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Chapter Three:

Clinical Assessment, Diagnosisand Research Methods

Rick Grieve, Ph.D.

Department of Psychology

Western Kentucky University

DSM-IV-TR

zDiagnostic and Statistical Manual, FourthEdition, Text Revision

zTaxonomy of behavioral, mental, andpsychiatric disorders

{Atheoretical

{Nomothetical

History of DSM-IV

zBased on work of Emil Kraepelin{Late 1800s to early 1900s

zDSM published in 1945 at 120 pages

zDSM-IV-TR is the sixth revision at over 900pages

zWhile there are problems with DSM-IV, it stillhas had a great impact on the field.

zDSM-IV has engendered a lot of research


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DSM-IV

zDefinition of mental disorder:

{Clinically significant behavior orpsychological syndrome or pattern which isassociated with 1) present distress or 2)disability

{Must be associated with a significantlyincreased risk of suffering, death, pain,disability, or loss of freedom

{Must not be an expected response to aparticular event

DSM-IV Disorders

zNo sharp dividing line between onedisorder and another

zNo sharp dividing line between having adisorder and not

General Features of DSM-IV

zDisorders grouped by shared clinicalfeatures

zDescriptive and atheoretical approach

zSystematic description of each disorder{Essential and associated features

{Age and gender variables

{Course of the disorder

{Impairment from disorder

{complications


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General Features of DSM-IV

{Predisposing factors

{Prevalence rates{Familial pattern

{Differential diagnoses

zDiagnostic Criteria

Diagnostic Criteria

z Diagnostic Cri teria for 307.1 Anorexia

Nervosa

{A. Refusal t o maint ain body weight at or abov e a

minimally nor mal weight for age and height (e.g.,

weight loss leading to maintenance of body weight

less than 85% of that expected; or failur e to make

expected weight gain during period of growth,

leading to body weight l ess than 85% of that

expected).

Diagnostic Criteria

{B. Intense fear of gaining weight orbecoming fat, even though u nderweight.

{C. Disturbance in the way in which onesbody weight or shape is experienced,undue influence of body weight or shape

on self-evaluation, or denial of theseriousness of the current low bodyweight.

{D. In postmenarcheal females,amenorrhea, i.e., the absence of at leastthree consecutive menstrual cycles. (Awoman is considered to have amenorrheaif her periods occur only followinghormone, e.g., estrogen administration.)


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Multi-Axial SystemzAxis I{Clinical syndromes and V-Codes

z

Axis II{Developmental and Personality Disorders

zAxis III{Physical disorders

zAxis IV{Severity of Psychosocial Stressors

zAxis V{Global Assessment of Functioning

Appendices

zAppendix A

{Controversial new disorders

zAppendix B

{Decision Trees

zAppendix C

{Glossary of Technical Terms

Cautions in Using DSM-IV

zDiagnosis is only the initial step

zNeed specialized training to use DSM-IVto make diagnosis

zDSM-IV diagnosis is not necessarily alegal document

zNeed to consider norms of culturesoutside of western culture


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Criticisms of the DSM-IV

zQuestionable reliability

zQuestionable validityzImplies homogeneity

zNot enough flexibility

zImplies qualitative difference rather than aquantitative continuum

zCreated by psychiatrists

{Too much medical model

Criticisms of the DSM-IV

zChild and adolescent disorders notadequately covered

zPromotes cookie cutterapproach

zFalse impression about sophistication ofunderstanding of mental disorders

zFocuses on signs and symptoms to theexclusion of other facets of the disorder

How to Fix the DSM

zEmphasize environmental influences

zMove from disorder to discorder


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Why Use the DSM-IV

zProvides appropriate terminology

zCommon language among health serviceproviders

z500-lb gorilla

DSM-V

zChanges to expect:

{Conform with ICD

{Maybe change diagnosis

{Maybe change theoretical orientation

{Maybe increased emphasis on testing andassessment

New WHO Diagnostic Schematic

zTwo parts, each with two components:

{Functioning and Disability

zBody functions and structures

zActivities and Participation

{Contextual Factors

zEnvironmental Factors

zPersonal Factors


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Diagnoses

zPractice comes from medicine

zDiagnosis is the assignment of a labelthat serves as shorthand for a cluster ofrelated behavioral features which mayor may not be related to demonstrableorganic varibles

zPsychological diagnoses arent yet tothe level of medical diagnoses

Categorical versus DimensionalCategorical versus Dimensional

ConditionsConditions

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Frequency

Scores

(A)(A) DichotomyDichotomy

There are only twoThere are only two

levels, and all peoplelevels, and all people

are at one of thoseare at one of those

two levelstwo levels

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Frequency

Scores

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Frequency

Scores

(B) Dimensional(B) Dimensional

Considerable varietyConsiderable variety

across populationacross population




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20

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1 3 5 7 9 11 1 3 15 1 7 1 9

Frequ

ency

Scores

20

60

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Frequency

Scores

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Frequency

Scores

(C) Bimodal(C) Bimodal

DistributionDistribution

Variability withinVariability within

each categoryeach category



Problems With/Abuses of Diagnostic Terms/Labels

zSelf-fulfilling prophesy

zDistorting diagnoses to get insurancecoverage

zLabel viewed as immutable

zCircular use of label

zDisagreement of diagnoses

zInconsistency in the definition of the label

Problems With/Abuses of Diagnostic Terms/Labels

zCareless assignment of labels

zPotentially harmful effects on a person

zPolitical and economic exploitation

zconfidentiality


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Positive Uses for Diagnostic Labels

zFacilitate communication

zPrevent confusionzClassify clients for definition of

treatment issues

zUsed in:{Clinical communities

{Insurance companies

{Research

{Statistical purposes

Methods of Assessment

zClinical Interview

{Most widely used method

{Covers:

zIdentifying data

zPresenting Problem

zPsychosocial History

zPsychiatric History

zMedical History


{Interview Formats:

Computer admin & scoring

Used in research & clinicalsettings

Creates favorable changesAllows comparability

Increases rapportMay increase defensiveness andresistance

Picks up idiosyncratic infoMay miss idiosyncratic info

Increased flexibilityDecreased flexibilityDecreased reliability and validityIncreased reliability and validity

UnstructuredUnstructuredStructuredStructured


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{Interview vs. Conversation

zInterview designed to achieve certain goalszInterview may require discussion of unpleasant

things

zInterviewer directs and controls the flow of theinterview

zOne-sided

zTime Limited


zMental Status Exam

{Appearance and behavior

{Thought processes

{Mood and affect

{Intellectual functioning

{Sensorium

zPhysical Exam



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z

Psychological Tests{Used to evaluate reasonably stable traitssuch as intelligence and personality

{Standardized

{Two important concepts:zValidity

The extent to which a test measures what itpurports to measure

zReliabilityThe extent to which a test obtains comparable

scores across time

Three Concepts Determine the Valueof Assessment


{Intelligence Tests

zStanford Binet

zWechsler Scale

zDeviation IQ score

{Self-Report Personality Tests

zObjective tests

zEmpirically derived

zMMPI-2

zMCMI


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This inkblot resembles the ambiguous figures presented in theRorschach test


{Projective Personality Tests

zRationale for these

zValidity

zRorschach Inkblot TestzThematic Apperception Test

{Neuropsychological Assessment

zBender Visual Motor Gestalt Test

zHalstead-Reitan Neuropsychological Battery

zLuria Nebraska Battery


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{Behavioral Assessment

zFunctional analysiszSelf-monitoring

Reactivity

zAnalogue Measures

zBehavioral Rating Scales

{Cognitive Assessment

{Physiological Measurement

zGSR


zEEG

zEMG

zBrain Imaging

CT Scan

PET Scan

MRI

fMRI

BEAM

Science and Abnormal Behavior

zNature of Science{Way of knowing the world unlike normal everyday ways

of knowing

{Science values empiricism, objectivity, and replicability

{Science demands rigorous standards of proof{Science is a means for testing hypotheses and

theoretical claims

{Science as a human enterprise is often value laden, notvalue free


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Science and Abnormal Behavior

zQuestions Driving a Science of

Psychopathology{What problems cause distress or impair

functioning?

{Why do people behave in unusual ways?

{How can we help people behave in moreadaptive ways?

Basic Components of Research

z Starts with a Hypothesis or Educated Guess{Not all hypotheses are testable

{Hypotheses in science are formulated so that they aretestable

zResearch Design{A method to test hypotheses

{ Independent variable The variable that causes orinfluences behavior

{Dependent variable The behavior influenced by theindependent variable

Considerations in Research Design

zBalancing Internal vs. External Validity{ Internal validity Confidence that effects are due to the

independent variable

{External validity Extent to which the findings are

generalizablezWays to Increase Internal Validity by Minimizing

Confounds{Use of control groups

{Use of random assignment procedures

{Use of analog models

zRelation Between Internal and External Validity


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Statistical Methods and ClinicalMeaningfulness

z Statistical Methods{Branch of mathematics

{Helps to protect against biases in evaluating data

z Statistical vs. Clinical Significance{Statistical significance Means that the results are

beyond chance or coincidence

{Clinical significance Refers to whether the results areclinically meaningful

{Statistical significance does not imply clinicalmeaningfulness

Statistical Methods and ClinicalMeaningfulness

zBalancing Statistical vs. ClinicalSignificance

{Evaluate effect size

{Evaluate social validity

zGeneralizability and the PatientUniformity Myth

Types of Research

zCase Study

zCorrelational Study

zExperimental Study{Single Case Experimental Design

{Genetic Studies

{Studying Behavior Across Time

{Studying Behavior Across Cultures

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