Chapter 3: Clinical Assessment & Diagnosis

Clinical Assessment

The systematic evaluation and measurement of psychological, biological, and social factors in an individual presenting with a possible psychological disorder.

Diagnosis

The process of determining whether the particular problem afflicting the individual meets all criteria for a psychological disorder, as set forth in the DSM-5.

Three basic concepts that help determine the value of our assessments:

• Reliability

• Validity

• Standardization

Reliability

• The degree to which a measurement is consistent.

• If a test, survey, or experiment gives stable and repeatable results, it’s reliable.

Validity

• Measures what it is designed to measure.

• Are you measuring the right thing?

Concurrent or Descriptive Validity

Comparing the results of an assessment measure under consideration with the results of others that are better known allows you to begin to determine the validity of the first measure.

• “Does this new test match a trusted one right now?”

Predictive Validity

How well your assessment tells you what will happen in the future.

• “Can this test predict something that happens later?”

Standardization

The process by which a certain set of standards or norms is determined for a technique to make its use consistent across different measurements.

• Procedures of testing, scoring, and evaluating data

• The conditions are the same for everyone.

CLINICAL INTERVIEW

Gathers information on current and past behavior, attitudes, and emotions, as well as a detailed history of the individual’s life in general and of the presenting problem.

Mental Status Exam (MSE)

Involves the systematic observation of an individual’s behavior.

Appearance and Behavior

Overt physical behaviors (leg twitching), individual’s dress, general appearance, posture, and facial expression.

Psychomotor Retardation

slow and effortful motor behavior

"loose association" or "derailment"

A disorganized speech pattern where ideas are presented with no logical connection, often seen in schizophrenia.

delusion of persecution

The belief that others are out to get you or are watching/harming you.

delusion of grandeur

The belief that you are all-powerful, famous, or have special abilities beyond reality.

ideas of reference

Thinking that other people’s actions or conversations are directly related to you, even when they’re not.

hallucinations

Sensing things (seeing/hearing) that aren’t really there.

Mood

The predominant feeling state of the individual.

Affect

The feeling state that accompanies what we say at a given point.

Appropriate Affect

We laugh when we say something funny or look sad when we talk about something sad.

Blunted or Flat Affect

Talking about a range of happy and sad things with no affect.

Intellectual Functioning

Reasonable vocabulary, talk in abstraction and metaphors, and person’s memory

What does the term sensorium refer to in clinical assessment?

person’s general awareness of their surroundings.

What would it suggest if someone doesn’t know the time, place, or who they are?

Possible brain dysfunction or toxic/neurological impairment.

Semi-structured Clinical Interviews

Made up of questions that have been carefully phrased and tested to elicit useful information in a consistent manner so that clinicians can be sure they have inquired about the most important aspects of particular disorders.

Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5)

• Clinician first asks if the patient is bothered by thoughts, images, or impulses (obsessions) or feels driven to experience some behavior or thought repeatedly (compulsions).

• Clinician then asks the patient to rate each obsession on two measures: persistence–distress (how often it occurs and how much distress it causes) and resistance (types of attempts the patient makes to get rid of the obsession).

• For compulsions, the patient provides a rating of their frequency.

PHYSICAL EXAMINATION

Aware of the medical conditions and drug use and abuse that may contribute to the kinds of problems described by the patient.

BEHAVIORAL ASSESSMENT

• Using direct observation to formally assess an individual’s thoughts, feelings, and behavior in specific situations or contexts.

• Appropriate to use individuals who are not old enough or skilled enough to report their problems and experience.

Role-Play Simulations

See how people might behave in similar situations in their daily lives

The ABCs of Observation

Antecedents, Behavior, Consequences

Antecedents

What happened just before the behavior.

Behavior

Observable action.

Consequences

What happened afterward.

Formal Observation

Involves identifying specific behaviors that are observable and measurable (Operational Definition).

Self-Monitoring (Self-Observation

Observe their own behavior to find patterns.

Checklists and Behavior Rating Scales

Formal and structured way to observe behavior.

Brief Psychiatric Rating Scale

• Assesses 18 general areas of concern.

• Each symptom is rated on a 7-point scale from 0 (not present) to 6 (extremely severe).

• The rating scale screens for moderate to severe psychotic disorders and includes such items as somatic concern, guilt feelings, and grandiosity

Reactivity

• A phenomenon that can distort any observational data.

• Your presence may cause them to change their behavior

Projective Testing

• Ambiguous stimuli (pictures, inkblots) are presented to people who are asked to describe what they see.

• People project their own personality and unconscious fears onto other people and things and, without realizing it, reveal their unconscious thoughts to the therapist.

Name three common projective tests.

Rorschach Inkblot Test, Thematic Apperception Test (TAT), Sentence-Completion Method.

Who developed the Rorschach Inkblot Test?

Hermann Rorschach.

What does the Rorschach test involve?

Showing 10 inkblots and asking what the person sees.

What system was developed to standardize the Rorschach test?

• A standardized version of the Rorschach inkblot test.

• Exner’s system of administering and scoring the Rorschach specifies how the cards should be presented, what the examiner should say, and how the responses should be recorded.

• by John Exner

Who developed the TAT?

Christiana Morgan and Henry Murray.

What does the Thematic Apperception Test ask the patient to do?

Tell a dramatic story about each picture shown.

Are there versions of the TAT for specific populations?

Children’s (CAT), Senior (SAT), and culturally adapted versions.

One of the formal scoring systems for TAT stories.

Social Cognition and Object Relations Scale

Personality Inventories

Self-report questionnaires that assess personal traits.

Minnesota Multiphasic Personality Inventory (MMPI)

• The individual being assessed reads statements and answers either “true” or “false.”

• 550 items on the original version and now the 567 items on the MMPI-2.

MMPI-A

A version of the MMPI that is appropriate for adolescents.

Lie Scale

Identify if the the person may be falsifying answers to look good

Infrequency Scale

Measures false claims about psychological problems or determines whether the person is answering randomly

Subtle Defensiveness Scale

Assesses whether the person sees herself in unrealistically positive ways.

Alfred Binet and Theodore Simon

Commissioned by the French government to develop a test that would identify “slow learners” who would benefit from remedial help.

Lewis Terman

Psychologist from Stanford University who translated and revised the Binet intelligence test for use in the United States.

What is the Stanford-Binet Test?

An American version of the original Binet test; introduced the concept of Intelligence Quotient (IQ).

What is Deviation IQ?

A method of scoring IQ by comparing a person’s performance to others of the same age.

Why was Deviation IQ developed?

To provide a more accurate comparison across age groups than the original IQ formula.

Wechsler Tests

Developed by psychologist David Wechsler.

• Developed by psychologist David Wechsler. • Wechsler Adult Intelligence Scale, fourth edition, or WAIS-IV: for adults.

• Wechsler Intelligence Scale for Children, fifth edition, or WISC-V: for children.

• Wechsler Preschool and Primary Scale of Intelligence, fourth edition, or WPPSI-IV: for young children.

NEUROPSYCHOLOGICAL TESTING

Assesses brain dysfunction by observing the effects of the dysfunction on the person’s ability to perform certain tasks

Bender Visual–Motor Gestalt Test

A child is given a series of cards on which are drawn various lines and shapes then the child will copy what is drawn on the card.

Disadvantage: The nature or location of the problem cannot be determined with this test.

Luria-Nebraska & Halstead-Reitan Neuropsychological Batteries

Two widely used test batteries to assess brain (organic) damage and help locate the specific area affected.

Purpose of Halstead-Reitan Neuropsychological Battery

To detect and localize brain damage through a series of structured subtests.

Halstead-Reitan: Rhythm Test

Tests sound recognition, attention, and concentration by asking the person to compare rhythmic beats.

Halstead-Reitan: Strength of Grip Test

Compares the grip strength of the right and left hands to detect lateralized brain dysfunction.

Halstead-Reitan: Tactile Performance Test

The person places blocks into a form board while blindfolded to test sensory, motor, and memory skills.

Disadvantage of Neuropsychological Testing: False Positive

Indicates a brain problem when none actually exists.

Disadvantage of Neuropsychological Testing: False Negative

Fails to detect a brain problem even though one is present.

Two Main Categories of Neuroimaging

1. Structural imaging – examines the physical structure of the brain.

2. Functional imaging – examines brain activity (e.g., blood flow, metabolism).

Structural Imaging Techniques

CAT (CT) Scan and MRI – used to detect abnormalities in brain structure or anatomy.

CAT Scan (CT Scan) – Overview

• First developed in the 1970s.

• Uses multiple X-ray exposures from different angles.

• Computer reconstructs cross-sectional brain images.

CAT Scan – Advantages

• Identifies structural and anatomical brain abnormalities.

• Detects tumors, injuries, and malformations.

MRI – Overview

• Involves placing the head in a strong magnetic field.

• Radio frequency signals are transmitted through the brain.

• Lesions appear as lighter or darker areas in the scan.

MRI – Purpose

• Provides greater detail than a CT scan.

• Used to detect damage or lesions not visible on X-ray-based imaging.

Functional Brain Imaging Techniques

PET, SPECT, and fMRI – assess brain activity and function (e.g., blood flow, oxygen use, metabolism).

PET Scan – Overview

• Involves injecting a tracer with radioactive isotopes.

• Measures interaction with blood, oxygen, or glucose.

• Reveals which brain areas are active or inactive.

PET Scan – Advantages

• Supplements MRI and CT scans in localizing trauma or tumors.

• Identifies abnormal metabolism in various psychological disorders.

SPECT Scan – Overview

• Similar to PET but uses a different tracer.

• Less accurate but more affordable than PET.

fMRI – Overview

• Tracks real-time brain activity by detecting blood flow changes.

• Allows visualization of brain response to tasks or stimuli.

BOLD-fMRI

• Most common fMRI technique.

• Stands for Blood-Oxygen-Level-Dependent fMRI.

• Widely used in psychological disorder research

Psychophysiology

Measurable changes in the nervous system that reflect emotional or psychological events.

Electroencephalogram (EEG)

• Measuring electrical activity in the head related to the firing of a specific group of neurons reveals brain wave activity.

• Electrodes are placed directly on various places on the scalp to record the different low-voltage currents.

Event-Related Potential (ERP) Or Evoked Potential

Event-related voltage changes in the ongoing EEG activity that are time-locked to sensory, motor, and cognitive events.

Alpha Waves

• Waking activities are characterized by a regular pattern of changes healthy adults.

• Associated with relaxation and calmness

Idiographic Strategy

Determine what is unique about an individual’s personality, cultural background, or circumstances.

Nomothetic Strategy

Determine a general class of problems to which the presenting problem belongs

Classification

Any effort to construct groups or categories and to assign objects or people to these categories on the basis of their shared attributes or relations.

Taxonomy

The classification is in a scientific context.

Nosology

If you apply a taxonomic system to psychological or medical phenomena or other clinical areas.

Nomenclature

Describes the names or labels of the disorders that make up the nosology.

Classical (Pure) Categorical Approach

• Originated from Emil Kraepelin’s work.

• Assumes each disorder has one unique cause.

• Disorders are distinct and non-overlapping.

• Each diagnosis has a clear pathophysiological cause.

Dimensional Approach

• Views symptoms on a continuum of severity.

• Assesses variety of moods, cognitions, and behaviors.

• Patients are rated on different dimensions (e.g., anxiety, mood)

Prototypical Approach

• Disorders are defined by a typical combination of symptoms.

• A diagnosis is made if enough criteria (features) are met.

• Allows for variation among individuals within the same disorder.

Dementia Praecox

• Identified by Emil Kraepelin as an early term for schizophrenia.

• Deterioration of the brain that sometimes occurs with advancing age (dementia) and develops earlier than it is supposed to, or “prematurely” (praecox).

• He also described what is now known as bipolar disorder (then called manic depressive psychosis)

1948 – World Health Organization (WHO)

Included mental disorders in the 6th edition of the International Classification of Diseases (ICD-6).

1952 – DSM-I

The first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) was published by the American Psychiatric Association.

1968 – DSM-II

• The second edition of the DSM was published.

• Continued the effort to classify mental disorders in the U.S.

DSM-III (Published in 1980)

• Marked a radical departure from earlier DSM versions.

• Led by Robert Spitzer.

• Introduced an atheoretical approach, focusing on describing disorders without relying on psychoanalytic or biological theories.

• Criteria were precise and detailed, improving reliability and validity in diagnosis.

Key Contributions of DSM-III

• Atheoretical diagnosis – Focused on observable symptoms.

• Standardized criteria – Allowed for more consistent and research-based diagnoses.

DSM-IV (Published in 1994)

• Removed the distinction between organically based and psychologically based disorders.

• Reflected a more integrated understanding of mental disorders.

• Continued the use of specific diagnostic criteria for reliability and validity.