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 and focus
Narrow to specific problem areas

Key Concepts in Assessment

Reliability
Consistency is measurement
Examples include test-retest and inter-rater reliability

Validity
What an assessment approach measures and how well it does so
Examples include concurrent, discriminant, and predictive validity

Standardization
Standards and norms help ensure consistency in the use of a
technique
Examples include structured administration, scoring, and evaluation
procedures

Concepts that determine the value of clinical assessments

Figure 3.1

Domains of Assessment: The Clinical Interview and Physical Exam

Clinical Interview
Most common clinical assessment method
Structured or semi-structured

Mental Status Exam Important Part of Clinical Assessment

Appearance and behavior
Thought processes
Mood and affect
Intellectual functioning
Sensorium

Physical Exam potential medical reasons

Domains of Assessment:
The Clinical Interview and Physical Exam (cont.)

Figure 3.2
Components of the mental status exam

Domains of Assessment: Behavioral Assessment and Observation

Behavioral Assessment
Focus on the present Here and now
Focus on direct observation of behavior-environment relations
Purpose is to identify problematic behaviors and situations
Identify 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 methods

Domains of Assessment:
Behavioral Assessment and Observation (cont.)

Figure 3.3
The ABCs of observation

Domains of Assessment: Psychological Testing and Projective Tests

Psychological Testing
Must be reliable and valid

Projective Tests
Project aspects of personality onto ambiguous test stimuli
Roots in psychoanalytic tradition
Require high degree of clinical inference in scoring and
interpretation
Examples include the Rorschach Inkblot Test, Thematic
Apperception Test
Reliability and validity data tend to be mixed

Domains of Assessment: Psychological

Testing and Projective Tests (cont.)

Figure 3.4
This inkblot resembles the ambiguous figures presented in the Rorschach test

Domains of Assessment: Psychological

Testing and Projective Tests (cont.)

Figure 3.5
Example of a picture resembling those in the Thematic Apperception Test

Domains of Assessment: Psychological Testing and Objective Tests

Objective Tests
Test stimuli are less ambiguous
Roots in empirical tradition
Require minimal clinical inference in scoring and interpretation

Objective Personality Tests

Minnesota Multiphasic Personality Inventory (MMPI, MMPI-2,
MMPI-A)
Millon series e.g., MCMI-III; Personality Assessment Inventory (PAI)
Extensive reliability, validity, and normative database

Objective Intelligence Tests

Nature of intellectual functioning and IQ
The deviation IQ
Verbal and performance domains

Domains of Assessment: Neuropsychological Testing

Neuropsychological Tests
Assess broad range of motor, cognitive, memory skills and abilities
Goal is to understand brain-behavior relations (i.e., persons assets
and deficits)
Examples include the Luria-Nebraska and Halstead-Reitan
Batteries

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

Domains of Assessment: Neuroimaging and Brain Structure

Neuroimaging: Pictures of the Brain

Allows for a window on brain structure and function

Imaging Brain Structure

Computerized axial tomography (CAT or CT scan) Utilizes X-rays
Magnetic resonance imaging (MRI) Utilizes strong magnetic fields

Domains of Assessment: Neuroimaging and Brain Function

Imaging Brain Function

Positron emission tomography (PET)
Single photon emission computed tomography (SPECT)
Both involve injection of a tracer substance containing radioactive
isotopes
Radioactive isotopes react with oxygen, blood, and glucose in the
brain
Functional MRI (fMRI) Provides a view of brief changes in brain
activity

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 Cardiorespiratory activity
Electrodermal response and levels Sweat gland activity

Uses of Routine Psychophysiological Assessment.

Disorders involving a strong emotional component
Examples include PTSD, sexual dysfunctions, sleep disorders,
headache, and hypertension

Diagnosing Psychological Disorders: Foundations in Classification

Diagnostic Classification
Classification is central to all sciences
Assignment to categories based on shared attributes or relations

Terminology of Classification Systems

Taxonomy Classification in a scientific context (i.e., entities/things)
Nosology Application of a taxonomy to psychological/medical
phenomena
Nomenclature Labels that comprise the nosology (e.g., anxiety
disorders)

Issues with Classifying and Diagnosing Psychological Disorders

Categorical vs. Dimensional Approaches

Classical (or pure) categorical approach Strict categories
Dimensional approach Classification along dimensions
Prototypical approach Combines classical and dimensional views

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 - 5);
published by the American Psychiatric Association
DSM-5 published and adopted May 2013. see www.dsm5.org

The DSM - 5

Basic Characteristics
Major diagnosis Considers
Clear inclusion and exclusion criteria for disorders, including
duration; culture considerations
Disorders are categorized under broad headings (new headings in
DSM-5)
Prototypic approach to classification; one that is empirically
grounded
Subtypes and Specifiers now part of diagnosis
Mild, Moderate, Severe; Major Depression with Psychosis

Measures: Self-Rated Cross Cutting Symptom Measure Adult &

Child (age 6-17)

Clinician-Related Dimensions of Psychosis Symptom Severity

WHODAS Disability Assessment Schedule 2.0

Unresolved Issues in the DSM- - 5

Labeling issues and stigmatization

Dimensional v. categorical

Clinician reliability

Move toward medical-biologic causation model

Summary of Clinical Assessment and Diagnosis

Clinical Assessment and Diagnosis

Designed to provide a complete understanding of the client
Designed to aid in understanding and ameliorating human suffering
Requires reliable, valid, and standardized information

Dangers of Diagnosis
Problem of reification
Problem of stigmatization

Clinical Assessment and Diagnosis: The Core of Abnormal

Psychology

Conducting Research in Psychopathology

Questions Driving a Science of Psychopathology

What problems cause distress or impair functioning?
Why do people behave in unusual ways?
How can we help people behave in more adaptive ways?

Basic Components of Research

Starts with a Hypothesis or Educated Guess

Not all hypotheses are testable
Hypotheses in science are formulated so that they are testable

Research Design
A method to test hypotheses
Independent variable The variable that causes or influences
behavior
Dependent variable The behavior influenced by the independent
variable

Considerations in Research Design

Internal Validity vs. External Validity

Internal validity Confidence that effects are due to the
independent variable
External validity Extent to which the findings are generalizable

Ways to Increase Internal Validity by Minimizing Confounds

Use of control groups
Use of random assignment procedures
Use of analog models

Relation Between Internal and External Validity

Statistical vs. Clinical Significance

Statistical Methods
Branch of mathematics
Helps to protect against biases in evaluating data

Statistical vs. Clinical Significance

Statistical significance Means the results are beyond chance or
coincidence
Clinical significance Refers to whether the results are clinically
meaningful
Statistical significance does not imply clinical meaningfulness

Balancing Statistical vs. Clinical Significance

Evaluate effect size
Evaluate social validity

Generalizability and the Patient Uniformity Myth

Studying Individual Cases

Case Study Method

Extensive observation and detailed description of a client
Foundation of early historic developments in psychopathology

Limitations
Lacks scientific rigor and suitable controls
Internal validity is typically weak
Often entails numerous confounds

Research by Correlation

The Nature of Correlation

Statistical relation between two or more variables
No independent variable is manipulated
Range from 1.0 to 0 to +1.0
Negative vs. positive correlation

Limitations
Correlation does not imply causation
Problem of directionality

Epidemiological Research: An Example of the Correlational Method

Incidence
Prevalence
Course of disorders and diseases (e.g., AIDS, extent of trauma
following disaster)

Hypothetical correlations between age and sleep problems

Figure 3.61

Research by Experiment

Nature of Experimental Research

Manipulation of independent variables
Attempt to establish causal relations

Group Experimental Designs

Control groups: Placebo vs. double-blind controls

Comparative Treatment Designs

Type of group design
Compare different forms of treatment in similar persons
Used to address treatment process and treatment outcome

Single-Case Experimental Designs

Nature of Single Subject Design

Rigorous study of single cases over varied experimental conditions
and time
Repeated measurement and evaluation of variability, level, and
trend
Premium on internal validity

Types of Single-Subject Design: Their Nature, Assets, and Liabilities

Withdrawal designs
Multiple baseline designs

Evaluation of trend and variability in Wendys anxiety

via the single-subject design method

Figure 3.7

Genetic Research Strategies

Behavioral Genetics
Examine interaction between genes, experience, and behavior
Phenotype vs. genotype

Strategies Used in Genetic Research

Family studies Examine behavioral pattern/emotional traits in
family members
Adoptee studies Allow separation of environmental from genetic
contributions
Twin studies Evaluate psychopathology in fraternal vs. identical
twins
Genetic linkage and association studies Locate sites of defective
genes

Studying Behavior Over Time

Rationale and Overview

How does the problem or behavior change over time?
Important in prevention and treatment research

Time-Based Research Strategies

Rationale driving cross-sectional designs Problem of the cohort
effect
Rationale driving longitudinal designs Problem of the crossgenerational effect
Sequential designs Combine cross sectional and generational
designs

Assets and Liabilities of Time-Based Research Strategies

Two research designs (i.e., longitudinal and cross-sectional designs)

Figure 3.9

Studying Behavior Across Cultures

Value of Cross-Cultural Research: Overcoming Ethnocentric Research

Assets and Liabilities of Cross Cultural Research

Assets Clarify how psychopathology manifests in different ethnic
groups
Problems with cross-cultural research

The Nature of Programmatic Research and Research Ethics

Components of a Research Program

Set of inter-related research questions A tree with many branches
Draw on several methodologies in finding answers
Conducted in stages, often involving replication

Research Ethics: Institutional Review Boards and the APA Ethics

Codes
Informed consent Historical evolution post WWII
Competence Ability to provide consent
Voluntarism Lack of coercion
Full information Necessary information to make an informed
decision
Comprehension Understanding about benefits and risks of
participation

Summary of Research Methods

Nature of Research: Establishing and Testing Hypotheses

Value of Research Designs Vary Depending on the Questions Posed

Abnormal Psychology Is Founded in the Scientific Method

Understand the nature of abnormality and human suffering
Understand the causes of psychological disorders
Understand the course of psychological disorders
Understand how to prevent and treat psychological disorders

Replication Is the Corner Stone of Science and Programmatic

Research

Research Must Occur in the Context of Ethical Considerations and

Values

Name
Changes for
DSM - 5
See DSM5.org
For forms, assessment, and
updates

Mental Retardation

Intellectual Disability
(Intellectual Developmenta
Disorder)

Dementia
Neurocognitive Disorder

Hypochondriasis

Illness Anxiety Disorder

Gender Identity Disorder

Gender Dysphoria

Depersonalization Disorder
Depersonalization Derealization
Disorder

Male

Orgasmic Disorder

Delayed Ejaculation

Brand New
Categories

NEWDSM5Diagnoses
HoardingDisorder
BingeEatingDisorder
ExcoriationDisorder
MildNeurocognitiveDisorder
DisruptiveMoodDysregulationDisorder
PremenstrualDysphoricDisorder
SocialCommunicationDisorder
SomaticSymptomDisorder

Marriages

Autistic Disorder
Aspergers Disorder

Childhood Disintegrative
Disorder

Autism
Spectrum
Disorder ASD

Substance Abuse

Substance Dependence

Substance
Use
Disorder

Reading Disorder
Mathematics Disorder
Disorder Of Written
Expression

Specific
Learning
Disorder

Dysthymic Disorder

Persistent
Depressive
Disorder
Chronic Major Depressive
Disorder

Female Hypoactive
Sexual Desire Disorder

Female
Sexual
Interest/Arousal
Disorder

Female Sexual Arousal

Disorder

Vaginismus

Dyspareunia

Genito Pelvic
Pain/Penetration
Disorder

Divorces

Panic

Disorder

Agoraphobia

Anxiety

Disorders

Obsessive-Compulsive Disorder

Anxiety

Disorders

PTSD

Reorganizatio
n

OBSESSIVECOMPULSIVE&
RELATEDDISORDERS
OCD
BODY DYSMORPHIC DISORDER

HOARDING DISORDER
TRICHOTILLOMANIA
EXCORIATION DISORDER

SOMATICSYMPTOM&
RELATEDDISORDERS

SOMATIC SYMPTOM DISORDER

ILLNESS ANXITY DISORDER

CONVERSION DISORDER
FACTITIOUS DISORDER

PSYCHOLOGICAL FACTORS AFFECTING

OTHER MEDICAL CONDITIONS

Expansion
of
Boundaries

- Addiction = Substance and Behavioral

Addiction
- Somatic Symptom Disorder = Overreactions
To Imagined and Real Medical Ailments

New Criteria

- ADHD now - Symptoms Before Age 12

- Separation Anxiety Disorder now - Any
Age
- Bulimia Nervosa now - One Binge/Purge
Per Week
- Schizophrenia now - No Subtypes


Controversies

- Bereavement and Clinical Depression

- Somatic Symptom Disorder and Significant
Medical Conditions
- Elimination of Aspergers Disorder
- Fusion of Substance Abuse and Substance
Dependence
- Mild Neurocognitive Disorder
- Behavioral Addictions

Future?

Dimensional Model for Personality Disorders

Caffeine Use Disorder
Internet Use Gaming Disorder
Suicidal Behavior Disorder
Nonsuicidal Self-Injury
Attenuated Psychosis Syndrome

Dropped from
Consideration

Anxious Depression
Hypersexual Disorder