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Date Created: 09/17/14
Ch 3 Clinical Assessment and Diagnosis 91714 144 PM Assessing Psychological Disorders Clinical Assessment Systematic evaluation and measurement o Psychological 0 Biological o Social Diagnosis Degree of fit between symptoms and diagnostic criteria DSM 5 Purpose Understanding the individual Predicting behavior Treatment planning Evaluating outcomes Funnel analogy Broad multidimensional start Narrows to specific problems An integrative approach Key Concepts in Assessment Reliability the degree to which a measurement is consistent Measurement consistency Agreement Several types o Test retest consistency across time o Inter rater consistency across two or more raters Our perceptions can bias what we see and how we interpret certain data Validity the degree to which a technique measures what it is designed to measure Does the test measure what it39s supposed to Several types of validity o Concurrent or descriptive validity compares the results of one assessment measure with the results of others o Predictive validity how well the assessment predicts what will happen in the future 0 Construct validity degree to which the item measures something unobservable ie intelligence 0 Face validity whether the test items look reasonable and valid at first glance Standardization application of certain standards or norms is established for a technique to ensure its consistency across different measurements Consistent use of techniques Provides normative population data Examples 0 Administration procedures 0 Scoring 0 Evaluation of data The Clinical Interview Clinical Interview used primarily to gather information about past and present behavior Clinical core Structured Assesses multiple domains 0 Current and past behavior 0 Attitudes o Emotions 0 Detailed history 0 Presenting problem Mental Status Exam used to organize information obtained during an interview to determine if a disorder is present Involves systematic observation of a client39s behavior across 5 domains Appearance and behavior 0 Overt behavior attire appearance posture expressions Thought processes how a person talks 0 Rate of speech continuity of speech content of speech Mood and affect o Predominant feeling state of the individual 0 Feeling state accompanying what the individual says Intellectual functioning 0 Type of vocabulary 0 Use of abstractions and metaphors 0 Poverty of speech being unable to find one s words Sensorium general awareness of surroundings o oriented times 3quot person place time Other Interviews Unstructured not standardized no format followed Semi structured o Assesses most critical items 0 Departures from format Physical Examination Diagnose or rule out physical etiologies causes associated with psychological disorders 0 Toxicities 0 Medication side effects 0 Allergic reactions 0 Metabolic conditions Behavioral Assessment The purpose of behavioral assessment is to identify and target behaviors problematic behaviors and environmental events that may become targets of therapeutic intervention 0 Identification and observation of target behaviors here and now focus Direct observations Minimally inferential More appropriate for young clients or clients who cannot report their problems The ABC39s of observations observational assessment focuses on o Antecedents what happened just before the behavior 0 Behaviors 0 Consequences what happened afterward following the behavior Behavioral Observation 0 Formal vs Informal behavioral observation may either be formal or informal Formal the observation procedures are usually structured and systematic and involve behavior rating O scales or checklists and clear operational definitions how the behavior is measured of target behaviors Informal less standardized and systematic Sef monitoring vs others observing people may be asked to observe their own behavior using a technique called self monitoring or sef observation eg recording the number of cigarettes smoked per day Self monitoring may be formal eg using scales coding sheets checklists or informal eg recording overall mood each day A more formal and structured way to observe behavior is through checklists and behavior rating scales which may be used before during or after treatment Reactivity refers to changes in behavior resulting from knowing that one is being observed Reactivity can occur while being observed by others or when someone is self monitoring In reactivity behaviors tend to shift in the desired direction and also move away from undesired behavior eg moving toward good friends and moving away from bad friends Psychological Testing Specific tools for assessment 0 O O Cognition Emotion Behavior Neuropsychological testing 0 Neuroimaging Projective tests theory proposes people will protect their own true personality or unconscious thoughts and fears onto ambiguous test stimuli that will reveal their hidden unconscious thoughts and feelings to the therapist O O O 0 Presentation of ambiguous stimuli Projection of personality and the unconscious Psychoanalytic roots Examples Rorschach Inkblot Test developed by Hermann Rorschach to study perceptual processes and to diagnose psychological disorders Currently the Rorschach contains ten inkblot pictures that serve as ambiguous stimuli John Exner developed a standardized version of the Rorschach Inkblot test called the Comprehensive System Its use remains controversial Thematic Apperception Test TAT the best known projective test developed in 1935 by Morgan and Murray The TAT consists of 31 cards depicting ambiguous pictures The test taker is asked to tell a dramatic story about what they see in the picture The TAT is based on the notion that people will reveal their unconscious mental processes on their stories about the pictures TAT has limited reliability validity and standardization procedures A Children39s Apperception Test CAT and Senior Apperception Test SAT have also been developed for those age groups 0 Criticisms and controversies Scoring and interpretation Reliability and validity o Strengths Qualitative date icebreakers standardization efforts Personality Inventories generally more empirically based standardized than projective tests 0 Face vs construct validity o Empiricay based o Minimally ambiguous stimuli 0 Minimal inference Scoring Interpretation Minnesota Multiphasic Personality Inventory 0 567 items MMPI 2 o truefalse responses 0 adolescent version o extensive normative data reliability and validity o interpretation individual scales profiles Assessment Intelligence Testing Initial purpose is predictive validity predicting academic success Intelligence tests were initially developed to predict how well persons would do in school eg Alfred Binet and Theodore Simmon s work with the French Government in 1904 The Binet Simon Test was revised and translated by Lewis Terman of Stanford University in 1916 and became known as the Stanford Binet in the US IQ derived by taking the child39s mental age based on the IQ test and dividing it by hisher chronological age and multiplying by 100 0 Problems occurred due to the lack of comparability in scores across age groups 0 Deviation IQ where a person39s score is compared only to scores of others of the same age Domains 0 Verbal 0 Performance Weschler Intelligence Tests 0 Weschler Intelligence Scale for Children WASC an intelligence test for schoolage children 0 Weschler Adult Intelligence Scale WAIS used for adults 0 Weschler Preschool and Primary Scale of Intelligence WPPSI for young children 0 All tests contain verbal eg vocabulary general knowledge verbal reasoning short term memory and performance scales eg psychomotor abilities nonverbal reasoning ability to learn new relationships and fu scae IQ IQ vs Intelligence IQ should NOT be confused with intelligence IQ is a score on a test that may predict academic success Many argue intelligence also involves adaptability to the environment ability to generate new ideas and ability to process new information efficiently Neuropsychology Testing Neuropsychological tests assess Broad base of skills and abilities Brain behavior relations Assets and deficits Methods Fixed versus flexible batteries Concerns False Positives False Negatives Overlap between intelligence testing and neurological testing Purpose possible existence of brain impairment or brain dysfunction Neuroimaging Pictures of the Brain Neuroimaging a name for a set of procedures that allow a window into brain structure ie parts of the brain and function ie what the brain does via blood flow metabolic activity etc 0 Images of Brain Structure Computerized axial tomography CATCT o X rays of brain 0 Pictures in slices Magnetic resonance imaging MRI 0 Strong magnetic field 0 Improved resolution 0 Brief changes in brain activity PET and SPECT 0 Injection of radioactive isotopes o React with brain oxygen blood and glucose 0 Reveal metabolic deficiencies Utility Locating tumors injuries structural or anatomical abnormalities Advantages and limitations 0 Yield detailed information o Expense 0 Lack adequate norms 0 Limited clinical utility Psychological Assessment Psychophysiology refers to measurable changes in the nervous system reflecting emotional or psychological events Psychophysiological assessment refers to methods of assessing brain structure and function specifically and nervous system activity more generally Emotional or psychological events reflected by changes in the nervous system Electroencephalogram EEG a peripheral measure of electrical activity in the head related to the firing of a specific group of neurons which yields a measure of brain wave activity ie ow votage current usually associated with the cortex of the brain Used to assess brain activity associated with waking and sleep states Brain wave activity Evoked potentials or event reated potentials ERP Alpha and delta waves Other bodily responses Electrodermal o Galvanic skin response Biofeedback Assessing a response to a stimuli is useful in disorders with a strong emotional component PTSD Sexual dysfunctions Headache Hypertension Diagnosing Psychological Disorders Diagnosis identifying a general class of problems that seem to come together is useful for obtaining information about psychological profiles etiology and treatment The clinician may be able to use the psychiatric diagnosis to help establish a prognosis or the likely future course of a disorder under certain conditions Classification is an integral part of science Classification refers to any effort to construct groups or categories and to assign objects or people to these categories based on their shared attributes or relations ie a nomothetic strategy Approaches Idiographic determining the individualistic unique features or attributes of a person eg the person39s cultural background or unique personality traits Nomothetic the identification and examination of large groups of people with the same disorder to note similarities and develop general laws determining general classes and common attributes Diagnostic classification Categories based on commonalities Terminology of classification systems Taxonomy Nosology Nomenclature Classification Issues Classification of behavior disorders is often in a categorical or dimensional form Classical or pure categorical approach assumes that each disorder is unique ie different with its own unique underlying pathophysiological cause Only one set of defining criteria is needed for a given disorder and all people must meet all of the criteria to receive a diagnosis Dimensional approach places symptoms on several dimensional ratings It uses scales that indicate the degree to which a person is experiencing various cognitions moods and behaviors This is a view that is problematic when theorists cannot agree on the number and types of required dimensions Prototypical approach an alternative to the categorical and dimensional approaches It is a categorical approach that combines in part the features of the other approaches It 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 eg there are several ways one could meet criteria for major depression or panic disorder but still get the diagnosis The DSM is based on this approach Two widely used classification systems ICD 10 international classification of diseases DSM 0 Categories in the DSM 5 range across the lifespan eg childhood adolescence adulthood and old age Severity of most disorders noted range 04 severe There is more of a dimensional approach in the DSM 5 Common behavioral and genetically based disorders are grouped together There is no miltiaxial system used no axes It follows the codes of the ICD 10 In the rating scales used in the DSM 5 the higher the score indicates a worst condition for the client It allows for integration of important social and cultural influences in relation to the diagnosis eg what are the person39s beliefs cultural values and what is the extent to which the person is westernized into mainstream culture Criticisms of DSM 5 Comorbidity Emphasize reliability sometimes at the expense of validity Complexity of categorizing psychopathology A Caution About Labeling and Stigma Problems with pitfalls and labels Negative connotations labeling of a cognitive or behavioral O disorder has negative connotations Pejorative associated disapproved of Stigmas we should label the behavior pattern not the person Overidentification Individuals may identify with their label and this will affect their sef esteem Reification viewing an abstract immaterial concept as if it was a concrete thing There is particularly the tendency to reify diagnostic categories ie treat them as things that exist When we think of the diagnostic category as a thing we make an error called reification Key Questions 1 What are the symptoms 4 Cognitive thinking problems with memory reasoning delusions one s belief system Perceptual perceiving the world differently like learning disabilities hallucinations Mood affect or emotion Is the person depressed have flat affect oreupho c Behavior activity level mannerisms tics what is the person doingnot doing Physical Appearance is it appropriate for the situation What is the person39s personal appearance Physiological Symptoms cardiovascular or neurological symptoms like heart palpitations headaches etc What is the approximate duration How severe or pervasive shows up in all areas of one s life is the disorder Was there a precipitating event yesno In mental disorders we always check the frequency duration and intensity of the symptoms 91714 144 PM 91714 144 PM
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