comer, fundamentals of abnormal psychology, 3e 1 chapter 4 clinical assessment, diagnosis, and...
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Comer, Fundamentals of Abnormal Psychology, 3e
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Chapter 4
Clinical Assessment, Diagnosis, and Treatment
Slides & Handouts by Karen Clay Slides & Handouts by Karen Clay Rhines, Ph.D.Rhines, Ph.D.
Seton Hall UniversitySeton Hall University
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Clinical Assessment: How and Why Does the Client Behave
Abnormally?• What is assessment?
– The collecting of relevant information in an effort to reach a conclusion
– Clinical assessment is used to determine how and why a person is behaving abnormally and how that person may be helped
• Focus is idiographic – on an individual person• Also may be used to evaluate treatment progress
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Clinical Assessment: How and Why Does the Client Behave
Abnormally?• The specific tools used in an assessment
depend on the clinician’s theoretical orientation
• Hundreds of clinical assessment tools have been developed and fall into three categories:– Clinical interviews– Tests– Observations
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Characteristics of Assessment Tools
• To be useful, assessment tools must be standardized and have clear reliability and validity– To standardize a technique is to set up
common steps to be followed whenever it is administered
– One must standardize administration, scoring, and interpretation
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Characteristics of Assessment Tools
• Reliability refers to the consistency of a test– A good test will yield the same results in the same
situation– Two main types:
• Test–retest reliability– To test for this type of reliability, a subject is tested on two
different occasions and the scores are correlated – the higher the correlation, the greater the test’s reliability
• Interrater reliability– Independent judges agree on how to score and interpret a
particular test
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Characteristics of Assessment Tools
• Validity refers to the accuracy of a test’s results– A good test must accurately measure what it is
supposed to be measuring– Three specific types:
• Face validity – a test appears to measure what it is supposed to measure; does not necessarily indicate true validity
• Predictive validity – a test accurately predicts future characteristics or behavior
• Concurrent validity – a test’s results agree with independent measures assessing similar characteristics or behavior
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Clinical Interviews
• Conducting the interview– Focus depends on theoretical orientation– Can be either unstructured or structured
• In unstructured interviews, clinicians ask open-ended questions
• In structured interviews, clinicians ask prepared questions, often from a published interview schedule
– May include a mental status exam
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Clinical Interviews
• Limitations:– May lack validity or accuracy– Interviewers may be biased or may make
mistakes in judgment– Interviews, particularly unstructured ones,
may lack reliability
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Clinical Tests
• Devices for gathering information about a few aspects of a person’s psychological functioning, from which broader information can be inferred
• More than 500 different tests are in use– They fall into six categories…
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Clinical Tests
1. Projective tests– Responses come from the unconscious mind– Mainly used by psychodynamic practitioners– Most popular:
• Rorschach Test• Thematic Apperception Test• Sentence Completion Test• Drawings
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Clinical Test: Rorschach Inkblot
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Clinical Test:Thematic Apperception Test
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Clinical Test: Sentence-Completion Test
• “I wish ___________________________”
• “My father ________________________”
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Clinical Test: Drawings
• Draw-a-Person (DAP) test:– “Draw a person”– “Draw another person of the opposite sex”
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Clinical Tests
1. Projective tests– Strengths and weaknesses:
• Helpful for providing “supplementary” information• Have rarely demonstrated much reliability or
validity• May be biased against minority ethnic groups
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Clinical Tests
2. Personality inventories– Designed to measure broad personality
characteristics– Focus on behaviors, beliefs, and feelings– Usually based on self-reported responses– Most widely used: Minnesota Multiphasic
Personality Inventory• For Adults: MMPI (original) or MMPI-2 (1989
revision)• For Adolescents: MMPI-A
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Clinical Test: MMPIMinnesota Multiphasic Personality Inventory
• Consists of 550 self-statements that can be answered “true,” “false,” or “cannot say”– Statements describe physical concerns;
mood; morale; attitudes toward religion, sex, and social activities; and psychological symptoms
– Assesses careless responding & lying
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Clinical Test: MMPIMinnesota Multiphasic Personality Inventory
• Comprised of ten clinical scales:– Hypochondriasis (HS)– Depression (D)– Conversion hysteria (Hy)– Psychopathic deviate (PD)– Masculinity-femininity (Mf)
• Scores range from 0 – 120– Above 70 = deviant– Graphed to create a “profile”
– Paranoia (P)– Psychasthenia (Pt)– Schizophrenia (Sc)– Hypomania (Ma)– Social introversion (Si)
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Clinical Tests
2. Personality inventories– Strengths and weaknesses:
• Easier, cheaper, and faster to administer than projective tests
• Objectively scored and standardized• Appear to have greater validity than projective
tests– Measured traits often cannot be directly examined –
how can we really know the assessment is correct?
• Tests fail to allow for cultural differences in responses
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Clinical Tests
3. Response inventories – Usually based on self-reported responses– Focus on one specific area of functioning
• Affective inventories (example: Beck Depression Inventory)
• Social skills inventories• Cognitive inventories
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Clinical Tests
3. Response inventories – Strengths and weaknesses:
• Have strong face validity• Rarely include questions to assess careless or
inaccurate responding• Not all have been subjected to careful
standardization, reliability, and/or validity procedures (BDI and a few others are exceptions)
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Clinical Tests
4. Psychophysiological tests – Measure physiological response as an
indication of psychological problems• Includes heart rate, blood pressure, body
temperature, galvanic skin response, and muscle contraction
– Most popular is the polygraph (lie detector)
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Clinical Tests
5. Neurological and neuropsychological tests– Neurological tests directly assess brain function
by assessing brain structure and activity• Examples: EEG, PET scans, CAT scans, MRI
– Neuropsychological tests indirectly assess brain function by assessing cognitive, perceptual, and motor functioning• Most widely used is the Bender Visual-Motor Gestalt
Test
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Clinical Test: Bender Visual-Motor Gestalt Test
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Clinical Tests
5. Neurological and neuropsychological tests
– Strengths and weaknesses:• Can be very accurate• At best, though, these tests are general
screening devices– Best when used in a battery of tests, each targeting a
specific skill area
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Clinical Tests
6. Intelligence tests– Designed to measure intellectual ability– Composed of a series of tests assessing
both verbal and nonverbal skills– Generate an intelligence quotient (IQ)
• Most popular: Wechsler Adult Intelligence Scale (WAIS) & Wechsler Intelligence Scale for Children (WISC)
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Clinical Observations
• Systematic observation of behavior
• Several kinds:– Naturalistic: in the subject’s environment– Analog– Self-monitoring: the subject records his/her
own behaviors, thoughts, emotions, etc.
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DSM-IV-TR
• Published in 1994, revised in 2000 (TR)• Lists approximately 400 disorders
– Listed in the inside back flap of your text
• Describes criteria for diagnoses, key clinical features, and related features which are often but not always present
• People can be diagnosed with multiple disorders…
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Lifetime Prevalence of DSM-IV-TR Diagnoses
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The DSM-IV-TR
• Multiaxial– Uses 5 axes (branches of information) to
develop a full clinical picture– People usually receive a diagnosis on either
Axis I or Axis II, but they may receive diagnoses on both
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The DSM-IV-TR
• Axis I – Most frequently diagnosed disorders, except
personality disorders and mental retardation
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Major Axis I Diagnostic Categories
Anxiety disorders Mood disorders
Disorders first diagnosed in infancy and childhood
Substance-related disorders
Schizophrenia and other psychotic disorders
Delirium, dementia, amnestic, and other cognitive disorders
Mental disorders due to a general medical condition
Somatoform disorders
Factitious disorders Dissociative disorders
Other conditions that are the focus of clinical attention
Eating disorders
Sexual and gender identity disorders
Impulse-control disorders
Adjustment disorders Sleep disorders
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The DSM-IV-TR
• Axis II– Personality disorders and mental retardation
• Long-standing problems
• Axis III– Relevant general medical conditions
• Axis IV– Psychosocial and environmental problems
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The DSM-IV-TR
• Axis V– Global assessment of psychological, social,
and occupational functioning (GAF)• Current functioning and highest functioning in
past year• 0–100 scale
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Are Classifications Reliable and Valid?
• In this case reliability = different diagnosticians agreeing on a diagnosis using the same classification system– DSM-IV-TR has greater reliability than any
previous editions• Used field trials to increase reliability
– Reliability is still a concern
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Are Classifications Reliable and Valid?
• In this case validity = accuracy of information that the diagnostic categories provide– Predictive validity is of the most use clinically– DSM-IV-TR has greater validity than any
previous editions• Conducted extensive literature reviews and ran
field studies
– Validity is still a concern
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Are Classifications Reliable and Valid?
• Beyond concerns about reliability and validity, a growing number of theorists believe that two fundamental problems weaken the DSM-IV-TR:– Basic assumption that disorders are qualitatively
different from normal behavior– Reliance on discrete diagnostic categories
• With such concerns, DSM-V certainly will include some key changes, but the new edition is not imminent
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Can Diagnosis and Labeling Cause Harm?
• Misdiagnosis always a concern– Major issue is reliance on clinical judgment
• Also present is the issue of labeling and stigma– Diagnosis may be a self-fulfilling prophecy
• Because of these problems, some clinicians would like to cease the practice of diagnosis