Clinical Assessment Notes

Clinical Assessment

Clinical assessment is a fundamental aspect of psychology. Here's why psychologists assess people:

• Diagnosis: To identify and classify psychological disorders.
• Understanding Personality Dynamics: To gain insights into personality traits and how they influence an individual's life and symptoms.
• Guidance for Psychotherapy Goals: To establish clear objectives for therapeutic interventions.
• Answering External Referral Questions: To provide information requested by external parties.

Steps in Conducting a Psychological Assessment

The major steps in conducting a psychological assessment are as follows:

1. Determine the Reason for Referral and Presenting Problem: Understand why the assessment is being conducted and the specific issues the individual is facing.
2. Choose What to Assess: Decide which aspects of the individual's functioning need to be evaluated.
3. Select the Method of Assessment: Choose appropriate assessment techniques, such as interviews, psychological tests, or behavioral observations.
4. Gather the Assessment Data: Collect data using the selected methods.
5. Consider the Data and Draw Conclusions: Analyze the data and formulate interpretations.
6. Convey the Conclusions to Appropriate Parties: Communicate the findings to relevant individuals or organizations.

Clinical Interviewing

Clinical interviewing is a crucial method for gathering information. Here's a breakdown:

• Definition: A structured conversation with a client to gather information relevant to their psychological well-being.
• Interview Types:
  • Crisis Interview: Conducted when someone is in immediate danger. Goals include addressing immediate problems, decreasing distress, motivating the client to seek treatment, ensuring safety, and considering involuntary hospitalization if necessary. Assessed factors include ideation, plan, means, and intent.
  • Intake-Admission Interview: Determines why the individual is seeking services and whether the facility is the right place for them.
  • Social/Case History Interview: Obtains a comprehensive history to understand context and potential etiological mechanisms.
  • Mental Status Examination: Assesses in-the-moment cognitive, emotional, and behavioral characteristics.
  • Diagnostic Interview: Used to formulate a formal DSM-based diagnostic picture of the client.

Social History Interview

The purposes of a social history interview are:

• To obtain a thorough history of the individual.
• To understand the context of their life.
• To identify possible etiological (causal) mechanisms.

What's included:

• Childhood/family history
• Social/interpersonal history
• Trauma history
• Educational history
• Occupational history
• Medical history
• Psychiatric history
• Substance use history
• Legal history
• Sexual history
• Religious beliefs
• Hobbies
• etc.

Mental Status Examination

A mental status examination assesses the presence of in-the-moment cognitive, emotional, or behavioral characteristics. Information gathered may or may not be relevant to the case and is often recorded as behavioral observations in the psychological report.

The components of Mental Status Examination are:

• General presentation
• State of consciousness
• Attention and concentration
• Speech
• Orientation
• Mood and affect
• Thought processes & content
• Perceptual experiences
• Memory and intelligence
• Insight and judgment

Mini-Mental State Examination (MMSE)

The MMSE is a structured cognitive assessment tool used to evaluate various cognitive functions. It includes tasks assessing:

• Orientation to time and place (e.g., identifying the year, season, date, day of the week, month, state, county, town/city, hospital, and floor).
• Attention and calculation (e.g., counting backward from 100 by sevens or spelling "WORLD" backward).
• Immediate and delayed recall.
• Language abilities (e.g., naming objects, repeating a phrase, following written instructions, writing a sentence).
• Visual-spatial skills (e.g., copying a picture with specific requirements).

The maximum total score on the MMSE is 30, with scores indicating different levels of cognitive function.

Diagnostic Interviewing

• Used to formulate a formal DSM-based diagnostic picture of the client.
• Unstructured interviews
• Structured interviews
  • e.g., Structured Clinical Interview for DSM-5 Disorders (SCID)
  • e.g., MINI International Neuropsychiatric Interview
• Pros and Cons…

Elements of an Interview

Key aspects to consider during an interview include:

• Physical Setting: Creating a comfortable and private environment.
• Rapport Building: Establishing a trusting relationship with the client.
• Taking Notes: Recording relevant information accurately.
• Recording Sessions: Considering the use of audio or video recording with the client's consent.
• Communication Style: Adapting communication to the client's needs, including:
  • Casual conversation
  • Language
  • Silence
  • Listening
  • Nonverbal cues
• Types of Interview Questions:
  • Open-ended
  • Facilitative
  • Clarifying
  • Confronting
  • Direct
• Role of the Clinician: Maintaining objectivity, empathy, and professionalism.

Psychological Testing

• Objective Personality Testing
• Projective Personality Testing
• Intelligence Testing
• Neuropsychological Testing (if time)
• Behavioral Assessment

Personality Testing

Personality is defined as the stability and consistency in a person’s thoughts, feelings, and behavioral style over time. A personality trait is a stable and consistent way of perceiving the world and of behaving.

There are two basic types of Personality Testing:

• "Objective" Testing
• "Projective" Testing

Objective Personality Tests

Objective tests have standardized questions or statements, with fixed-option responses

Advantages:

• Economical; can be given to groups or individuals
• Simple instructions; simple scoring
• Relatively objective and reliable

Disadvantages:

• Responses may not indicate actual behavior.
• Respondents may more easily fake responses.
• Experience, culture, and context can influence question interpretation and responses.

The MMPI & MMPI-2

The Minnesota Multiphasic Personality Inventory (MMPI) is a widely used objective personality test. Key points include:

• Background: First published in 1943.
• Method of construction
• MMPI-2 published in 1989
• 567 true-false items
• Includes clinical, validity, content, and supplementary scales.

MMPI/MMPI-2 Clinical Scales

The MMPI and MMPI-2 include the following clinical scales:

1: Hypochondriasis (Hs)

2: Depression (D)

3: Hysteria (Hy)

4: Psychopathic Deviate (Pd)

5: Masculinity-Femininity (Mf)

6: Paranoia (Pa)

7: Psychasthenia (Pt)

8: Schizophrenia (Sc)

9: Hypomania (Ma)

0: Social Introversion (Si)

MMPI/MMPI-2 Other Scales

• Validity Scales
  • to detect problematic responding.
• Content Scales
  • face valid scales reflecting a variety of symptoms.
• Supplementary Scales
  • extra scales built by others that have stood the test of time.

MMPI/MMPI-2 interpretation

• MMPI raw scores converted to T scores and plotted.
• Check the validity scales
• Clinical scales interpreted through actuarial methods
  • Interpretation through patterns and content
  • Codetypes

MMPI/MMPI-2 Critical Evaluation

Strengths:

• over 10,000 studies
• reliable and valid for many purposes
• somewhat resistant to faking

Weaknesses:

• Atheoretical
• Not a comprehensive personality measure
• Question of incremental validity
• Scales are heterogeneous and overlapping

MMPI-3

• Psychometric concerns with the MMPI-2 led a team of MMPI researchers to restructure it.
• Process started in 2008 with a restructured form of the MMPI-2 called the MMPI-2-RF. Not enough.
• MMPI-3 released this past year.
• MMPI-3 features:
  • Much shorter than the MMPI and MMPI-2 (335 items)
  • Studies supporting its reliability and validity are starting to come online.
  • Restructured clinical scales more homogeneous and show better discriminant validity.

Another Personality Model and Measure

Big Five Five-factor Model

The Big Five / FFM

The Big Five/FFM (Five-Factor Model) is a widely recognized model of personality, encompassing five broad dimensions:

I. Extraversion (or Surgency)

II. Agreeableness

III. Conscientiousness

IV. Neuroticism (vs. Emotional Stability)

V. Openness to Experience (or Intellect / Culture)

Revised NEO Personality Inventory-3rd Ed. (NEO-PI-3)

• Measures five broad domains of personality (i.e., the “five-factor” or “big five” model):
  • Neuroticism
  • Extraversion
  • Openness to Experience
  • Agreeableness
  • Conscientiousness
• +6 facets for each domain, 30 scales total.
• 240 items answered on 5-point scale

NEO-PI-3 dimensions/domains and facets

• Neuroticism: Anxiety, Hostility, Depression, Self-Consciousness, Impulsiveness, Vulnerability
• Extraversion: Warmth, Gregariousness, Assertiveness, Activity, Excitement Seeking, Positive Emotions
• Openness to Experience: Fantasy, Aesthetics, Feelings, Actions, Ideas, Values
• Agreeableness: Trust, Straightforwardness, Altruism, Compliance, Modesty, Tender-Mindedness
• Conscientiousness: Competence, Order, Dutifulness, Achievement Striving, Self-Discipline, Deliberation

NEO-PI-3 (cont.)

• Reliability
• Validity
• Factor Structure
• Normal- vs. abnormal-range personality
• Strengths & Weaknesses
• Cross-cultural “universality”?

Projective Personality Tests

Projective personality tests, also known as "performance-based tests," involve unstructured or ambiguous stimuli to which individuals must respond. Key characteristics include:

• Unstructured or ambiguous stimuli
• Forced to impose structure
• Method is indirect
• Freedom of response
• Many variables

Examples:

• Rorschach Inkblot Test
• Thematic Apperception Test (TAT)
• Incomplete Sentence Blank

The Rorschach Inkblot Test

The Projective Personality Tests aka “performance-based tests”: Hermann Rorschach used inkblots for psychiatric diagnosis and observed responses of people to ambiguous situations (inkblots).

The Rorschach Test has 10 printed inkblots. The administration consists of:

• Respondent tells what is seen
• Clinician records responses verbatim
• Inquiry: Clinician asks for causes/prompts for responses; elaboration and clarification of responses

The Rorschach Inkblot Test Scoring methods vary, three criteria often used:

• Location: area of card to which individual responds
• Content: nature of object perceived in inkblot
• Determinants: aspects of card that evoked response
• More weight given to determinants than content

Interpretation is complex, and subject to illusory correlation:

• Overuse of form may suggest conformity
• Poor form may suggest psychosis
• Color may relate to emotionality
• Overuse of white spaces may indicate opposition
• Details may indicate a compulsive, obsessional person
• Small animals may mean passivity; blood hostility
• Turning a card may indicate suspicion
• Reflection responses may mean narcissism

The Thematic Apperception Test

The Thematic Apperception Test (TAT) was introduced by Morgan and Murray, where Individuals respond to a series of pictures. It consists of 31 cards (one is blank) of people in varied situations and is less ambiguous and unstructured as the Rorschach
Clinicians select 6–12 cards and respondents' stories are transcribed verbatim
Reliability and Validity?. Is difficult to establish because There are many variations in:

• instructions
• methods of administration
• number of cards used
• type of scoring/interpretation system
• Lack of norms
• Clinicians rely on qualitative impressions rather than computing scores

Rotter’s Incomplete Sentence Blank

It consists of 40 open-ended statements, e.g.,

• “I like ”
• “What annoys me ”

Defining Intelligence

What is it?

• Broad view of intelligence
  • Involves attention, perception, memory, learning, language, thinking, conceptual understanding, problem solving, etc.
• Spearman’s “g”
• Raymond B. Cattell: 2 factors under “g”
  • Fluid ability
  • Crystallized ability

Traditional Intelligence Assessment: What is an IQ?

• Why assess intelligence?
• What is an IQ?
  • “Ratio IQ”: MA / CA * 100
  • “Deviation IQ”

IQ Measures

• How they are administered…
• Exemplar measures:
  • Wechsler Adult Intelligence Scale (WAIS-5)
  • Wechsler Intelligence Scale for Children (WISC)
  • Wechsler Preschool and Primary Scale of Intelligence (WPPSI)
  • Stanford Binet-5th edition
  • Wonderlic Cognitive Ability Test

WAIS: History

• Wechsler-Bellevue 1939
• Wechsler-Bellevue II 1946
• WAIS 1955
• WAIS-R 1981
• WAIS-III 1997
• WAIS-IV 2008
• WAIS-5 2024

WAIS-5 primary indices are:

• Verbal Comprehension Index (VCI): Measures verbal reasoning, comprehension, and expression.
• Visual-Spatial Index (VSI): Measures the ability to evaluate visual details and spatial relationships.
• Fluid Reasoning Index (FRI): Measures logical thinking and problem-solving in novel situations, independent of acquired knowledge.
• Working Memory Index (WMI): Measures the ability to temporarily store and manipulate information for cognitive tasks.
• Processing Speed Index (PSI): Measures the speed and efficiency of visual processing and decision-making.

The WAIS-5 primary indices reliability and validity Studies and has a normative sample of ages 16-90
Normative sample of N = 2200 which is 200 examinees per age band for ages 16-69 and 100 examinees per age band for ages 70-90.
Demographic Representation: reflects the most current U.S. Census data, matching five key demographic variables: age, gender, ethnicity, education level, and geographic region.

Heritability of IQ

Relationship Correlation

• MZ Twins .86
• DZ twins .60
• Siblings .47
• Parents/offspring .42
• Cousins .15
• MZ twins raised apart .72
• Siblings raised apart .24

Alternative Theories of Intelligence

• Sternberg: Triarchic theory of intelligence
  • Componential aspect: i.e., analytical thinking
  • Experiential aspect: i.e., creative thinking
  • Contextual aspect: i.e., “street-smartness”
• Gardner: theory of multiple intelligences
  • Linguistic
  • Spatial
  • Musical
  • Bodily-kinesthetic
  • Logical-mathematical
  • Personal

Neuropsychological Assessment

Definitions

• Neuropsychology
• Neuropsychological Assessment

Functions of Neuropsychology

Functional Model

Idea is that different areas of the brain interact to produce behavior.

Nature of a given behavioral deficit will depend on which functional system has been affected and the localization of damage within this functional system:

Brain Structure & Function

• Hemispheres
• Lobes:
  • Frontal
  • Temporal
  • Parietal
  • Occipital

Causes of Brain Pathology

• Trauma
• Cerebrovascular accidents
• Tumors
• Degenerative diseases
• Nutritional deficiencies
• Chronic alcohol/substance abuse
• Toxic disorders

Some Symptoms of Brain Pathology

• Impaired orientation
• Impaired memory
• Impaired intellectual functions
• Impaired judgment
• Shallow or labile affect
• Loss of resilience
• Frontal lobe syndrome
  • e.g., “acquired sociopathy”

Neuropsych Assessment Methods

• Two major approaches
  • Fixed or standard battery (4-8 hours)
    • e.g., Halstead-Reitan or Nebraska-Luria
  • Flexible or hypothesis-testing approach (2-4 hrs)
    • Smaller tests selected & tailored to individual patients (e.g., Wisconsin Card Sort, etc.)

Behavioral Assessment

Introduction

A-B-C model to summarize functional analysis.
Methods of Behavioral Assessment:

• Interview
• Naturalistic Observation
  • e.g., at home, at school, etc.
  • use of coding systems / rating scales
• Controlled Observation
• Role playing
• Self-Monitoring
  | Factors Affecting Reliability and Validity of BA: Complexity of target behavior, Observer drift, Unit of analysis, Type of rating, Reactivity, Ecological Validity|

Clinical Decision Making

• Interpretation of Test Results
  • In the context of normative data
  • Differences within an individual
  • Pattern analysis (e.g., MMPI codetypes)
  • Pathognomonic signs
  • Statistical prediction formulas

Clinical Judgment Versus Actuarial (Statistical) Prediction

• Clinical Judgment
  • a subjective form of decision-making
  • Psychologist draws conclusions and makes decisions and uses expert knowledge, personal experience, client perspectives, and other insights.
• Actuarial (Statistical) Judgment
  • Actuarial Prediction
    • judgments and decisions on statistically determined probabilities
    • Objective method
    • Eliminates human factor

The Psychological Report

The psychological report includes:

• Identifying info
• Referral info
• Behavioral observations
• History of the presenting problem
• Other important history
• Assessment results
• Diagnostic impressions
• Case conceptualization and/or conclusions
• Recommendations and/or Treatment plan

Classification of Psychopathology

What is “Abnormal” Behavior?

What is “Psychopathology”? Definition is difficult because…

• Changes over time
• Value judgments
• Cultural relativity
• No single feature
• No discrete boundary

Possible Definitions of “Abnormal”:

• Deviations from Statistical Norms?
• Subjective Distress?
• Disability or Dysfunction?
• Some combination?

“The DSM” Diagnostic and Statistical Manual of Mental Disorders

• Published by the American Psychiatric Association
• Serves as the primary classification system in the US
• Elements of a classification system
• Signs vs. Symptoms vs. Syndromes
• Categories vs. Dimensions
• Monothetic vs. Polythetic
• The evolution of the DSM…

DSM-5 def’n of mental disorder

• “A mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.”
• “Mental disorders are usually associated with significant distress in social, occupational, or other important activities.”
• “An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder.”
• “Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above."
• Revision process completed in 2013
• Workgroups for each major disorder group
• Shift to some dimensional elements, but mostly a categorical system.
• Final decisions were based on various amounts of science AND professional politics –. e.g., personality disorder mess, if time

DSM-5 def’n of mental disorder

• “A mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.”
• “Mental disorders are usually associated with significant distress in social, occupational, or other important activities.”
• “An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder.”
• “Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above."
  Revision process completed in 2013. Workgroups for each major disorder group. Shift to some dimensional elements, but mostly a categorical system. Final decisions were based on various amounts of science AND professional politics –. e.g., personality disorder mess, if time

Chapters within DSM-5

• Neurodevelopmental disorders
• Schizophrenia spectrum and other psychotic disorders
• Bipolar and related disorders
• Depressive disorders
• Anxiety disorders
• Obsessive-compulsive and related disorders
• Trauma- and stressor-related disorders
• Dissociative disorders
• Somatic symptom disorders
• Feeding and eating disorders
• Elimination disorders
• Sleep-wake disorders
• Sexual dysfunctions
• Gender dysphoria
• Disruptive, impulse control and conduct disorders
• Substance use and addictive disorders
• Neurocognitive disorders
• Personality disorders
• Paraphilic disorders
• Section III – Emerging Measures and Models

e.g., Depressive Disorders

The DSM-5 outlines specific criteria for depressive disorders:

• “…presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s ability to function.”
• Chapter includes unipolar disorder such as major depressive disorder, persistent depressive disorder, and other variations.
• Separated from bipolar mood disorders in DSM-5

Major Depressive Disorder

Major Depressive disorder include Symptoms must be present most of the day, nearly every day, for two weeks…

• Sad, depressed mood
• Loss of interest/pleasure
• Weight/appetite loss or gain
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Worthlessness or guilt
• Difficulty thinking or concentrating
• Recurrent thoughts of death/suicide

Major Depressive Disorder (cont.)

Other criteria:

• Symptoms cause significant distress/impairment.
• Symptoms not attributable to effects of substance or another medical condition.
• Not better accounted for by another mental disorder.
• No evidence of previous manic episode.
• Typically recurrent
• Episode length
• Age of onset

Posttraumatic Stress Disorder (PTSD)

• Criterion A: exposed to actual or threatened death, serious injury, or sexual violence.
• Criterion B: ≥ 1 intrusion symptoms
• Criterion C: ≥ 1 avoidance symptoms
• Criterion D: ≥ 2 negative changes in mood
• Criterion E: ≥ 2 arousal or reactivity Sxs

Diagnostic Summary:

Conrad from Ordinary People

• Clinical syndromes: Major Depression, Single Episode Posttraumatic Stress Disorder (provisional)
• No evidence of personality disorder
• No evidence of complicating medical problems
• Psychosocial factors: Death of brother; conflict with mother

Benefits of Psychiatric Classification:

• Research
• Communication
• Treatment

Problems with DSM-style Psychiatric Classification

• Categorical system (i.e., “medical model”)
  • Results in loss of important information re: severity.
  • Lack of evidence for categories.
  • To be contrasted with “dimensional” systems.
• Stigma associated with labels
• Diagnostic comorbidity
• Heterogeneity within disorders
• Disorder thresholds are largely arbitrary

Alternatives to the DSM?

• International Classification of Diseases (ICD)
  • Published by the World Health Organization
• Research Domain Criteria (RDoC)
  • Developed by the National Institute of Mental Health
• Hierarchical Taxonomy of Psychopathology (HiTOP)
  • Developed by a grassroots consortium of psychologists and psychiatrists from around the world.

RDoC and HiTOP are “dimensional models” What does that mean?

• Dimensional models acknowledge that patients often vary in degree of severity.
• Dimensional models look to describe & explain underlying biopsychosocial processes rather than simply describing messy combinations of signs and symptoms.
• Dimensional models are more consistent with how psychopathology presents in people.
• Dimensional models should lead to more targeted, precise treatments.