Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Chapter 3

Clinical Assessment and Diagnosis

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Assessing Psychological Disorders

  Purposes of Clinical Assessment  To understand the individual    To predict behavior To plan treatment To evaluate treatment outcome Analogous to a Funnel  Starts broad   Multidimensional in approach Narrow to specific problem areas

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Three Concepts Determine the Value of Assessment

   Reliability  Consistency in measurement  Examples include test-retest, inter-rater reliability Validity  What the test measures and how well it does so  Examples include content, concurrent, discriminant, construct, and face validity Standardization and Norms  Foster consistent use of techniques   Provide population benchmarks for comparison Examples include administration procedures, scoring, and evaluation of data

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Three Concepts Determine the Value of Assessment

Figure 3.1

Concepts that determine the value of clinical assessments.

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Domains of Assessment: The Clinical Interview and Physical Exam

   Clinical Interview  Most common clinical assessment method  Structured or semi-structured Mental Status Exam      Appearance and behavior Thought processes Mood and affect Intellectual functioning Sensorium Physical Exam

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Mental Status Exam

Figure 3.2

Components of the mental status exam.

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Domains of Assessment: Behavioral Assessment and Observation

  Behavioral Assessment  Focus on here and now    Tends to be direct and minimally inferential Target behaviors are identified and observed Focus on antecedents, behaviors, and consequences Behavioral Observation and Behavioral Assessment    Can be either formal or informal Self-monitoring vs. others observing Problem of reactivity using direct observation

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Domains of Assessment: Behavioral Assessment and Observation

Figure 3.3

The ABCs of observation.

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Domains of Assessment: Psychological Testing and Projective Tests

  Psychological Testing  Must be reliable and valid Projective Tests  Project aspects of personality onto ambiguous stimuli   Roots in psychoanalytic tradition High degree of inference in scoring and interpretation  Examples include the Rorschach Inkblot Test, Thematic Apperception Test  Reliability and validity data tend to be mixed

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Rorschach Test

Figure 3.4

test.

This inkblot resembles the ambiguous figures presented in the Rorschach

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Thematic Apperception Test

Figure 3.5

Example of a picture resembling those in the Thematic Apperception Test.

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Domains of Assessment: Psychological Testing and Objective Tests

   Objective Tests  Test stimuli are minimally ambiguous   Roots in empirical tradition Require minimal inference in scoring and interpretation Objective Personality Tests  Minnesota Multiphasic Personality Inventory (MMPI, MMPI 2, MMPI-A)   Over 549 true or false items Extensive reliability, validity, and normative database Objective Intelligence Tests  Nature of intellectual functioning and IQ   The deviation IQ Verbal and performance domains

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Domains of Assessment: Psychological Testing and Neuropsychology

  Neuropsychological Tests  Assess broad range of skills and abilities    Goal is to understand brain-behavior relations Used to evaluate a person’s assets and deficits Examples include the Luria-Nebraska and Halstead-Reitan Batteries  Overlap with intelligence tests Problems with Neuropsychological 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”

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Domains of Assessment: Neuroimaging and Brain Structure

  Neuroimaging: Pictures of the Brain  Allows examination of brain structure and function Imaging Brain Structure      Computerized axial tomography (CAT or CT scan) CAT utilizes X-rays of brain; pictures in slices Magnetic resonance imaging (MRI) MRI has better resolution than CAT scan MRI operates via strong magnetic field around head

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Domains of Assessment: Neuroimaging and Brain Function (cont.)

  Imaging Brain Function  Positron emission tomography (PET)     Single photon emission computed tomography (SPECT) Both involve injection of radioactive isotopes Radioactive isotopes react with oxygen, blood, and glucose in the brain Functional MRI (fMRI) – Brief changes in brain activity Advantages and Limitations  Provide detailed information regarding brain function   Procedures are expensive, lack adequate norms Procedures have limited clinical utility

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Domains of Assessment: Psychophysiological Assessment

   Psychophysiological Assessment  Methods used to assess brain structure, function, and activity of the nervous system Psychophysiological Assessment Domains  Electroencephalogram (EEG) – Brain wave activity    Heart rate and respiration Electromyography (EMG) – Cardiorespiratory activity Electrodermal response and levels – Sweat gland activity – Muscle tension Uses of Routine Psychophysiological Assessment  Disorders involving a strong emotional component  Examples include PTSD, sexual dysfunctions, sleep disorders, headache, and hypertension

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Diagnosing Psychological Disorders: Foundations in Classification

   Clinical Assessment vs. Psychiatric Diagnosis  Assessment – Idiographic approach  Diagnosis – Nomothetic approach  Both are important in treatment planning and intervention Diagnostic Classification  Classification is central to all sciences  Develop categories based on shared attributes Terminology of Classification Systems  Taxonomy – Classification in a scientific context  Nosology contexts – Taxonomy in psychological / medical  Nomenclature – Nosological labels (e.g., panic disorder)

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Diagnosing and Classifying Psychological Disorders

  The Nature and Forms of Classification Systems  Classical (or pure) categorical approach – Categories   Dimensional approach – Classification along dimensions Prototypical approach – Both classical and dimensional Two Widely Used Classification Systems  International Classification of Diseases and Health Related Problems (ICD-10); published by the World Health Organization  Diagnostic and Statistical Manual of Mental Disorders (DSM); published by the American Psychiatric Association; currently the DSM-IV and DSM-IV-TR

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Purposes and Evolution of the DSM

   Purposes of the DSM System  Aid communication   Evaluate prognosis and need for treatment Treatment planning DSM-I (1952) and DSM-II (1968)  Both relied on unproven theories and were unreliable DSM-III (1980) and DSM-III-R   Were atheoretical, emphasizing clinical description Multiaxial system with detailed criterion sets for disorders  Problems included low reliability, and reliance on committee consensus

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

The DSM-IV

   Basic Characteristics  Five axes describing full clinical presentation  Clear inclusion and exclusion criteria for disorders   Disorders are categorized under broad headings Empircally grounded prototypic approach to classification The Five DSM-IV Axes  Axis I – Most major disorders  Axis II – Stable, enduring problems (e.g., personality disorders, mental retardation)  Axis III – Medical conditions related to abnormal behavior   Axis IV – Psychosocial problems Axis V – Global clinician rating of adaptive functioning Other Unique Features of the DSM-IV

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Unresolved Issues in the DSM-IV

    What Are the Optimal Thresholds for Diagnosis?

 Examples include level or distress, impairment, number of required symptoms Arbitrary Time Periods in the Definitions of Diagnoses Should Other Axes Be Included?

 Examples include premorbid history, treatment response, family functioning Is the DSM-IV System Optimal for Treatment or Research?

  The 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

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow

Chapter 3: Clinical Assessment and Diagnosis

Summary of Clinical Assessment and Diagnosis

   Clinical Assessment and Diagnosis  To provide a complete picture of the client  To aid understanding and ameliorating human suffering  Require reliable, valid, and standardized information Dangers of Diagnosis  Problem of reification  Problem of stigmatization Assessment and Diagnosis   The core of abnormal psychology Requires a multidimensional perspective