Introduction to Clinical

Assessment: Diagnosis
• Collecting and evaluating
info to make dx and plan tx
• Your orientation will affect
how you view client’s
presentation
• Foundation of effective tx
plan
• Biopsychosocial approach
(= use several sources of
info)
 Current Paradigms in
Psychopathology
• PARADIGM = perspective
or conceptual framework
from within which a
scientist operates (Thomas
Kuhn)
• Genetics
• Neuroscience
• Cognitive-Behavioral
Model
Genetics Paradigm
• Nature VIA Nurture
• Genes, genotype,
phenotype
• Heritability
• Polygenic transmission
• Gene expression
• EPIGENETICS = how
environment alters gene
expression
 Genetic Paradigm
• Almost all behavior is • Terminology:
heritable to some degree – Gene expression
• Genes do not operate in – Polygenic
isolation from the – Heritability
environment
– Behavior genetics
• Challenges:
• specifying how genes and environment
• Genotype
•
reciprocally influence one another
The complexity of this dance and the amount of
• Phenotype
genes contributing to one disorder – Molecular genetics
 Neuroscience Paradigm

• Neurotransmitters
• Brain structure and
function
• Neuroendocrine system
– HPA axis
– PNI
(psychoneuroimmunology)
 Neurotransmitters
• Dopamine (DA)--mood, motivation, focus, learning, reward;
high in schizophrenia, low in depression, dystonia
• Norepinephrine (NE)—part of fight/flight/freeze response;
high in schizophrenia, low in depression
• Serotonin (5-HT)—mood, sleep, appetite, sensory perception;
low in depression, anxiety, OCD
• GABA—inhibitory neurotransmitter; relaxation; low in anxiety
• Acetylcholine (ACTH)—learning, memory, movement; high in
depression, low in dementia
• Adrenaline—high in anxiety, trauma
• Possible Mechanisms: levels, reuptake, receptors…?
 Brain Structure
• Left and Right hemispheres
• 4 lobes:
– Frontal
– Parietal
– Temporal
– Occipital

• Cerebellum, brainstem, deep structures of

brain
 Cognitive-Behavioral
Paradigm
• Attends to thoughts, perceptions, • Therapies:
judgments, self-statements, beliefs, and
– CBT
unconscious assumptions
• Cognitive restructuring
• Rooted in:
– learning principles
– Cognitive Therapy
• Operant conditioning (behavioral – ACT (acceptance and
activation, time-outs) commitment therapy)
• Classical conditioning (exposure • Challenges:
therapy, extinction) – do not seem to explain much
– cognitive science – Where does the negative
• Thoughts, feelings, behaviors schema come from?
• Schema
• Attention
• Unconscious/implicit memories
A Cognitive-Behavioral Model…
Biopsychosocial Model
Biopsychosocial Model
 Sources of Information
• Clinical interviews
– RAPPORT—trust and
credibility
• Collateral contacts and
referrals
– Family, spouse, teachers,
physicians, medical
records
• Behavioral assessments
• Psychological testing
 Initial Interview: INTAKE
• To evaluate client’s situation, to identify nature of problem, to
determine whether you can help, to provide informed
consent to client
• Current circumstances
• Presenting problem/chief complaint
• History of the problem
• Mental health and substance abuse history
• Medical history
• Risk of harm to self or others
• Diagnosis and related conditions
– Gathering specific Signs and Symptoms of the Problem:
• MSE
• Emotional/affective signs and sx
• Physical signs and sx
 Other Issues Addressed in Clinical
Assessment
• Family and social history
• Educational history
• Employment history
• Client characteristics
• Patient strengths
• Preliminary personality assessment
• Indicators of social/interpersonal dysfunction
• Expectations for therapy
• Treatment goals
 Considerations for
Culturally Diverse Clients
• Cultural variability
• Prevalence of AMI (2017) by
ethnicity:
– Hispanic = 15.2%
– White = 20.4%
– Black = 16.2%
– Asian = 14.5%
– Pacific Islander = 19.4%
• Be aware of your own
– Native American = 18.9% cultural biases and
– 2 or more = 28.6% influences
• SES, discrimination  stress • Educate yourself
– Racism, trauma, refugees
• Be willing to modify your
– Social and political factors
style to facilitate
communication
Other Psychological Factors
• Childhood, historical
antecedents (e.g. ACEs)
– Object relations
– Attachment
• Relational, social factors
– IPT (interpersonal tx)
• Sociocultural factors
Stages of Change (transtheoretical)
Model
 Diathesis-Stress Model

Diathesis = predisposition/vulnerability, often genetic

Stress = environmental influences
- Gene-Environment Interactions (reciprocal gene-environment model)
- Creation of a Risk Environment
Judy develops a blood phobia…
MSE: Mental Status Exam
• To evaluate current mental
functioning
• Observe client’s behavior in
informal yet systematic way
• Collect data via:
– Observation
– Direct questions
– Rapport and cooperation
from the client
– Testing (neuropsych screens)
 MSE Categories: JOIMAT
• JUDGMENT
– Decision-making and daily functioning, common sense
• ORIENTATION
– Oriented x 3 (person, place, and time)
– May be indicative of organicity or psychosis
• INTERVIEW BEHAVIOR
– Including nonverbal behavior and general attitude
• INTELLECT
– Verbal ability, vocabulary, education level
– Ability for abstract vs. concrete thought
• INSIGHT
– Psychological mindedness
 MSE Categories: JOIMAT
• MOTOR ACTIVITY
– Under/overactivity, gait and motor coordination
• MOOD
– Emotion experienced by client, underlying tone
– Assess lability
• MEMORY
– Immediate, recent, remote
– Confabulation or clouding of consciousness
• APPEARANCE
– Looks, dress, personal hygiene
– Actual age vs. physical presentation
 MSE Categories: JOIMAT
• AFFECT
– “emotional landscape”—observable state
– Flat, blunted, restricted, inappropriate
• ATTENTION
– Ability to concentrate and attend to a task
• THOUGHT PROCESSES
– Hallucinations, dissociation
• THOUGHT CONTENT
– Delusions, phobias, obsessions
– Ideas of reference, thought broadcasting/insertion
• THOUGHT FLOW
– Loose associations, flight of ideas, thought blocking,
neologisms, clanging, word salad, echolalia, perseveration