Download PowerPoint * Lecture Notes Presentation Chapter 2

PSY 301
INTRODUCTION to PSYCHOPATHOLOGY
Dr. İlkiz Altınoğlu Dikmeer
Fall 2014
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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
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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
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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
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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
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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
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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
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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
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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.
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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.
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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
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Figure 3.2:
Multiaxial Classification System in DSM-IV-TR and Likely DSM-5
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• 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.
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Table 3.1:
Descriptions of
Mania in DSMII vs. DSM-IVTR
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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
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Figure 3.3:
Chapters in DSM-IV-TR and DSM-5
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Figure 3.3:
Chapters in DSM-IV-TR and DSM-5
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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
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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?
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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
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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.
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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
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Table 3.3 Number of Diagnostic Categories per Edition
of DSM
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Figure 3.6:
Interrater Reliability
 Extent
to which
clinicians agree on
the diagnosis
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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)
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Figure 3.7:
Construct
Validity of
Diagnostic
Categories
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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.
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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.
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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
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Figure 3.8:
Sample Item from SCID
• Branching interview :
client’s response to one
question determines the
next question asked.
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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
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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
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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
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Behavioral and Cognitive Assessment
•
•
•
•
Focus on aspects of environment
Characteristics of the person
Frequency and form of problematic behaviors
Consequences of problem behaviors
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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
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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
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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”
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Table 3.7:
Psychological Assessment Methods
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Table 3.8:
Neurobiological Assessment Methods
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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
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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
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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.
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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
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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
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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
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