CHAPTER 3



Chapter 3

Clinical Assessment and Diagnosis

Chapter Overview

This chapter outlines the processes of clinical assessment and diagnosis. Both domains are central to the study of psychopathology. Clinical assessment refers to a systematic evaluation and measurement of psychological, biological, and social factors in people with psychiatric disorders to provide idiographic information that may be helpful in treatment planning. Diagnosis is the process of determining whether a particular problem that distresses a person meets criteria for a psychological disorder. This chapter covers assessment techniques (clinical interview, behavioral assessment, physical examination, psychological and neuropsychological testing, neuroimaging procedures, and psychophysiological assessment), psychometric issues related to assessment and diagnosis (reliability, validity, and standardization), the nature and history of the DSM system, and issues surrounding diagnosis and classification (e.g., categorical, dimensional, and prototypic approaches). Throughout the chapter, the issues are illustrated with the case of Frank (young, serious, and anxious).

Chapter Outline

ASSESSING PSYCHOLOGICAL DISORDERS

KEY CONCEPTS IN ASSESSMENT

The Clinical Interview

Physical Examination

Behavioral Assessment

Psychological Testing

Neuropsychological Testing

Neuroimaging: Pictures of the Brain

Psychophysiological Assessment

DIAGNOSING PSYCHOLOGICAL DISORDERS

CLASSIFICATION ISSUES

Diagnosis Before 1980

DSM-III and DSM-III-R

DSM-IV and DSM-IV-TR

DSM-5

Creating a Diagnosis

Beyond DSM-5: Dimensions and Spectra

Detailed Outline

Assessing Psychological Disorders

( Clinical assessment is the systematic evaluation and measurement of psychological, biological, and social factors in an individual with a possible psychological disorder; diagnosis is the process of determining that those factors meet all criteria for a specific psychological disorder.

( Reliability(consistency), validity (accuracy), and standardization (norming) are important components in determining the value of a psychological assessment.

( To assess various aspects of psychological disorders, clinicians may first interview and take an informal mental status exam of the patient. More systematic observations of behavior are called behavioral assessment.

➢ Discussion Point:

What does a mental status exam tell you about pursuing particular questions in your assessment?

➢ Discussion Point:

What are the potential problems in using a behavioral assessment? Do you think that a person should be told what they are looking for or should they go into the assessment without that information? Why?

( A variety of psychological tests can be used during assessment, including projective tests, in which the patient responds to ambiguous stimuli by projecting unconscious thoughts; personality inventories, in which the patient takes a self-report questionnaire designed to assess personal traits; and intelligence testing, which provides a score known as an intelligence quotient (IQ).

➢ Discussion Point:

How might using a combination of projective and objective tests provide a more comprehensive picture of a client’s functioning?

( Biological aspects of psychological disorders may be assessed through neuropsychological testing designed to identify possible areas of brain dysfunction. Neuroimaging can be used more directly to identify brain structure and function. Finally, psychophysiological assessment refers to measurable changes in the nervous system, reflecting emotional or psychological events that might be relevant to a psychological disorder.

➢ Discussion Point:

Every form of assessment has strengths and weaknesses. If you had to choose one and only one form to assess a new client, which would you use? Why? How would you overcome the weaknesses of that particular method?

Diagnosing Psychological Disorders

( The term classification refers to any effort to construct groups or categories and to assign objects or people to the categories on the basis of their shared attributes or relations. Methods of classification include classical categorical, dimensional, and prototypical approaches. Our current system of classification, the Diagnostic and Statistical Manual, fifty edition (DSM-5) is based on a prototypical approach in which certain essential characteristics are identified but certain “nonessential” variations do not necessarily change the classification. The DSM-5 categories are based on empirical findings to identify the criteria for each diagnosis. Although this system is the best to date in terms of scientific underpinnings, it is far from perfect, and research continues on the most useful way to classify psychological disorders.

➢ Discussion Point:

If the authors had adopted a trulydimensional system of classification for DSM-V, how might that affect the field?

( One of the most notable changes in the DSM-5 was the removal of the multiaxial diagnostic system, which had been in place since DSM-III. The first three axes were combined into the descriptions of the disorders themselves, and clinicians can separately comment on psychosocial or contextual factors (formerly axis IV) and the extent of the impact of a given condition (formerly axis V).

( A dimensional approach has advantages in being more comprehensive in its descriptions of

client behavior. However, finding the essential dimensions of anorexia, for example, may

elicit considerable debate among theorists. A dimensional system may affect insurance

reimbursement if there is not a clear demarcation noting mental illness. Researchers and

clinicians would both need to adapt to this new approach of classifying and describing

behavior.

Key Terms

clinical assessment, 69 electroencephalogram (EEG), 84

diagnosis, 69 idiographic strategy, 86

reliability, 71 nomothetic strategy, 86

validity, 71 classification, 86

standardization, 71 taxonomy, 86

mental status exam, 72 nosology, 86

behavioral assessment, 74 nomenclature, 86

self-monitoring, 77 classical categorical approach, 87

projective tests, 78 dimensional approach, 87

personality inventories, 79 prototypical approach, 87

intelligence quotient (IQ), 82 familial aggregation, 89

neuropsychological test, 82 comorbidity, 92

false positive, 83 labeling, 92

false negative, 83

psychophysiological

assessment, 84

Ideas for Instruction

1. Activity: An Introduction to Assessment Methods. To help familiarize students with the various clinical assessment tools, begin by introducing a partial case history of a client. Your students may work in groups or individually, but ask them to evaluate what tests and methods they would use with each client to determine a diagnosis. Students may be encouraged to focus on the strengths and limitations of each to emphasize that no single assessment method is entirely comprehensive. For example, you may present the following cases:

a. Jack was brought into the rehabilitation unit last week. Three weeks ago, he suffered a head injury in a car accident. He has been referred to your office to determine the extent of his cognitive damage. What tests and methods of assessment should you use in your evaluation? The answer: referral for medical exam/neuroimaging, mental status, behavioral observation, intelligence tests, neuropsychological tests, and perhaps interviews with other sources.

b. Carla reports feeling very depressed. She has isolated herself from friends and family, and has been unable to work. Carla’s family is concerned that she might try to commit suicide. They have approached you for help and advice. What tests and methods of assessment should you use in your evaluation? The answer: clinical/structured interview, physical examination, checklist or rating scales (e.g., Beck Depression Inventory, projective and/or objective psychological tests).

c. Norman performs poorly in school compared to his classmates. He is fidgety and aggressive, and has great difficulty completing his homework assignments. His teachers are considering holding him back a year and want your advice. What tests and methods of assessment should you use in your evaluation? The answer: clinical interview, behavioral assessment and observation in therapy and in class, physical examination, teacher and parent checklists or rating scales, and intelligence and achievement tests.

d. A man shows up at the emergency room at a hospital. You are called to consult on this case. The man does not know his own name. He is unable to identify what city he lives in, and is not sure how he got to the hospital. What tests and methods of assessment would you want to administer at this point? The answer: physical and mental status examinations.

Note. You may want to draw from additional cases from the abnormal psychology casebooks. This exercise helps students learn about the assessment tools and learn that the assessment process entails choosing assessment devices and methods that appropriately address individual clients’ needs.

2. Activity: Reliability, Validity, and Perceptual Bias in Clinical Assessment. A neat and simple exercise that can readily illustrate the relation between reliability and validity and the problem of personal bias is to do the following. First, tell students that you are about to put something up on the screen and that you want them all to watch carefully. As soon as the image disappears, they are to write down exactly what they saw. After these opening remarks, select a transparency master with the text “Paris in the the spring” and flash it up on a projection screen briefly (i.e., no longer than 5 seconds). Then, take it away and ask students to write down what they saw. You can then poll the students and tally responses on the board. What usually happens is that the majority of the class will report seeing “Paris in the spring.” Indeed, you could go ahead and calculate the inter-observer reliability for the class and you would likely find it to be quite high. You can then go on to point out that while most of the class was in agreement, most of the class was also wrong. You can then put up the overhead for a closer examination and point out that what was flashed on the screen were the words “Paris in the the spring.” This is also a good time to point out the relation between reliability and validity and the issue of how our own experiences and preconceptions can bias what we see and how we interpret and respond to sense data during clinical assessment.

3. Activity: Self-Monitoring, Reactivity, and Behavior Change. To illustrate the demands of self-monitoring, including reactivity, you can have students select some specific behavior, thought, or emotion that they would like to change (either increase in frequency or decrease in frequency). Examples might include the number of times they say “um” during a conversation, the number of cigarettes they smoke, the amount of time they spend studying, number of pages of text they read each day, the amount of food or drink they consume daily, the number of steps walked each day, etc. Then have students record the occurrence of the behavior immediately after it occurs for a period of one week. Students can then be asked to plot their data by day (i.e., “y axis” = frequency of the behavior, “x axis” = day). Reactivity should produce changes in the behavior in the desired direction. Encourage students to select a behavior that they would like to change, but also one that they would be comfortable discussing in class. Use this exercise to talk about reactivity, the demands of self-monitoring more generally, and the importance of accurate (reliable and valid) self-monitoring in clinical assessment. Most students will find it hard to monitor the frequency of each occurrence of the selected behavior.

4. The Rorschach Test. The theory behind the test, created by Hermann Rorschach, is that the test taker’s spontaneous or unrehearsed responses reveal deep secrets or significant information about the taker’s personality or innermost thoughts. See for a more in-depth discussion and the actual ink blots. Use these ink blots to lead a discussion of the validity and reliability of this method of assessment.

COPYRIGHT (c) 2015 Cengage Learning

HANDOUT 3.1

Somatotypes

In the space provided, rate the degree to which you think you possess each of the three body types using a scale from 1 (low) to 7 (high) with a mean of 4 (average).

➢ Endomorphic Body Type:

Soft body; underdeveloped muscles; round shaped; over-developed digestive system

Associated personality traits: love of food; tolerant; evenness of emotions; love of comfort; sociable; good humored; relaxed; need for affection

Your Rating: ______

➢ Mesomorphic Body Type:

Hard, muscular body; overly mature appearance; rectangular shaped; thick skin; upright posture

Associated personality traits: adventurous; desire for power and dominance; courageous; indifference to what others think or want; assertive; bold; zest for physical activity; competitive; love of risk and chance

Your Rating: ______

➢ Ectomorphic Body Type:

Thin; flat chest; delicate build; young appearance; tall; lightly muscled; stoop-shouldered; large brain

Associated personality traits: self-conscious; preference for privacy; introverted; inhibited; socially anxious; artistic; mentally intense; emotionally restrained

Your Rating: ______

Questions to Consider:

1. Do the personality traits associated with your ratings seem accurate (i.e., valid)?

2. Do you think this somatotype theory is generally accurate for most people?

3. Do you know any people for whom this theory works or doesn’t work?

4. What might be some problems with this theory and test?

Supplementary Reading Material

Additional Readings:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.

Burke, M. J., & Normand, J. (1987). Computerized psychological testing: Overview and critique. Professional Psychology: Research and Practice, 18, 42-51.

Danna, R. H. (1993). Multicultural assessment perspectives for professional psychology. Boston: Allyn & Bacon.

Golden, C. J. (1990). Clinical interpretation of objective psychological tests. Boston: Allyn and Bacon.

Halleck, S. L. (1991). Evaluation of the psychiatric patient: A primer. New York: Plenum.

Kellerman, H. (1991). Handbook of psychodiagnostic testing: An analysis of personality in the psychological report. Boston: Allyn and Bacon.

Lukas, S. R. (1993). Where to start and what to ask: An assessment handbook. New York: Norton.

Mash, E. J., & Terdal, L. G. (Eds.) (1988). Behavioral assessment of childhood disorders (2nd ed.). New York: Guilford.

Matarazzo, J. D. (1992). Psychological testing and assessment in the 21st century. American Psychologist, 47, 1007-1018.

Pope, B. (1979). The mental health interview: Research and application. New York: Pergamon Press.

Trzepacz, P. T. (1993). The psychiatric mental status examination. New York: Oxford University Press.

Widiger, T. A., & Trull, T. J. (1991). Diagnosis and clinical assessment. Annual Review of Psychology, 42, 109–133.

Suggested Videos

Abnormal behavior: Fact and fiction. (Insight Media). This video examines both historical and current misconceptions and stereotypes regarding mental illness. Showing clips of two survivors of mental illness discussing their experiences, the video addresses the difficulties faced by these individuals in such everyday tasks as finding jobs and maintaining families. The video concludes by offering different approaches to viewing mental illness and advocating a more compassionate and humane understanding. (60 min)

Basic interviewing skills. (Insight Media). This video presents vignettes that focus on techniques for interviewing clients. The five basic skills—listening, reflecting, questioning, expressing, and interpreting—are taught in separate segments that progress from basic to complex situations. The video concludes with a session in which all of these skills are integrated. (51 min)

Behavioral interviewing with couples. (Research Press). Shows the six basic stages of an initial marriage counseling interview. (14 min).

Comprehensive clinical assessment. (Insight Media). This video discusses the range of skills that exemplify the art of social work practice and that are critical for effective intervention. (30 min)

Emotional intelligence. (Insight Media). Emotional intelligence describes a person’s comfort level with emotions and fluency with such social skills as listening, sharing, and being kind. This video presents research showing that school-aged children who cope better with daily social stresses stay healthier and learn more effectively. (30 min)

Intelligence. (Insight Media). This video explains what IQ tests are designed to measure, describing their origins, their uses, and some of their failures. It addresses the debates on whether IQ tests measure aptitude or achievement and whether intelligence is fixed or changeable. (30 min)

Intelligence testing. (Insight Media). This three-volume set features noted experts discussing aspects of intelligence testing. Arthur Jensen defends his contention that intelligence is a genetic fact of nature that correlates with certain physical attributes, Jonathan Baron offers a more social definition of intelligence, and Richard Burian responds to each contention. (3 volumes, 114 min total)

Multiple intelligences: Intelligence, understanding, and the mind. (Insight Media). The first part of this set presents Howard Gardner’s theory of multiple intelligences. It discusses naturalist intelligence, recent work on performance-based assessments, new ideas about education for understanding, myths and applications of multiple intelligence theory, and teaching for understanding. The second presents Gardner fielding questions from educators about his theory. (2 volumes, 90 min total)

Personality. (CRM/McGraw-Hill). Depicts a college student undergoing a thorough assessment by a clinical psychologist that includes self-report, report from collateral sources, and the use of intelligence and projective tests. (30 min)

The assessment/therapy connection. (Research Press). Arnold Lazarus performs a multi-modal assessment of a 45-year-old depressed woman. (29 min)

The clinical psychologist. (Insight Media). Depicts an initial assessment using different methods of assessment. (24 min)

Violence risk assessment. (Insight Media). While clinicians can never predict violence or incidences of repeat violence with certainty, there are social, psychological, and biological risk factors that can be examined as part of a thorough assessment. This video uses a case dramatization to present a model for violence risk assessment. (37 min)

Online Resources

APA



The American Psychological Association homepage.

Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV)



This site provides diagnostic criteria and information relevant to the DSM-IV-TR.

Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR)



This site provides information about the text revision to DSM-IV-TR, including information about diagnostic criteria.

Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5)



This site provides information about the recent release of DSM-5, including information about diagnostic criteria.

Glossary of DSM-5 Technical Terms



This website provides a glossary of terms and definitions of DSM-5 technical terms.

Neuroimaging Links



This site contains a series of excellent links to resources related to neuroimaging, neuroanatomy, and their relation to psychopathology.

Neuropsychology Central



This site contains information and links about neuropsychology and neuropsychological assessment.

Psychological Testing



This APA website contains information and useful links related to psychological testing, including the ethics of testing.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download