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Assessment and Diagnosis
Chapter 3
Chapter Outline
Clinical Assessment
Assessment Instruments
Diagnosis and Classification
Clinical Assessment
Process of gathering information about a
person and his/her environment to make
decisions about the nature, status, and
treatment of psychological problems
-Begins with a set of referral questions
-Questions determine goals of assessment
-Selection of appropriate psychological tests and
measurements
Goals of Assessment
Differential diagnosis is a
process in which a clinician
weighs how likely it is that a
person has one diagnosis
instead of another.
 Deciding what assessment  Screening (identify psychological
procedures and instruments
to administer
 When conducting an
assessment, it is important
to take into consideration
the age, developmental
level, and cultural
implications of the testtaker.
problems or predict the risk for future
problems)
 Diagnosis (identification of illness)
 Description
 Treatment plan (individual’s plan of
care to meet mental health needs)
 Outcome evaluation
The Usual Properties of Assessment
Instruments Are…
Standardization
Normative comparisons
Self-referent comparisons
Reliability
These are important in
reviewing the
psychometric properties
of instruments to ensure
a clinician’s confidence
in the testing results.
-Test-retest reliability
-Interrater agreement
Validity
-Construct, criterion, concurrent, predictive
Developmental and Cultural
Considerations
Age
Nature of test chosen
Developmental
Testing environment
status
Cultural factors
People involved in “Cultural fair”
testing
Assessment Instruments – Informed Consent
prior to any type of assessment
Self-report measures (ask patients to evaluate their own
symptoms)
Clinician-rated measures (clinician rates symptoms)
Subjective responses vs. objective responses
Types of assessments
-Clinical interviews
-Psychological tests
-Behavioral Assessments
-Psychophysiological Assessments
Remember a patient’s “perception is their reality” when they
report information related to the assessment.
Self-Report Measures
 Is a type of survey/questionnaire in which patients read the
question and select a response by themselves without
interviewer interference.
 Usually administered at the beginning of treatment, and
depending on the treator, throughout the treatment process.
Clinical Interviews
 Conversation between an interviewer and a patient,
the purpose of which is to gather information and
make judgments related to assessment goals
 Purpose of interviews (screening, diagnosis, treatment
planning, or outcome evaluation)
 Types of interviews
-Unstructured (open-ended questions that allow
flexibility and close ended questions)
-Structured (asking a standard set of questions, typically
for diagnostic purposes)
Psychological Tests
Personality tests (psychological test that measures
personality characteristics)
Minnesota Multiphasic Personality Inventory
(MMPI; Hathaway & McKinley, 1943) – over 500
items
 Nine clinical subscales: hypochondriasis, depression,
hysteria, psychopathic deviance, masculinity-femininity,
paranoia, psychasthenia, schizophrenia, & hypomania
The Million Clinical Multiaxial Inventory (MCMI)
Tests for specific symptoms
Validity scales of MMPI
 The F scale: “faking good” or “faking bad.” asks questions designed to
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determine if test-takers are contradicting themselves in their responses.
The L scale: “lie scale,” this validity scale was developed to detect attempts by
patients to present themselves in a favorable light.
The K scale: “defensiveness scale,” is a more effective and less obvious way of
detecting attempts to present oneself in the best possible way.
TRIN Scale: The True Response Inconsistency Scale - to detect patients who
respond inconsistently. This section consists of 23 paired questions that are
opposite of each other.
VRIN Scale: The Variable Response Inconsistency Scale - to detect inconsistent
responses.
The Fb Scale: This scale is composed of 40 items that less than 10% of normal
respondents support. High scores on this scale sometimes indicate that the
respondent stopped paying attention and began answering questions randomly.
Number of items unanswered: 30 or more
Neuropsychological Testing
Used to detect
impairment in
cognitive
functioning
Measures: memory,
attention and attention,
motor skills, perception,
abstraction, and learning
abilities
 Halstead-Reitan
Neuropsychological Battery
(Reitan & Davidson, 1974)
 Wisconsin Card Sorting Test
(WCST)
 Bender Visual Motor Gestalt Test
Mini Mental State Exam
 A brief 30-point questionnaire used to screen for
cognitive impairment.
 Commonly used to screen for dementia, to estimate the
severity of cognitive impairment, and to follow the
course of cognitive changes in an individual over time.
 It is also used by mental health clinicians at intake, in
order to test how oriented or disoriented a patient is,
and how their cognition is affected by their symptoms.
Wisconsin Card Sorting Task: This instrument
measures set shifting or the ability to display flexibility in thinking as the goal
of the task changes – requires attention memory, working memory, and visual
processing – frontal lobe test (schizophrenia, brain injuries, dementia,
Parkinson’s etc.)
From Nevid/Rathus/Greene, Abnormal Psychology in
a Changing World, 5e, p. 91 . Copyright © 2008
Pearson/Prentice Hall. Reprinted by permission.
Figure 3.6 The Bender Visual Motor
Gestalt Test
The average IQ is 100 (mean) and the
standard deviation is 15. So if someone
has an IQ of 130 that means their IQ is
two standard deviations above the
mean.
Intelligence Tests
Used to measure
 Stanford-Binet Intelligence Scale
intelligence
quotient (IQ)
Intelligence
Quotient (a source of
 Wechsler Adult Intelligence Scale
cognitive functioning that
compares a person’s
performance to his or her
age-matched peers)
(WAIS-IV; Wechsler, 2008)
 Wechsler Intelligence Scale for
Children (WISC-IV, 7-16 years)
 Wechsler Preschool and Primary
Scale of Intelligence (WPPS-III,
2½-7 years)
Wechsler Adult Intelligence Scale
(WAIS-IV)
 Currently in its fourth edition
 Adapted from the tests that the US Army used.
 Produces four index scores
 Verbal Comprehension Index (VCI)
 Working Memory Index (WMI)
 Perceptual Reasoning Index (PRI)
 Processing Speed Index (PSI)
WAIS-IV CONTD.
Verbal Comprehension
Index
Vocabulary (timed)
Comprehension (timed)
 Why do plants need water?
Similarities
 How are an apple and
orange similar?
Reading rate (timed)
Working Memory Index
Digit Span
 “46”, “583”, “6835”,
“79248”
 backwards
Arithmetic
WAIS-IV CONTD.
Perceptual Reasoning
Index
Visual puzzles
 Arrange a set of blocks so
that they reproduce a
design
Matrix reasoning
 Choose which pattern
logically follows after a set
of patterns
WAIS-IV CONTD.
Processing Speed Index
Trails making (timed)
 Making a trail
Projective Tests
 Tests derived from psychoanalytic theory in which
people are asked to respond to ambiguous stimuli
 Rorschach Inkblot Test (Rorschach, 1921)
 Thematic Apperception Test (TAT; 1935)
-Consists of 31 black-and-white pictorial cards and the patient is
asked to make up a story about the image
Can you please describe to me what you
see? Where do you see it?
 Plate 1
 The nine questions in scoring:
1.What is the location?
2.What is the developmental quality
3.What are the determinants?
4.What is the form quality?
5.Is there a pair?
6.What are the contents?
7.Is it a popular?
8.Are there any special scores?
The Rorschach Inkblot Test
Fact: 75% of the Exner’s Examine the Evidence: It’s important to
Comprehensive System
remember 25% of the CS scores are not
(CS) scores warrant
considered reliable, “the norms”
published by Exner is extremely
internal validity which is
outdated (from the 1970s and 1980s),
based on sums of
and adequate validity only exists for 20
individual scores.
of the 180 CS scores.
Some previous studies found that
validity increases when clinicians use
their clinical judgment to incorporate
the Rorschach results with information
gathered from other sources.
Conclusion: There continues to be critics
and advocates for the utility of the
Rorschach; however no sound
empirical data exists.
The goal of behavioral
assessments is to understand
behavior within the context
of learning, “learned
behavior.”
Behavioral Assessment
Functional analysis – where a clinician identifies
causal links between behavior and environment
Self-monitoring – a patient records and observes his
or her own behavior (advantage: not retrospective)
Behavioral observation – measurement of
behavior by a trained observer. (event recording or
interval recording in a natural or analogue fashion)
Behavioral avoidance tests – strategies used to
assess avoidance behavior
Psychophysiological Assessment
 Assessment strategies that measure brain and nervous
system activity
 Electroencephalography (EEG, a noninvasive procedure that
measures and records brainwaves) sleep, comatose, and relaxation states
 Electrodermal activity (EDA, measures changes in electrical
conductance produced by increased or decreased sweat
gland activity) formerly called Galvanic Skin Response
 Biofeedback (trains patients to recognize and modify
physiological signals)
The Historical Roots of Diagnosis…
American Psychiatric Association (APA,
1952)
Diagnostic and Statistical Manual of
Mental Disorders (DSM, current edition
DSM-V,
2013)
Multiaxial system of diagnosis and
classification
International Classification of Diseases
(ICD-10, 1992) published by WHO
Global Assessment of Functioning (GAF) a way for clinician’s to
use a rating system to assess one’s functioning.
 91-100 Excellent functioning in all aspects of life
 81-90 Good functioning, only everyday problems like
traffic
 71-80 Starting to shows slight impairment in Axis IV
areas
 61-70 Starting to show mild symptoms and social
supports still intact
 51-60 Starting to show moderate symptoms and an
increase in the level of distress and impairment in
Axis IV areas
Global Assessment of Functioning (GAF) continued…
 41-50 Symptoms are severe and obvious and there is
severe impact on one’s Axis IV areas
 31-40 Major difficulties in reality orientation, judgment,
and communication, as well as extreme difficulties in Axis
IV areas
 21-30 One is actively having delusions and hallucinations
and an inability to function in all aspects of life
 11-20 One is experiencing thoughts of DTO/DTS (e.g., danger
to others and danger to self) behaviors and poor hygiene
 1-10 Actively suicidal and homicidal with a current plan
and continued poor hygiene
Comorbidity
The presence of more
With each new edition
than one disorder
of the DSM new
diagnostic categories
50% of people who
meet diagnostic criteria arise
for one mental disorder The DSM has tripled
meet criteria for at least in size since the 1st
one other disorder
edition
Why do you think so many individuals meet diagnostic criteria for more
than one mental disorder? How do you feel about the increasing number
of disorders with each new DSM?
Developmental and Cultural
Considerations
 Diagnostic criteria may need to vary across the life span
 Differences in prevalence (men vs. women)
-Women and depression vs. men and substance abuse
disorders
 Differences in symptoms and disorders (based on
ethnicity and race)
 Culture-bound syndrome (sets of symptoms that occur
together uniquely in certain ethnic or racial groups)
When is a diagnostic system harmful?
Stereotypes &
Prevention of a
labels
Premature or
inaccurate
assumptions by
clinicians
Self-fulfilling
prophecies
thorough evaluation or
comprehensive
treatment plan
Stigma
DSM (limited knowledge of
an era and too many disorders)
Over-medicalization
Common issues related to DSM
 Distinction between what is normal and not normal or
mental disorder and problem of living
 Mind-body dualism (mental vs. physical disorders)
 Limited understanding of mental disorders
 Mostly descriptive rather than explanatory
 Categorical and prototypical approach vs. dimensional approach
 Gender biases and too much emphasis on culturally accepted
norms
Dimensional Systems vs. Categorical
Systems
 Dimensional (suggests that people with disorder are not
qualitatively distinct from people without disorders)
-Psychiatric illness conceptualized as dimensions of
functioning versus discrete clinical conditioning
 Features that support the value of dimensional approaches
-High frequency of comorbidity and within category
variability
-“Common language” of classification
 Cons of dimensional system
Issues with the DSM-IV-TR:
Criticism
 Lacks an overarching conceptual base (theory)
 No consistent rationale for different diagnoses
 Emphasis on reliability over validity
 No vision for a better society
 Lacks treatment specificity
 Comorbidity still an issue
 Complex, long, and not user-friendly
Issues with the DSM-IV-TR
Support
 Based on empirical data – empirical review carefully done and
further tests are on their way
 Complex due to the inherent nature of mental disorders
 Gender biases have been a concern, but the differences in ratio
may just reflect differences in men and women traits
DSM-5: PROPOSED REVISIONS:
 Removal of the multiaxial system
 Changes in the names of certain disorders
 Autism-related disorders changed to Autism- spectrum
disorders, Asperger’s deleted;
 Mental retardation may be changed to intellectual disability
 Addiction related disorders for substance abuse or dependence
DSM-5: PROPOSED REVISIONS:
 Proposal of new disorders
 behavioral addictions – gambling; binge eating disorder; temper
dysregulation with dysphoria
 ‘disruptive mood dysregulation disorder’ to “diagnose children
who exhibit persistent irritability and frequent episodes of
behavior outbursts three or more times a week for more than a
year”.
DSM-5: PROPOSED REVISIONS:
 Risk syndromes category
 To identify risk of cognitive impairment earlier in the progression
of psychotic and neurocognitive/neurodegenerative disorders
(like dementia)
 New suicide and self-harm assessment criteria seperately for
children and adults
 Changes to the diagnosis of certain disorders
 Bereavement exclusion is not included in the diagnosis of
depressive episode anymore
DSM-5: PROPOSED REVISIONS:
 Proposal of a dimensional system
 Severity ratings (mild, moderate, severe, very severe) for disorders
 Quantitative cross-cutting measures of the presence of symptoms
that cut across the boundaries of any specific diagnoses or
disorders– stepwise evaluation
 Level 1 assessment: cross-cutting symptoms on a 4-rating scale
(none, slight, mild, moderate, severe)
 Level 2 assessment: for those symptoms that are scored higher
than a certain cutoff – in a clinically significant range.
DSM 5
 The DSM-V Task Force: 27 members, including a chair
and vice chair, collectively represent research scientists
from psychiatry and other disciplines. Scientists
experienced in research, clinical care, biology, genetics,
statistics, epidemiology, public health and consumer
advocacy.