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PSY 301 INTRODUCTION to PSYCHOPATHOLOGY Dr. İlkiz Altınoğlu Dikmeer Fall 2014 © 2012 John Wiley & Sons, Inc. All rights reserved. PowerPoint Lecture Notes Presentation Chapter 3 Diagnosis and Assessment Abnormal Psychology, Twelfth Edition by Ann M. Kring, Sheri L. Johnson, Gerald C. Davison, & John M. Neale Copyright © 2012 John Wiley & Sons, Inc. All rights reserved. Chapter Outline • Chapter 3: Diagnosis and Assessment I. Cornerstones of Diagnosis and Assessment II. Classification and Diagnosis III. Psychological Assessment IV. Neurobiological Assessment V. Cultural and Ethnic Diversity and Assessment © 2012 John Wiley & Sons, Inc. All rights reserved. Diagnosis and Assessment • Diagnosis – The classification of disorders by symptoms and signs. • Advantages of diagnosis: – Facilitates communication among professionals – Advances the search for causes and treatments – Cornerstones of clinical care: reliability & validity © 2012 John Wiley & Sons, Inc. All rights reserved. Reliability Consistency of measurement • Inter-rater Agreement b/w two independent observers • Test-retest Similarity of scores across repeated test administrations or observations • Alternate Forms Similarity of scores on tests that are similar but not identical • Internal Consistency Extent to which test items are related to one another © 2012 John Wiley & Sons, Inc. All rights reserved. Validity • How well does a test measure what it is supposed to measure? • Content validity – Extent to which a measure adequately samples the domain of interest, e.g., all of the symptoms of a disorder • Criterion validity – Extent to which a measure is associated with another measure (the criterion) • Concurrent – Two measures administered at the same point in time • Predictive – Ability of the measure to predict another variable measured at some future point in time © 2012 John Wiley & Sons, Inc. All rights reserved. Validity Construct validity (Cronbach & Meehl, 1955) • A construct is an abstract concept or inferred attribute • Involves correlating multiple indirect measures of the attribute e.g., self-report of anxiety correlated with increased HR, shallow breathing, racing thoughts • Important for validating our theoretical understanding of psychopathology • Method for evaluating diagnostic categories © 2012 John Wiley & Sons, Inc. All rights reserved. Classification and Diagnosis • Diagnostic and Statistical Manual of Mental Disorders (DSM) published by American Psychiatric Association – First edition published in 1952 • Current edition: DSM-IV-TR (fourth edition, revised) – Published in 1994, text revised in 2000 • New edition expected in 2013: DSM-5 © 2012 John Wiley & Sons, Inc. All rights reserved. Multiaxial Classification System in DSM-IV-TR • Multiaxial system provides a broad range of information to the clinician • • • • • Axis I – Clinical Disorders Axis II – Developmental Dis.s & Personality Dis.s Axis III – General Medical Conditions Axis IV – Psychosocial & Environmental Problems Axis V – Global Assessment of Functioning (GAF) Scale © 2012 John Wiley & Sons, Inc. All rights reserved. Axis I – Clinical Disorders • Includes all diagnostic critera except personality disorders and mental retardation • Under 14 titles there are more than 100 diagnoses • Most people consult a mental health professional for an Axis I condition, but there might be an Axis II condition beyond the diagnosis. © 2012 John Wiley & Sons, Inc. All rights reserved. Axis II – Developmental Disorders & Personality Disorders • Axis II has three subsections: – Mental retardation – 10 Personality disorders (e.g., paranoid PD, schizoid PD, borderline PD,antisocial PD etc) – Other conditions that may be a focus of clinical attention (e.g., abuse /neglect, relational problems, bereavement etc) • Presence of an Axis II Disorder makes the treatment of Axis I disorder harder. © 2012 John Wiley & Sons, Inc. All rights reserved. Axis III – General Medical Conditions • Covers general medical conditions. • Is the disorder due to a medical condition or substance abuse? Axis IV – Psychosocial & Environmental Prob.s • Psychosocial problems that may contribute to the disorder (e.g., occupational, economic) Axis V – Global Assm. of Func. (GAF) Scale • Person’s current level of adaptive functioning assessed by considering social rel.sh.s, occupational functioning & use of leisure time © 2012 John Wiley & Sons, Inc. All rights reserved. Figure 3.2: Multiaxial Classification System in DSM-IV-TR and Likely DSM-5 © 2012 John Wiley & Sons, Inc. All rights reserved. • Each new version of DSM included improvements. The first two versions included descriptions about disorders, but after the 3rd edition more reliable and valid diagnostic criteria were added. © 2012 John Wiley & Sons, Inc. All rights reserved. Table 3.1: Descriptions of Mania in DSMII vs. DSM-IVTR © 2012 John Wiley & Sons, Inc. All rights reserved. Likely Changes in DSM-5 • Changes in multiaxial system – Five axes in DSM-IV-TR changed to two axes in DSM-5 • Clinical Syndromes • Psychosocial and Environmental Problems • Axis 5 removed specific rating scales for each disorder • Changes in organization of diagnoses – DSM-IV-TR clusters diagnoses on similarity of symptoms. – Some offered to organize diagnoses around etiology (e.g., neurotransmitter activity, emotional dysregulation etc) – DSM-5 diagnoses are reorganized to reflect new knowledge of comorbidity and shared etiology • OCD moved from anxiety cluster to new cluster that also includes hoarding and body dysmorphic disorder © 2012 John Wiley & Sons, Inc. All rights reserved. Figure 3.3: Chapters in DSM-IV-TR and DSM-5 © 2012 John Wiley & Sons, Inc. All rights reserved. Figure 3.3: Chapters in DSM-IV-TR and DSM-5 © 2012 John Wiley & Sons, Inc. All rights reserved. Likely Changes in DSM-5 • DSM-IV-TR based on categorical classification – If you have minimum number of symptoms, you are diagnosed with disorder. If one short, you are not. • Little research support for this diagnosable threshold – DSM-5 preserves categorical approach • NOS (“Not Otherwise Specified”) likely to remain in use for subthreshold cases DSM-5 adds a Continuous Severity Rating – Dimensional system describes degree of severity of disorder © 2012 John Wiley & Sons, Inc. All rights reserved. Figure 3.4: Categorical Versus Dimensional Systems of Diagnosis Categorical • Presence/absence of a disorder Either you are anxious or you are not anxious. Dimensional • Rank on a continuous quantitative dimension Degree to which a symptom is present How anxious are you on a scale of 1 to 10? © 2012 John Wiley & Sons, Inc. All rights reserved. Likely Changes in DSM-5 • Personality Disorder Diagnoses – DSM-IV-TR’s 10 different personality disorders will likely be reduced to 5 types in DSM-5 • New Diagnoses – Disruptive mood dysregulation, mixed anxiety depressive disorder, language impairment disorder, etc. • Combining Diagnoses – Substance use disorder replaces substance abuse and substance dependence, etc. • Clearer Criteria © 2012 John Wiley & Sons, Inc. All rights reserved. Ethnic and Cultural Considerations • Mental illness universal • Culture can influence: – Risk factors – Types of symptoms experienced – Willingness to seek help – Availability of treatments • DSM-IV-TR includes: – Enhanced cultural sensitivity – Appendix of 25 culture-bound syndromes • Amok, Drat, Koru, Taijin kyofusho, Hikikomori, etc. © 2012 John Wiley & Sons, Inc. All rights reserved. Criticisms of the DSM • Too many diagnoses? – Should relatively common reactions be pathologized? – Comorbidity • Presence of a second diagnosis • 45% of people diagnosed with one disorder will meet criteria for a second disorder • Reliability in everyday practice © 2012 John Wiley & Sons, Inc. All rights reserved. Table 3.3 Number of Diagnostic Categories per Edition of DSM © 2012 John Wiley & Sons, Inc. All rights reserved. Figure 3.6: Interrater Reliability Extent to which clinicians agree on the diagnosis © 2012 John Wiley & Sons, Inc. All rights reserved. Construct Validity of Diagnostic Categories • Construct validity of highest concern • Diagnoses are constructs – For most disorders, no lab test available to diagnose with certainty • Strong construct validity predicts wide range of characteristics – Possible etiological causes (past) – Clinical characteristics (current) – Predict treatment response (future) © 2012 John Wiley & Sons, Inc. All rights reserved. Figure 3.7: Construct Validity of Diagnostic Categories © 2012 John Wiley & Sons, Inc. All rights reserved. Criticisms of Classification Stigma against mental illness. • Treated differently by others • Difficulty finding a job Categories person. do not capture the uniqueness of a • The disorder does not define the person. She is an individual with schizophrenia, not a “schizophrenic” Classification may emphasize trivial similarities • Relevant information may be overlooked. © 2012 John Wiley & Sons, Inc. All rights reserved. Psychological Assessment • Techniques employed to: – – – – – – Describe client’s problem Determine causes of problem Arrive at a diagnosis Develop a treatment strategy Monitor treatment progress Conducting valid research • Ideal assessment involves multiple measures and methods – Interviews, personality inventories, intelligence tests, etc. © 2012 John Wiley & Sons, Inc. All rights reserved. Clinical Interviews • Informal/less structured interviews – Interviewer attends to how questions are answered – Is response accompanied by appropriate emotion? – Does client fail to answer question? – Good rapport essential to earn trust – Empathy and accepting attitude necessary – Reliability lower than for structured interviews • Structured interviews – All interviewers ask the same questions in a predetermined order – Structured Clinical Interview for Axis I of DSM (SCID) • Good interrater reliability for most diagnostic categories © 2012 John Wiley & Sons, Inc. All rights reserved. Figure 3.8: Sample Item from SCID • Branching interview : client’s response to one question determines the next question asked. © 2012 John Wiley & Sons, Inc. All rights reserved. Assessment of Stress • Stress – Subjective experience of distress in response to perceived environmental problems • Bedford College Life Events and Difficulties Schedule (LEDS) – Semi-structured interview – Evaluates stressors within the context of each individual’s circumstances • Self-Report Stress Checklists – Faster way to assess stress – Test-retest reliability low © 2012 John Wiley & Sons, Inc. All rights reserved. Psychological Tests • Personality Tests – Self-reported Personality Inventories • Minnesota Multiphasic Personality Inventory (MMPI) – Yields profile of psychological functioning – Specific subscales to detect lying and faking “good” or “bad” – Projective Tests • Rorshach Inkblot Test and Thematic Apperception Test (TAT) • Projective hypothesis • Responses to ambiguous stimuli reflect unconscious processes © 2012 John Wiley & Sons, Inc. All rights reserved. Psychological Tests • Intelligence tests (IQ tests) – Assess current mental ability – Wechsler Scales • Wechsler Adult Intelligence Scale, 4th ed. (WAIS-IV) • Wechsler Intelligence Scale for Children, 4th ed. (WISC-IV) • Wechsler Preschool and Primary Scale for Children, 3rd ed. (WPPSI-III) – Stanford-Binet, 5th ed. (SB5) – Used to predict school performance, diagnose learning disabilities or intellectual developmental disorder (mental retardation), identify gifted children, as part of a neuropsychological examination – Mean IQ = 100, SD = 15 (Wechsler) or SD = 16 (SB) – Lower IQs associated with higher psychopathology and mortality – Performance on IQ tests impacted by Stereotype Threat © 2012 John Wiley & Sons, Inc. All rights reserved. Behavioral and Cognitive Assessment • • • • Focus on aspects of environment Characteristics of the person Frequency and form of problematic behaviors Consequences of problem behaviors © 2012 John Wiley & Sons, Inc. All rights reserved. Behavioral and Cognitive Assessment • Observe behavior as it occurs • Sequence of behavior divided into segments – Antecedents and consequences • Behavioral Assessments often conducted in lab setting – e.g., mother and child interact in a lab living room • Interaction observed through one-way mirror or videotaped for later coding © 2012 John Wiley & Sons, Inc. All rights reserved. Self-Observation • Self-monitoring – Individuals observe and record their own behavior • e.g., moods, stressful events, thoughts, etc. • Ecological Momentary Assessment (EMA) – Collection of data in real time using diaries or smart phones • Reactivity – The act of observing one’s behavior may alter it • Desirable behaviors tend to increase whereas undesirable behaviors decrease © 2012 John Wiley & Sons, Inc. All rights reserved. Cognitive-Style Questionnaires • Use to help plan treatment targets • Format often similar to personality tests • Dysfunctional Attitude Scale (DAS) – Identifies maladaptive thought patterns • “People will think less of me if I make mistakes” © 2012 John Wiley & Sons, Inc. All rights reserved. Table 3.7: Psychological Assessment Methods © 2012 John Wiley & Sons, Inc. All rights reserved. Table 3.8: Neurobiological Assessment Methods © 2012 John Wiley & Sons, Inc. All rights reserved. Neurobiological Assessment: Brain Imaging • Computerized Axial Tomography (CT or CAT scan) – Reveals structural abnormalities by detecting differences in tissue density • e.g., enlarged ventricles • Magnetic Resonance Imaging (MRI) – Similar to CT but higher quality – fMRI (functional MRI) • Images reveal function as well as structure • Measures blood flow in the brain – (BOLD=blood oxygenation level dependent) • Positron Emission Tomography (PET scan) – Brain function © 2012 John Wiley & Sons, Inc. All rights reserved. Neurobiological Assessment: Neurotransmitter Assessment • Postmortem studies • Metabolite assays – Metabolite levels • Byproducts of neurotransmitter breakdown found in urine, blood serum or cerebral spinal fluid – May not reflect actual level of neurotransmitter – Correlational studies © 2012 John Wiley & Sons, Inc. All rights reserved. Neurobiological Assessment: Neuropsychological Assessment • Neuropsychologist – Studies how brain abnormalities affect thinking, feeling, and behavior • Neuropsychological Tests – Reveal performance deficits that can indicate areas of brain malfunction – Halstead-Reitan battery • Tactile Performance Test-Time • Tactile Performance Test-Memory • Speech Sounds Perception Test – Luria-Nebraska battery • Assesses motor skills, tactile and kinesthetic skills, verbal and spatial skills, expressive and receptive speech, etc. © 2012 John Wiley & Sons, Inc. All rights reserved. Psychophysiological Assessment • Psychophysiology – Study of bodily changes that accompany psychological characteristics or events • Electrocardiogram (EKG) – Heart rate measured by electrodes placed on chest • Electrodermal responding (skin conductance) – Sweat-gland activity measured by electrodes placed on hand • Electroencephalogram (EEG) – Brain’s electrical activity measured by electrodes placed on scalp © 2012 John Wiley & Sons, Inc. All rights reserved. Cultural and Ethnic Diversity and Assessment • Cultural Bias in Assessment – Measures developed for one culture or ethnic group may not be valid or reliable for another. – Not simply a matter of language translation • Meaning may be lost • Cultural bias can lead to minimizing or exaggerating psychological problems © 2012 John Wiley & Sons, Inc. All rights reserved. Strategies to Avoid Bias • Increase graduate students’ sensitivity to cultural issues • Insure participants’ understanding of task • Establish rapport • Distinguish “cultural responsiveness” from “cultural stereotyping” (Lopez, 1994) – Conclusions should be tentative and alternative hypotheses should be entertained © 2012 John Wiley & Sons, Inc. All rights reserved. COPYRIGHT Copyright 2012 by John Wiley & Sons, Inc. All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission of the copyright owner. © 2012 John Wiley & Sons, Inc. All rights reserved.