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Chapter 3

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Psychology 2030A/B
David Vollick

Abnormal  Psychology:  Chapter  3:   Clinical  Assessment  and  Diagnosis     Introduction   • Clinical  assessment  and  diagnosis  are  central  to  the  study  of   psychopathology  and  to  the  treatment  of  psychological  disorders   • Clinical  Assessment:  systematic  evaluation  and  measurement  of   psychological,  biological,  and  social  factors  in  a  person  presenting  with  a   possible  psychological  disorder   • Diagnosis:  process  of  determining  whether  a  presenting  problem  meets  the   established  criteria  fro  a  specific  psychological  disorder     Assessing  Psychological  Disorders   • Process  of  clinical  assessment  in  psychopathology  begins  by  collecting  a  lot   of  information  across  a  broad  range  of  the  individuals  functioning   • After,  the  clinician  narrows  the  focus  by  ruling  out  problems  in  some  areas   and  concentrating  on  area  that  seem  most  relevant     • Assessment  techniques  are  subject  to  a  number  of  strict  requirements   • Value  of  assessment  depends  on:   o Reliability:  the  degree  to  which  a  measurement  is  consistent   o Validity:  the  degree  to  which  a  technique  measure  what  it  is  designed   to  measure   o Standardization:  application  of  certain  standards  to  ensure   consistency  across  different  measurements   • Improve  reliability  by  carefully  designing  their  assessment  devices  and  then   conducting  research  on  them  to  ensure  that  two  or  more  raters  will  get  the   same  answers  (interrater  reliability).  Also  determine  whether  these   techniques  are  stable  across  time   • Comparing  the  results  of  one  assessment  measure  with  the  results  of  others   that  are  better  know  allows  you  to  begin  to  determine  the  validity  of  the  first   measure  called  concurrent  or  descriptive  validity   • Predictive  validity  is  how  well  your  assessment  tells  you  what  will  happen  in   the  future   • Clinical  assessment  consists  of  strategies  and  procedures  that  help  clinicians   acquire  the  information  they  need  to  understand  their  patients  and  assist   them   • These  procedures  include:  clinical  interview  and  mental  status  exam  that  can   be  administered  though  physical  exam,  behavioural  observation  and   assessment,  and  psychological  tests     The  Clinical  Interview   • Clinical  interview  gathers  information  on  current  and  past  behaviour,   attitudes,  and  emotions,  as  well  as  a  detailed  history  of  the  individuals  life  in   general  and  f  the  presenting  problem     The  Mental  Status  Exam   • The  mental  status  exam  involves  the  systematic  observation  of  somebody’s   behaviour   • Exams  are  performed  relatively  quickly  by  experienced  clinicians   • The  exams  cover  five  categories:   1. Appearance  and  Behaviour   • Overt  behaviour   • Attire   • Appearance,  posture,  expression   2. Thought  Processes   • Rate  of  speech   • Continuity  of  speech   • Content  of  speech   • Evidence  of  delusions  of  persecution  (think  people  are  after  you),   ideas  of  reference  (things  other  people  do  relate  back  to  you),  and   hallucinations   3. Mood  and  Affect   • Predominant  feeling  state  of  the  individual   • Feeling  state  accompanying  what  individual  says   4. Intellectual  Functioning   • Type  of  vocabulary     • Use  of  abstractions  and  metaphors   5. Sensorium   • Awareness  of  surrounding  in  terms  of  person,  time,  place  –   oriented  times  3   • They  allow  the  clinician  to  make  a  preliminary  determination  of  which  areas   of  the  patients  behaviour  and  condition  should  be  assessed  in  more  detail   and  perhaps  more  formally   • Provides  more  focus  for  the  assessment  and  diagnostic  activities  to  come   • Patients  usually  have  a  good  idea  of  their  major  concerns  in  a  general  sense   occasionally,  the  problem  reported  by  the  patient  may  not,  after  assessment,   be  the  major  issue  in  the  eyes  of  the  mental  health  clinician   • Psychologists  are  trained  in  methods  that  put  patients  at  ease  and  facilitate   communication  using  nonthreatening  ways  of  seeking  information  and   having  appropriate  listening  skills   • Information  provided  by  patients  is  protected  by  laws  of  “privileged   communication”  or  confidentiality     Semistructured  Clinical  Interviews   • Different  types  and  styles  of  interviews:  unstructured  interview  and   structured  interviews   • Clinicians  may  also  depart  from  set  questions  to  follow  up  on  specific  issues   • Disadvantages  of  semistructured  interviews:   o Robs  the  interviewer  of  some  of  the  spontaneous  quality  of  two   people  talking  about  a  problem   o If  applied  rigidly,  may  inhibit  the  patient  form  volunteering  useful   information  that  is  not  directly  relevant  to  the  questions  being  asked   • Fully  structured  interviews  administered  wholly  by  a  computer  but  have  not   caught  on   • For  OCD  patients  the  clinician  asks  the  patient  to  rate  each  obsession  on  two   measures:  persistence  distress  and  resistance     Physical  Examination   • If  the  patient  has  not  had  a  physical  exam  in  the  past  year,    clinician  might   recommend  one  with  particular  attention  to  the  medical  conditions   sometimes  associated  with  the  specific  psychological  problem   • Many  problems  presenting  as  disorders  have  a  clear  relationship  to  a   temporary  toxic  state,  caused  by  bad  food,  the  wrong  medication,  or  the   onset  of  a  medical  condition   • Usually  psychologists  are  well  aware  of  the  medical  conditions  and  drug  use   and  abuse  that  may  contribute  to  the  kinds  of  problems  described  by  the   patient     • If  a  current  medical  condition  or  substance  abuse  situation,  exists,  the   clinician  must  ascertain  whether  it  is  merely  co-­‐existing  or  causal,  usually  by   looking  at  the  onset  of  the  problem       Behavioural  Assessment     • Behavioural  Assessment:  measuring,  observing,  and  systematically   evaluating  the  clients  thoughts,  feelings,  and  behaviour  in  the  actual  problem   situation  or  context   • Should  explain  why  he  or  she  is  having  difficulties  at  this  time     • Clinical  interviews  sometimes  provide  limited  assessment  information   • Children  or  individuals  who  are  not  verbal  because  of  the  nature  of  their   disorder  or  because  of  cognitive  deficits  or  impairments  are  not  good   candidates  for  clinical  interviews   • Target  behaviours  are  identified  and  observed  with  the  goal  of  determining   the  factors  that  seem  to  influence  those  behaviours   • Most  clinicians  assume  that  a  complete  picture  of  a  persons  required  direct   observation  in  naturalistic  environments,  but  isn’t  always  possible  or   practical,  so  clinicians  sometimes  set  up  analogue  settings   • Therapist  can  see  how  patients  respond  and  observations  are  latter  used  for   treatment   • Observational  assessment  is  usually  focused  on  the  here  and  now   • Observational  assessments  focuses  on:   o Antecedents  –  what  happened  before  the  behaviour   o Behaviour   o Consequences  –  what  happened  after  the  behaviour   • A  problem  with  informal  observation  is  that  it  relies  on  the  observers   recollection  as  well  as  on  his  or  her  interpretation  of  the  events   • Formal  observation  identifying  specific  behaviours  that  are  observable  and   measurable   • Once  the  target  behaviour  is  selected  and  defined,  an  observer  writes  down   each  time  it  occurs,  along  with  what  happened  just  before  and  just  after   • The  goal  is  to  see  whether  there  are  any  obvious  patterns  of  behaviour  and   then  to  design  a  treatment  on  those  patterns   • Self-­‐monitoring  or  self  observation  can  tell  you  exactly  how  big  your   problems  are  and  what  situations  lead  you  to  do  them  more   • Clinicians  often  ask  clients  to  self-­‐monitor  their  behaviour  to  get  more   detailed  information  on  the  problem   • Behaviour  Rating  Scales:   • Brief  Psychiatric  Rating  Scale  assesses  18  general  areas  of  concern.  Each   symptom  is  rated  on  a  seven  point  scale  (0-­‐6)  which  includes  items  of   somatic  concern  (physical  illness),  guilt  feelings,  and  grandiosity   (exaggerated  self  opinion)   • Reactivity  can  distort  any  observational  data,  Your  presence  may  cause  them   to  change  their  behaviour     • Clinicians  sometimes  depend  on  the  reactivity  of  self-­‐monitoring  to  increase   the  effectiveness  of  their  treatments       Psychological  Testing   • Test  used  to  assess  psychological  disorders  and  must  be  reliable  and  valid   • Psychological  tests  include  specific  tests  to  determine  cognitive,  emotional,   or  behavioural  responses  that  might  be  associated  with  a  specific  disorder   and  more  general  tests  that  assess  long-­‐standing  personality  features   • Intelligence  testing’s,  neurological  testing  and  neurobiological  procedures   are  specialized  areas   • Projective  Testing:  psychoanalytically  based  measures  that  present   ambiguous  stimuli  to  clients  on  the  assumption  that  their  responses  will   reveal  their  unconscious  conflicts.  Such  tests  are  very  inferential  and  lack   high  reliability  and  validity   • Theory  here  is  that  people  project  their  own  personality  and  unconscious   fears  onto  other  people  and  things   • These  tests  are  based  on  psychoanalytic  theory,  they  have  been,  and  remain   controversial   • Projective  tests  are  the  Rorschach  inkblot  test  and  Thematic  Apperception   Test   • Rorschach  inkblot  test  includes  10  inkblots  pictures  that  serve  as  the   ambiguous  stimuli.  Lack  of  reliability  or  validity,  among  other  things   • You  may  get  different  responses  as  the  result  of  your  administering  the  test   differently  on  the  two  occasions   • John  Exner  developed  a  standardized  version  of  the  Rorschach  inkblot  test,   called  the  comprehensive  system   • Despite  the  attempts  to  bring  standardization  its  use  remain  controversial   • Thematic  Projective  Test  (TAT)  best  known  projection  test  after  the   Rorschach  consists  of  31  cards:  30  pictures  and  one  blank.    Involves  a   description  of  what  the  test  taker  sees   • Several  variations  of  the  TAT:  children’s  apperception  test  (CAT)  and  senior   apperception  test  (SAT)   • TAT  and  its  variants  continue  to  be  used  inconsistently.  The  stories  are   interpreted  depending  on  the  examiners  frame  of  reference  as  well  as  on   what  the  patient  may  say.  There  is  little  reliability   • Despite  increasing  standardization,  most  clients  who  used  projective  tests   have  their  own  methods  of  administration  and  interpretation   • Lack  of  reliability  and  validity  make  them  less  useful  as  diagnostic  tests   • Clinicians  responsible  for  knowing  how  to  administer  tests  must  be  aware  of   research  that  suggests  the  tests  have  limited  usefulness  as  a  means  of   diagnosing  psychopathology   • Personality  Inventories:   • MMPI  is  an  empirical  approach  that  involves  reading  statements  and   answering  true  or  false   • Clinicians  have  little  room  for  interpretation  for  MMPI   • A  problem  with  administering  the  MMPI  is  the  time  and  tedium  of   responding  to  the  550-­‐567  items     • The  response  pattern  is  examined  and  scored  by  computer  which  includes  an   interpretation  of  the  results  which  reduces  problems  of  reliability   • MMPI  includes  four  additional  scales:   o Lie  Scale  (L)  –  are  they  lying   o Infrequency  Scale  (F)  –  determines  is  person  is  answering  randomly   o Defensiveness  Scale  (K)  –  does  the  person  see  themselves  in   unrealistically  positive  ways   o Cannot-­‐Say  Scale  (?)  –  no  response   • Standardization  sample  include  people  from  Minnesota  who  had  no   psychological  disorders  and  several  groups  of  people  who  had  particular   disorders   • New  items  have  been  added  such  as  type  A  personality,  low  self-­‐esteem,  and   family  problems   • Reliability  of  the  MMPI  is  excellent  and  validity     • Some  clinicians  look  at  an  MMPI  profile  and  interpret  the  scales  only  on  the   basis  of  their  own  clinical  experience  but  this  compromises  reliability  and   validity   • Hare  developed  the  PCL-­‐R  as  an  instrument  to  assess  the  characteristics  of   psychopathology  using  interviews  with  the  client  along  with  material  from   institutional  files  or  significant  others.  Checklist  of  20  items.   • Alfred  Binet  and  Theodore  Simon  measured  the  skills  children  need  to   succeed  in  school   • They  gave  series  of  tasks  to  number  of  children  and  called  the  test  the   Stanford-­‐Binet   • The  test  provided  a  score  known  as  the  intelligence  quotient  (IQ).  The  mental   age  divided  by  the  chronological  age  multiplied  by  100   • Current  tests  use  a  deviation  IQ  score  compared  only  with  scores  of  others  of   the  same  age   • Wechsler  tests  include  versions  for  adults,  children,  and  young  children  and   contain  verbal  scales,  and  performance  scales   • The  adult  version  has  four  distinct  intellectual  abilities:  verbal  apprehension,   perceptual  organization,  processing  speed,  and  working  memory     • Data  suggest  that  many  of  the  items  may  be  tapping  different  abilities  and   skills  in  children  from  these  cultural  groups  than  in  children  from  the   majority  population   • IQ  scores  determine  your  chance  of  doing  well  in  our  educational  system   • A  lower  than  average  score  does  not  mean  a  person  in  not  intelligent   • Reasons  for  a  low  score  could  be  that  it  was  administered  not  in  that  persons   native  language   • IQ  tests  tend  to  be  reliable  and  valid  assessment  tools     Neuropsychological  Testing     • Neuropsychological  Testing:  assessment  of  brain  and  nervous  system   functioning  by  testing  an  individuals  performance  on  behavioural  tasks   • The  method  of  testing  assess  brain  dysfunction  by  observing  its  effects  on  the   person’s  ability  to  perform  certain  tasks   • Neuropsychological  tests  used  with  children  is  the  Bender  Visual-­‐Motor   Gestalt  Test  is  a  series  of  cards  on  which  are  drawn  various  lines  and  shapes   • A  child  copies  what  is  drawn  on  the  card.  If  the  number  of  errors  exceeds  a   certain  amount,  then  brain  dysfunction  is  suspected   • Nature  or  location  of  the  problem  cannot  be  determined  with  this  test   • Most  popular  advanced  tests  that  allow  more  precise  determinations  of  the   location  of  the  problem  are  the  Luria-­‐Nebraska  Neuropsychological  Battery   and  the  Halstead-­‐Reitan  Neuropsychological  Battery  which  assess  a  variety   of  skills   • Research  on  he  validity  of  neuropsychological  tests  suggests  they  may  be   useful  for  detecting  organic  damage  and  cognitive  disorders     • Neuropsychological  tests  may  even  be  useful  in  predicting  the  development   of  certain  cognitive  disorders     • Most  often,  neuropsychological  tests  are  used  to  help  differentiate  those  who   already  have  a  given  cognitive  disorder  from  those  who  do  not   • False  positives  and  false  negatives  are  possible   • These  tests  primarily  serve  as  screening  devices  and  are  routinely  paired   with  other  assessments  to  improve  the  likelihood  that  real  problems  will  be   found   • Downside,  they  can  require  hours  to  administer  and  are  therefore  not  used   routinely  unless  brain  damage  is  suspected       Neuroimagining:  Pictures  of  the  Brain   • Neuroimaging:  sophisticated  computer-­‐aided  procedures  that  allow   nonintrusive  examination  procedures  that  allow  nonintrusive  examination  of   nervous  system  structure  and  function   • Neuroimaging  is  divided  into  two  categories:     o Structure  of  the  brain        Computerized  Axial  Tomography  (CAT  scan)  –  takes  15   minutes  and  locates  abnormality
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