Abnormal Psychology – Chapter 3 – Clinical

Assessment and Diagnosis

Clinical Assessment
• Systematic evaluation and measurement of psychological,
biological and social factor in an individual with possible psychological
disorder.
• Assessment involves gathering of data using different methods
including psychological testing and interviews.
Diagnosis
• Whether a specific problem afflicting the individual meets all the
criteria for a specific psychological disorder.
• Clinical assessment in psychological disorders may use the funnel
approach in gathering data. It entails gathering a large amount of
data, filtering out irrelevant information, and focusing on what is
important.
• To be able to determine the source of the conflict.
• General to specific
Diagnosis
• Assessment techniques should be evidence based
Evidence-Based Practice/ Manualized Therapy

• When researchers measure therapy outcome, they often use

therapy manuals
• To ensure uniformity across therapists
• To minimize variability
• When outcome data supports the use of a manualized therapy,
the treatment is known as “evidence based”
• Treatments formerly called “empirically validated” and “empirically
supported”
• “Evidence-based practice” includes the treatment and factors related to
people providing and receiving the treatment
Advantages of Evidence-Based Practice /Manualized Therapy

• Scientific legitimacy
• Establishing minimal levels of competence ( trainings and
seminars to keep one up to date)
• Training Improvements
• Decreased reliance on clinical judgment
Disadvantages of Evidence-Based Practice/Manualized Therapy

• Threats to the psychotherapy relationship

• Diagnostic complications
• “Textbook” cases vs. “real world” cases
• Clean Disorders vs. Comorbidity
• Restrictions on practice
• Mandated manuals vs. creatively customized treatments
• Debatable criteria for empirical evidence
Reliability
• Consistency of results and measurement
• Interrater reliability: same results / diagnosis from one psychologist
to another.
• Test re test reliability – stable across time, you'll get same score.
Validity
• measures it aims to measure.
• Concurrent or descriptive validity: short form and long form version
of test yields the same results
• Predictive validity: Assessment tells you what will happen in the
future.
The Clinical Interview
• Core of clinical work, gathers information on current or past
behavior, attitude and emotion.
• Detailed life history (significant life events, trauma)
• Indispensable in assessment process.
The Clinical Interview
• Assessment is closely linked with the identity of clinical
psychologists
• No other mental health profession incorporates assessment into their work as
clinical psychologists do
• Clinical interviews are the most frequent assessment tool
• More than any specific test
• Vast majority of practicing clinical psychologists use interviews
The Interviewer
• General skills
• Quieting yourself
• Minimize excessive internal, self-directed thoughts that detract from
listening
• Being self-aware
• Know how you tend to affect others interpersonally, and how others tend to relate to
you
• Develop positive working relationships
• Can segue into psychotherapy
• Respectful and caring attitude is key
The Interviewer (cont.)
• Specific behaviors
• Listening—the primary task of the interviewer, consisting of numerous
building blocks
• Eye contact
• Body language
• Vocal qualities
• Verbal tracking
• Referring to client by proper name
Components of the Interview
• Rapport
• Positive, comfortable relationship between interviewer and client
• How an interviewer is with clients
• Technique
• What an interviewer does with clients
• Directive vs. nondirective styles
Semi Structured Interview
• Multiple Choice Questions Vs. Essay
• Semi structured questionnaire allows to probe deeper, but may
eventually steer you away from your objective
• Structured questionnaire immediately gives you the correct response
that you want but may miss the chance to get more necessary data.
• Questions could be directly related to the criteria.
Specific Interviewer Responses
• Open-ended and closed-ended questions
• Open-ended questions
• Allow individualized and spontaneous responses from clients
• Elicit long answers that may or may not provide necessary info
• Closed-ended questions
• Allow less elaboration and self-expression by the client
• Yield quick and precise answers
Specific Interviewer Responses (cont.)
• Clarification
• Question to make sure the interviewer accurately understands the
client’s comments
• Confrontation
• For discrepancies or inconsistencies in a client’s comments
• Paraphrasing
• Restatement of client’s comments to show they have been heard
Specific Interviewer Responses (cont.)
• Reflection of feeling
• Echo client’s emotions, even if not explicitly mentioned
• Summarizing
• Tie together various topics, connect statements that may have been
made at different points, and identify themes
Mental Status Examination
• Organize information and Behavior to determine if a psychological
disorder is present
• Appearance and Behavior: Psychomotor retardation, depression
• Thought process: flow of speech, is the person making sense, loose
association or derailment, difficulty organizing thoughts. Content: delusion
of persecution and hallucination
• Mood and Affect: mood is the predominant feeling (anxious, angry,
depressed and elated mood)
• Affect: appropriate, inappropriate, blunt or flat
Mental Status Examination
• Intellectual functioning, level of functioning (abstraction and
metaphor)
• Sensorium: Oriented times 3, place, person and time.
Physical Examination
• Medical Condition associated with specific psychological disorders,
toxic state, side effects
• Hyperthyroidism: General anxiety disorders
• Hypothyroidism: hallucination
• Withdrawal from drugs: Panic attacks
Behavioral Assessment
• Appropriate with children not capable of expressing themselves.
• Determine factors that influence them (environment, workplace and
home)
ABCs of observation
• Antecedent (what happened just before behavior),
consequences (what happened afterwards)
• Self monitoring: subjective by nature “reactivity”
• Self monitor (purging)
Psychological Testing
• Projective Test
• Personality Test
Thematic Apperception Test
Bender Visual Motor Gestalt
Test
 Before the DSM
Abnormal behavior was recognized and studied in ancient civilizations
In 19th century, asylums in Europe and U. S. arose (see Chapter 2)
Around 1900, Emil Kraepelin put forth some of the first specific categories of mental illness
Some early categorical systems were for statistical/census purposes
In the mid-1900s, the U.S. Army and Veterans’ Administration developed their own early categorization system in an effort
to facilitate the diagnosis and treatment of soldiers returning from World War II. This served as a precursor to the first
DSM.
DSM-I and DSM-II
• DSM-I published in 1952
• DSM-II published in 1968
• Similar to each other, but different from later editions
• Not scientifically or empirically based
• Based on “clinical wisdom” of leading psychiatrists
• Psychoanalytic/Freudian influence
• Contained three broad categories of disorders
• Psychoses, neuroses, character disorders
• No specific criteria; just paragraphs with somewhat vague descriptions
DSM – More Recent Editions
• DSM-III
• Published in 1980
• Very different from DSM-I and DSM-II
• More reliant on empirical data
• Specific criteria defined disorders
• Atheoretical (no psychoanalytic/Freudian influence)
• Multi-axial assessment (5 axes)
• Much longer—included many more disorders
• DSM-III-R (minor changes from DSM-III) was published in 1987
DSM – More Recent Editions
• DSM-IV was published in 1994
• DSM-IV-TR was published in 2000
• TR stands for “text revision”
• Only text, not diagnostic criteria, differ between DSM-IV and DSM-IV-TR
• So, these two editions are essentially similar
DSM – More Recent Editions
• DSM-IV included significant cultural advances
• Text describing disorders often included culturally specific information
• Culture-Bound Syndromes were listed
• Not official diagnostic categories, but experiences common in some cultural groups
• Outline for Cultural Formulation
• Helped clinicians appreciate impact of culture on symptoms
DSM-5
• Current edition of the DSM
• Released in 2013
• Task Force led Work Groups, each focusing on a particular area of
mental disorders
• Attempted greater consistency between DSM and International
Classification of Diseases (ICD)
Changes DSM-5 Didn’t Make
• Paradigm shift to emphasize neuropsychology/biological roots of
mental disorder
• Dimensional definition of all mental disorders
• Dimensional approach for personality disorders
• Remove five of the 10 personality disorders
• Proposed disorders
• Attenuated psychosis syndrome
• Mixed anxiety-depressive disorder
• Internet gaming disorder
New Features in DSM-5
• Naming shift from Roman numerals (e.g., DSM-IV) to Arabic numerals
(e.g., DSM-5)
• Minor updates will be denoted as new versions (e.g., DSM-5.1, DSM-5.2, etc.)
• Elimination of the multiaxial assessment system
New Disorders in DSM-5
• Premenstrual dysphoric disorder
• Disruptive mood dysregulation disorder
• Binge eating disorder
• Mild neurocognitive disorder
• Somatic symptom disorder
• Hoarding disorder
Revised Disorders in DSM-5
• Major depressive episode
• “Bereavement exclusion” dropped
• Autism spectrum disorder (new scope in DSM-5)
• Encompasses autistic disorder, Asperger’s disorder, and related
developmental disorders from DSM-IV
• Attention-Deficit/Hyperactivity Disorder
• Age at which symptoms must first appear raised from 7 to 12
• Bulimia nervosa
• Frequency of binge eating decreased from twice to once per week
Revised Disorders in DSM-5 (cont.)
• Anorexia nervosa
• Removed requirement that menstrual periods stop
• “Low body weight” changed from numeric definition to less specific
description
• Substance use disorder (new scope in DSM-5)
• Encompasses substance abuse and substance dependence disorders from
DSM-IV
• Intellectual disability disorder
• Mental retardation from DSM-IV
• Specific learning disorder
• Covers separate learning disorders in reading, writing, and math from DSM-IV
DSM-5 Controversy
• Allen Frances’ criticisms
• DSM-5 features changes that “seem clearly unsafe and scientifically unsound”
• DSM-5 “will mislabel normal people, promote diagnostic inflation, and
encourage inappropriate medication use”
• Key areas of criticism
• Diagnostic overexpansion
• Questionable transparency of the revision process
• Work Groups predominantly composed of researchers, not clinicians
• Field trial problems
• Price of DSM-5