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
 Narrow to specific problem areas
Three Concepts Determine the Value of Assessment
Three Concepts Determine the Value of Assessment
 Reliability
 Examples include test-retest, inter-rater reliability
 Validity
 Examples include content, concurrent,
discriminant, construct, and face validity
 Standardization and Norms
 Examples include administration procedures,
scoring, and evaluation of data
Domains of Assessment:
The Clinical Interview and Physical Exam
 Physical Exam – Referral to physician
 Rule out medical conditions
 Clinical Interview
 Most common clinical assessment method
 Structured or semi-structured
 Mental Status Exam
 Appearance and behavior
 Thought processes
 Mood and affect
 Intellectual functioning
 Sensorium
Mental Status Exam
Domains of Assessment:
Behavioral Assessment and Observation
 Behavioral Assessment
 Focus on here and now
 Tends to be direct and minimally inferential
 Target behaviors are identified and observed
 Focus on 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
Domains of Assessment:
Behavioral Assessment and Observation
Domains of Assessment:
Psychological Testing and Projective Tests
 Psychological Testing
 Must be reliable and valid
 Projective Tests
 Project aspects of personality onto ambiguous
stimuli
 Roots in psychoanalytic tradition
 High degree of inference in scoring and
interpretation
 Examples include the Rorschach Inkblot Test,
Thematic Apperception Test
 Reliability and validity data tend to be mixed
Rorschach Test
Thematic Apperception Test
Domains of Assessment: Psychological
Testing and Objective Tests
 Objective Tests
 Test stimuli are minimally ambiguous
 Roots in empirical tradition
 Require minimal inference in scoring and interpretation
 Objective Personality Tests
 Minnesota Multiphasic Personality Inventory (MMPI, MMPI2, MMPI-A)
 Millon Clinical Multiaxial Inventory
 Objective Intelligence Tests
 WAIS/WISC – Performance and Verbal Scales
 Stanford-Binet – Mental Age/Age = IQ
 Raven Progressive Matrices Test – Non-verbal
Domains of Assessment: Psychological
Testing and Neuropsychology
 Neuropsychological Tests
 Assess broad range of skills and abilities
 Goal is to understand brain-behavior relations
 Used to evaluate a person’s assets and deficits
 Examples include the Luria-Nebraska and
Halstead-Reitan Batteries
 Overlap with intelligence tests
Domains of Assessment:
Neuroimaging and Brain Structure
 Neuroimaging: Pictures of the Brain
 Allows examination of brain structure and function
 Imaging Brain Structure
 Computerized axial tomography (CAT or CT scan)
 CAT utilizes X-rays of brain; pictures in slices
 Magnetic resonance imaging (MRI)
 MRI has better resolution than CAT scan
 MRI operates via strong magnetic field around
head
Domains of Assessment:
Neuroimaging and Brain Function (cont.)
 Imaging Brain Function
 Positron emission tomography (PET)
 Single photon emission computed tomography (SPECT)
 Both involve injection of radioactive isotopes
 React with oxygen, blood, and glucose in the brain
 Functional MRI (fMRI) – Brief changes in brain activity
 Used mainly in research
Diagnosing Psychological Disorders:
Foundations in Classification
 Clinical Assessment vs. Psychiatric Diagnosis
 Assessment – Idiographic approach
 Diagnosis – Nomothetic approach
 Both are important in treatment planning and
intervention
 Diagnostic Classification
 Classification is central to all sciences
 Develop categories based on shared attributes
 Terminology of Classification Systems
 Taxonomy – Classification in a scientific context
 Nosology – Taxonomy in psychological / medical
contexts
 Nomenclature – Nosological labels (e.g., panic
disorder)
Diagnosing and Classifying Psychological
Disorders
 The Nature and Forms of Classification Systems
 Classical (or pure) categorical approach – Categories
 Dimensional approach – Classification along dimensions
 Prototypical approach – Both classical and dimensional
 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); published by the American Psychiatric Association;
currently the DSM-IV and DSM-IV-TR
Purposes and Evolution of the DSM
 Purposes of the DSM System
 Aid communication
 Evaluate prognosis and need for treatment
 Treatment planning
 DSM-I (1952) and DSM-II (1968)
 Both relied on unproven theories and were unreliable
 DSM-III (1980) and DSM-III-R
 Were atheoretical, emphasizing clinical description
 Multiaxial system with detailed criterion sets for
disorders
 Problems included low reliability, and reliance on
committee consensus
The DSM-IV
 Basic Characteristics
 Five axes describing full clinical presentation
 Clear inclusion and exclusion criteria for disorders
 Disorders are categorized under broad headings
 Empircally grounded prototypic approach to
classification
 The Five DSM-IV Axes
 Axis I – Most major disorders
 Axis II – Stable, enduring problems (e.g., personality
disorders, mental retardation)
 Axis III – Medical conditions related to abnormal
behavior
 Axis IV – Psychosocial problems
 Axis V – Global clinician rating of adaptive functioning
 Other Unique Features of the DSM-IV
Unresolved Issues in the DSM-IV
 What Are the Optimal Thresholds for Diagnosis?
 Examples include level or distress, impairment, number
of required symptoms
 Arbitrary Time Periods in the Definitions of Diagnoses
 Should Other Axes Be Included?
 Examples include premorbid history, treatment response,
family functioning
 Is the DSM-IV System Optimal for Treatment or Research?
 The Problem of Comorbidity
 Defined as two or more disorders for the same person
 High comorbidity is the rule clinically
 Comorbidity threatens the validity of separate diagnoses
Summary of Clinical Assessment and Diagnosis
 Clinical Assessment and Diagnosis
 To provide a complete picture of the client
 To aid understanding and ameliorating human
suffering
 Require reliable, valid, and standardized
information
 Dangers of Diagnosis
 Problem of reification
 Problem of stigmatization
 Assessment and Diagnosis
 The core of abnormal psychology
 Requires a multidimensional perspective