Module 2 Notes: Assessment of Psychological Disorders

Module 2 Notes: Assessment of Psychological Disorders

Overview of Clinical Assessment

  • Clinical assessment is used to determine how and why a person is behaving abnormally and how that person may be helped.

  • It takes a holistic approach, evaluating psychological, biological, and social factors to arrive at a clinical impression or diagnosis.

  • Purposes of assessment:

    • Determine the nature of the problem (what is happening and why).

    • Help plan treatment and track progress over time.

    • Decide whether treatment should be changed or continued.

  • Example discussed: client diagnosed with PTSD undergoing four months of therapy to determine if therapy is beneficial.

  • Assessment relies on multiple information sources, not just symptoms: projective tests, case studies, interviews, etc.

  • Note: In real-life practice, clinicians corroborate information with multiple tools to improve accuracy.

Diagnosis and Assessment Tools

  • Diagnosis is the process of determining whether the problem meets all criteria for a psychological disorder as set forth in the DSM-5-TR.

  • The moment the client enters the clinic, assessment and initial diagnosis begin, including observation of how the client carries herself (dress, attention, gait, facial reactions).

  • The client is often asked to describe in an open-ended way the reasons for seeking therapy and may discuss job, school, relationships, and other life circumstances to form a fuller picture.

  • Nonverbal cues are crucial: eye contact, posture, body language, facial expressions help gauge current state.

Assessment Methods: Tools and Techniques

  • Projective tests (interpret vague stimuli):

    • Rorschach (inkblot) test

    • Thematic Apperception Test (TAT)

    • Sentence completion tests

    • Draw-a-Person test

    • Draw-a-Tree test

  • Personality inventories (self-report):

    • MMPI (Minnesota Multiphasic Personality Inventory) – indicates deviance from typical personality patterns.

  • Response inventories (focus on a specific domain):

    • Beck Depression Inventory (BDI) – focuses on mood, appetite, and other depression-related features.

  • Psychophysiological tests (examples):

    • CT scan, MRI, blood chemistry, etc.

  • Purpose of these tools: ensure that diagnoses are meaningful and accurate by triangulating data from different sources.

Reliability, Validity, and Standardization

  • These three concepts determine the value of assessment tools:

    • Standardization: a test is administered to a large, representative sample to establish norms. Administration, scoring, and interpretation must be uniform across all participants to generalize results.

    • Process (bird’s-eye view): representativeness of participant sample; identical test conditions (e.g., environment, instructions, time) for all participants.

    • Generalization: results can be applied to the bigger population.

    • Reliability: consistency of a measure.

    • Test–retest reliability: high when the same test yields similar results on different occasions for the same individuals.

    • Formal expression: r{tt} = \text{corr}(X1, X_2) where X1 and X2 are scores from two administrations.

    • Example: a client’s intelligence test score should be similar if repeated after a short interval, assuming stable ability.

    • Other forms of reliability exist (not elaborated here).

    • Validity: accuracy of the measure (does it measure what it is intended to measure?).

    • Example: a brief depression screen should yield results consistent with a well-established longer depression measure.

    • Criterion/concurrent validity example: r_{XY} = \text{corr}(X, Y) where X is the brief test and Y is the longer criterion test; a high r indicates good validity.

  • Quick visual analogy: reliability means the tool gives the same results under the same conditions; validity means the tool actually measures the intended construct.

  • Caveat examples:

    • Reliable but not valid: tool yields consistent but wrong results (measures something else).

    • Valid but not reliable: tool measures the intended construct but yields inconsistent results under the same conditions.

    • Unreliable and invalid: worst case for assessment.

Diagnostic Tools and Early Interview Components

  • Clinical interview and observation are foundational:

    • The interview is often the first contact and collects information about problems, feelings, lifestyle, relationships, religion, values, and beliefs.

    • The therapist asks about expectations of therapy and motives for seeking help.

  • Building rapport is essential for honest disclosure:

    • Explain the interview process honestly to reduce anxiety and establish trust.

    • Keep questions relevant to the client’s help seeking to avoid perceptions of irrelevance or hostility.

    • If a client is not comfortable answering, allow postponement and provide rationale for questions.

  • During the interview, assess factors such as onset, precipitating stressors, predisposing life events, and maintaining influences to develop a holistic explanation.

  • Example case: client with two weeks of low mood, hopelessness, appetite loss, poor concentration, and a recent breakup, with a history of a broken home; clinicians weigh biological, psychological, and social factors to determine possible depression and the role of loss as a normal response.

  • Nonverbal observations to record:

    • Appearance and behavior (e.g., leg shaking, posture, clothing, weariness)

    • Thought processes (coherence, logical flow, content such as suicidal ideation)

    • Mood and affect (current feeling state vs. observed emotional expression)

    • Sensorium (awareness of surroundings, memory, attention, recollection, ability to recall the breakup story, concentration)

  • Interpersonal and additional domains to assess:

    • Current and past relationships, family environment, social support

    • Sexual development and religious status

    • Educational status and social history (bullying, friendships, dependence on partner)

Mood, Affect, and Sensorium

  • Mood: the client's internal feeling state at the moment.

  • Affect: the outward emotional state expressed in behavior or speech; may be congruent or incongruent with mood.

  • Sensorium (sensorium): awareness of surroundings and events; ability to recall and retell important personal events; concentration and focus.

  • Other assessed areas:

    • Interpersonal relationships (family, peers, past partners)

    • Religious beliefs and sexual development

    • Social history and educational background

    • Ability to form and maintain relationships; risk factors for negative outcomes

Interview Types: Open-ended vs Closed-ended Questions

  • Open-ended questions:

    • Allow clients to respond in their own words and unfold experiences (e.g., "What made you feel that way?"; "How often do you feel sad?")

  • Closed-ended questions:

    • Answerable with yes or no or brief phrases (e.g., "Do you feel lonelier during the day than at night?")

  • Rationale for open-ended questions: elicit richer information and encourage reflection; closed-ended questions can supplement by clarifying specifics.

Physical Examination and Medical Considerations

  • Holistic assessment may include a physical exam when symptoms could reflect a medical condition (biological factors):

    • Depression can be a symptom of hypothyroidism; referral to psychiatry for medical evaluation and possible pharmacotherapy may be warranted.

    • Impaired decision-making or impulsivity may suggest neurological issues (e.g., brain tumor) rather than purely ADHD.

  • Behavioral observations in natural settings (children): play therapy or observation in school or during social events to understand feelings and behavior when verbal expression is limited.

Psychological Tests and Assessment Tools (Revisited)

  • In addition to interviews, clinicians use psychological tests to augment information and improve diagnostic accuracy.

  • Tools include:

    • Projective tests: Rorschach, TAT, sentence completion, draw-a-person, draw-a-tree.

    • Personality inventories (e.g., MMPI).

    • Depression inventories (e.g., Beck Depression Inventory).

  • These tools should be used with consideration of their reliability and validity to ensure a useful diagnosis.

DSM-5-TR: Structure, Scope, and Ethical Considerations

  • DSM-5-TR role:

    • Classifies disorders, not people; avoid labeling people with disorders (e.g., say “a person with schizophrenia” rather than “a schizophrenic”).

    • Descriptive but not explanatory; describes symptom patterns rather than origins or theoretical causes.

    • Evidence-based; anchored in research and clinical observation.

  • DSM-5-TR is both categorical and dimensional:

    • Categorical: determines whether a person meets the diagnostic criteria (present vs. not present).

    • Dimensional: assesses severity and the degree to which symptoms are present; captures gray areas between diagnoses.

  • Diagnostic criteria and elements:

    • Diagnostic criteria enumerate the symptoms and thresholds for a given disorder.

    • Subtypes: variations of a disorder to reflect different presentations (usually only one subtype applies at a time).

    • Specifiers: additional features such as onset, duration, severity, or particular symptom patterns (one diagnosis can have multiple specifiers).

  • Example interpretations:

    • Some clients may meet the minimum number of criteria for a disorder but vary in severity; specifiers help describe this variance.

    • Subtypes and specifiers enhance clinical description and treatment planning.

Practical and Ethical Implications in Assessment

  • Ethical language use:

    • Avoid stigmatizing terms; use person-first language (e.g., "a person with depression" rather than "a depressive").

  • Cultural considerations:

    • Assess behavior within cultural context to determine whether actions are culturally accepted or indicative of a disorder.

  • Clinical decision-making and progression:

    • Use a combination of interviews, tests, and observations to determine diagnosis.

    • Track progress over time to decide if treatment is beneficial or needs adjustment.

  • Communication with clients:

    • Explain findings and the rationale for questions to maintain rapport and trust.

    • Provide autonomy: clients may choose not to answer certain questions; respect such choices and explain why information is helpful.

Summary of Key Concepts

  • Clinical assessment is holistic and includes psychological, biological, and social factors.

  • Diagnosis is formed by DSM-5-TR criteria, observation, and multiple information sources.

  • Tools include interviews, case studies, projective tests, personality tests, and medical evaluations.

  • Core reliability and validity concepts (r{tt}, r{XY}, \, \alpha, C\text{ronbach}'s $\alpha) underpin the usefulness of assessment instruments.

  • The DSM-5-TR is descriptive, uses both categorical and dimensional approaches, and emphasizes person-first language and cultural sensitivity.

  • The clinical interview focuses on rapport, relevant questioning, and careful observation of mood, affect, sensorium, thought process, and content.

  • Open-ended questions encourage detailed responses; closed-ended questions provide specific information.

  • Ethical practice requires attention to stigma, culture, and informed consent; assessment should inform treatment planning and progress monitoring.

Quick Reference: Key Terminology and Formulas

  • Reliability:r{tt} = \text{corr}(X1, X_2)

  • Validity (criterion/concurrent):r_{XY} = \text{corr}(X, Y)

  • Standardization: uniform administration across participants to establish norms and enable generalization.

  • Dimensional vs. Categorical diagnosis: severity scores vs. yes/no diagnostic criteria; subtypes and specifiers refine descriptions.

  • Diagnostic rule (example):n \ge k where n is the number of criteria met and k is the minimum threshold for a diagnosis.

  • Cronbach's alpha (internal consistency) (example formula):\alpha = \frac{m}{m-1}\left(1 - \frac{\sum{i=1}^m \sigmai^2}{\sigmaT^2}\right) where m is the number of items, \sigmai^2 are item variances, and \sigma_T^2 is total test variance.

Note: If you have questions, please post them in the comment section, or bring them to our next session for discussion.