CLINICAL ASSESSMENT, DIAGNOSIS, & TREATMENT CHAPTER 4 LEE WOODS CLINICAL ASSESSMENT • USED TO DETERMINE WHETHER, HOW, AND WHY A PERSON IS BEHAVING ABNORMALLY AND HOW THAT PERSON MAY BE HELPED. • THREE CATEGORIES: • CLINICAL INTERVIEWS • TESTS • OBSERVATIONS • MUST BE STANDARDIZED, AND HAVE CLEAR RELIABILITY AND VALIDITY ASSESSMENT TOOLS • STANDARDIZE – COMMON STEPS TO BE FOLLOWED WHENEVER IT IS ADMINISTERED. • RELIABILITY – THE CONSISTENCY OF ASSESSMENT MEASURES. • YIELDS SIMILAR RESULTS EVERY TIME IT IS GIVEN TO THE SAME PEOPLE, I.E. TEST-RETEST RELIABILITY. • VALIDITY – IT MUST ACCURATELY MEASURE WHAT IT IS SUPPOSED TO MEASURE. • EX: WEIGHT SCALE READS 12 LB. WHEN A 10 LB. BAG OF SUGAR IS PLACED ON IT. RELIABLE, BUT NOT VALID. VALIDITY • FACE VALIDITY – THE APPEARANCE THAT THE ASSESSMENT SEEMS VALID AND MAKES/IS REASONABLE. • PREDICTIVE VALIDITY – A TOOL’S ABILITY TO PREDICT FUTURE CHARACTERISTICS OR BEHAVIOR. • CONCURRENT VALIDITY – THE DEGREE TO WHICH MEASURES GATHERED FROM ONE TOOL AGREE WITH THE MEASURES GATHERED FROM OTHER ASSESSMENT TECHNIQUES. CLINICAL INTERVIEWS • A FACE-TO-FACE ENCOUNTER. • MENTAL STATUS EXAM (MSE) – A SET OF QUESTIONS AND OBSERVATIONS THAT SYSTEMATICALLY EVALUATE THE CLIENT’S AWARENESS, ORIENTATION WITH REGARD TO TIME AND PLACE, ATTENTION SPAN, MEMORY, JUDGMENT AND INSIGHT, THOUGHT CONTENT PROCESS, MOOD, AND APPEARANCE. • LIMITATIONS? CLINICAL TESTS • DEVICES FOR GATHERING INFORMATION ABOUT A FEW ASPECTS OF A PERSON’S PSYCHOLOGICAL FUNCTIONING FROM WHICH BROADER INFORMATION ABOUT THE PERSON CAN BE INFERRED. • EXAMPLES INCLUDE: • • • • • • PROJECTIVE TESTS PERSONALITY INVENTORIES RESPONSE INVENTORIES PSYCHOPHYSIOLOGICAL TESTS NEUROIMAGING AND NEUROPSYCHOLOGICAL TESTS INTELLIGENCE TESTS PROJECTIVE TESTS • A TEST CONSISTING OF AMBIGUOUS MATERIAL THAT PEOPLE INTERPRET OR RESPOND TO. • RORSCHACH TEST • THEMATIC APPERCEPTION TEST (TAT) • SENTENCE-COMPLETION TEST • DRAWINGS • HOUSE-TREE-PERSON (HTP) PERSONALITY INVENTORIES • A TEST, DESIGNED TO MEASURE BROAD PERSONALITY CHARACTERISTICS, CONSISTING OF STATEMENTS ABOUT BEHAVIORS, BELIEFS, AND FEELINGS THAT PEOPLE EVALUATE AS EITHER CHARACTERISTIC OR UNCHARACTERISTIC OF THEM. • EX: MINNESOTA MULTIPHASIC PERSONALITY INVENTORY (MMPI) • ORIGINAL PUBLISHED IN 1945 • MMPI-2 • STREAMLINED VERSION, MMPI-2-RESTRUCTURED FORM • ADOLESCENTS, MMPI-A • NEWEST EDITION, MMPI-3 MMPI • MORE THAN 500 SELF-STATEMENTS. • STATEMENTS RANGE FROM PHYSICAL CONCERNS, MOOD, SEXUAL BEHAVIORS, AND SOCIAL ACTIVITIES. • 10 CLINICAL SCALES, SCORES RANGE FROM 0-120. >70 = DEVIANT MMPI 1. HYPOCHONDRIASIS – CONCERN WITH BODILY FUNCTIONS 2. DEPRESSION – EXTREME PESSIMISM AND HOPELESSNESS 3. HYSTERIA – PHYSICAL/MENTAL SYMPTOMS FROM AVOIDING CONFLICTS/RESPONS. 4. PSYCHOPATHIC DEVIATE – DISREGARD FOR SOCIAL CUSTOMS, SHALLOW EMOTIONS 5. MASCULINITY-FEMININITY – SEPARATE MALE AND FEMALE RESPONDENTS 6. PARANOIA – ABNORMAL SUSPICIOUSNESS, DELUSIONS OF GRANDEUR OR PERSECUTE. 7. PSYCHASTHENIA – OBSESSIONS, COMPULSIONS, ABNORMAL FEARS, GUILT/INDECISIV. 8. SCHIZOPHRENIA – BIZARRE OR UNUSUAL THOUGHTS OR BEHAVIOR 9. HYPOMANIA – EMOTIONAL EXCITEMENT, OVERACTIVITY, FLIGHT OF IDEAS 10. SOCIAL INTROVERSION – SHYNESS, LITTLE INTEREST IN PEOPLE, INSECURITY RESPONSE INVENTORIES • TESTS DESIGNED TO MEASURE A PERSON’S RESPONSES IN ONE SPECIFIC AREA OF FUNCTIONING, SUCH AS AFFECT, SOCIAL SKILLS, OR COGNITIVE PROCESSES. • AFFECTIVE INVENTORIES • SOCIAL SKILLS INVENTORIES • COGNITIVE INVENTORIES PSYCHOPHYSIOLOGICAL TESTS • A TEST THAT MEASURES PHYSICAL RESPONSES (SUCH AS HEART RATE AND MUSCLE TENSION) AS POSSIBLE INDICATORS OF PSYCHOLOGICAL PROBLEMS. • POLYGRAPH TEST, AKA. LIE DETECTOR NEUROIMAGING & NEUROPSYCHOLOGICAL TESTS NEUROIMAGING, OR BRAIN-SCANNING TECHNIQUES, ARE DESIGNED TO MEASURE BRAIN STRUCTURE AND ACTIVITY DIRECTLY. • EX: ELECTROENCEPHALOGRAM (EEG) – RECORDS BRAIN WAVES, THE ELECTRICAL ACTIVITY THAT TAKES PLACE WITHIN THE BRAIN AS A RESULT OF NEURONS FIRING. • EX: COMPUTERIZED AXIAL TOMOGRAPHY (CT SCAN OR CAT SCAN) – X-RAYS OF THE BRAIN STRUCTURE ARE TAKEN AT DIFFERENT ANGLES AND COMBINED. • EX: MAGNETIC RESONANCE IMAGING (MRI) – A PROCEDURE THAT USES THE MAGNETIC PROPERTY OF CERTAIN HYDROGEN ATOMS IN THE BRAIN TO CREATE A DETAILED PICTURE OF THE BRAIN’S STRUCTURE. • FMRI IS THE CONVERSION OF MRI PICTURES INTO DETAILED PICTURES OF NEURON ACTIVITY, GIVING A PICTURE OF THE FUNCTIONING BRAIN. NEUROIMAGING & NEUROPSYCHOLOGICAL TESTS TESTS THAT DETECT BRAIN IMPAIRMENT BY MEASURING A PERSON’S COGNITIVE, PERCEPTUAL, AND MOTOR PERFORMANCES. • EX: BENDER VISUAL-MOTOR GESTALT TEST – CONSISTS OF NINE CARDS THAT DISPLAY A SIMPLE GEOMETRICAL DESIGN THAT PATIENTS ARE REQUIRED TO LOOK AT THE DESIGNS, DRAW THEM, AND THEN RECREATE THEM FROM MEMORY AT A LATER TIME. • BATTERY – THE COLLECTION OF TESTS ADMINISTERED TO PATIENTS. INTELLIGENCE TESTS TESTS DESIGNED TO MEASURE A PERSON’S INTELLECTUAL ABILITY. INTELLIGENCE WAS IDENTIFIED AS “THE CAPACITY TO JUDGE WELL, TO REASON WELL, AND TO COMPREHEND WELL” (BINET & SIMON, 1916, P. 192). • INTELLIGENCE QUOTIENT (IQ) – THE OVERALL SCORE DERIVED FROM INTELLIGENCE TESTS. CLINICAL OBSERVATIONS DIFFERENT VERSIONS OF OBSERVATIONS: • NATURALISTIC OBSERVATIONS – CLINICIANS OBSERVE CLIENTS IN THEIR EVERYDAY ENVIRONMENTS. • ANALOG OBSERVATIONS – THEY OBSERVE THEM IN AN ARTIFICIAL SETTING, SUCH AS A CLINICAL OFFICE OR LABORATORY. • SELF-MONITORING – CLIENTS ARE INSTRUCTED TO OBSERVE THEMSELVES. DIAGNOSIS • INFORMATION FROM INTERVIEWS, TESTS, AND OBSERVATIONS TO CONSTRUCT AN INTEGRATED PICTURE OF THE FACTORS THAT ARE CAUSING AND MAINTAINING A CLIENT’S DISTURBANCE, A CONSTRUCTION KNOWN AS A CLINICAL PICTURE. • CAN ALSO BE INFORMED BY A CLINICIAN’S THEORETICAL ORIENTATION. • A DETERMINATION THAT A PERSON’S PROBLEMS REFLECT A PARTICULAR DISORDER. CLASSIFICATION SYSTEMS • SYNDROME – A CLUSTER OF SYMPTOMS. • CLASSIFICATION SYSTEM – A LIST OF CATEGORIES OR DISORDERS WITH DESCRIPTIONS OF THE SYMPTOMS AND GUIDELINES FOR ASSIGNING INDIVIDUALS TO THE CATEGORIES. DSM ICD DSM-5 • DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS • FIRST DEVELOPED IN 1883 BY EMIL KRAEPELIN • CURRENTLY USED BY AMERICAN PSYCHIATRIC ASSOCIATION • DSM-5 PUBLISHED IN 2013 • TOOK OVER A DECADE TO DEVELOP DSM-5 • LISTS MORE THAN 500 MENTAL DISORDERS • INCLUDES CATEGORICAL AND DIMENSIONAL INFORMATION FOR A PROPER DIAGNOSIS: • CATEGORICAL INFORMATION – THE NAME OF THE DISTINCT CATEGORY OR DISORDER INDICATED BY THE CLIENT’S SYMPTOMS • DIMENSIONAL INFORMATION – A RATING OF HOW SEVERE A CLIENT’S SYMPTOMS ARE AND HOW DYSFUNCTIONAL THE CLIENT IS ACROSS VARIOUS DIMENSIONS OF PERSONALLY AND BEHAVIOR CATEGORICAL INFORMATION EXAMPLE 1 ANXIETY DISORDERS: • PEOPLE WITH ANXIETY DISORDERS MAY EXPERIENCE GENERAL FEELINGS OF ANXIETY AND WORRY (GENERALIZED ANXIETY DISORDER); FEARS OF SPECIFIC SITUATIONS, OBJECTS, OR ACTIVITIES (PHOBIAS); ANXIETY ABOUT SOCIAL SITUATIONS (SOCIAL ANXIETY DISORDER); REPEATED OUTBREAKS OF PANIC (PANIC DISORDER); OR ANXIETY ABOUT BEING SEPARATED FROM ONE’S PARENTS OR FROM OTHER KEY INDIVIDUALS (SEPARATION ANXIETY DISORDER). CATEGORICAL INFORMATION EXAMPLE 2 DEPRESSIVE DISORDERS: • PEOPLE WITH DEPRESSIVE DISORDERS MAY EXPERIENCE AND EPISODE OF EXTREME SADNESS AND RELATED SYMPTOMS (MAJOR DEPRESSIVE DISORDER), PERSISTENT AND CHRONIC SADNESS (PERSISTENT DEPRESSIVE DISORDER), OR SEVER PREMENSTRUAL SADNESS AND RELATED SYMPTOMS (PREMENSTRUAL DYSPHORIC DISORDER). DIMENSIONAL INFORMATION EXAMPLE 1 • DIAGNOSIS: MAJOR DEPRESSIVE DISORDER WITH ANXIOUS DISTRESS • SEVERITY: MODERATE • ADDITIONAL INFORMATION: RELATIONSHIP DISTRESS ICD-11 • INTERNATIONAL CLASSIFICATION OF DISEASES • DEVELOPED BY WORLD HEALTH ORGANIZATION (WHO) • LISTS BOTH MEDICAL AND PSYCHOLOGICAL DISORDERS • ICD-11, NEWEST EDITION, PUBLISHED IN 2018 IS THE DSM-5 EFFECTIVE? IS THE DSM-5 EFFECTIVE? • IN THE TEXT, “IS DSM-5 AN EFFECTIVE CLASSIFICATION SYSTEM?” • JUDGED BY RELIABILITY AND VALIDITY. • HISTORICALLY, DSM HAS BEEN MODERATELY RELIABLE. • HAS SOME PREDICTIVE VALIDITY. • BUT LACKING VALIDITY. NEW CLASSIFICATION SYSTEM, WHO DIS? • RESEARCH DOMAIN CRITERIA (RDOC) • THE PRIMARY CLASSIFICATION GUIDE BY MANY RESEARCHERS • ACCORDING TO NATIONAL INSTITUTE OF MENTAL HEALTH (NIMH, 2020A) • NIMH NO LONGER FUNDS RESEARCH BASED ON DSM-5 CRITERIA CAN DIAGNOSIS AND LABELING CAUSE HARM? • PERSONAL BIASES: • GENDER, AGE, RACE, ETHNICITY, AND SOCIOECONOMIC STATUS • MISDIAGNOSIS • SELF-FULFILLING PROPHECY • STIGMA TREATMENT • EMPIRICALLY SUPPORTED TREATMENT – THERAPY THAT HAS RECEIVED CLEAR RESEARCH SUPPORT FOR A PARTICULAR DISORDER AND HAS CORRESPONDING TREATMENT GUIDELINES. • AKA EVIDENCE-BASED TREATMENT EFFECTIVENESS OF TREATMENT • HOW DO YOU KNOW IT IS SUCCESSFUL? WHAT FACTORS CONTRIBUTE TO THERAPY OUTCOMES? INFORMATION FROM CUIJPERS ET. AL. (2019); PETERSON (2019); MCCLINTOCK ET AL. (2017); DAVIDSON & CHAN (2014); NORCROSS & LAMBERT (2011); COOPER (2008). • COMMON FACTORS: • CLIENT FACTORS = 10% • THERAPIST FACTORS = 10% • CLIENT-THERAPIST RELATIONSHIP = 20% • EXPECTANCY OF THERAPY’S SUCCESS = 15% • SPECIFIC THERAPY TECHNIQUES = 15% • EVENTS IN CLIENT’S LIFE (E.G. SOCIAL SUPPORT, FORTUITOUS EVENTS, SPONTANEOUS IMPROVEMENT) = 30% OTHER EFFECTIVE TREATMENT PRACTICES • PSYCHOPHARMACOLOGY • A PSYCHIATRIST WHO PRIMARILY PRESCRIBES MEDICATIONS, AND THE OTHER A PSYCHOLOGIST, SOCIAL WORKER, OR OTHER THERAPIST WHO CONDUCTS PSYCHOTHERAPY.
