfunctions
Sleep disorders
Headache
Hypertension

Diagnosing Psychological Disorders

Approaches
Idiographic
Nomothetic
Diagnostic Classification
Categories based on commonalities
Terminology of Classification Systems
Taxonomy
Nosology
Nomenclature

Classification Issues

Nature and Forms of Approach

Classical (or pure) categorical
Dimensional
Prototypical
Two Widely Used Classification Systems
ICD-10
DSM

The DSM System

Critical Issues
Reliability
Decreases bias
Validity
Improved coherence
Purposes
Communication
Prognosis
Treatment planning

Diagnosis Before 1980

Emil Kraepelins Psychiatry: A textbook (1913)

ICD 6 (1948)
DSM-I (1952) and DSM-II (1968)
Low precision
Based on unproven theories
Poor reliability

Diagnosis: The 1980s

DSM-III (1980) and DSM-III-R (1987)
Atheoretical
Increased criterion specificity and detail
Multiaxial system
Low reliability
Reliance on consensus

The Present: The DSM-IV

Basic Characteristics
Comprehensive
Clear inclusion and exclusion criteria
Broad categorization headings
Empirically grounded
Prototypic approach

The Present: The DSM-IV

The Five DSM-IV Axes
I major disorders
II Stable, enduring problems
III Medical conditions (related)
IV Psychosocial problems
V rating of adaptive functioning

The DSM-IV - Social and Cultural Considerations

Cultural features
Culture-bound syndromes
ataque de nervios vs panic attacks
Outline of Cultural Formulation
Identity
Explanations
Factors
Axis IV
"V codes"

Criticisms of the DSM-IV

Thresholds

Time
Other Axes?
Treatment
Comorbidity
Validity?

A Caution About Labeling

Problems and pitfalls with labels
Negative connotation
Stigmas
Over-identification

Creating a Diagnosis
Sub-clinical or atypical presentations
Presentations outside current categories
Clear impairments
Treatment is indicated
Insurance coverage is needed
Examples
Mixed Anxiety-Depression