Clinical Psychology- University of Iowa Exam 2

What information does clinical-directed conversations want to gain?

problem definition

Diagnosis

Case formulation

Goal specification

Prevalence of Alcohol Use Disorder in Adults

14% Current

29% Lifetime

Common A&P Goals in Psychology

1) Screening: identification of those experiencing clinically significant difficulties

2) Diagnosis/ Case Formulation: specification of DSM clinical diagnosis and conceptualization of clinically significant difficulties

3) Prognosis/ Prediction: estimation of the likelihood of clinically significant difficulties

4) Treatment Monitoring and Evaluation: examination of how well prevention or intervention is working

Alcohol Use Disorders Identification Test (AUDIT)

Developed by the World Health Organization to screen current alcohol problems in last year

Best available brief screener for alcohol dependence, alcohol abuse, high-risk drinking that doesn't meet criteria

AUDIT is....

standardized, reliable and useful

Internal consistency of AUDIT

Consistency of responses across items on measure

Average Cronbach's alpha across studies: 0.81

Test-retest reliability of AUDIT

Consistency of responses overtime (r >0.7 good)

Average r across studies: 0.91

Inter-rater reliability of AUDIT

Consistency of judgments across raters (kappa > 0.75 excellent)

Content validity

extent to which item content reflects concept of interest

Face validity

extent to which measure appears to assess concept of interest "on its face"

Concurrent validity

association of measure with another presumably related measure at same point

Predictive validity

association of measure with another presumably related measure in the future

Convergent validity

moderate to strong association of measures intended to measure same or similar concepts

Discriminant validity

weaker association of measures intended to measure different concepts

Incremental validity

Extent to which measure predicts more than what already could predict

Low cutoff for dx

High sensitivity, low specificity

more liberal, more people are given the diagnosis

High cutoff for dx

low sensitivity, high specificity

more conservative, fewer people are given the diagnosis

Sensitivity

proportion of those with disorder correctly detected by AUDIT

Specificity

proportion of those without disorder correctly detected by AUDIt

Cutoff selection depends on what

we value more:

correctly detecting disorder- increase in TPs

not classifying those without disorder as disordered - decrease in FPs

cost of low specificity example

sending an innocent person to jail

Clinical Assessment

completely unstructured

Clinician selects, measures, and combines risk factors and produces risk estimate solely according to clinical experience and judgement

Actuarial (statistical) assessment

completely structured

Risk assessment completely determined by prediction equation and establish cutoff scores

Violence Risk Apprasial Guide (VRAG)

12 item scale used to make completely actuarial predictions of violence following release in violent, mentally disordered offenders

How well did VRAG predict incarcerated men's violent recidvism?

Moderately

Sensitivity & specificity: 0.65

Role of Base rates in prediciton

Base rates of violent recidivism typically very low

Less frequent event (suicide, violence) are harder to predict

Unstructured Interview

No standard set of questions or structured method for integrating and summarizing obtained information

Structured Interview

very specific format for asking questions, determining follow-up question, integrating and summarizing obtained information

Structured Clinical Interview for Mental Disorders

Gold standard structured diagnostic instrument

Training and supervision usually extensive

Goal of Behavioral Observation overview

Maladaptive behavior is key aspect of many mental health problems

Every behavior has a function/purpose/reason

Observation used to identify behavior patterns and generate hypotheses about causal/ maintaining factors (reasons for behavior)

Clinicial Interviews

Observation of verbal and non-verbal behavior plays central role

Clinician usually observes specific areas

Mental Status Exam

commonly used system of behavioral observation in psychiatric

Naturalistic behavioral observation

observation within normal situation contexts and under naturally occurring reinforcements and consequences

ex) observing a child in school

Typically over a short period of time

Validity and reliability and cost of naturalistic behavioral observation

External validity is higher, Internal validity is lower b/c we are not controlling

test retest and inter-rater reliability is low

Structured behavioral observation

Observation in role-played scenarios in which person engages in one or more simulated social interactions

Ex) facilitating a family discussion about finances

Validity, reliability and cost of structured behavioral observation

Internal validity is higher, and external validity is lower

Reliability a bit higher, both costly

ABCs of Functional Behavioral Assessment

Antecedent: What ahppens before person does it?

Behavior: What is person doing?

Consequence: What happens after person does it?

Self Monitoring

observing and recording own behaviors, thoughts, emotions, bodily sensations, events, etc.

Provides a great deal of info at low cost

Can be used to track treatment progress

Contributes to objective self awareness

Probelms with self monitoring

inaccuracy and distortion, reliabilty and validity

Role of Monitoring in Cognitive Behavioral Therapy for Panic Disorder

70-80% panic free

50-70% within normal range of functioning

Gains largely maintained over 2 year follow-up

Treatment components in monitoring for PD

education

breathing retraining

cognitive restructuring- to identify, challenge, and replace distorted thoughts and beliefs

exposure

Singular Model (Spearman) Intelligence theory

Intelligence is singular (i.e. reflects a single ability)

"g" for general (single intelligence)

Plural Model (Thurstone) Intelligence theory

Intelligence is multiple abilities that may not relate to each other

There are many different kinds of intelligence that do not necessarily correlate strongly

Hierarchical Model

blends singular and plural methods

a global, overall intelligence factor that includes relatively ability- specific factors

most current intelligence test follow a hierarchical model of intelligence

Purpose of Intelligence testing

Predict future achievement (ex: school)

Characterize functional impairment (academic planning, changes over time)

Influences approach to assessment

Influence approach to therapy

Wechsler's view of intelligence (1939)

"The global capacity of a person to act purposefully, to think rationally, and to deal effectively with his/her environment"

Wechsler Adult Intelligent Scale Structure

Four Subscales:

Verbal Comprehension Scale

Perceptual Reasoning Scale

Working Memory Scale

Processing Speed Scale

Verbal comprehension scale

verbal concept formation and verbal reasoning

tasks:

Similarities- abstract verbal reasoning

Vocab- degree to which one has learned, can comprehend, can express vocab

info- degree of general cultural info

comprehension- ability to deal with abstract social conventions, rules expressions

Perceptual reasoning Scale

Spatial processing and visual-motor integration

tasks:

block design- spatial perception, visual abstract processing, problem solving

matrix reasoning- nonverbal abstract problem solving, inductive reasoning, spatial reasoning

visual puzzles- non verbal reasoning

picture completion- ability to percieive visual details quickly

Working Memory Scale

capacity to store transform and recall incoming info data in short term memory

tasks:

digit span- attention, concentration, mental control

arithmetic- concentration while manipulating mental mathematical problems

etter-numbering sequencing- attention and working memory

Processing speed scale

ability to rapidly and accurately process simple or rote information

symbol search- visual perception, speed

coding- visual motor coordination, motor and mental speed

cancellation- visual perceptual speed

Intellectual disability range

70 and below

"Gifted" range

130<

WAIS-IV psychometrics

High Standardization

High Reliability for FSIQ and Subscales: internal consistency (alpha> .90), Test-retest (r from .67 to .94)

Good Validity for FSIQ and Subscales

High Utility

What does the WAIS- IV predict?

Grades in school

Number of school years completed

Academic performance through 1st year of college

Landing a job

WAIS-IV challenges

Time intensive

Scores can be influenced by factors that are unrelated to intelligence

Scale may not adequately cover the concept of intelligence

Flynn effect

population IQ rises ~3 points every decade

Heritability of IQ

0.51-0.81

Heritability of IQ may be lower in poorer families and higher in more affluent families

Genes supporting intelligence may not be able to express unless people have adequate nutrition and dont have early deprivation

Objective Personality Assessment

Administration of standard set of questions or statements with fixed set of responses

Pros of Objective Personality Assessment

Administration and scoring simple and economical

Potentially high levels of standardization, reliability, validity, utility

Cons of Objective Personality Assessment

Response sets: tendency to respond to items not reflective of true feelings

Faking responses: deliberate attempt to create good or bad impression

Projective Personality Assessment

Administration of unstructured or ambiguous stimuli with open ended responses

Pros of Projective Personality Assessment

Hard to fake good/ bad, freedom of response, more info

Cons of Projective Personality assessment

Administration and scoring complex and expensive

Problems with standardization, reliability, validity, utility

Minnesota Multiphasic Personality Inventory

Over 500 self-descriptive T/F sentences

Most popular and psychometrically sound self report inventory of personality and psychopathology

1st version of the MMPI-2 published in 1943

Normative sample: almost exclusively Caucasian, working class rural Minnesotans with average of 8 years of education

>> Challenges external validity of norms

"Empirical Approach" to test construction

a theoretical approach with low face and content validity

2nd version of the MMPI-2 published in 1989

Normative sample: 2900 adults from diverse geographic regions and communities across US

Eliminated offensive items

Revised items using outdated language or cultural references

New items developed using "Theoretical (Content) Approach"

>>items developed to tap concept of interest and its presumed subcomponents

>>effort to increase content validity

Validity scales

developed to evaluate potential threats to interpretability of responses

Clinical Scales

Developed to distinguish psychiatric categories (using diagnostic classification system from 1940 and 1950)

Content Scales

developed to identify more contemporary clinical conditions

T-Scores

Standardized score with a mean of 50 based on the original normative sample

Infrequency (F), Infrequency Back (F, sub b)

Measures the tendency to exaggerate psychological problems or endorse an extreme number of problems in the first part of the booklet; also detects random responding

Lie (L)

Measures the tendency to claim excessive virtue or attempt to present an overall favorable image

Defensiveness (K)

Measures the tendency to present oneself in an unrealistic positive way

Four themes of the Content Scales

Internal symptoms

External or aggressive tendencies

Devalued view of self

General problem areas

Defensiveness (K)

Measures the tendency to present oneself in an unrealistic positive way

Defensiveness (K)

Measures the tendency to present oneself in an unrealistically positive way

Four themes of content scales

Internal symptoms

External or aggressive tendencies

Devalued view of self

General problem areas

Malingering

Feigning or exaggerating symptoms for external gain (ex: skipping work)

Validity scales of F and F(sub)b highly succesful at distinguishing protocols of feigned and real depression

Strengths of MMPI-2

High Reliability

High concurrent and predictive validity

Ability to detect untruthful responses

Limitations to the MMPI-2

Very long- 564 true/false

Reading and attention requirements

Emphasis on pathology/ abnormality

Personality differs dimensionally not categorically

What is personality

individual differences in characteristic patterns of thinking, feeling, and behaving

Temperament

Individual difference in reactivity and self regulation that are:

1) biologically based

2) Early appearing

3) Relatively stable

Core of personality is temperament

What is the structure of personality

"The Big Five"

5 independent dimensions- a person can be low or high on any given dimension

"The Big Five"

OCEAN

Openness to experience (vs. close mindedness)

Conscientiousness (vs. disorganiztion)

Extraversion (vs. intro)

Agreeableness (vs. dis-)

Neuroticism (vs. emotional stability)

What is a personality disorder?

Maladaptive, extreme variants of normal personality traits

General Personality Disorder Criteria

A. An enduring pattern of inner experience and behavior that deviates markedly from the experience of the individual's culture. Manifested in two or more of the following areas:

1) cognition

2) affectivity

3) Interpersonal functioning

4) impulse control

B. Onset in adolescence or early adulthood

C. Stable over time, situation

D. Leads to significant distress or impairment

How do personality disorder differ from other clinical disorders we have discussed?

Other clinical disorders do not have to be stable over time but personality disorder do

Other disorders can be on set in either early childhood or adulthood

Prevalence of Personality disorders in U.S. adults

15%

High co- morbidity from different clusters

Concerns about personality disorder diagnosis in the DSM-5

Extensive comorbidity among PDs

Extreme differences among patients with same PD diagnosis

Temporal instability (poor test- restest reliability) of PDs

Poor coverage of personaluity psychopathology

Poor convergent validity

Personality varies continously, not categorically