PSY360: Abnormal Psychology

Clinical Assessment and

Diagnosis

Dr. Sumaira Khurshid Tahira

Associate Prof

NNU, China

Clinical Assessment: How and Why Does

the Client Behave Abnormally?

• Assessment is collecting relevant information in an effort to reach a conclusion

• Clinical assessment is used to determine how and why a person is behaving abnormally and how that person may be helped

• Focus is idiographic (i.e., on an individual person)

• Also may be used to evaluate treatment progress

Characteristics of Assessment Tools

• To be useful, assessment tools must be standardized and have clear reliability and validity

• To standardize a technique is to set up common steps to be followed whenever it is administered

• One must standardize administration, scoring, and interpretation

Characteristics of Assessment Tools

• Reliability refers to the consistency of an assessment measure

• A good tool will always yield the same results in the same situation

• Two main types:

• Test–retest reliability – yields the same results every time it is given to the same people

• Interrater reliability – different judges independently agree on how to score and interpret a particular tool

Characteristics of Assessment Tools

• Validity refers to the accuracy of a tool's results

• A good assessment tool must accurately measure what it is supposed to measure

• Three specific types:

• Face validity – a tool appears to measure what it is supposed to measure; does not necessarily indicate true validity

Characteristics of Assessment Tools

• Predictive validity – a tool accurately predicts future characteristics or behavior

• Concurrent validity – a tool's results agree with independent measures assessing similar characteristics or behavior

Clinical Interviews

• These face-to-face encounters often are the first contact between a client and a clinician/assessor

• Used to collect detailed information, especially personal history, about a client

• Allow the interviewer to focus on whatever topics they consider most important

• Focus depends on theoretical orientation

Clinical Interviews

• Conducting the interview

• Can be either unstructured or structured

• In an unstructured interview, clinicians ask open-ended questions

• In a structured interview, clinicians ask prepared questions, often from a published interview schedule

• May include a mental status exam

The mental status

examination is an

assessment of

current mental capacity

through evaluation of

general appearance,

behavior, any unusual or

bizarre beliefs and

perceptions (eg,

delusions,

hallucinations), mood,

and all aspects of

cognition (eg, attention, orientation, memory).

Clinical Interviews

• Limitations:

• May lack validity or accuracy

• Individuals may be intentionally misleading

• Interviewers may be biased or may make mistakes in judgment

• Interviews, particularly unstructured ones, may lack reliability

Clinical Tests

• Tests are devices for gathering information about a few aspects of a person's psychological functioning, from which broader

information can be inferred

• More than 500 clinical tests are currently in use

Clinical Tests

• Projective tests

• Require that clients interpret vague and ambiguous stimuli or follow open-ended instruction. Mainly used by psychodynamic practitioners

• Rorschach Test

• Thematic Apperception Test

• Sentence completion tests

• Drawings

Psychology’s Wiki Leaks?

• In 2009 an emergency room physician posted all 10 Rorschach cards on the online encyclopedia, Wikipedia

• Many psychologists argue that test responses of patients who have previously seen the cards on Wikipedia cannot be trusted.

Clinical Test: Rorschach Inkblot

Clinical Test: Sentence-Completion Test

• “I wish ___________________________”

• “My father ________________________”

• For example Rotter Incomplete Sentences Blank

Clinical Test: Drawings

• Draw-a-Person (DAP) test:

• “Draw a person”

• “Draw another person of the opposite sex”

Clinical Tests

• Projective tests

• Strengths and weaknesses:

• Helpful for providing “supplementary” information

• Have rarely demonstrated much reliability or validity

• May be biased against minority ethnic groups

Clinical Tests

• Personality inventories

• Designed to measure broad personality characteristics

• Focus on behaviors, beliefs, and feelings

• Usually based on self-reported responses

• Most widely used: Minnesota Multiphasic Personality Inventory • For adults: MMPI (original) or MMPI-2 (1989 revision)

• For adolescents: MMPI-A

Clinical Test: Minnesota Multiphasic

Personality Inventory (MMPI)

• Consists of more than 500 self-statements that can be answered “true,” “false,” or “cannot say”

• Statements describe physical concerns, mood, morale, attitudes toward religion, sex, and social activities, and

psychological symptoms

• Assesses careless responding and lying

Clinical Test: Minnesota Multiphasic

Personality Inventory (MMPI)

• Comprised of ten clinical scales:

• Hypochondriasis (HS)

• Depression (D)

• Conversion hysteria (Hy)

• Psychopathic deviate (PD)

• Masculinity-femininity (Mf)

• Scores range from 0 to 120

• Above 70 = deviant

• Graphed to create a “profile”

• Paranoia (P)

• Psychasthenia (Pt)

• Schizophrenia (Sc)

• Hypomania (Ma)

• Social introversion (Si)

Clinical Tests

• Personality inventories(Strengths and weaknesses)

• Easier, cheaper, and faster to administer than projective tests

• Objectively scored and standardized

• Appear to have greater validity than projective tests

• Tests fail to allow for cultural differences in responses

Standardized tests are designed by

experts and come with explicit

instructions for administering them.

They are taken by a large quantity of

learners under the same conditions.

Questions, administration, and scoring

are consistent for every evaluated group.

Clinical Tests

• Response inventories

• Usually based on self-reported responses

• Focus on one specific area of functioning

• Affective inventories (example: Beck Depression Inventory)

• Social skills inventories

• Cognitive inventories

Clinical Tests

• Response inventories

• Strengths and weaknesses:

• Have strong face validity

• Not all have been subjected to careful standardization, reliability, and/or validity procedures (Beck Depression

Inventory and a few others are exceptions)

Clinical Tests

• Psychophysiological tests

• Measure physiological response as an indication of psychological problems

• Includes heart rate, blood pressure, body temperature, galvanic skin response, and muscle contraction

• Most popular is the polygraph (lie detector)

Clinical Tests

• Psychophysiological tests

• Strengths and weaknesses:

• Require expensive equipment that must be tuned and maintained

• Can be inaccurate and unreliable

Clinical Tests

• Neurological and neuropsychological tests

• Neurological tests directly assess brain function by assessing brain structure and activity

• Examples: EEG, PET scans, CAT scans, MRI, fMRI

• Neuropsychological tests indirectly assess brain function by assessing cognitive, perceptual, and motor functioning

• Most widely used is the Bender Visual-Motor Gestalt Test

• Clinicians often use a battery of tests

Clinical Tests

• Neurological and neuropsychological tests

• Strengths and weaknesses:

• Can be very accurate

• At best, though, these tests are general screening devices

• Best when used in a battery of tests, each targeting a specific skill area

Clinical Tests

• Intelligence tests

• Designed to indirectly measure intellectual ability

• Typically comprised of a series of tests assessing both verbal and nonverbal skills

• General score is an intelligence quotient (IQ)

• Represents the ratio of a person's “mental” age to his or her “chronological” age

Clinical Tests

• Intelligence tests

• Strengths:

• Are among the most carefully produced of all clinical tests

• Highly standardized on large groups of subjects

• Have very high reliability and validity

Clinical Tests

• Intelligence tests

• Weaknesses:

• Performance can be influenced by nonintelligence factors (e.g., motivation, anxiety, test-taking experience)

• Tests may contain cultural biases in language or tasks

• Members of minority groups may have less experience and be less comfortable with these types of tests, influencing their results

Intelligence Tests, Too? eBay and the

Public Good

• Intelligence tests can be found for sale on eBay’s online auction site

• Test producer is concerned that they will be misused

Clinical Observations

• Systematic observations of behavior

• Several kinds:

• Naturalistic

• Analog

• Self-monitoring

Clinical Observations

• Naturalistic and analog observations

• Naturalistic observations occur in everyday environments

• Can occur in homes, schools, institutions (hospitals and prisons), and community settings

• Most focus on parent–child, sibling–child, or teacher–child interactions

Clinical Observations

• Observations are generally made by “participant observers” and reported to a clinician

• If naturalistic observation is impractical, analog observations are used and conducted in artificial settings

Clinical Observations

• Naturalistic and analog observations

• Strengths and weaknesses:

• Reliability is a concern

• Different observers may focus on different aspects of behavior

Clinical Observations

• Validity is a concern

• Risk of “overload,” “observer drift,” and observer bias

• Client reactivity may also limit validity

• Observations may lack cross-situational validity Reactivity is a phenomenon that occurs

when individuals alter their performance or

behavior due to the awareness that they are

being observed. The change may be

positive or negative, and depends on the

situation.

Observer drift Gradual,

systematic changes over a period of

time by a particular observer in his

or her application of criteria for

recording or scoring observations.

Overload is a psychological condition in

which situations and experiences are so

cognitively, perceptually, and

emotionally stimulating that they tax or

even exceed the individual's capacity to

process incoming information

Clinical Observations

• Self-monitoring

• People observe themselves and carefully record the frequency of certain behaviors, feelings, or cognitions as they occur over

time

Clinical Observations

• Self-monitoring

• Strengths and weaknesses:

• Useful in assessing infrequent behaviors

• Useful for observing overly frequent behaviors

• Provides a means of measuring private thoughts or perceptions

Clinical Observations

• Validity is often a problem

• Clients may not record information accurately

• When people monitor themselves, they often change their behavior

Diagnosis: Does the Client's Syndrome

Match a Known Disorder?

• Using all available information, clinicians attempt to paint a “clinical picture”

• Influenced by their theoretical orientation

• Using assessment data and the clinical picture, clinicians attempt to make a diagnosis

• A determination that a person's psychological problems constitute a particular disorder. Based on an existing classification system

Classification Systems

• Lists of categories, disorders, and symptom descriptions, with guidelines for assignment

• Focus on clusters of symptoms (syndromes)

• In current use in the U.S.: DSM-5

DSM-5

• Lists approximately 500 disorders

• Describes criteria for diagnoses, key clinical features, and related features that are often, but

not always, present

Lifetime Prevalence of DSM-5 Diagnoses

How many people in the United States qualify for a DSM diagnosis during their lives? Almost half, according to some surveys. Some people even

experience two or more different disorders, which is known as comorbidity. (Information from: Greenberg, 2011; Kessler et al., 2005.)

Categorical Information

• DSM-5 requires clinicians to provide both categorical and dimensional information as part of a proper diagnosis.

• Categorical information refers to the name of the category (disorder) indicated by the client’s symptoms.

• Dimensional information is a rating of how severe a client’s symptoms are and how dysfunctional the client is across various dimensions of personality.

•

Is DSM-5 an Effective Classification System?

• A classification system, like an assessment method, is judged by its reliability and validity

• Here, reliability means that different clinicians are likely to agree on a diagnosis using the system to diagnose the same client

• DSM-5 appears to have greater reliability than any previous edition

• Used field trials to increase reliability

• Reliability is still a concern

Is DSM-5 an Effective Classification System?

• The validity of a classification system is the accuracy of the information that its diagnostic categories provide

• Predictive validity is of the most use clinically

• DSM-5 has greater validity than any previous edition

• Conducted extensive literature reviews and ran field studies

• Validity is still a concern

Is DSM-5 an Effective Classification System?

• The framers of DSM-5 followed certain procedures in their development of the new manual to help ensure that DSM-5 would

have greater reliability than the previous DSMs

• A number of new diagnostic criteria were developed and categories, expecting that the new criteria and categories were in fact reliable.

• Some critics continue to have concerns about the procedures used in the development of DSM-5

DSM-5 Changes

• Adding a new category, “autism spectrum disorder,” that combines certain past categories such as “autistic disorder” and “Asperger’s syndrome” (see Chapter

17)

• Viewing “obsessive-compulsive disorder” as a problem that is different from the anxiety disorders and grouping it instead along with other compulsive-like

disorders such as “hoarding disorder,” “body dysmorphic disorder,” “hair-

pulling disorder,” and “excoriation (skin-picking) disorder” (see Chapter 5)

• Viewing “posttraumatic stress disorder” as a problem that is distinct from the anxiety disorders (see Chapter 6)

DSM-5 Changes

• Adding a new category, “somatic symptom disorder” (see Chapter 7)

• Replacing the term “hypochondriasis” with the new term “illness anxiety disorder” (see Chapter 7)

• Adding a new category, “premenstrual dysphoric disorder” (see Chapter 8)

• Adding a new category, “disruptive mood dysregulation disorder” (see Chapters 8 and 17)

DSM-5 Changes

• Adding a new category, “binge eating disorder” (see Chapter 11)

• Adding a new category, “substance use disorder,” that combines past categories “substance abuse” and “substance dependence” (see Chapter 12)

• Viewing “gambling disorder” as a problem that should be grouped as an addictive disorder alongside the “substance use disorders” (Chapters 12)

• Replacing the term “gender identity disorder” with the new term “gender dysphoria” (see Chapter 13)

DSM-5 Changes

• Replacing the term “mental retardation” with the new term “intellectual developmental disorder” (Chapter 17)

• Adding a new category, “specific learning disorder,” that combines past categories “reading disorder,” “mathematics disorder,” and “disorder of written expression” (see Chapter 17)

• Replacing the term “dementia” with the new term “neurocognitive disorder” (Chapter 18)

• Adding a new category, “mild neurocognitive disorder” (see Chapter 18)

Can Diagnosis and Labeling Cause Harm?

• Misdiagnosis is always a concern

• Major issue is the reliance on clinical judgment

• Also present is the issue of labeling and stigma

• Diagnosis may be a self-fulfilling prophecy (In a self-fulfilling prophecy an individual's expectations about another person or entity eventually result in

the other person or entity acting in ways that confirm the expectations.)

Thanks