Chapter 3 Notes
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Irving Kilback PhD
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Date Created: 09/20/15
Chapter 3 Clinical Assessment Diagnosis amp Research in Psychopathology Assessing psychological disorders I Clinical assessment systematic evaluation and measurement of factors in person presenting with possible psychological disorder I Purposes of clinical assessment empirically supported assessment to understand the individual predict behavior plan treatment and evaluate treatment outcome I Diagnosis process of determining whether the particular problem afflicting the individual meets all criteria for a psychological disorder I Process is analogous to a funnel starts broad multidimensional in approach and narrow to specific problem areas Key concepts in assessment I 3 basic concepts help determine the value of clinicians assessments o Reliability consistency in measurement degree to which a measure is consistent EX testretest and inter rater reliability I Interrater reliability consistency across two or more rates and stable across time I Testretest reliability consistency across time EX if you go to a clinician on Tuesday and are told you have an IQ of 110 you should expect a similar result if you take the same test again 0 Validity what an assessment measure and how well it does so EX concurrent discriminant and predictive validity I Concurrentdescriptive validity compare results of an assessment measure under consideration with the results of others I Predictive validity how well your assessment tells you what will happen in the future I Measuring construct adequately measures what is supposed to measure I Example of validity question Are people who get higher scores on a measure of anxiety actually more anxious o Standardization Ensures consistency in the use of a technique and provides population benchmarks for comparison EX structured administration scoring amp evaluation procedures The Clinical Interview and Physical Exam I Clinical interviewmost common clinical assessment methods it gathers information on current and past behavior attitudes and emotions as well as a detailed history of the individuals life I Clinical interviews may range from half an hour to 4 hours depending on the needs of the patient and the purpose of the assessment Longer assessments are necessary for some research studies and when you are trying to get a complete psychological history EX previous diagnoses as well as current The Mental Status Exam I Exam that involves the systematic observation of an individuals behavior covers 5 categories 1 Appearance and behavior overt behavior attire appearancepostureexpressions 2 Though processes rate of speech continuity of speech and content of speech 3 Mood and affect predominant feeling state of the individual feeling state accompanying what individual says 4 Intellectual functioning type of vocabulary use of abstraction and metaphors 5 Sensorium awareness of surroundings in terms of person self and clinician time space and place Information provided by patients to clinicians is protected by laws of quotprivilege communication or confidentiality 0 Exception occurs when the clinician judges that some harm or danger to either the patient or someone else Semi structuredStructured Clinical Interviews MOST COMMON have an outline or questions that are followed but some flexibility to ask more or less about certain areas depending on the needs of the interviewee o Disadvantage robs the interview of some of the spontaneous quality of 2 people talking about a problem if applied to rigidly may inhibit the patient from volunteering useful information o EX of semistructured interview Anxiety Disorders Interview Schedule for DSM5 ADIS 5 has modules pertaining to anxiety mood and related disorders designed to assess DSM5 criteria fSCID Structured Clinical Interview for DSM Disorders MINl 70 MINI International Neuropsychiatric Interview Structured you ask the exact same questions in the same order Physical Exam Physical exams are often the quotfirst pit stop in assessing mental health because many patients visit a primary care physician first Physical exams are more common in inpatient or hospital settings or in the case of mental illnesses that are likely to affect physical functioning EX substance use disorders eating disorders somatic symptom disorders disorders in which a patient is taking meds with a lot of side effects EX schizophrenia EX a doctor might ascertain whether panic attacks are the result of a heart or respiratory condition or whether depression could be due to the side effects of a medication BEHAVIORAL Behavioral Assessment Focus on the present here and now direct observation of behavior environment relations 0 Purpose to identify problematic behaviors and situations target behaviors The ABCs of Observation Clinician s attention is directed to the immediate behavior its antecedents what happened right before the behavior and its consequences what happened afterward EX violent boy and his mother 1 his mother asking him to put his glass in the sink antecedent 2 the boy throwing the glass behavior 3 the mother s lack of response consequence o The ABCs might suggest that the boy was being reinforced for his violent outburst by not having to clean up his mess no negative consequence act violently again This was an EX of informed observation 0 Problem relies on the observers recollection as well as interpretation Formal observation identifies specific behaviors that are observable and measurable operational definition GOAL see whether there are any obvious patterns of behavior and then to design a treatment based on these patterns SelfMonitoring Selfmonitoring can be used to increase desired behaviors and decrease undesired behaviors EX people trying to quit smoking may write down of times smoked and lets them know severity of problem and what situations cause them to smoke more Reactivity can distort any observational data anytime you observe how people behave the mere fact of another persons presence may cause them to change their behavior EX observing child s behavior in classroom Psychological testing Must be reliable so that 2 or more people administrating the same test to the same person will come to same conclusion AND must be valid so they can measure accurately These tests include specific tools to determine cognitive emotional or behavioral response that might be associated with a specific disorder Projective Testing Projective tests rooted in psychoanalytic tradition used to assess unconscious processes require high degree of inference in scoring and interpretation Method Project aspects of personality onto ambiguous test stimuli include a variety of methods in which ambiguous stimuli pictures or things are presented to people who are asked to describe what they see EX The Rorschach inkblot test Thematic Apperception Test Reliability and validity data tend to be mixed 0 TAT you see an ambiguous picture and tell a story about it o The idea of projective tests is that when you re presented with ambiguous stimuli the way you interpret them says something about your personality Personality Inventories Objective tests roots in empirical tradition that test stimuli are less ambiguous and require minimal clinical inference in scoring and interpretation Personality tests inventories self report questionnaires that assess personality traits 0 Minnesota Multiphasic Personality Inventory MMPl based on empirical approach collection and evaluation of data individual being assessed reads statements and answers either true or false and the pattern of responses is reviewed I Validity scales Lie scale helps determine if individual is falsifying answers to look good nfrequency scale measures false claims about psychological problems or determines whether the person is answering randomly Subtle Defensiveness scale assesses whether the person sees herself in unrealistic positive ways I Clinical scales Intelligence Tests Nature of intellectual functioning amp IQ Originally developed by Binet and Simon as a measure of degree to which children s performance diverged from others in their grade mental agechronological age MACA x 100 IQ o The deviation IQ current tests compare a person s scores against those of other people who are the same age Intelligence tests use verbal amp performance scales process reflects American version of what is involved in intelligence process working memory and processing speed Neuropsychological Testing Purpose assess broad range of skills and measure abilities in areas such as receptive amp expressive language attention amp concentration memory motor skills perceptual abilities and learning amp abstraction Goal is to understand brainbehavior relations Problems with these tests 0 80 correct to detect brain damage 0 False positives Mistakenly shows a problem where there is none test results are positive 0 False negatives Fails to detect a problem that is present test results are negative The LuriaNebraska and HalsteadReitan batteries 0 Both asses a variety of skill sin adolescents and adults to assess for organic brain damage test diverse skills ranging from grip strength to sound recognition attention concentration Halstead Reitan Battery 0 Rhythm test asks person to compare rhythmic beats thus testing sound recognition attention and concentration 0 Strength of Grip Test compares the grips of the right and left hands 0 Tactile Performance tests requires the test taker to place wooden blocks in a form boar while blindfolded thus testing memory and learning skills Other related tests 0 TrailMaking Test measures time to connect a sequence of numbers or alternating numbers and letters 0 Halstead Category Test including seven subtests which form several factors a Counting factor subtests I and II a Spatial Positional Reasoning factor subtests III IV and VII a Proportional Reasoning factor subtests V VI and VII and an Incidental Memory factor subtest VII 0 Seashore Rhythm Test Speech Sounds Perception Test Finger Oscillation Test Sensory Perceptual Examination and lateral Dominance Examination Neuroimaging Pictures of the Brain 2 categories 1 Understand brain structure a Computerized axial tomography CAT or CT scan utilizes Xrays b Magnetic resonance imaging M R utilizes strong magnetic fields better resolution than CT scan 2 Understand brain function map blood flow and other metabolic functions a Positron emission tomography PET b Single photon emission computed tomography SPECT c Both involve injection of radioactive isotopes isotopes react with oxygen blood and glucose in the brain d Functional MRI fMRI brief changes in brain activity replacing PET scans BOLD fMRI Psychophysiological Assessment Assess brain structure function and activity of the nervous system Electroencephalogram EEG reveals brain wave activity 0 ERP Event related potentials brain response to a specific experience eg hearing a tone Other bodily functions also play a role in assessment 0 Heart rate respiration and electrodermal response measure of sweat gland activity controlled by PNS Stress reduced treatments by relaxation 0 Alpha waves awake resting patterns 0 Delta waves asleep relaxed patterns Panic attacks delta wave activity during wakefulness may indicate localized dysfunction Uses of routine psychophysiological assessment biofeedback disorders involving a strong physiological component EX PTSD sexual dysfunctions sleep disorders headache and hypertension Diagnosing psychological disorders Diagnostic classification nosology classification is central to all sciences and assignment to categories based on shared attributes or relations Terminology of classification systems 0 Taxonomy classification in a scientific context 0 Nosology taxonomy in psychologicalmedical phenomena 0 Nomenclature labels in a nosological system eg quotpanic disorder quotdepressive disorders Strategies useful for assessment 1 ldiographic strategy what is unique about an individual s personality cultural background or circumstances ldiographic determination of individual unique features or attributes 2 Nomothetic strategy often used when identifying a specific psychological disorder to make a diagnosis Nomothetic determination of general classes and common attributes involves the study of large groups with shared features Categorical and Dimensional Approaches Classical or pure categorical approach strict categories eg you either have social anxiety disorder or you don t Dimensional approach classification along dimensions eg different people have varying amounts of anxiety in social situations Prototypical Approach Combines classical and dimensional views Identifies essential features of a psychological disorder so that it can be classified but allows for nonessential variations that do not necessarily change the classification The DSM 5 is based on this approach Widely used Classification Systems Diagnostic and Statistical Manual of Mental Disorders DSM 0 Updated every 10 20 years 0 Current edition released May 2013 DSM5 2013 Previous edition called DSM IV TR lCD10 International Classification of Diseases CD 10 Published by the World Health Organization WHO Historical Perspective on Strengths and Weaknesses of the DSM Prior to the 19505 classification in the US was disorganized no standard system in place prior to WWI little interest in developing a systematic classification of mental disorders DSM 1952 Clear brief descriptions facilitated interrater reliability among clinicians and researchers DSM 1968 Greater detail concerning signs and symptoms DSM I amp Weaknesses Due to vague definitions interrater reliabilities low Neither theoretically agnostic influenced by psychoanalytic concepts Conceptualized mental disorders from perspective of Meyer most psychopathology due to aberrant reactions to life events thus use of term reactions in dx Precursors to the DSM 19705 an explanation of why the DSM III used the term disorder The influence of Robins Guze Winokur and other giants of descriptive psychopathology preliminary diagnostic criteria and algorithms for 14 major mental disorders in the early 19705 0 Feighner St Louis amp Spitzer and Endicott NY communicate combining data across research groups improve reliability I Feighner used terms illness diagnostic category disorder clinical picture syndrome psychiatric condition as synonyms o Kendell et al 1971 identified fundamental problem of diagnostic low interrater reliability History of the DSM DSM Introduction of DSMIII in 1980 revolutionized classification Classification newly relied on specific lists of symptoms improving reliability amp validity Diagnoses classified along five Axes describing types of problems eg disorder categories health problems life stressors 1 Axis I Clinical syndromes most psychological disorders what person has superimposed on individuals presenting condition 2 Axis II personality disorders and mental retardation more pervasive what person is longstanding ways of viewing and relating to world 3 Axis HI relevant medical conditions physical disorders 4 Axis IV Relevant life stressors 5 Axis V Global assessment of functioning 0 100 rating assess level of functioning DSM5 no longer uses the axis system This information is still taken into account by clinicians but it s not discussed in terms of axes DSMlllR 1987 Moved away from monothetic signs and symptoms singly necessary and jointly sufficient approach of DSM Ill and emphasized polythetic signs and symptoms neither necessary not sufficient for diagnosis approach 0 Disadvantages of polythetic approach heterogeneity However few if any signs or symptoms of psychopathology are pathognomonic can be used by self to establish diagnosis Shift away from hierarchical exclusion rules of DSM I History of the DSM DSM IV DSM IV 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 added appendix for culture bound syndromes somewhat exotic Clinical significance criterion added Expansion of disorders and explanations DSMlVTR DSM IV TR quottext revision of DSM IV ZOOO incorporated new research and slightly altered criteria accordingly Criticism of the DSMIV TR Comorbidity 0 High levels of co occurrence and covariation among many diagnostic categories 0 Axis II disorders particularly vulnerable to comorbidity Stuart et al 1998 0 Yet it is premature to assume comorbidity reflects overlap among etiologically distinct conditions as opposed to slightly different variants of the same underlying condition o Comorbidity in clinical practice is underestimated because ofdiagnostic overshadowing that is the tendency for more florid disorder to draw attention from less florid co occurring disorder example borderline overshadows other cluster B disorders I Explanations for comorbidity 2 types of possibilities 1 Substantive explanations a one disorder to predispose to other disorder b both may mutually influence each other or c both express latent factor latent liability 2 Methodologicalexplanations a Clinical selection bias client seek tx only when develops a co occurring disorder or b logical errors of diagnostician they assume 2 unrelated conditions are correlated The DSM5 I Removed axial system and clear inclusion and exclusion criteria for disorders I Disorders are categorized under broad headings 20 chapters I Empiricallygrounded prototypic approach to classification I Hybrid of categorical amp dimensional severity I DSM5 represented some changes to classification One major change is that the Axis system used in DSM IV TR was eliminated I Unresolved issues in DSM5 o The problem of comorbidity two or more disorders for the same person I High comorbidity is extremely common I Emphasizes reliability maybe at the expense of validity ie may artificially split diagnoses that are very similar 0 Dimensionalclassification I DSM was intended to move toward a more dimensional approach but critics say it does not improve much from DSM IV o Labeling issues and stigmatization I Some labels have negative connotations and may make patients less likely to seek treatment Research in Psychopathology Basic Components of Research I Research design a method to test hypotheses I Independent variable It is manipulated and the variable that causes or influences behavior I Dependent variable aspect of behavior that is measure and the behavior we expect to be influenced by the independent variable I Internal validity Extent to which results of a study are due to the independent variable 0 Increase internal validity by minimizing confounds o A confound or confounding variable any factor occurring in a study that makes the results uninterpretable because a variable other than the IV may also affect the DV 0 IV 9confound9DV 0 Ways to increase internal validity 1 Use of control groups IV vs no IV a Control group A comparison group of similar composition that is usually not manipulated in the same way as the group under study or they are quothealthynormal b EX In a study of anxiety treatment compare anxious patients who are treated with anxious patients who do NOT receive treatment In a study of information processing compare the performance of people who are depressed with the performance of people who are NOT depressed 2 Use of random assignment procedures 3 Use of analog models create conditions comparableanalogous to phenomenon of study recreating the phenomenon under study in lab conditions I External validity extent to which results of a study are generalizable to the population it s study Hypothesis I Research sarts with a hypothesis or quoteducated guess I After you develop a hypothesis why put it into words that are unambiguous and in a form that is testable Concept of testability ability to support hypothesis 0 Not all hypotheses are testable o Hypotheses in science are formulated so that they are testable Statistic vs Clinical Significance I Statistical methods branch of mathematics helps to protect against biases in evaluating data I Clinical significance are results clinically meaningful A result actually matters employs effect size mathematical model to determine how much each treated and untreated person in study improves or worsens Consider not just M overall group but individual change 0 Social validity Wolf do clients feel a change has been made I Statistical significance are results due to chance A result is unlikely to have occurred by chance Statistical significance does not imply clinical meaningfulness o EX I Hypothesis Evaluate whether the discussion or lecture method is better for teaching reading to 7th graders I Research Design For six weeks we use the discussion method to teach reading to Class A while using the lecture method to teach reading to Class B At the end of the six weeks both groups take the same test I FindingsResults The discussion group Class A averages 92 while the lecture group Class B averages 84 I Statistics We would evaluate the results using a t test The results give us a value for p telling us ifp lt05 for example the discussion method is superior for teaching reading to 7th graders I What this fails to tell us is the magnitude of the difference In other words how much more effective was the discussion method To answer this question we standardize the difference and compare it to 0 I Significant Results Among 7th graders in Lowndes County Schools taking the CRCT reading exam N 336 there was a statistically significant difference between the two teaching teams team 1 discussion M 81892 SD 1611 and team 2 lecture M 82828 SD 1409 t98 309 p s 05 CI95 1537 335 Therefore we reject the null hypothesis that there is no difference in reading scores between teaching teams 1 and 2 Further Cohen s effect size value d 62 suggested a moderate to high practical significance I NOT significant results Among 7th graders in Lowndes County Schools taking the CRCT science exam N 336 there was no statistically significant difference between scores of teaching team 1discussion students M 83400 SD 3281 and teaching team 2 lecture students 84108 SD 2876 t98 115 p 2 05 Cl95 1932 516 Therefore we fail to reject the null hypothesis that there is no difference in science scores between students in lecture and discussion groups Further Cohen s effect size value d 09 suggested low practical significance 0 A significance test does not tell the size of a difference between two measures practical significance nor can it easily be compared across studies To account for this the American Psychological Association APA recommended all published statistical reports also include effect size I Neill 2008 a When examining effects using small sample sizes significance testing can be misleading Contrary to popular opinion statistical significance is not a direct indicator of size of effect but rather it is a function of sample size effect size and p level b When examining effects using large samples significant testing can be misleading because even small or trivial effects are likely to produce statistically significant results Balancing Statistical vs Clinical significance 0 Evaluate effect size how large a difference between groups not just the fact they are different A statistical process that estimates how large a change in a measure occurred 0 Evaluate social validity o Generalizability The extent to which results are applicable to the larger population being studied The Average Client Patient uniformity myth researchers sometimes mistakenly see all participants as one homogenous group leads to inaccurate generalizations about disorders and their treatments 0 Mean scores may not reflect the individual differences within a client diagnostic group Types of research methods Studying Individual Case Studies Case study method Extensive observation amp detailed description of a client Foundation of early historic developments in psychopathology Limitations Lacks scientific rigor and suitable controls no cause and effect conclusions nterna validity is typically weak often entails numerous confounds Research by Correlation Assess the degree to which levels of certain variables are linked to levels of other variables necessary when you can t manipulate variables Nature of correlation statistical relation between 2 or more variables no independent variable is manipulated ranges from 10 to 10 Positive correlation vs negative 0 EX Higher levels of education are linked to higher levels of income Limitations does not imply causation problem of directionality Epidemiological research an example of the correlational method Incidence prevalence amp course of disorders EX AIDS trauma following disaster Experimental Research Manipulation of independent variables Attempt to establish causal relations I Group experimental designs 0 Control groups I Placebo Some participants are given an inactive treatment eg sugar pill but participants don t know which treatment they are getting expectation of change I Doubleblind Participants and assessors are unaware of what kind of treatment participants are getting Control for the allegiance effect Comparative Treatment Research I Type of group design an alternative to using notreatment control groups compare different forms of treatment in similar persons addresses treatment process and outcome 0 Process focus on mechanism of change active ingredients cause of change dismantling study quotWhy does it work 0 Outcome focus on changes that occur after treatment Single Case Experimental Design I Rigorous study of single cases I Differ from case studies in use of various strategies to improve internal validity I Varied experimental conditions and time repeated measurement and evaluation of variability level and trend I Premium on internal validity I Types 0 Repeated measures behavior is measured several times instead of only once before you change the independent variable and once afterward Important aspects I The level or degree of behavior change I The variability or degree of change over time I The trend or direction 0 Withdrawal designs stop treatment to see if behaviorsymptoms return to the way they were before treatment not always appropriate due to ethical issues and ability to unteach learned skills 0 Multiple baseline designs start treatment at different times in different conditions EX in home vs school settings or 2 or more behaviors see if changes occur in conjunction with introduction of treatment Genetic and Behavior across Time and Cultures Studying Genetics I Family studies behaviorsemotional traits in family members check for family aggregation proband I Adoptee studies separate environmental from genetic factors I Twin studies psychopathology in fraternal vs identical twins I Genetic linkage genetic markers win family amp association studies gt markers in person w than wout disorder sites of defective genes I Endophenotypes RDoc Genetic mechanisms that contribute to underlying problems causing the symptoms and difficulties experienced by individuals with psychopathology 0 Positive valence negative valence arousal cognition social Behavioral Genetics I Interaction between genes experience and behavior I Studying behavior over time Rationale and overview How does the problem or behavior change over time mportant in prevention and treatment research I Time based research strategies o Crosssectional designs and the cohort effect members of a cohort are similar in age and experience I Cohort effect confounding of age and experience a limitation Systematic differences in participants may simply be due to their age group EX kids growing up during the AIDS crisis probably have unique opinions about STIs This isn t because they re in their 305 and 405 but rather because they heard about serious STIs as children 0 Longitudinal designs I Crossgenerational effect how historical experience varies by trying to generalize findings to groups whose experiences are very different from those of the study participants I Sequential designs combine both strategies Studying Behavior Across Cultures I Value of cross cultural research overcoming ethnocentric research Symptoms may differ across cultures varying tolerance for abnormal behaviors across cultures I Assets and liabilities of cross cultural research 0 Assets to clarify how psychopathology manifests in different ethnic groups I Problems with cross cultural research limited by available measures Programs of Research I Components of a research program 0 Set of interrelated research questions 0 Draw on several methodologies in finding answers 0 Conducted in stages often involving replication I Allows for more nuanced complete picture of a phenomenon I Replication is critical protects against fluke results Research ethics I Institutional review boards IRBs oversee the rights of human participants in research at an institution make sure research and data are handled responsibly I The principles in the Ethics Code stress not only informed consent but also the researcher s responsibility to protect the welfare of research participant the welfare of the participant is given priority over any other consideration including experimental design psychological harm o All information is confidential o Deception must involve debriefing I Ethical principals o Informed consent historical evolution post WWII I Participant s formal agreement to cooperate in a study following full disclosure of the nature of the research and participant s role I 4 components of informed consent a Competence ability to provide consent b Voluntarism lack of coercion c Full information necessary information to make an informed decision d Comprehension understanding about benefits and risks of participation I Replication is the cornerstone of science and programmatic research I Research must occur in the context of ethical considerations and values I Nature of research establishing and testing hypotheses I Research design varies depending on the questions posed each has unique benefits and drawbacks KNOW FOR EXAM Abnormal psychology is founded in the scientific method 0 0000000 Understand the nature of abnormality and human suffering Understand the causes of psychological disorders Understand the course of psychological disorders Understand how to prevent and treat psychological disorders What are clinical assessment and diagnosis What are the basic components and methods of psychopathology research How do researchers study behavior across time and culture Why are ethical principles important in research see page 108
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