Lecture 5 Clinical Psychology
Assessment: Concepts & Classification Clinical Psychology Lectures
Importance of Theory Don t want to learn only that when X happens do Y. Want to learn framework to figure out what needs to be done
Major Functions of Theories Means of explaining how people acquire and change personality or behaviour Helps to understand differences in the expression of those behaviours Helps us understand, predict, and change behaviour
Determine how abnormal behaviour is understood, diagnosed, studied, and measured Choice of treatment approach Permit development of specific hypotheses about particular cases
Core Competencies of Assessment Krishnamurthy et al. (2004) Overview of issues related to the development of competencies in psychological assessment Derived from Competencies Conference: Future Directions in Education and Credentialing in Professional Psychology
Eight Specific Competencies in Psychological Assessment 1. Background in psychometric theory 2. Knowledge of scientific, theoretical, empirical, and contextual bases of assessment 3. Knowledge, skill, techniques to assess cognitive, affective, behavioural, and personality dimensions of human experience
4. Ability to assess outcomes of treatment/intervention 5. Ability to evaluate roles, contexts, relationships within which patients and psychologists function, and the reciprocal impact of those roles, contexts, and relationship on assessment activity.
6. Establish, maintain, and understand the collaborative professional relationship that provides a context for all psychological activity 7. An understanding of the relationship between assessment and intervention, assessment as an intervention, and intervention planning
8. Technical skills: Problem identification and case conceptualization Understanding and selection of appropriate assessment methods Effective application of the assessment procedures Systematic data gathering Integration of information, inference, and analysis Communication of findings, recommendations Provision of feedback
Goals of Psychological Assessment Problem Explication Formulation Prognosis Treatment Issues and Recommendations Provision of Therapeutic Context Communication of Findings
Diagnosis and Formulation Diagnosis: Assigning diagnostic category or label Formulation: Attempt to explain genesis, maintenance, and process related information for treatment Structured Interviews Diagnosis Psychological Assessment Some Diagnostic Information and Formulation
Most clinicians agree that need both, although likely majority indicate that formulation is actually more important May be changing somewhat inadvertently with notion of empirically validated treatment work
Diagnosis and Formulation Assumptions Diagnosis Diagnostic Entities Uniform Diagnosis involves assigning the diagnostic construct or label Structured Interviews Based on current Diagnostic System Formulation Formulation assumes each person unique Formulation involves the person Interview, objective & projective tests, process variables Based on theoretical perspective
Overview of Information For Formulation Intra-individual issues Interpersonal issues Environmental Issues Process-related Issues
Example of Formulation McWilliams (1999) It sounds like you are shy and sensitive by temperament, but it seems that no one in your family knew how to help you get braver around people. With the best intentions, they made things worse by forcing you into social situations, where you clutched. Because you had one after another failure socially, you began to think there was something very strange about you, and eventually, you related only to yourself and your thoughts.
You were lonely, but the idea of being close to someone terrified you. Then when your boss criticized you, you retreated even further into yourself, to the point that you were hearing voices. We need to work on getting you more comfortable with others, including me, and part of that will involve looking at things that you believed makes you so alien. Once we understand the meaning of some of your preoccupations, I think you ll find you re not so bizarre. In the meantime, if you re still hearing voices, you may want to consider seeing someone who will prescribe antipsychotic medications. Does that make sense to you?
Goals of Psychological Assessment Problem Explication Formulation Prognosis Treatment Issues and Recommendations Provision of Therapeutic Context Communication of Findings
Prognosis: Expected course, and the degree and speed of recovery
Goals of Psychological Assessment Problem Explication Formulation Prognosis Treatment Issues and Recommendations Provision of Therapeutic Context Communication of Findings
Goals of Psychological Assessment Problem Explication Formulation Prognosis Treatment Issues and Recommendations Provision of Therapeutic Context Communication of Findings
Goals of Psychological Assessment Problem Explication Formulation Prognosis Treatment Issues and Recommendations Provision of Therapeutic Context Communication of Findings
Classification of Psychological Disorders
Classification Normal vs. Abnormal Charles Manson
Classification Need to further define abnormal Divide abnormal into subclasses
Classification - Purposes Description and need to identify Communication Research Treatment Insurance Theory Development Epidemiological Information
Diagnosis leads to treatment From medical perspective: Appendicitis Gas Pains
Diagnosis does not always lead to specific treatment: Alzheimer s Disease Depression and families of drugs
How to Classify? 1. Divide disorders into mutually exclusive and collectively exhaustive subclasses a. Mutually Exclusive: disorders should be distinct and cannot belong to two different subclasses (e.g., poisonous and edible mushrooms???) b. Collectively Exhaustive: all disorders must be classified
How to Classify Cont d Reliability: Each time you (or someone else) uses the classification system, should get the same result Need to identify psychological problems in a clear and reliable manner Also need agreement among mental health professionals or can have individuals referring to same term to describe different disorders E.G., Schizophrenia and split personality (i.e., dissociative identity disorder)
How to Classify Cont d Validity: Classification system should say something about the true world Homosexuality example New Disorders Being Considered
Classification Discrete? Can people be placed in a neat diagnostic box or not?
Discrete Categories Male Female Pregnant Not Pregnant
Classification Continuous? Are the disorders on a continuum? Nondepressed Depressed
Discrete Categories? Depressed Not Depressed Normal Abnormal
Diagnostic Schemes Diagnostic and Statistical Manual of Mental Disorders (DSM most used research-wise) International Classification of Diseases (ICD most used clinical-wise) Psychodynamic Diagnostic Manual (different approach and used more and more) Operationalized Psychodyanmic Diagnostics (used more in Europe)
DSM IV Text Revision & DSM 5
DSM Revised periodically: DSM first published 1952 DSM II published 1968 DSM III published 1980 DSM III Revised published 1987 DSM IV published 1994 DSM IV Text Revision 2000 (Current one used) DSM 5 published 2014
DSM IV TR Over 400 disorders DSM provides descriptive information not based on any one theoretical perspective (although this is debatable) Categorical Approach Descriptive features are based on observable features:
DSM IV TR Provides information on: Diagnostic Features Associated Features and Disorders Associated Laboratory Findings Age-related, Culture-related and Gender-related features
DSM IV TR Diagnoses made along five Axes Attempt to take into account more of the person and his/her context The Five Axes are:
Major Axis I Diagnostic Categories Anxiety disorders Disorders first diagnosed in infancy and childhood Schizophrenia and other psychotic disorders Mental disorders due to a general medical condition Factitious disorders Other conditions that are the focus of clinical attention Sexual and gender identity disorders Adjustment disorders Mood disorders Substance-related disorders Delirium, dementia, amnestic, and other cognitive disorders Somatoform disorders Dissociative disorders Eating disorders Impulse-control disorders Sleep disorders
Pros and Cons Pro: Reliability has improved over previous editions Provides information on research and reliable and valid information Axis IV and V very good in terms of attempting to take into account many factors
Pros and Cons Con: Only first 3 Axes tend to used and even then Axis 2 used inappropriately Labeling and stigma still issue Biological tests not used Fees paid based on diagnosis and some patients diagnosed inappropriately Doesn t lead to differential treatment decisions for most part Still very subjective
DSM Categorical approach (contradicts itself) Similar to ICD although ICD has other disorders not appearing in DSM.
Psychodynamic Diagnostic Manual (PDM)
PDM DSM provides one level of description Some argue don t measure some of the most important things PDM: there is more to people than what is described in DSM Attempts to describe and categorize elements not found in DSM Attempts to provide information that will improve comprehensive treatments
PDM Not developed to supplant DSM but to supplement DSM Developed from a theoretical perspective: Current Psychodynamic Theory: Psychoanalysis Object Relations Attachment Theory
PDM Diagnostic framework Describes the whole person: Surface and deeper levels of personality, person s emotional and social functioning Based on current neuroscience and treatment outcome studies
PDM Developed By American Psychoanalytic Association American Academy of Psychoanalysis International Psychoanalytic Association American Psychological Association Division 39 National Membership Committee on Psychoanalysis in Clinical Social Work
PDM The elements include: Personality patterns Social and emotional capacities Unique mental profiles Personal experiences of individuals
PDM- Rationale Human behaviour is complex DSM simplifies behaviour too much Want to direct focus on full range of affect, thought, behaviour in context of an individual s own unique history
PDM- Rationale Cont d Consistent with idea that: Rather than thinking of people having discrete disorders (i.e., ego dystonic, separate, outside of self), see disorders as result of some process (personality, incorporation of upbringing, etc.) and the process is what is important
PDM Dimensions 1. Personality Patterns and Disorders (P Axis) 2. Mental Functioning (M Axis) 3. Manifest Symptoms and Concerns (S Axis)
P Axis Person s location on Continuum: Healthy -----------------Disordered Ways in which person organizes mental functioning and interacts with world Maxim: Need to understand person in order to understand problem
P Axis Includes many of the Axis II diagnoses from DSM Adds other ones that are seen as extremely important: Depressive Personality Disorder Sadistic and Sadomasochistic PD Masochistic (Self-defeating) PD Somatizing PD Dissociative PD
M Axis Detailed look at emotional functioning E.G., Information processing, self-regulation, relationships, emotional expression, learning, coping/defenses, etc.
S Axis Using the DSM categories, focus on personal experience of difficulties Need to be seen in context of personality and mental functioning
PDM Attempt to develop a thorough and comprehensive diagnostic picture Takes whole person into account
PDM Published in 2006 so little early to evaluate Welcomed by most clinicians as an addition to aid in treatment planning Aids in formulation: Diagnosis doesn t give you all relevant information for treatment Need to determine etiology, maintenance factors, process-related issues, history of relationships, etc. which guide treatment
OPD
Interpersonal Diagnosis Lorna Benjamin