Clinical Assessment and Diagnosis

Clinical Assessment and Diagnosis

Assessing Psychological Disorders Purposes of clinical assessment To understand the individual To predict behavior To plan treatment To evaluate treatment outcome

Assessing Psychological Disorders Analogous to a funnel Starts broad Multidimensional in approach Narrow to specific problem areas

Key Concepts in Assessment Reliability Consistency in measurement Examples include test-retest and inter-rater reliability Validity What an assessment measures and how well it does. Examples include concurrent, discriminant, and predictive validity

Key Concepts in Assessment Standardization Ensures consistency in the use of a technique Provides population benchmarks for comparison Examples include structured administration, scoring, and evaluation procedures

Concepts That Determine the Value of Clinical Assessments

Key Concepts in Assessment Inter-rater reliability Observer agreement Test-retest reliability Similarity of scores across repeated test administrations or observations Content validity Extent to which a measure adequately samples the domain of interest, e.g., all of the symptoms of a disorder Criterion validity Concurrent validity Two measures administered at the same point in time Predictive validity Ability of the measure to predict another variable measured at some future point in time

Example of Interrater Reliability

The Clinical Interview Clinical interview Most common clinical assessment method Structured or semistructured Example of semistructured interview: Anxiety Disorders Interview Schedule for DSM-5 (ADIS-5) has modules pertaining to anxiety, mood, and related disorders, designed to assess DSM-5 criteria

Sample Item form SCID

The Clinical Interview Mental status exam Appearance and behavior Thought processes Mood and affect Intellectual functioning Sensorium

Components of Mental Status Exam Subsequent focus possible existence of disorder characterized by intrusive, unwanted thoughts, and resistance to them. Mental Status Exam 1. Appearance and behavior Overt Behaviour Appearance, posture, expressions 2. Thought Rate of speech Continuity of speech Content of speech 3. Mood and affect Predominant feeling state of the individual says 4. Intellectual functioning Type of vocabulary Use of abstractions and metaphors 5. Orientation Awareness of surroundings in terms of person (self and clinician), time, and place Frank Persistent twitch Appearance appropriate Flow and content of speech reasonable Clanging (combining unrelated words due to similar sounds Korktuğum zaman, aman, saman, yaman Anxious mood Affect appropriate Intelligence within normal limits Oriented

Behavioral Assessment and Observation Behavioral assessment Focus on the present here and now Direct observation of behavior-environment relations Purpose is to identify problematic behaviors and situations ABCs identify antecedents, behaviors, and consequences

Behavioral Assessment and Observation Behavioral observation and behavioral assessment Can be either formal or informal Self-monitoring vs. being observed by others Problem of reactivity using direct observation

ABCs of Observation

Psychological Testing: Projective Tests Psychological testing Must be reliable and valid Projective tests Rooted in psychoanalytic tradition Used to assess unconscious processes Project aspects of personality onto ambiguous test stimuli Require high degree of inference in scoring and interpretation

Psychological Testing: Projective Tests Examples The Rorschach inkblot test Thematic Apperception Test Reliability and validity data tend to be mixed

Sample Item from TAT Size verilen kartlardan hareketle başı, ortası ve sonu olan bir hikaye hayal etmenizi ve anlatmanızı istiyorum. Resimdeki konuyu başlatan olayı, kişilerin ne düşündüğünü, ne hissettiğini ve orada neler olduğunu anlatınız. Aklınıza gelen düşünceleri hemen söyleyiniz. Her bir resim için 5 dakika süreniz var.

Sample Item from Rorschach

Objective Tests and Personality Tests Objective tests Roots in empirical tradition Test stimuli are less ambiguous Require minimal clinical inference in scoring and interpretation Personality tests Minnesota Multiphasic Personality Inventory (MMPI) Extensive reliability, validity, and normative database

Sample MMPI Profile

Psychological Testing and Objective Tests Intelligence tests Nature of intellectual functioning and IQ Originally developed as a measure of degree to which children s performance diverged from others in their grade The deviation IQ Compare a person s scores against those of other people who are of the same age Verbal and performance domains

Neuroimaging and Brain Structure Neuroimaging: pictures of the brain Two objectives Understand brain structure Understand brain function Lanius et al. 2010, dissociative subtype of PTSD

Neuroimaging and Brain Structure Imaging brain structure Computerized axial tomography (CAT or CT scan) Utilizes X-rays Magnetic resonance imaging (MRI) Utilizes strong magnetic fields Better resolution than CT scan

Neuroimaging and Brain Function Imaging brain function Positron emission tomography (PET) Single photon emission computed tomography (SPECT) Both involve injection of radioactive isotopes Isotopes react with oxygen, blood, and glucose in the brain Functional MRI (fmri) brief changes in brain activity

Neuroimaging and Brain Function CT Scan fmri Image PET Scan

Psychophysiological Assessment Psychophysiological assessment Assess brain structure, function, and activity of the nervous system Psychophysiological assessment domains Electroencephalogram (EEG) brain wave activity. Heart rate and respiration cardiorespiratory activity Electrodermal response and levels sweat gland activity

Psychophysiological Assessment Uses of routine psychophysiological assessment Disorders involving a strong physiological component Examples Sexual dysfunctions, sleep disorders Headache and hypertension

Diagnosing Psychological Disorders: Foundations in Classification Diagnostic classification Classification is central to all sciences Assignment to categories based on shared attributes or relations

Issues with Classifying and Diagnosing Psychological Disorders Categorical and dimensional approaches Classical (or pure) categorical approach strict categories (e.g., you either have social anxiety disorder or you don t) Dimensional approach classification along dimensions (e.g., different people have varying amounts of anxiety in social situations) Prototypical approach combines classical and dimensional views

Categorical vs Dimensional Classification

History of DSM DSM I, 1952 DSM II, 1968 DSM IV, 1994 DSM III, 1980 DSM IV-TR, 2000 DSM III-R, 1987 DSM 5, 2013

Issues with Classifying and Diagnosing Psychological Disorders Widely used classification systems Diagnostic and Statistical Manual of Mental Disorders (DSM) Updated every 10 20 years Current edition (released May 2013): DSM-5 Previous edition called DSM-IV-TR

History of the DSM Prior to 1980, diagnoses were made based on biological or psychoanalytic theory Introduction of DSM-III in 1980 revolutionized classification Classification newly relied on specific lists of symptoms, improving reliability and validity Diagnoses classified along five axes describing types of problems (e.g., disorder categories, health problems, life stressors)

History of the DSM DSM-IV was introduced in 1994 Eliminated previous distinction between psychological vs. organic mental disorders Reflected appreciation that all disorders are influenced by both psychological and biological factors DSM-IV-TR ( text revision of DSM-IV) incorporated new research and slightly altered criteria accordingly

History of the DSM

The DSM-5 Basic characteristics Removed axial system Clear inclusion and exclusion criteria for disorders Disorders are categorised under broad headings Empirically grounded, prototypic approach to classification

Unresolved Issues in DSM-5 The problem of comorbidity Defined as two or more disorders for the same person High comorbidity is extremely common Emphasizes reliability, maybe at the expense of validity (i.e., may artificially split diagnoses that are very similar)

Unresolved Issues in DSM-5 Dimensional classification DSM was intended to move toward a more dimensional approach, but critics say it does not improve much from DSM-IV Labeling issues and stigmatization Some labels have negative connotations and may make patients less likely to seek treatment Mental retardation vs Intellectual disability Attention deficit disorder, sexual dysfunctions