Chapter 4 Flashcards
Psychological assessment
Refers to procedure by which clinicians, using psychological tests, observation and interviews, develop summary of clients symptoms and problems. Ongoing process, may be important at various points of treatment.
Clinical diagnosis
Process through which clinician arrives at general summary classification of patients symptoms by following clearly defined system such as dsm-5 or icd-10 (international classification of disease, published by who)
Function of pretreatment assessment
- Initial assessment, attempt is usually made to identify main dimensions of problem and predict probably course of events under various conditions to make crucial decisions (treatment, hospitalization, inclusion of family members).
- establishing baselines for various psychological functions so effects of treatment can be measured. Criteria based on these measurements may be established as part of treatment plan.
- comparison of pretreatment assessment results with post treatment results
Presenting problem
Major symptoms and behaviour client is experiencing. First thing clinician needs to find out
Why is it important to have adequate classification of presenting problem?
Knowledge of persons type of disorder can help in planning and managing appropriate treatment.
Essential to know range of diagnostic problems that are represented in client population and to determine which treatment facilities need to be available.
Formal diagnosis usually needed before insurance claims can be filed to cover client treatment costs
Other than diagnostic label, what else does adequate assessment include?
Clear understanding of individuals behavioural history, intellectual functioning, personality characteristics, and environmental pressures and resources. Excesses, deficits, and appropriateness are key dimensions to be noted
Assessment and personality factors
Assessment should include description of any relevant long term personality characteristics
Assessment and social context
Assess the social context in which the individual functions. What type of demands are placed on them and what supports or special stressors exist in their situation?
Dynamic formulation
“Picture” of client that integrates diverse and often conflicting bits of information about individuals personality traits, behaviour patterns, environmental demands etc.
Describe current situation and includes hypotheses about what is driving person to behave in maladaptive ways. It should allow clinician to develop hypotheses about clients future behaviour also
Decisions about treatment
Where feasible, decisions about treatment are made collaboratively with consent and approval of individual. When disorder is severe, decisions may have to be made without clients participation or sometimes without consulting responsible family members. This is where knowledge of clients strengths and resources are important. May involve coordinated use of physical, psychological and environmental assessment procedures
Cultural competence
Critical for psychologists to be informed of issues involved in multicultural assessment and to use testing procedures that have been adapted and validated for culturally diverse clients. To fairly consider such individuals, consider various test factors, test taking abilities and other characteristics of person being assessed (such as situational, linguistic, and cultural differences) that might affect their judgments or reduce accuracy of their interpretations
What do psychologists who use tests in culturally competent manner need to bear in mind?
A range of issues and factors involved with culturally and linguistically diverse clients. Issues involve importance id ensuring test being employed is appropriate across cultures and that potential biasing factors do not interfere with critical thinking in overall assessment process
Challenges of understanding clients when performing multicultural assessments
Involve both test instrument characteristics and sociocultural factors such as relationships among culture, behaviour and psychopathology. Psychologists need to ensure that test procedures they employ are autorotate for particular client. Meaning and cultural significance of test items should be similar across cultural groups and norms used to compare client should be appropriate. In using western developed tests, need to take into account dominant language, socioeconomic status, ethnicity and gender of clients (when using translated version, be aware of possible differences that may arise). Need to be aware of available research on using that instrument with target population. Need to be concerned with impact and fairness of instruments they employ with clients from diverse groups
MMPI-2 in diverse populations
Minnesota Multiphasic personality inventory has been widely evaluated both in international applications with translated versions and in diverse subcultural groups in USA. Spanish language versions of test have been developed. Support for use of MMPI-2 with minorities
Reliability
Describing degree to which an assessment measure produces same results each time it is used to evaluate same thing. Index of extent to which measurement instrument can agree that persons behaviour fits given diagnostic class. If observations are different, may mean that classification criteria are not precise enough to determine whether suspected disorder is present
Validity
Extent to which measuring instrument actually measures what it is supposed to measure. Degree to which measure accurately conveys to us something clinically important about person whose behaviour fits the category, such as helping to predict future course of disorder. Normally presupposes reliability. But good reliability does not in itself guarantee validity
Standardization
Process by which psychological test is administered, scored, and interpreted in consistent or standard manner. Standardized tests considered to be more fair than nonstandardized tests in that they are applied consistently and in same manner to all persons taking them. Many psychological tests are standardized to allow comparison with reference population/normative sample.
T score distribution
Comparing particular individuals test score on distribution of test scores from large normative population can enable user to evaluate whether individuals score is low, average, or high along distribution of scores
Relationship between client and clinician
Client must feel comfortable with clinician. Client just feel that testing will help practitioner gain clear understanding of problems and how they will be incorporated into clinical evaluation. Clinician should explain what will happen during assessment and how info will be used. Clients need to be assured that feelings , beliefs, attitudes and personal history being disclosed will be used appropriately and kept in confidence
Where person is being tested for third party such as court system
Referring source is third party (court/judge) not individual being tested. Testing relationship is likely to be strained and test taking behaviour is likely to be different; interpretation of test needs to reflect different motivation created by unwillingness to cooperate
What happens when patients are given appropriate feedback on test results?
They tend to improve, just from gaining perspective on problems as result of testing. Can be powerful clinical intervention. Can also increase self esteem as result of having clearer understanding of their own resources
Physical examination
May be part of evaluation when physical symptoms are part of presenting clinical picture. Consists of kind of procedures in a medical checkup. Medical history is obtained and major systems is body are checked. Important for disorders that entail physical problems such as psychologically based physical conditions, addictive disorders and organic brain syndromes, as well as variety of organic conditions that can produce behavioural symptoms due to hormonal irregularities. Also sometimes long lasting pain results from emotional factors
Electroencephalogram (EEG)
Assesses brain wave patterns in awake and sleeping patients. Graphical record of brains electrical activity. Obtained by placing electrodes on scalp and amplifying brain wave pulses from various brain areas, which moves oscillating pens on a strip of paper. Divergences from normal pattern reflect abnormalities in brain function that might be caused by brain tumour or lesion. May also reveal dysthymia in brains electrical activity, then other techniques can be used to look for more precise diagnosis
Dysthymia
Irregular pattern
Computerized axial tomography (CAT) scan
Specialized radiological technology. Through use if x-rays, cat scan reveals images of parts of brain that might be diseased. Provides rapid access, without surgery, about localization and extent of anomalies in brains structure. Uses X-ray beams across sections of patients brain to produce images that neurologist can interpret
Magnetic resonance imaging (MRI) vs cat scan
Produces sharper images of interior of brain than cat scans because of ability to differentiate subtle variations in soft tissue. Normally less complicated to administer than cat scan and doesn’t subject patients to ionizing radiation.
MRI
Involves precise measurement of variations in magnetic fields caused by varying amounts of water content in various organs and parts of organs. Makes possible visualization of all but most minute abnormalities of brain structure. Useful in confirming degenerative brain processes
Problems with MRI
Some patients have claustrophobia to being placed in MRI machine. Current beliefs about MRI draw on cultural ideas about technology and are reinforced by health care policies and insurance reimbursement patterns. Studies have concluded that MRI studies do not always lead to better outcomes for patients
Positron emission tomography (PET) scan
Allows for appraisal of how an organ is functioning. Provides metabolic portraits by tracking natural compounds such as glucose as they are metabolized by brain and other organs. Enables medical specialists to obtain more clear cut diagnoses of brain pathology by pinpointing sites responsible for each problem. May be able to reveal problems that are not immediately apparent anatomically. May also aid in important discoveries about organic processes underlying disorders and aid in treatment
Limitations of pet scans
Limited value because of low fidelity pictures obtained and their cost. Some investigators recommend questioning their use in forensic evaluations
Functional MRI (fMRI)
Most often measures changes in local oxygenation (blood flow) of specific areas of brain tissue that in turn depends on neuronal activity in those specific regions. Ongoing psychological activity can thus be “mapped”, revealing specific areas of brain that appear to be involved in neurological process. Required development of high speed devices for enhancing recording process, and computer analysis of incoming data - improvements likely to lead to increase in studying using functional imaging. Thought by some to hold more promise for depicting brain abnormalities than currently used procedures such as neuropsychological examination
What have studies using fMRI shown?
Explored cortical functioning that underlies various psychological processes. Some researchers have pointed out that fMRI had high potential for contributing to treatment approach in mental health care. But fMRI has been ruled against as lie detector. FMRI technique has potential of adding to our understanding of early development of psychological disorder
Aphasia
Disorder in which there in loss of ability to communicate verbally
Methodological limitations of fMRI
Both MRI and fMRI are sensitive to instrument errors or inaccurate observations as result of slight movements of person being evaluated. Results of fMRI studies difficult to interpret. Results don’t often provide much specific info about processes studied.
Primary value of fMRI currently
Research into cortical activity and cognitive processes, though shows promise for understanding brain functioning
Neuropsychological assessment
Involves use of various testing devices to measure persons cognitive, perceptual and motor performance as clues to extent and location of brain damage. Such testing may even provide clues to probable location of brain damage, though other tests may be more effective in determining exact location of injury
Individualized tests vs standardized tests
Neuropsychologists may prefer to administer individualized tests or a standard set of tests that have been preselected to sample a broad range of psychological competencies known to be adversely affected by various types of brain injury. Use of constant tests has advantages, though may compromise flexibility
Halstead-Reitan neuropsychology test battery
Composed of several tests and variables from which “index of impairment” can be computed. Also provides specific info about subjects functioning in several skill areas. Made up of a group of tests such as: Halstead category test Tactual performance test Rhythm test Speech sounds perception test Finger oscillation task
Halstead category test
Measures subjects ability to learn and remember material and can provide clues as to their judgment and impulsivity. Subject is presented with stimulus that suggests number between 1-4. Subjects presses button indicating number they believe it is suggesting. Correct choice is followed by sound of doorbell, incorrect by buzzer. Person must determine pattern from series of doorbells and buzzers for what correct choice is
Tactual performance test
Measures subjects motor speed, response to unfamiliar, and ability to learn and use tactile and kinaesthetic cues. Test surface is board that has space for 10 blocks if varies shapes. Subject is blindfolded and asked to place blocks into correct grooves in board. Later, asked to draw blocks and board from tactile memory
Rhythm test
Measures attention and sustained concentration through auditory perception task. Includes 30 pairs of rhythmic beats presented on tape recorder, subjects asked whether pairs are same or different
Speech sounds perception test
Determine whether individual can identify spoken words. Nonsense words are presented on tape recorder and subject is asked to identify presented word in list of 4 printed words. Task measures subjects concentration, attention and comprehension
Finger oscillation task
Measures speed at which individual can depress lever with index finger. Several trials are given for each hand
What does psychosocial assessment attempt to provide?
A realistic picture of an individual in interaction with their social environment. Includes relevant info about personality, present level of functioning, and info about stressors and resources in life situation. Clinicians typically form hypotheses and discard or confirm them as they proceed. Ex of psychosocial procedures are: assessment interviews, clinical observation of behaviour, and psychological tests
Assessment interviews
Often considered central element of assessment process, usually involves face to face interaction where clinician obtains info. May be simple or detailed, may be open in character or more tightly controlled and structured
Structured vs unstructured interviews
Research data shows more controlled and structured interviews yields more reliable results than flexible format
Structured interviews
Predetermined set of questions throughout interview. Beginning statements and introduction to interview follow set procedures. Themes and questions are predetermined to obtain particular responses for all items. Interviewer cannot deviate and all questions are asked in purest way.
Negatives if structured interviews
Typically take longer to administer and and may include seemingly tangential questions. Clients can sometimes be frustrated by overly detailed questions in areas that are of no concern to them
Unstructured assessment interviews
Subjective, do not follow predetermined set of questions. Beginning statements are usually general and follow up questions are tailored for each client. Content is influenced by habits or theoretical views of interviewer, where they subjectively decide what to ask based on clients response to previous questions.
Negatives of unstructured interviews
Because questions are asked in unplanned way, important criteria needed for DSM-5 diagnosis might be skipped. Responses are difficult to quantify or compare, thus use in research is limited
Positive of unstructured interviews
Clients may view these interviews as being more sensitive to their needs or problems than more structured procedures. Plus more spontaneous follow up questions that emerge can provide valuable info that would not emerge in structured interviews
Rating scales
Help focus inquiry and quantify interview data. Enhances reliability of assessment interviews. Formal structure of scale is likely to keep observer inferences to minimum. Most useful rating scales allow user to indicate presence/absence of trait and also its prominence or degree. Ex rating scale: brief psychiatric rating scale (BPRS)
Can clinical interviews be subject to error?
Yes, because they rely in human judgment to choose the questions and process the info. Evidence of this comes up when different clinicians arrive at different formal diagnoses on basis of interview data they elicited from client. This is reason why DSM emphasizes operational assessment approach, one that specifies observable criteria for diagnosis and provides specific guidelines for making diagnostic judgements - leads to more reliable psychiatric diagnoses, at increased cost in reduced interviewer flexibility
Racial and ethnic factors when conducting interviews
Interview process and outcome can be substantially influenced by ethnicity of interviewer and client
Purpose of direct observation
Learn more about persons psychological functioning by attending to their appearance and behaviour. Ideally takes place in natural environment, but is more likely to take place upon admission to hospital
Analogue situations
More controlled rather than naturalistic behavioural setting for conducting observations. Designed to yield info about persons adaptive strategies, might involve staged role playing, event reenactment, family interaction assignments, or think aloud procedures
Self monitoring
Self observation and objective reporting of behaviour, thoughts, feelings as they occur in various natural settings. Many clinicians enlist clients help by providing them instructions for this. Can help determine situations in which maladaptive behaviour is likely to occur
Brief Psychiatric Rating Scale (BPRS)
Provides structured and quantifiable format for rating clinical symptoms such as overconcern with physical symptoms, anxiety, emotional withdrawal, guilt feelings, hostility, suspiciousness, and unusual thought patterns. Distinct patterns of behaviour reflected in BPRS ratings enable clinicians to make standardized comparisons of symptoms with behaviour of other patients. Extremely useful in clinical research, but not widely used for making treatment or diagnostic decisions in clinical practice. Hamilton rating scale for depression (HRSD) is similar
DSM-5 rating scales
Provides several rating scales called “cross cutting symptom measures” that clinicians use to obtain symptom experiences of clients and for follow up evaluations of symptoms over time. Rating scales are completed by client or parent if patient is child
Psychological tests
More indirect means of assessing psychological characteristics. Standardized sets of procedures or tasks for obtaining samples of behaviour. Responses are compared with people who have comparable demographic characteristics and clinicians can then draw inferences about how much differs from reference group. Often are more precise and more reliable than interviews or some observational techniques
What characteristics can psychological tests measure?
Coping patterns, motives patterns, personality characteristics, role behaviour, values, levels of depression or anxiety and intellectual functioning
What are downsides to psychological tests
Value depends on competence of clinician who interprets them. Pathology may be revealed in people who appear to be normal, or general impression of something wrong can be checked against more precise information
2 general categories of psychological tests
Intelligence tests and personality tests (projective and objective)
Intelligence tests
Ex: Wechsler intelligence scale for children-revised (WISC-IV) and Stanford-Binet intelligence scale widely used in clinical settings for children. For adults, usually Wechsler adult intelligence scale-revised (WAIS-IV)
Wechsler adult intelligence scale (WAIS-IV)
Includes verbal and performance material, consists of 15 subtests. 2 examples of subtests: vocabulary (verbal) and digit span (performance)
Vocabulary (verbal) subtests of wais-iv
Consists of list of words to define that are presented orally to individual. Designed to evaluate knowledge of vocabulary, which has shown to be highly related to general intelligence
Digit sign (performance) subtests of wais-iv
Test of short term memory, sequence of numbers administered orally. Individual asked to repeat digits in order administered. Another task could have individual reversing order sequence
4 reasons why practitioners are reluctant to use computer-based assessment procedures
- Practitioners trained before use of computers may feel uncomfortable with them and don’t have time to get acquainted
- They may limit practice of psychological treatment and do not have extensive pretreatment assessment in practice
- May have little interest in or time for systemic evaluation of treatment efficacy that periodic formal assessments facilitate
- May feel that impersonal and mechanized look of keyboard or booklets and answer sheets is inconsistent with image and style of warm and personal engagement they want to convey to clients
When are intelligence tests crucial?
In cases where intellectual impairment or organic brain damage is thought to be central to patient’s problem, may be crucial diagnostic tool
Intelligence testing in clinical settings
These tests are time consuming and for many cases, gaining such a thorough understanding is unnecessary.
2 types of personality tests
Projective and objective
Projective personality tests
Unstructured, rely on various ambiguous stimuli such as inkblots or vague pictures. Persons responses are not limited to true/false/cannot say. Through their interpretations, people reveal a lot about personal preoccupations
Assumptions underlying use of projective personality tests
In trying to make sense if vague, unstructured stimuli, individuals project their own problems, motives, and wishes into situation. Normative range of responses is determined and this is used to identify deviant responding
What is the aim of projective tests?
Discovering ways in which individuals past learning and personality structure may lead them to organize and perceive ambiguous info from environment
Common projective personality tests
Rorschach inkblot test
thematic apperception test (TAT)
Sentence completion tests
Rorschach inkblot tests
Developed over century ago, but still widely used. Uses 10 inkblot pictures, to which a subject responds with what they see, think and what it means after being instructed in specific way. Use of this test requires considerable training.
Criticism for Rorschach inkblot test
Test can take many hours.
Method of administering test varies.
Results can be unreliable because of subjective nature of test interpretations.
Criticized for low or negligible validity
Why has use of Rorschach inkblot test decreased?
Many clinical treatments requires specific behavioural descriptions rather than descriptions of personality dynamics. Also insurance companies do not pay for time needed to administer, score and interpret test
Why can Rorschach inkblot test be useful?
Can be useful in uncovering certain psychodynamic issues, such as impact of unconscious motivations
Rorschach and computer interpretations
Was adapted for computer interpretation. Found that clinicians tend to draw same conclusions from Rorschach responses as computer system did
Rorschach and pathology
It was found that Rorschach tends to over pathologize people taking the test, showing psychopathology even when person is normal.
Thematic apperception test (TAT)
Uses series of simple pictures about which subject is instructed to make up stories. Content of pictures is ambiguous as to actions and motives, so subjects tend to project own conflicts and worries into them. Often clinician will make qualitative and subjective determination of how story content reflects persons underlying traits, motives etc. Much room for error in such informal procedure
Criticism for tat test
Time consuming to apply scoring and interpretation systems and little evidence that they make a clinically significant contribution.
Dated quality to test stimuli, pictures are from 1930s and subjects have hard time identifying with characters in pictures.
Interpretation is generally subjective, limits reliability and validity of test
Teaching tat test
Though test remains popular among clinicians, it is often not taught in graduate schools and contemporary resources are hard to find. Even examiners who are good at making accurate predictions with test have difficulty teaching these skills to others, pointing to artistic element involved at this skill level
Sentence completion test
Consists of beginning of sentences that person must complete. Somewhat more structured than other projective tests. Help pinpoint important clues to persons problems, attitudes and symptoms through content of their responses. Interpretation is generally subjective and unreliable. Interpretation done in ad hoc manner and without benefit of normative comparisons, though test stimuli are standard
Objective personality tests
Structured, involve more controlled format than projective tests, more amenable to objectively based quantification. Precision enhanced reliability of test outcomes. Ex: NEO-PI (neuroticism-extroversion-opened personality inventory), millon clinical multiaxial inventory (MCMI-III), MMPI-2
NEO-PI (neuroticism-extroversion-opened personality inventory)
Provides info on major dimensions in personality, widely used in evaluating personality factors in normal range populations
Millon clinical multiaxial inventory (MCMI-III)
Assesses focused clinical problems. Developed to evaluate underlying personality dimensions among clients in psychological treatment or prior to beginning therapy
Minnesota multiphasic personality inventory (MMPI)
Most widely used personality assessment for clinical and forensic assessment and psychopathology research. Also most frequent test taught in graduate programs. Translated versions are used internationally
What did original mmpi consist of?
Self report questionnaire, consisted of 550 items covering topics ranging from physical condition and psychological states to moral and social attitudes. Clients answer as true or false
Clinical scales of mmpi
Answers to items were item analyzed to see which ones differentiated various groups. On basis of findings, 10 clinical scales constructed, each consisting of items that were answered by one of patient groups in direction opposite to predominant response of normal group: “empirical keying”. Each of scales measures tendencies to respond in deviant ways. Results are compared to normal and plotted on mmpi profile form; shows how far from normal parents performance is
Empirical keying
Involves no subjective prejudgment about meaning of answer to any item. Meaning resides entirely in whether answer is same as answer defiantly given by patients of varying diagnoses. Should pattern of answers represent particular pathological group, us reasonable inference that they share other psychiatric characteristics
Validity scales
To detect whether patient has answered questions in straight forward, honest manner
Typical use of mmpi
Used as diagnostic standard. By comparing profile groups, info about patients in that group can suggest broad descriptive diagnosis for patient
Critics of original mmpi
Some psychodynamically oriented clinicians thought mmpi was superficial and didn’t reflect complexities of individual. Behaviourally oriented clinicians criticized mmpi (and all personality tests) as being too oriented towards measuring unobservable, mentalistic constructs. More specific criticism was leveled at datedness of mmpi
Mmpi revision
Created in response to criticism. Original 10 clinical scales kept on revised version, just had minimal item deleting and rewording. Has been validated in many clinical studies. Validity scales remained same. Reinforced with three additional scales to detect tendencies to respond untruthfully to some items
Advantages of self report inventories (such as mmpi)
Cost effective, highly reliable and objective, and can be scored and interpreted by computer.
Criticisms against self report inventories
Some clinicians consider them too mechanistic to portray complexity of humans and problems accurately. Tests cannot be taken by patients who are illiterate or confused. Individuals cooperation is required and it is possible that person might distort their answers to create particular impression (validity scales are attempt to deal with this criticism)
Objective personality tests and automation
Because of scoring formats and validation, objective personality tests can have automated interpretation. Computer based mmpi interpretations systems typically employ powerful actuarial procedures. Are important and dependable in clinical assessment. Computers provide quick and efficient means of providing info
Actuarial procedures
Descriptions of actual behaviour or other characteristics of many subjects with particular patterns of test scores have been stored in computer. When person had one of these test score patterns, appropriate description is printed out in completes evaluation. Accumulation id actuarial data for mmpi is difficult, time consuming, and expensive, because of complexity of mmpi and due to rareness of some conditions that have vital clinical importance or are psychologically complex (in this case, clinicians must use practical experience to formulate clinical descriptions)
Problems with automation in objective personality tests
Sometimes paragraphs generated by computer have inconsistencies resulting from fact that different parts of subjects test pattern call up different paragraphs from computer. Then human element comes in where professional interprets and monitors assessment data
Case study of Andrea C, who experienced violence in workplace
Andrea suffered number of physical injuries and recurring symptoms after attack. Was fearful to return to work but company rejected her disability request. She filed lawsuit for personal injury disability. Company requested psychological evaluation, where MMPI was performed. The mmpi clinical scale pattern shows clear mental health problems with high scores on D (depression), Hs (hypochondriasis), and Pt (anxiety) scales, along with high score on ptsd scale. Case went to trial ABS Andrea was awarded substantial damages as result of injuries and trauma
Evaluating Andreas computer generated mmpi report
Report contains technical info so only to be used in professional to professional consultations. Report contains detailed data about relative frequency of test patterns occurrence in relevant clinical settings and in normative and standardized population
What does mmpi report contain?
Profile Validity Symptomatic patterns Profile frequency Profile stability Interpersonal relations Diagnostic considerations Treatment considerations
Content based scales (mmpi)
Mmpi has 15 content based scales, scales comprised of homogenous content themes. These scales address specific problem themes in patients with mental health challenges
Psychopathology 5 scales
Address personality disorder content domains referred to as big 5 personality dimensions: aggressiveness, psychoticism, disconstraint, negative emotionality/neuroticism, introversion/low positive emotionality
Integrating assessment data
Significance of assessment data must be interpreted and integrated into coherent model for planning. In small private practice, clinician may assume complicated task in own. In larger centre/hospital, assessment data evaluated at conference with interdisciplinary team, to determine if findings complement each other and can form definitive clinical picture. May lead to tentative diagnosis and treatment. Findings are entered into case record to keep track of why treatment was given, how accurate diagnosis was and how valid treatment decision turned out to be. New assessment data collected during treatment provides feedback and allows for modifications
What do clinicians need to keep in mind when evaluating assessment test results in order to remain ethical?
- Potential cultural bias of instrument or clinician
- Theoretical orientation of clinician
- Underemphasis on external stimulation
- Insufficient validation
- Inaccurate data or premature evaluation
Cognitive prototype
Pattern
What does classification involve in abnormal psychology?
Attempt to delineate meaningful subvarieties of maladaptive behaviour. Necessary first step toward introducing order into discussing such behaviour. Makes it possible to communicate about particular clusters of abnormal behaviour in precise way. Also involves gathering statistics and meeting needs of insurance companies
All classification is product of…
Human invention. It is a matter of making generalizations based on what was observed and make inferences about underlying similarities and differences. Classification is ongoing work in progress as new knowledge demonstrates earlier thought to be flawed
Successful classification is accomplished only through…
Precise techniques of psychological or clinical assessment, techniques they have been increasingly refined over the years
3 basic approaches to classification
- The categorical approach
- The dimensional approach
- The prototypal approach
The categorical approach to classification
Assumes:
- That’s all human behaviour can be divided into categories of healthy and disordered
- That within latter there exist discrete, nonoverlapping classes or types of disorder that have high degree id within class homogeneity in both symptoms displayed and underlying organization of disorder identified
Three dimensional approach to classification
Assumed that persons typical behaviour is product of differing strengths or intensities of behaviour along several definable dimensions such as mood, emotional stability, aggressiveness, gender identity, anxiousness, interpersonal trust, clarity of thinking and communication, social introversion etc. People suffer from one another in configuration of dimensional traits, not in terms of dysfunctional entity that gives rise to disordered pattern of behaviour
How is normal discriminated from abnormal in dimensional Irish m approach?
In terms of precise statistical criteria derived from dimensional intensities among unselected people in general, most of whom may be presumed to be close to average (ex could decide that anything above 97th percentile in aggressiveness and below 3rd percentile on sociability would be considered abnormal)
How does dimensionally based diagnosis benefit?
Directly addresses treatment options. Patients profile is psychological characteristics will consist of deviantly high and low points, therapies can be designed to moderate those of excessive intensity
Downsides of dimensional approach
Could be possible that profiles tend to cluster together in types and even have some of types be correlated, but unlikely that individuals profile will exactly fit narrowly defined type or that types identified will have overlapping features
Prototype
A conceptual entity depicting idealized combination of characteristics that more or less regularly occur together in less than perfect or standard way at level of observation
Prototypal approach to classification
Suggests that a prototypical case of each personality disorder be listed in DSM rather than just having list of diagnostic criteria as it now has. Diagnostician could indicate on 5 point scale the extent to which patient matches description, and clinician would rate overall similarity between patient and prototype. Official diagnostic criteria usually end up creating prototypical ones anyways and strict categorical approach may be unattainable
Comorbidity
When 2 or more identified disorders regularly occur together in sane individual
2 major psychiatric classification systems
- International classification of diseases (ICD-10) system, published by WHO
- Diagnostic and statistical manual of mental disorders (DSM-5) published by American psychiatric association
Both systems use symptoms as focus of classification and in dividing problems into different facets, but certain differences in way symptoms are grouped can sometimes result in different classification between 2 systems.
The DSM specifies…
What subtypes of mental disorders are currently officially recognized and provides set id defining criteria. Claims to be Categorical system, but is actually a prototypal one with fuzziness of boundaries and considerable interpretation
What do criteria define in DSM?
Symptoms and signs. Diagnostician must observe these criteria in order to make diagnosis
Symptoms
Refers to patients subjective description, complaints they present about what is wrong
Signs
Objective observations that diagnostician may make directly or indirectly
Evolution of DSM
First edition was outgrowth of attempts to standardize synaptic practices in use among military personage during ww2. Next edition reflected additional insights from expanded postwar research effort in mental health sponsored by federal government. Next editions provided further modification and elaboration of disorders with efforts to make diagnostic classification clearer. Recent edition incorporated more theoretical shifts in diagnostic thinking and has been most controversial alteration to diagnostic thinking to date
Issues with early editions of DSM
Various types of disorders identified were described in narrative and jargon laden terms that proved too vague for mental health professionals to agree on meaning. Result was serious limitation to diagnostic reliability
What did DSM-III attempt to do to address clinical and scientific impasse
Introduced radically different approach to remove subjective judgment. Adopted operational method of defining various disorders that would officially be recognized, so DSM would specify exact observations that must be made for given diagnostic label to be given, and specific number of signs and symptoms must be present. This enhanced diagnostic reliability, made efforts to include cultural and ethnic considerations
Why has number of recognized mental disorders increased through DSM editions?
Due to additions of new diagnoses and to elaborate subdivision of older ones. Mental health professionals view their fields in different light than previously. DSM is now more comprehensive and more finely differentiate into subsets of disorders
Gender differences in diagnosis
Some disorders show higher prevalence rates for males (antisocial personality) than females, some are opposite (anorexia). Makes and females diagnosed with same disorder often show different symptom patterns. Makes have higher rates of fighting and aggression and females have greater tendency to lie and be truant from school and tend to run away from home. DSM-5 allows for gender related differences to be incorporated into diagnosis
Appraisal of cultural background in DSM-5
People who have not been acculturated to environment in which they live can appear more psychologically disturbed on tests and interviews than they actually are. DSM-5 provides structured interviews that focuses on patients approach to problems: The cultural formulation interview
Cultural formulation interview
Contains 16 questions that
practitioner can use to obtain info during mental health assessment about potential impact clients culture can have in mental health care. Questions inquire about patients perspective on present problems, how they perceive influence of others in influencing problems, and ways in which their cultural background can influence adjustment. Also inquires about patients previous experiences when seeking treatment for problems. Attempts to obtain clients perspectives without typecasting their problems
Problem of labeling
Criticism is that diagnosis is just a label applied to defined category of socially disapproved behaviour. Once a label has been assigned, it may close off further inquiry and can lead to assumptions being made about other behaviour. Can influence clinically important interactions and treatment choices. Patient may accept redefined identity and play out expectations of that role. Labels can be stigmatizing. Can affect a person’s morale, self esteem, and relationships with others
Patients and clients
Previously, person who went to see mental health professionals was a patient, waiting passively for diagnosis. Now preferred term is client because it implies greater participation on part of individual and more responsibility for bringing about recovery
Usefulness of diagnosis?
Diagnosis may be of limited usefulness. Arrival at diagnosis usually required before commencement is clinical services, mostly due to insurance requirements. Usually this info is elicited through interviews. Interviewer introduces various questions that become increasingly more specific
Unstructured diagnostic interviews
Examiner follows no preexisting plan with respect to content and sequence of probes. Questions asked based on responses to previous questions. Method ordered by many clinicians. Info that interviewer yields is limited to content of interview. In another unstructured interview, different clinical picture might be constructed
Structured diagnostic interviews
Probes client in manner that is highly controlled. Guided by some sort of plan, clinician using structured interviews typically seeks to discover whether persons symptoms and signs for diagnostic criteria. Use of precise criteria and of highly structured diagnostic interviewing has improved diagnostic reliability, but this interview type is only used sporadically in clinical research. A number of structured diagnostic interviews have been developed that can be used in various contexts. Ex schedules of clinical assessment in neuropsychiatry (SCAN), enables diagnostician to arrive at ICD-10 diagnosis
Some broad changes in DSM-5
Some categories were modified, moved to different living in system, or dropped
One of most widely discussed problems with earlier diagnostic manuals
Manner in which personality disorders were classified, in a categorical rather than dimensional system
PTSD in diagnostic manuals
Were found to be unclear, limited, it overly narrow in others. Earlier diagnostic manuals required direct involvement in experienced trauma in order for ptsd diagnosis to be applied
Ptsd classification and 9/11
Many people were traumatized through constant media coverage of events, but diagnostic criteria of ptsd was not appropriate for this. This requirement resulted in many authorities proposing modification of criteria to reduce limitation, while others remained concerned this would result in diagnostic expansion of ptsd
How are diagnostic criteria in DSM viewed by moody mental health professions
Not as fixed component systems but as workable criteria that evolve and develop to accommodate new research and practical developments. Remaining of manual is never smooth, but result is valuable conceptual guide that enables clear communication snout mental disorders
Axes of DSM 4
The DSM four categorized diseases into five different axes. This was changed in the DSM five.  When the fifth edition, the DSM-5, was compiled, it was determined that there was no scientific basis for dividing the disorders in this manner, so the multi-axial system was done away with. Instead, the new non-axial diagnosis combines the former Axes I, II and III and include separate notations for the type of information which would have previously fallen into Axes IV and V.
Axis I: clinical disorders
Axis II: personality disorders
Axis III: general medical disorders
Axis IV: psychosocial and environmental factors
Axis V: the global assessing of function
