CHAPTER 3 CLINICAL ASSESSMENT AND DIAGNOSIS (PP. 72-103) 1 Assessment & Diagnosis Purpose Reliability Mental Exam Intro Value Interview Standardized Validity Physical Behavioural Domains Pers Proj Psych Cog Obj Classification Issues Diagnosis Neuro- Psych Neuro Imaging DSM Pre 1980 Psycho Physio Last Future Creating a Diagnosis IV & IVR III & IIIR 2 ASSESSING PSYCHOLOGICAL DISORDERS (P. 74) Purposes of Clinical Assessment To understand the individual General To predict behaviour (prognosis) To plan treatment To evaluate treatment outcome Process Specific Funnel analogy Starts broad: distressed, dysfunctional, Narrow to specific problem areas: anxiety phobia social situations, Multidimensional Top 20 procedures used by clinical psychologists (+1) Diverse domains / tools: Interview, 3 TOP 20 ASSESSMENT PROCEDURES 4 4? VALUE OF ASSESSMENT (PP. 75) 5 Three qualities determine value of measure (F3.1) Reliability Consistency of measurement E.g., test-retest, inter-rater reliability, internal, Validity How well test measures what it is suppose to (psychological construct) E.g., content, concurrent, discriminant, construct, face validity Standardization Standards and norms help ensure consistency in use of a technique E.g., administration procedures, scoring, evaluation of data DOMAINS: CLINICAL INTERVIEW (PP. 75-79) Clinical Interview Most common and important method (slide 4, right, +1) Current / Past behaviors, attitudes, emotions Detailed history of person and presenting problem Often includes Mental Status Exam (+2) 5 Domains: Appearance and behaviour, The first and most important 6 skill that the new clinician must learn is interviewing (Sundberg et al, 2002, p. 96) The clinical interview is the most widely employed assessment tool in clinical psychology. (Hecker & Thorpe, 2005, p. 159) Interviews and observations are central to clinical assessment and also play prominent roles in psychological treatment. (Nietzel et al, 2003, p. 128) single most important means of data collection during psychological evaluation is the assessment interview. (Groth- Marnat, 1990, p. 56) 1
IMPORTANCE OF INTERVIEWING Numerous clinical books address interviewing and related skills 7 MENTAL STATUS EXAM 8 (P. 77) 9 10 Structured / Semi-structured Interviews Series of questions to sample all relevant domains necessary for diagnosis More common than in past Structured Clinical Interview for DSM-IV (SCID-IV) Questions for major DSM-IV diagnostic categories (see later discussion of DSM-IV) Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) Specifically for diagnosing anxiety disorders Table 3.1 shows sample ADIS questions for assessing Obsessive-Compulsive Disorder (+1) 10 PHYSICAL EXAM Physical Exam If recent physical (medical) exam not available, psychologist may request one Especially relevant to psychological disorders due to toxic states, such as those due to Medication Disease (e.g., hyperthyroidism, brain tumour, ) Withdrawal from drugs (e.g., cocaine and panic attack-like symptoms) Certain diagnostic categories directly implicate medical causes or effects, such as Amnesia Alcoholism 11 BEHAVIOURAL ASSESSMENT (PP. 79-81) Behavioural Assessment Focus on here and now, rather than past Direct observation of client thoughts, feelings, and behaviors Purpose is to identify problematic behaviours and situations Identify Antecedents, Behaviours, Consequences (ABCs +1) Usually in naturalistic setting: home, school, work, Tends to be direct and minimally inferential By either Self-monitoring (e.g., diary) or External observer External observer Especially useful for young children, nonverbal adults, less-than-open adults, or others for whom interview limited Problem of reactivity: presence of observer might modify behavior of target individual or others in setting Informal: clinician operationally defines target behaviors and develops procedures for observation Formal (+2) 12 2
13 FORMAL OBSERVATION RATING SCALES 14 Formal Observation Rating Scales are predeveloped instruments Brief Psychiatric Rating Scale Conners Parent/Teacher Rating Scales (right) Sample items from child check list (+1) Numerous others Conners Parent or Teacher Rating Scales: Scales Oppositional Problems / Inattention Hyperactivity Anxious-Shy Perfectionism Social Problems Psychosomatic Conners Global Index DSM-IVSymptom Subscales ADHD Index SAMPLE ITEMS FROM CHECKLIST 0 = Not True (as far as you know) 1 = Somewhat or Sometimes True 2 = Very True or Often True 012 32. Feels he/she has to be perfect 012 33. Feels or complains that no one loves him/her 012 34. Feels others are out to get him/her 012 35. Feels worthless or inferior 012 36. Gets hurt a lot, accident-prone 012 37. Gets in many fights 012 38. Gets teased a lot 012 39. Hangs around with others who get in trouble 012 40. Hears sound or voices that aren t there (describe): 012 41. Impulsive or acts without thinking 012 42. Would rather be alone than with others 012 43. Lying or cheating 012 44. Bites fingernails 012 45. Nervous, highstrung, or tense 012 46. Nervous movements or twitching (describe): 15 PSYCHOLOGICAL TESTING Psychological Testing Ideally, would be reliable and valid, but not true of all psychological tests, according to some researchers Includes Personality and Intellectual assessments Constitute most of procedures shown earlier on list of top 20 tests used by Clinical Psychologists Personality tests: two types tests: viewed negatively by researchers as neither reliable nor valid, but still widely used by clinicians Objective tests: fewer reservations about reliability and validity 16 PROJECTIVE TESTS (PP. 81-82) Tests Present clients with ambiguous stimuli to which they respond Assume clients project personality onto ambiguous stimuli Roots in psychoanalytic tradition High degree of clinical inference in scoring and interpretation Rorschach Inkblot Test (+1) Stage 1: client states what they see in each inkblot Stage 2: clinician queries client about what aspect of card involved in each perception Thematic Apperception Test (+1) Clients tell story: what is happening in each picture, what led up to current situation, what will happen in future, Reliability and validity data mixed (at best) Efforts to develop scoring systems (e.g., Exner) criticized 17 18 SAMPLE STIMULI FOR PROJECTIVE TESTS (P 82) 3
19 OBJECTIVE TESTS (PP. 83-85) Objective Tests Test stimuli less ambiguous: statements with which clients (or interviewers, observers) agree or disagree; correct/incorrect Rooted in empirical (scientific) tradition Minimal clinical inference in scoring and interpretation Objective Personality Tests Minnesota Multiphasic Personality Inventory (MMPI) 567 true / false items Extensive Reliability, Validity, and Normative database 10 Clinical scales with average T scores of 50 (SD = 10) (+1) Validity scales to catch faking: Under- or Over-reporting Numerous additional scales: Content Scales, Supplementary Scales, Jeffrey Dahmer profile (+2) Revised Psychopathy Checklist (PCL-R) Developed by Robert Hare and colleagues (Hare, 1991) Assesses three facets of Psychopathic personality: 1 - Hypochondriasis disorder manifested by physical symptoms 2 -Depression depressed mood or clinical depression 3 Hysteria specific physical complaints, inability to deal with life stresses 4 - Psychopathic Deviate antisocial acts and feelings, hostility and anger, blame others for problems 5 - Masculine-Feminine Interests stereotypic masculine and feminine interests, issues related to gender roles MMPI CLINICAL SCALES 20 6 -Paranoia suspicious of people s intentions or motives 7 - Psychasthenia feelings of anxiety, concern, obsessive ruminations, general maladjustment 8 - Schizophrenia feel alienation, differentness, confusion, bizarre sensations, isolation 9 -Mania excessive energy, psychomotor acceleration, scattered behavior 10 - Social Introversion- Extraversion social shyness, preference for solitary pursuits, lack social assertiveness JEFFREY DAHMER PROFILE C8:21 21 OBJECTIVE TESTS OF INTELLIGENCE (PP. 83-85) 22 Intellectual functioning central to number of disorders, including: dementia, reading disorders, mental retardation, learning disabilities, Controversial because of differential performance of different ethnic groups, but high validity predicting school success and job performance Contemporary IQ testing IQ conceptualized as hierarchical in nature: General Intelligence (g), Specific Intelligences, Standard IQ tests often assess Verbal and Performance aspects, as on Wechsler tests (WAIS, WISC, ) Scored relative to Normative groups: deviation IQ calculated to ensure certain percentage of people within +/-1 SD, 2 SD, (i.e., Normal Distribution) NEUROPSYCHOLOGICAL TESTS (P. 86) General Introduction Assess broad range of motor, cognitive, memory skills, and abilities Goal to understand brain-behaviour relations (i.e., person s assets and deficits) E.g., Luria-Nebraska (+1) and Halstead-Reitan (+2) Batteries Some overlap between intelligence and neuropsychological tests Problems with Neuropsychological (and other) Tests False Positives: Saying you have a brain problem, but you do not False Negatives: Saying you do not have a brain problem, but you do 23 24 Luria-Nebraska Halstead-Reitan Category Test: classify drawings into 4 Appropriate for people categories given correct/incorrect feedback aged 13 and older Tactual Performance (+1): blindfolded fit 90 to 150 minutes wooden blocks into formboard with 269 items in following dominant, non-dominant hands. Later draw 11 clinical scales shapes. Trail Making (+1): connect numbered circles Clinical Scales and then alternating numbers and letters Reading Finger Tapping: tap key rapidly with index Writing finger of dominant, non-dominant hands Arithmetic Rhythm Test: whether 30 pairs of nonverbal sounds are same or different. Visual Speech Sounds Perception: spelling for 60 Memory tape-recorded nonsense syllables Expressive Language Reitan-Indiana Aphasia Screening: name Receptive Language pictures, write picture name without saying aloud, read text, repeat words, arithmetic, Motor Function draw shapes without lifting pencil Rhythm Reitan-Klove Sensory-Perceptual Tactile Examination: tactile, auditory, visual tasks Intellectual to detect if clients perceive stimulation on one side when both sides stimulated 4
25 NEUROIMAGING AND BRAIN STRUCTURE (P. 86-87) Neuroimaging Pictures of Brain obtained in various ways provide window on brain structure and function Imaging Brain Structure Computerized axial tomography (CAT or CT scan): type of X-ray; pictures brain in slices (right) Magnetic resonance imaging (MRI) operates via strong magnetic field around head and has better resolution than CAT scan (+1) 26 25 MRI SCANS 27 NEUROIMAGING AND BRAIN FUNCTION 28 (P. 87-88) Imaging Brain Function Positron Emission Tomography (PET +1) and Single Photon Emission Computed Tomography (SPECT +2) Both involve injection of tracer substance containing radioactive isotopes Radioactive isotopes react with oxygen, blood, and glucose in brain Researchers at UBC Mood Disorders Clinical Research Unit used PET to identify brain regions involved in dopamine overactivity Functional MRI (fmri) Provides view of brief changes in brain activity (+3) Advantages and Limitations Provide detailed information regarding brain function Procedures are expensive, lack adequate norms Procedures have limited clinical utility 27 PET SCAN AND DEPRESSION Scan on right shows marked increase in Prefrontal brain activity (top) after recovery from Depression 29 SPECT AND DEPRESSION SPECT scan shows increased activity following 12 sessions of Magnetic Seizure Therapy 30 5
FUNCTIONAL MRI AND ALZHEIMER S Brain activation during memory task for group with gene related to Alzheimer disease (top) and group without gene (middle) Both groups normal, but more activation in group at risk for Alzheimer disease may reflect greater work to overcome deficit that does not yet manifest itself PSYCHOPHYSIOLOGICAL ASSESSMENT (PP. 88-89) Psychophysiological Assessment Assess brain structure, function, and activity of nervous system Methods Electroencephalogram (EEG): Brain wave activity (+1) Heart rate and respiration: Cardiorespiratory activity Electrodermal response and levels: Sweat gland activity Electromyography (EMG): Muscle tension Uses of Routine Psychophysiological Assessment Disorders involving strong emotional component e.g., PTSD, sexual dysfunctions, sleep disorders, headache, and hypertension 31 32 EEG: electrodes at various locations on surface of skull (top image) record overall brain activation Pattern of activation varies across different psychological states (bottom image) Waves differ in amplitude, frequency, synchronicity (regularity), EEG abnormal in disorders such as Schizophrenia EEG 33 DIAGNOSING PSYCHOLOGICAL DISORDERS (P. 89-90) Terminology of Classification Systems Taxonomy: Classification in scientific context (i.e., entities / things) Nosology: Application of taxonomy to psychological / medical phenomena Nomenclature: Labels that comprise the nosology (e.g., Anxiety Disorders) Two major schemes APA s DSM-IV (later) WHO s ICD-10 34 CLASSIFICATION ISSUES (PP. 90-92) 35 EXEMPLARS OF CHAIRS Classification Issues Classification central to all sciences Assign cases to categories based on shared attributes Approaches to Classification Classical (or pure) categorical approach Strict categories with defining features Features necessary and sufficient Dimensional approach Quantify cognitions, emotions, along dimensions Prototype approach Categories defined in terms of average or typical (i.e., prototypical) cases Some cases (exemplars) more typical (dogs in text, chairs +1) Example from DSM-IV (+2) 36 6
DSM-IV Criteria for Major Depressive Disorder 37 Five (or more) symptoms present during 2 week period; at least one symptom either #1 or #2 1. Depressed Mood most of day 2. Diminished interest or pleasure in almost all activities 3. Significant weight loss or gain 4. Insomnia or hypersomnia nearly every day 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy nearly every day 7. Feelings of worthlessness or excessive guilt 8. Diminished ability to think or concentrate or indecision 9. Recurrent thoughts of death Prototypical approach because different cases will contain somewhat distinct characteristics, but will have family resemblance to one another PURPOSES AND EVOLUTION OF DSM (PP. 93) Purposes of DSM and ICD Systems Aid communication, evaluate prognosis, need for treatment, and treatment planning History DSM-I (1952) and DSM-II (1968) Both relied on unproven theories Both unreliable DSM-III (1980) and DSM-III-R Atheoretical, emphasized clinical description Multiaxial system with detailed criterion sets for each disorder Problems included low reliability, reliance on committee consensus 38 THE DSM-IV (PP. 93-95) Basic Characteristics Five axes describe full clinical presentation (person and environment) Clear inclusion and exclusion criteria for disorders, including duration Disorders categorized under broad headings Prototype approach to classification, empirical basis The Five DSM-IV Axes Axis I: Most major disorders (+1) Axis II: Stable, enduring problems (e.g., personality disorders, mental retardation) (+2) Axis III: Medical conditions related to abnormal behaviour Axis IV: Psychosocial problems affecting functioning or treatment Axis V: Global clinician rating of adaptive functioning 39 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 40 Common Axis II disorders include Borderline Personality Disorder (PD) Schizotypal PD Antisocial PD Narcissistic PD Mild Mental Retardation DSM AXISII 41 DIAGNOSTIC ISSUES 42 Reliability Consistency with which clinicians assign cases to diagnostic categories Much variability in reliability of diagnosis of different disorders, especially in earlier versions of DSM E.g., diagnosis of Personality Disorders quite unreliable Validity Various types: criterion, predictive, Special emphasis on Construct Validity Diagnosis relates in expected ways to measures of diverse other constructs: correlation between diagnosis of depression and suicide, happiness scales, Diagnosis distinct from conceptually distinct constructs: depression and antisocial personality disorder distinct 7
EVALUATION OF DSM-IV Stronger empirical foundations than earlier schemes Reviewed available scientific literature and conducted additional studies if necessary Reliability and Validity of criteria generally better Generally better (right), but still concerns in some areas Criteria to identify pathological gambling problem discriminate between general population and people in treatment program for gambling (+1) 43 44 UNRESOLVED ISSUES IN DSM-IV(PP. 95-101) 45 46 What are Optimal Thresholds for Diagnosis? Examples include level or distress, impairment, number of required symptoms Somewhat Arbitrary Time Periods in Definitions Other Axes? Examples include premorbid history, treatment response, family functioning Is DSM-IV System Optimal for Designing Treatments or Research? Problem of comorbidity Defined as two or more disorders for the same person High comorbidity is the rule clinically Comorbidity threatens the validity of separate diagnoses Per 100,000 Suicide across the World Social and Cultural Considerations Increased interest in implications of culture (nationality, ethnicity, religion, ) for psychopathology Certain groups more likely to manifest criteria for disorder e.g., eating disorders and young women in West Some cultures view psychological disorders more or less negatively. Problem of stigma widespread. People with disorders fare better in some cultures e.g., recidivism rates for recovered schizophrenics LOWER in less developed countries CREATING A DISORDER How diagnostic categories included / excluded Mixed Anxiety Depression Frequency of co-morbid (but moderate intensity) symptoms led to proposal for Mixed Anxiety Depression category (i.e., Negative Affect) International study found many people fitting this category, and with considerable dysfunction Placed in Appendix for DSM-IV, perhaps to become full diagnostic category in future versions with more research Premenstrual Dysphoric Disorder More extreme symptoms than Premenstrual Syndrome (PMS) Controversial for various reasons, including possible stigmatization of women and association with past problematic disorders (Hysteria) 47 SUMMARY OF CLINICAL ASSESSMENT AND DIAGNOSIS Clinical Assessment and Diagnosis Designed to provide complete picture of client Designed to aid in understanding and ameliorating human suffering Require reliable, valid, and standardized information Dangers of Diagnosis Problem of reification Problem of stigmatization Clinical Assessment and Diagnosis: The Core of Abnormal Psychology Multidimensional perspective of persons who are suffering 48 8