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Chapter 3- Clinical Assessment and Diagnosis

Abnormal Psychology (Brandeis University)

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Chapter 3: Clinical Assessment and Diagnosis

 Clinical Assessment- systematic evaluation and measurement of psychological,
biological, and social factors in an individual presenting with a possible psychological
disorder
 Diagnosis- process of determining whether the particular problem afflicting an individual
meets all criteria for a psychological disorder
o Collection of symptoms tending to occur in many similar ways
o Creates dysfunction or distress
o Shares common potential etiologies
o Responds in similar ways to treatment
o Diagnostic Classification Purposes
 Provide a nomenclature
 Furnish a basis for description and information retrieval
 Provide a basis for making predictions
Advantages Disadvantages
o Comfort in not being alone o Stigma
(others with disorder)
o Underlying scientific validity o Self-fulfilling prophecies
o Treatment/Prevention o Not yet a reliable and valid
identifiable science
o Facilitate communication o Affected by cultural
among health professionals differences
o False contrast between physical o Confirmation bias from
and mental labels

 Qualities of a Good Classification System

o Reliability- degree to which a measurement is consistent
 Inter-rate Reliability- increased reliability by carefully designing
assessment devices and conducting research to ensure multiple raters will
get same result
 Test-Retest Reliability- a grade on a test should be similar if you retake
test
 Internal Consistency- change from previous functioning in a given period
o Validity- whether something measures what it’s designed to measure
 Concurrent/Descriptive Validity- comparing results of an assessment
measure with results of others
 Predictive Validity- how well assessment tells what will occur in future
 Construct Validity- signs and symptoms chosen as criteria for diagnostic
category are consistently associated
 Criterion Validity- when outcome is criterion by which we judge
usefulness of diagnostic category
 Content Validity- if you create criteria for a diagnosis, it should reflect the
way most experts thinkproper labeling
 Convergent Validity-test things expected to be related that in fact are
related

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 Divergent Validity- test things expected to be unrelated that in fact are

unrelated
o Clear and precise operationally defined concepts
o Completeness
o Parsimony- should have no more subcategories than are necessary
o Patterns should be mutually exclusive
o Uses a nomothetic strategy rather than idiographic
 Standardization- process by which a certain set of standards or norms is determined for a
technique to make its use consistent across different measurements
 Mental Status Exam- used to organize info obtained during an interview; covers 5
categories
o Appearance and Behavior- clinician notes any overt physical behaviors, general
appearance, facial expression, posture, etc.
 Ex: Psychomotor Retardation- slow and effortful motor behavior that may
indicate depression
o Thought Processes- clinician listens to patient talk to get idea of them (speed of
speech, continuity, etc.)
 Ex: Loose Association or Derailment (disorganized speech) indicates
schizophrenia
 Delusions of Persecution- thinks someone is after them all the time
 Delusions of Grandeur-thinks they’re all-powerful in some way
 Ideas of Reference- everything someone does somehow relates back to
individual
 Hallucinations- things person sees or hears that aren’t really there
o Mood and Affect- (mood) predominant feeling/state of individual; (affect)
feeling/state that accompanies what we say at a given point
 Inappropriate Affect- when emotional response doesn’t match situation
(ex. laughing at a funeral)
 Flat Affect- no detectable emotion in speech
o Intellectual Functioning- memory, intelligence, abstract thinking, etc.
o Sensorium- general awareness of our surroundings
 Lack of could indicate brain damage/dysfunction
 Psychiatric Interview- used by mental health professionals to gather info on current and
past behavior, attitudes, emotions, and detailed history of patient’s life
o Demographic Info (age, sex, education, marital status, number of children, and
employment)
o Chief Complaint
o Present Illness/Medical History (background factors related to illness)
o Past Psychiatric hx (hx = medical history)
 Types of disorders, steps taken in Rx (treatment)
 Semistructured diagnostic interviews
o Personal and Social hx
 Info is important, but how it’s presented provides how client speaks,
thinks, feels, and evaluates situations
 Try to get complete family hx

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o Family medical hx
o Mental Status
o Semistructured Interview- consists of questions that have been carefully phrased
and tested to elicit useful info in a consistent manner to deduce indications of
particular disorders
o Unstructured Interview- based on presenting problems
 Behavioral Assessment- uses direct observation to assess an individual’s thoughts,
feelings, and behavior in specific situations
o More appropriate than interview for people who are not old or skilled enough to
report their problems and experiences
o Observational Assessment- focused on here and now; clinician’s attention
directed to immediate behavior, its antecedents, and its consequences
 Flaw: relies on recollection and interpretation of events of observer
 Form of informal observation
 Formal Observation- identifies specific behaviors that are observable and
measurable (operationally defined)
o Self-Monitoring- people observe their own behavior
 Behavior Rating Scales- used as assessment tools before treatment and
then periodically during treatment to assess changes in the person’s
behavior
 Brief Psychiatric Scale- assesses 18 general areas of concern; each
symptom is rated on a 7-point scale from 0 (not present) to 6 (extremely
severe)
1) Screens for psychotic disorders and includes such items as:
i) Somatic Concern (preoccupation with physical health, fear
of physical illness, hypochondriasis)
ii) Feelings of Guilt (self-blame, shame, remorse for past
behavior)
iii) Grandiosity (exaggerated self-opinion, arrogance,
conviction of unusual power or abilities)
 Reactivity- phenomenon that can distort any observational data (presence
of observer can cause a change in behavior of subject)
 Physical Examinations- diagnose or rule out physical etiologies
o Toxicities, medication side effects, allergic reactions
 Psychological Testing- tests used to assess psychological disorders that must meet strict
standards
o Must be reliable so that people administering test will reach same conclusion
o Must be valid so they measure what they should be measuring—presence of
psychological disorders
o Must include specific tools to determine cognitive, emotional, or behavioral
responses that might be associated with a specific disorder
o Must include general tools as well to assess long-standing personality features,
such as tendency to be suspicious
o Projective Tests- include a variety of methods in which ambiguous stimuli, such
as pictures of people or things, are presented to people who are asked to describe
what they see

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 The theory is that people project their own personality and unconscious
fears onto other people and things without realizing it
 Reveals unconscious thoughts to therapist
 Based on psychoanalytic theory
 Rorschach Inkblot Test- includes inkblots to serve as ambiguous stimuli
1) Concerns about reliability and validity so John Exner developed
standardized version called the Comprehensive System
 Thematic Apperception Test- (aka TAT) consists of a series of 31 cards:
30 with pictures and 1 blank card; involves asking for a straightforward
description of what test taker sees and to tell a dramatic story behind it
1) Reveals unconscious mental processes in their stories about
pictures
2) Not reliable or valid because depends on examiner’s frame of
reference to decrypt story
o Personal Inventories- significance is in what tests predict, not what questions
 Face Validity- the wording of the questions seems to fit the type of
information desired
 Minnesota Multiphasic Personality Inventory- (aka MMPI) based on
empirical approach, which is the collection and evaluation of data
o Intelligence Testing- specialized; determines structure and patterns of cognition
 Stanford-Binet Test- revised version of original intelligence test used to
identify children who were “slow learners” and predict academic success
 Intelligence Quotient- (aka IQ) score from an intelligence test; calculated
by mental age/chronological age x 100
1) Current test uses a deviation IQ in which a person’s score is
compared only with scores of others of the same age
 Wechsler Tests- include verbal scales (measure vocab, knowledge of
facts, short-term memory, and verbal reasoning skills) and performance
scales (assess psychomotor abilities, nonverbal reasoning, and ability to
learn new relationships)
1) Version for adults: WAIS (Wechsler Adult Intelligence Scale)
2) Version for children: WISC (Wechsler Intelligence Scale for
Children)
3) Version for younger children: WPPSI (Wechsler Preschool and
Primary Scale of Intelligence)
 Neuropsychological Testing- measure abilities in areas such as receptive and expressive
language, attention and concentration, memory, motor skills, perceptual abilities, and
learning and abstraction in a way that allows a clinician to make educated guesses about
person’s performance and possible brain impairment
o Specialized type of psychological testing
o Can pinpoint location of brain dysfunction
o Assesses brain dysfunction by observing the effects of the dysfunction on the
person’s ability to perform certain tasks (can’t see damage, but can see its effects)
o Bender Visual-Motor Gestalt Test- a child is given a series of cards with various
shapes and the child is told to copy what’s on the card (less precise)

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o Two of the most popular advanced tests of brain damage that allow for more
precise determinations are the Luria-Nebraska Neuropsychological Battery and
the Halstead-Reitan Neuropsychological Battery
 Includes the Rhythm Test, which asks the person to compare rhythmic
beats, thus testing sound recognition, attention, and concentration
 Includes the Strength of Grip Test, which compares the grips of the right
and left hands
 Includes the Tactile Performance Test, which requires the test taker to
place wooden blocks in a form board while blindfolded, thus testing
learning and memory skills
 These types of studies raise issues of false positives and false negatives
1) False Positives- when test shows a problem when none exists
2) False Negatives- when no problem is found even though some
difficulty is present
o Primarily used as screening devices and are routinely paired with other
assessments to improve the likelihood that real problems will be found
o Require hours to administer and are therefore not used unless brain damage is
suspected
 Neuroimaging- looking inside nervous system and taking increasingly accurate pictures
of structure and function of brain;
o Specialized type of psychological testing
o Can be divided into categories:
 One category includes procedures that examine the structure of the brain,
such as the size of various parts and whether there is any damage
 In the second category, there are procedures that examine the actual
functioning of the brain by mapping blood flow and other metabolic
activity
o Computerized Axial Tomography Scan- (aka CT scan) first neuroimaging
technique used multiple X-ray exposures of the brain from different angles
 X-rays are partially blocked more by bone than by brain tissue, so the
degree of blockage is picked up by detectors in the opposite side of the
head
 A computer then reconstructs pictures of various slices of the brain
 Proved useful in locating abnormalities in structure of brain or shape of
brains
 Also, useful in locating brain tumors and injuries
 Poses some risk of cell damage due to repeated x-radiation
o Magnetic Resonance Imaging- (aka MRI) patient’s head is placed in high-strength
magnetic field through which radio frequency signals are transmitted
 Where there are lesions or damage, the signal is lighter or darker
 More expensive than CT scan
 Claustrophobia inducing from being in a narrow tube
o Positron Emission Tomography- (aka PET scan) measure actual brain function;
subjects injected with a tracer substance attached to radioactive isotopes, or
groups of atoms that react distinctively
 Substance interacts with blood, oxygen, or glucose

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 When parts of the brain become active, blood, oxygen, or glucose rushes
to these areas of the brain, creating “hot spots,” which are picked up by
detectors that identify the location of the isotopes
 Thus, we can learn what parts of the brain are working and which are not
 Used increasingly to look at varying patterns of metabolism that might be
associated with different disorders
 Very expensive
o Single Photon Emission Computed Tomography- (aka SPECT) works similar to
PET, but a different tracer substance is used and this procedure is somewhat less
accurate
 Less expensive
 Requires far less sophisticated equipment, so it’s used more than PET
o Functional MRI- (aka fMRI) developed to work more quickly than the regular
MRI
 Take only milliseconds, so it can take pictures of the brain at work,
recording its changes from one second to the next
 Name is due to the fact that it measures the functioning of the brain
 Most common technique is BOLD-fMRI, which allows researchers to see
the immediate response of the brain to a brief event
 Psychophysiological Assessment- method for assessing brain structure and function as
well as nervous system activity
o Psychophysiology refers to measurable changes in the nervous system that reflect
emotional or psychological events
 Measurements may be taken either directly from brain or peripherally
from other parts of the body
o Electroencephalogram- (aka EEG) measures electrical activity in the head related
to the firing of a specific group of neurons that reveals brain wave activity
 Brain waves come from the low-voltage electrical current that runs
through neurons
 Electrodes are placed directly on various places on the scalp to record the
different low-voltage currents
 Event-Related Potential- (aka ERP or evoked potential) the response to
specific events during brief periods of when EEG patterns are recorded
 EEG patterns are often affected by physiological or emotional factors and
can be an index of these reactions, like a physiological measure
 Alpha Waves- regular pattern of changes in voltage that characterizes the
waking activities in a normal, healthy, relaxed adult
1) Many types of stress-reduction treatments attempt to increase the
frequency of the alpha waves
2) Pattern associated with relaxation and calmness
 Delta Waves- brain waves that are slower and more irregular than alpha
waves, which is normal for this stage of sleep to occur
1) Pattern shows during deepest, most relaxed stage of sleep
2) If frequent activity shows during waking state, might indicate
dysfunction of localized areas of brain

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 Electrodermal Responding- measure of sweat gland activity controlled by

the peripheral nervous system; formerly known as galvanic skin response
(aka GSR)
o Biofeedback- levels of physiological responding, such as blood pressure readings,
are fed back to the patient on a continuous basis by meters or gauges so that the
patient can try to regulate these responses
o Requires great deal of skill and technical expertise, but even when administered
properly, it can produce inconsistent results, so only used by specialists
 Idiographic Strategy- want to determine what is unique about an individual’s personality,
cultural background, or circumstances
o Tailors treatment to patient
 Nomothetic Strategy- must be able to determine a general class of problems to which the
presenting problem begins
o Attempt to name or classify problem
o Classification- refers simply to any effort to construct groups or categories on the
basis of their shared attributes or relations
 Taxonomy- classification for scientific purposes (for psychology—
behaviors)
1) Nosology- applying a taxonomic system to psychological or
medical phenomena or other clinical areas
2) Nomenclature- describes names or labels of disorders that make up
the nosology
 Classical Categorical Approach- assumes that every diagnosis has a clear
underlying pathophysiological cause, such as a bacterial infection, and that
each disorder is unique
1) Because each disorder is fundamentally different from every other,
we need only one set of defining criteria, which everybody in the
category has to meet
2) Inappropriate to the complexity of psychological disorders
 Dimensional Approach- notes the variety of cognitions, moods, and
behaviors with which the patient presents and quantifies them on a scale
 Prototypical Approach- this alternative identifies certain essential
characteristics of an entity so that you can classify it, but it also allows
certain nonessential variations that do not necessarily change the
classification
1) Not a perfect system because it blurs at the boundaries of
categories and some symptoms apply to more than one disorder
2) However, fits the best with the current state of knowledge of
psychopathology and it’s relatively user-friendly
3) Basis of DSM-V
 Familial Aggregation- the extent to which the disorder would be found among the
patient’s relatives
 Progression of Diagnoses
o Before 1980, the International Classification of Diseases and Related Health
Problems (aka ICD) and the first and second Diagnostic and Statistical Manual
did not have much influence

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o In 1980, the DSM-III brought a landmark in the history of nosology

 Attempted to take an atheoretical approach to diagnosis, relying on precise
descriptions of the disorders as they presented to clinicians rather than on
psychoanalytic or biological theories of etiology
 Became a tool for clinicians with a variety of points of view
 The specificity and detail with which the criteria for identifying a disorder
were listed made it possible to study their reliability and validity
 Allowed individuals with possible psychological disorders to be rated on
five dimensions or axes
 Multiaxial System- allowed the clinician to gather information about the
individual’s functioning in a number of areas rather than limiting
information to the disorder itself
1) Axis I: Schizophrenia or Mood disorders
2) Axis II: Chronic Personality Disorders
3) Axis III: Any physical disorders and conditions present
4) Axis IV: Psychosocial stress reported
5) Axis V: Current level of adaptive functioning
 Revised into DSM-III-R in 1987
o In 1987, DSM-IV was published
 Any changes in the diagnostic system were to be based on sound scientific
data
 Distinction between organically based disorders and psychological based
disorders was eliminated
 Multiaxial system remained with a few changes in the axes:
1) Axis II changed to only personality disorders and intellectual
disabilities
2) Developmental, learning, motor skills, and communication
disorders coded from Axis II to Axis I
3) Axis IV replaced as being used for reporting psychosocial and
environmental problems that might have an impact on the disorder
4) Axis III and V unchanged
o DSM-5- used to identify a specific psychological disorder in the process of
making a diagnosis; official system in US and widely used throughout world
 Divided into three sections:
1) First section introduces the manual and describes how best to use it
2) Second section presents the disorders themselves
3) Third section includes descriptions of disorders or conditions that
need further research before they can qualify as official changes
 Removed multiaxial system
 Takes cultural background into account through cultural formulation,
which allows the disorder to be described from the perspective of the
patient’s personal experience and in terms of his or her primary social and
cultural group
 Criticisms:

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1) Comorbidity- being diagnosed with more than one psychological

disorder at the same time because categories still blur at
boundaries, making diagnostic decisions difficult at times
2) Strongly emphasize reliability, sometimes at the expense of
validity
3) Methods of constructing a nosology of mental disorders have a
way of perpetuating definitions handed down to us from past
decades, even if they might be fundamentally flawed
 A related problem any time we categorize people is labeling
1) Particularly, with intellectual disabilities because categories like
moron would be stigmatized and would then have to be changed

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