PL3236 - Abnormal
Unit 3 Notes – Assessment and Diagnosis Term | Info | Intro | * Clinical Assessment - the process of gathering information about a person and his or her environment to make decisions about the nature, status, and treatment of psychological problems * Typically begins with a set of Referral Questions developed in response to a request for help * Determine the goals of the assessment and select appropriate psych tests or measures | Goals of Assessment | * What procedures and instruments to use – age, med condition, and symptoms influence tools – psychologist’s theoretical perspective also affects scope. * Integrate findings to develop preliminary answers – shares this – process sometimes has therapeutic effect – feedback | Screening | * Screening - an assessment process that attempts to identify psychological problems or predict the risk of future problems among people who are not referred for clinical assessment * All members of group are given a brief measure for which some identified cutoff score indicates the possibility of significant problems, e.g. Centre for Epidemiological Studies-D (CES-D) – possibility of depression. * General Health Questionnaire (GHQ) – broad-based – indicates if more thorough evaluation is needed. * AUDIT test – 10-item screen to identify substance abuse * To evaluate usefulness of screening, they must have: * Sensitivity – ability of the screener/instrument to identify a problem that actually exists. * Specificity – indicates % of time the absence of a problem is accurately identified. * False positives & False Negatives | Diagnosis and Treatment Planning | * Diagnosis - the identification of an illness – requires the presence of a cluster of symptoms – typically made after a clinical interview – facilitates commons between clinicians and researchers – critical for planning appropriate treatment * Differential Diagnosis - a process in which a clinician weighs how likely it is that a person has one diagnosis instead of another – often require more than one * Diagnostic Assessments – more extensive than screens – more through understanding of psych status * Diagnosis often made after pers tests, neuropsy tests, funct analy. | Outcome Evaluation | * Clinical assessments can be repeated regularly to evaluate progress. Getting better? Treatment finished? Mod needed? Satisfied? * Individual measures should represent a range of outcomes – symptoms severity, ability to function etc). Also include therapist’s and family’s perspectives. * Must be reliable and valid. Evaluation must measure the Degree of Change and the Actual Level of Functioning. * Clinical Significance - an observed change that is meaningful in terms of clinical functioning – Reliable Change Index (RCI) | Properties of Assessment Instruments - Standardisation | * Value of assessment instruments rests in part on its psychometric properties – affect confidence in results. * The score must be put in context * Normative Comparison – comparing a person’s score on a psychological test to a comparison group that is representative of the entire population or a subgroup similar to the patient – use standard deviation * Self-Referent Comparison - comparison of responses on a psychological instrument with a person’s own prior performance – examine the course of symptoms over time and to evaluate treatment outcome | Reliability | * Reliability - the extent to which a psychological assessment instrument produces consistent results each time it is given * Test-Retest Reliability - the extent to which a test produces similar scores over time when given to the same individual(s) – consistency – use correlation coefficient to estimate similarity between scores - .8 or higher is highly reliable * Inter-rater Agreement - the amount of agreement between two clinicians who are using the same measure to rate the same symptoms in a single patient – important if measure depends on judgement. – e.g. as 2 diff clinicians to give same interview to the same patients | Validity | * Validity - the degree to which a test measures what it is intended to assess – how well are we measuring complicated dimensions * Construct Validity – how well a measure accurately assesses a particular concepts, not others which may be related. * Criterion Validity – how well a measure correlates with other measures that assess the same or similar concepts – e.g. Concurrent Validity – assess the relationship between two measures given at the same time * Predictive Validity – ability of a measure to predict performance at a future date. * Accuracy of psychologist’s predictions or conclusions – they must predict based on statistical data or clinical observations. * Clinical Prediction – relies on clinician’s judgment – e.g. interview patient and predict he will commit a violent act in the near future – useful when relevant statistical data do not exist, when hypotheses need to be developed and plays a role in structured interview procedures * Statistical Prediction – when a clinician uses data from large groups of people to make a judgement about a specific individual – generally more accurate | Developmental and Cultural Considerations | * Nature of tests, normative values to compare, people involved in process and testing environment depend on age. Different cognitive abilities may require different tests. * Old people with cognitive impairment may need unique instruments that can capture more specific symptoms of problems such as dementia. * Kids – simpler wording, fewer response choices and different questions – Children’s Depression Inventory. * Geriatric Depression Scale (GDS) – older – better match experience and cognitive skills. * Assessment process – kids may need input from parents and teachers. Older with cog limits may need other adults who spend time. Limited vision. Limited attention span – short sessions with breaks. * Cultural factors – may produce biased results due to differences in education, language, cultural beliefs and values. Work on ‘culture fair’ assessments. * Translations – but may not be sufficient to reflect other cultural influences. Should rely more on nonverbal skills, e.g. Leiter International Performance Scale – Revised (LIPS-R) requires no speaking or writing by examiner of test taker. Increased cross-cultural utility | Ethics and Responsibility | * Those administering psych assessments must adhere to the American Psychological Association Code of Ethics. Section 9 – only use tests you are trained for. * Must use instruments with good reliability and validity and appropriate for the purpose of the examination. Not use outdated instruments. * Must get informed consent – testee understands the test’s purpose, fees and who will see the results. Data should eb confidential and stored securely. | Assessment Instruments | * Choosing the best set of instruments depends on the goals, the inst properties and the nature of the difficulties. * Clinician-Rated Measures or Self-Report Measures – patients evaluate their own symptoms * Subjective Responses (what patient perceives) or Objective Responses (what can be observed) * Structured (all patients get same questions) or Unstructured (vary) * Test Battery – group of tests given together | Clinical Interviews | * Clinical Interview - a conversation between an interviewer and a patient whose purpose is to gather information and make judgments related to assessment goals - Can serve screening, diagnosis, treatment planning or outcome evaluation * Unstructured Interview - a clinical interview in which the clinician decides what questions to ask and how to ask them * Initial interview is usually this – get to know – determine what other types of assessments – develop working relationship. Education about process and asking questions – open-ended or close ended. * Presenting Problem (the identified reason for the evaluations) and clinician’s theoretical perspective guide the content and style – then summarises what he has learned and gives guidelines about what happens next * Flexible – move in whatever direction. But potentially unreliable – diff interview diff conclusions if not same topics or Qs. * Structured Interview - a clinical interview in which the clinician asks a standard set of questions, usually with the goal of establishing a diagnosis. * Semi-structured Interview – after the standard Q, uses less structured supplemental Qs to get add info. Often used in scientifically based clinical practice and clin research. Reliable. Scores still rely on judgement, but the consistency in content and order of Qs increases inter-rater agreement. * Some give broad overview of diagnostic categories, others specific. * More focused interview usually used after unstructured screening int indicates that certain diag may be appropriate. Focused intv can be useful in research settings to ensure all patients in a study have a similar diag. Important in clin practices so a provider has enough detail about a diagnosis to design treatment plan. But less flexibility | Psychological Tests – Personality Tests | * Personality Test - a psychological test that measures personality characteristics * Minnseota Multiphasic Personality Inventory (MMPI) – overcame some subjectivity of earlier scoring using empirical keying – using stat analysis to identify items and patterns of scores that differentiated various groups – only these were retained. * Also has stat scales to evaluate test taking behaviours – Lie Scale to identify those not describing selves accurately. MMPI-2 has 567 items, 9 validity scales, 10 clinical subscales * Scored by PC – profile to interpret. Concerns about use with ethnic minorities – standardised on whites. * Million Clinical Multi-axial Inventory (MCMI) – 175 true-false corresponds to 8 basic pers styles, 3 pathol pers syndromes and 9 symptom disorders scales. Adequate reliability and validity – less time than MMPI. But concerns it does not map onto categories in DSM and culturally biased. * Those 2 were objective. Also psychoanalytic theory: * Projective Test - a test derived from psychoanalytic theory in which people are asked to respond to ambiguous stimuli * Rorschach Inkblot Test – ambiguous stimuli – patient projects unique interpretation that reflects underlying unconscious processes and conflicts – low reliability and validity * John Exner made a rigorous system for standardised admin and scoring of RIT known as the Comprehensive System (CS) – breaks into matrix of variables – scored to form Structural Summary. * Empirical data supports the utility of some CS scores used for certain purposes – but many not studied adequately to evaluate usefulness. Opinion differences reflects degree to which they rely on empirical data vs clinical judgements. * Thematic Appreciation Test – 31 cards – 20 used based on age/sex – asked to make up a story – no formalised scoring system – evaluate within theoretical orientation. Qualitative – subjective. * Often used to get the patient talking – may help some get in touch with what they are feeling | General Tests of Psychological Functioning | * Gather general info about the mental functioning of people who participate as healthy controls in a research study – compare behaviour across groups or pops or test people before and after an event or intervention. Broad overview. * Global Assessment of Functioning Scale (GAF) – describe overall well-being – 0 to 100 – symptom severity and level of impairment in social relationships and job/school performance. Dropped from DSM-5 due to lack of conceptual clarity * General Health Questionnaire (GHQ) – 12 items – snapshot of mental health status over previous weeks a provides a meaningful change score – degree of deviation from usualy experience. | Neuropsych-ological Testing | * Detect impairment in cognitive functioning using simple & complex tasks to measure language, memory, attention, concentration, motor skills, perception, abstraction and learning – insight into brain functioning * Halstead-Reitan Neuropsychological Battery – evaluate presence of brain damage – distinguishes healthy from cortical damage – 10 measures – memory, abstract thought, language, sensory-motor- dexterity etc * Wisconsin Card Sorting Test (WCST) – measures set shifting – ability to think flexibly as the goal of the task changes – frontal lobe test – those with elsions do poorly – useful for schizo, brain injuries, dementia and Parkinson’s * Bender Visual Motor Gestalt Test – detect problems in visual-motor development in kids and general brain damage and neuro impairment * Luria-Nebraska Neuropsychological Battery – like HR but more precise measure of organic brain damage – unstructured qualitative – 14 scores * Trained to ensure standardised approach – to ensure comparable across testers | Intelligence Tests | * Intelligence Test - a test that measures intelligence quotient (IQ) – created to measure success in school * Intelligence Quotient - a score of cognitive functioning that compares a person’s performance to his or her age-matched peers * Used to be mental age divided by chron age –by now scoring focuses on an individual’s performance relative to age-matched peers – predict academic perf in traditional learning environments. Not represent the broader concept of intelligence. * Stanford-Binet Intelligence Scale – evaluated for demographic bias, validity evaluated against other well-val intel tests including WAIS. Appropriate for use with very dumb and gifted. * Wechsler Adult Intelligence Scale (WAIS-IV) – 4 index scores – Verbal Comp Index, Working Memory, Perceptual Reasoning, Processing Speed – combine to form Full Scale IQ score – aged 16 to 90 – matched with census data. WISC-IV for ages 6 to 16, WPPS-III for 2-7. * Role of nature/nurture? – Conceptualisation of intelligence? – bias for sex, SES, cultural, race. Good for prediction of academic success, performance deficits and inequalities, cog impair and retard. | Tests for Specific Symptoms | * We may want to know how well treatments reduce symptoms – may test over course to see how well. * Brief Psychiatric Rating Scale (BPRS) – measures many symptoms. Others are more limited assessing symptoms for one disorder. * Beck Depression Inventory-II (BDI-II)– 21-item self-report questionnaire * Beck Anxiety Inventory (BAI) – 21 item self-report focuses on severity of anxiety symptoms * Allows comparisons across diff studies and patient groups. | Behavioural Assessment | * Applies principles of learning to understand behaviour – goal is: * Functional Analysis - a strategy of behavioural assessment in which a clinician attempts to identify causal links between problem behaviours and contextual variables; also called behavioural analysis or functional assessment – need to look at antecedents and consequences of behaviour for causality/maintenance. * Often starts with behavioural interview – specific questions – discover full sequence of events and behaviours around primary problems. Where? With who? Doing or thinking? After first sumptoms – think, feel do, other people do? Identify functional relationships | Self-Monitoring | * Self-Monitoring - a procedure within behavioural assessment in which the patient observes and records his or her own behaviour as it happens – real time info about frequency, duration and nature of symptoms – record contextual variables and sequences of events and behaviours for functional analysis. * Can look at how symptoms change over time. May create awareness of problem behaviour and reduce it. | Behavioural Observation | * Behavioural Observation - the measurement of behaviour as it occurs by someone other than the person whose behaviour is being observed * Define behaviour in a way to allow it to be clearly observed and reliably monitored. Then decide how to observe * Event Recording – monitoring each episode * Interval Recording – measure number of times during a particular interval of time * Natural Environment or Analogue (assessor creates a situation similar to allow direct observation) * Actigraphy – non-invasive way to measure activity level – like wristwatch – records vibrations associated with movement – detect diff patterns of activity – sleep patterns, circadian, insomnia, movement in ADHD kids * Behavioural Avoidance Test - the behavioural assessment strategy used to assess avoidance behaviour by asking a patient to approach a feared situation as closely as possible * Evaluate severity of symptoms at baseline and assess degree of change after treatment | Psycho-physiological Assessment | * Psychophysiological Assessment - the evaluation strategies that measure brain structure, brain function, and nervous system activity – measures physiological changes that reflect emotional or psychological events. * Electroencephalography – non-invasive - measures differences in electric voltage between parts of the brain – standardised electrodes. * Brain activity may be recorded when engaged in cognitive processing related to the presentation of a simple evoked stimulus - event-related potential (ERP). Measures rhythmic activity and non-rhythmic patterns and different wave freqs signal relax, sleep or coma. Non-rhythmic may be seizure activity. * Can be used for monitoring and diagnosing coma, brain death, anaesthesia * Sleep - W (beta waves), alpha as we relax and begin to fall asleep, N1 (theta), N2, N3 (delta), REM * EEG – very fast responses – only measure to directly assess elect act. But cannot determining functioning in a specific region. Can combine with functional brain imaging techniques. * Electrodermal Activity (EDA) – sweat glands controlled by PNS and react to emotional states – measures changes in electrical conductance – stress and anxiety * Biofeedback – incorporating EEG and EDA – the use of electronic devices to help people learn to control body functions that are typically outside of conscious awareness – goal is to recognise and modify physiological signal by bringing them under conscious control. E.g. promote relaxation and relieve pain * Can treat anxiety, panic and ADHD. Illustrates how feelings and emotions affect bodily functions and how changing emotional states can directly affect physical functioning. * Note: Oxytocin – increases ability to read people – reduction in social stress, increased attachment behaviour, trust, detect another’s thoughts and emotions through external observation | Classification | * Common language – helps clinicians and researchers communicate. Deciding diagnosis helps develop appr. Treatment plan. * Diagnostic and Statistical Manual of Mental Disorders (DSM) - a classification of mental disorders originally developed in 1952; has been revised over subsequent years and is a standard of care in psychiatry and psychology. * DSM-II – 1968 – reflected psychodynamic perspective – broad underlying conflicts or maladaptive reactions to life’s problems. * DSM-III – 1980 – based on description rather than assumptions about cause – biomedical approach. DSM-III-R (1987) * DSM-IV – 1994 – 297 disorders – steering committee – literature review, data from researchers to see if criteria needed changing, conducted multi-centre clinical trials. DSM-IV-TR (2000). * Multi-Axial System - a system of diagnosis and classification used by the DSM that requires classifying a patient’s behaviour on five different dimensions * DSM-V – 237 diag – developmental approach – emphasise culture and gender – uses more dimensional ratings to classify symptom severity * Accurate classification is a critical element of rigorous research * After determining the clinical syndrome – make ratings to explain to the patient characteristics that might be unique to that person such as psychosocial or env factors that may have a role in the onset or maintenance of the disorder – also rate how it affects his academic, social or occupational functioning. E.g. baseline Structured Clinical Interview * International Classification of Diseases and Relation Health Problems (ICD-10) - a classification system for mental disorders developed in Europe that is an international standard diagnostic system for epidemiology and many health management purposes | Comorbidity | * The presence of more than one disorder. Often symptoms cannot be fully characterised or diagnosed using a single category. Almost half of people with one have symptoms meeting criteria for another. * Misleading? – unclear if may be diff manifest of single disorder. Maybe result of rule in DSM III that same symptom could not appear in more than one disorder. Also addition of new diag categories – finer distinctions which may not reflect nature. | Developmental & Cultural Factors | * Manner in which symptoms express in kids may differ. Must understand how they vary by age. E.g. ‘the future??’ * Prevalence different by sex – depression and anxiety vs substance abuse. May develop diff disorders at diff rates – similar underlying difficulty may be expressed difficuly. * Symptoms and disorder influenced by race and ethnicity – Culture-bound Syndromes are sets of symptoms that occur together uniquely in certain groups, e.g. Ataque de nervios in Latinos | Diagnostic System Harmful? | * Require a specified number of symptoms from longer list – nto all with same diag have same symptoms * Most do not require connection to aetiology – may develop in diff ways. * People with same diag may not respond to the same treatments * May encourage stereotyped conceptions * May lead clinician to premature or inaccurate assumptions which may affect treatment or prevent a thorough evaluation * Labelling may result in self-fulfilling prophecies and create stigmas which impact ability to function socially or at work * Reflects the beliefs or limited knowledge of an era, e.g. Gays * Too many disorders - normal variations in behaviour may have been overmedicalised. | Dimensional Systems as Alternatives | * People with disorders not qualitative distinct from those without – symptoms are extreme variations of normal experience. Psych illness best conceptualised along dimensions of function rather than discrete clinical conditions. * Supporting this: high frequency of comorbidity and within-category variability. * Allows for richer description of difficulties across multiple areas. Rate functioning on range of dimensions or traits rather than on presence or absence of symptoms. * Better categorisation for when symptoms don’t fit squarely into categories. With categorical system, often sub-threshold syndromes. Dimensional would describe all symptoms regardless of meeting specified cutoffs. * Allow clinicians to deal differently with multiple symptoms within diag categories, known has heterogeneity – same disorder may have diff symptoms – adversely affects clinical practice and research. Dimensional leads to more relevant clinical info. * But – problem of clinical utility – no clear diagnostic label which is efficient way to share info. Innately more complex. Cats facilitates the nature of clinical decision making. Communication with patients and across researchers and clinicians difficult * No single, accepted dimensional theory – no consensus on type and number of dimensions for entire spectrum of illnesses |
Abnormal – Chapter 3 Definitions

Clinical Assessment - the process of gathering information about a person and his or her environment to make decisions about the nature, status, and treatment of psychological problems
Screening - an assessment process that attempts to identify psychological problems or predict the risk of future problems among people who are not referred for clinical assessment
Diagnosis - the identification of an illness
Differential Diagnosis - a process in which a clinician weighs how likely it is that a person has one diagnosis instead of another
Clinical Significance - an observed change that is meaningful in terms of clinical functioning
Normative - a comparison group that is representative of the entire population against which a person’s score on a psychological test is compared
Self-Referent Comparison - comparison of responses on a psychological instrument with a person’s own prior performance
Reliability - the extent to which a psychological assessment instrument produces consistent results each time it is given
Test-Retest Reliability - the extent to which a test produces similar scores over time when given to the same individual(s)
Inter-rater Agreement - the amount of agreement between two clinicians who are using the same measure to rate the same symptoms in a single patient
Validity - the degree to which a test measures what it is intended to assess
Clinical Interview - a conversation between an interviewer and a patient whose purpose is to gather information and make judgments related to assessment goals
Unstructured Interview - a clinical interview in which the clinician decides what questions to ask and how to ask them
Structured Interview - a clinical interview in which the clinician asks a standard set of questions, usually with the goal of establishing a diagnosis
Personality Test - a psychological test that measures personality characteristics
Projective Test - a test derived from psychoanalytic theory in which people are asked to respond to ambiguous stimuli
Intelligence Test - a test that measures intelligence quotient (IQ) – created to measure success in school
Intelligence Quotient - a score of cognitive functioning that compares a person’s performance to his or her age-matched peers
Functional Analysis - a strategy of behavioural assessment in which a clinician attempts to identify causal links between problem behaviours and environmental variables; also called behavioural analysis or functional assessment
Self-Monitoring - a procedure within behavioural assessment in which the patient observes and records his or her own behaviour as it happens
Behavioural Observation - the measurement of behaviour as it occurs by someone other than the person whose behaviour is being observed
Behavioural Avoidance Test - the behavioural assessment strategy used to assess avoidance behaviour by asking a patient to approach a feared situation as closely as possible
Psychophysiological Assessment - the evaluation strategies that measure brain structure, brain function, and nervous system activity
Diagnostic and Statistical Manual of Mental Disorders (DSM) - a classification of mental disorders originally developed in 1952; has been revised over subsequent years and is a standard of care in psychiatry and psychology
Multi-Axial System - a system of diagnosis and classification used by the DSM that requires classifying a patient’s behaviour on five different dimensions
International Classification of Diseases (ICD) - a classification system for mental disorders developed in Europe that is an international standard diagnostic system for epidemiology and many health management purposes
Comorbidity - the presence of more than one disorder