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Chapter Three: Clinical Assessment, Diagnosis and Research Methods

Rick Grieve, Ph.D. Department of Psychology Western Kentucky University

z Diagnostic and Statistical Manual, Fourth Edition, Text Revision z Taxonomy of behavioral, mental, and psychiatric disorders
{Atheoretical {Nomothetical

History of DSM-IV
z Based on work of Emil Kraepelin
{ Late 1800s to early 1900s

z DSM published in 1945 at 120 pages z DSM-IV-TR is the sixth revision at over 900 pages z While there are problems with DSM-IV, it still has had a great impact on the field. z DSM-IV has engendered a lot of research

z Definition of mental disorder:
{Clinically significant behavior or psychological syndrome or pattern which is associated with 1) present distress or 2) disability {Must be associated with a significantly increased risk of suffering, death, pain, disability, or loss of freedom {Must not be an expected response to a particular event

DSM-IV Disorders
z No sharp dividing line between one disorder and another z No sharp dividing line between having a disorder and not

General Features of DSM-IV

z Disorders grouped by shared clinical features z Descriptive and atheoretical approach z Systematic description of each disorder
{Essential and associated features {Age and gender variables {Course of the disorder {Impairment from disorder {complications

General Features of DSM-IV

{Predisposing factors {Prevalence rates {Familial pattern {Differential diagnoses

z Diagnostic Criteria

Diagnostic Criteria
z Diagnostic Criteria for 307.1 Anorexia Nervosa
{ A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).

Diagnostic Criteria
{B. Intense fear of gaining weight or becoming fat, even though underweight. {C. Disturbance in the way in which ones body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight. {D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen administration.)

z Axis I

Multi-Axial System
{Clinical syndromes and V-Codes

z Axis II
{Developmental and Personality Disorders

z Axis III
{Physical disorders

z Axis IV
{Severity of Psychosocial Stressors

z Axis V
{Global Assessment of Functioning

z Appendix A
{Controversial new disorders

z Appendix B
{Decision Trees

z Appendix C
{Glossary of Technical Terms

Cautions in Using DSM-IV

z Diagnosis is only the initial step z Need specialized training to use DSM-IV to make diagnosis z DSM-IV diagnosis is not necessarily a legal document z Need to consider norms of cultures outside of western culture

Criticisms of the DSM-IV

z Questionable reliability z Questionable validity z Implies homogeneity z Not enough flexibility z Implies qualitative difference rather than a quantitative continuum z Created by psychiatrists
{Too much medical model

Criticisms of the DSM-IV

z Child and adolescent disorders not adequately covered z Promotes cookie cutter approach z False impression about sophistication of understanding of mental disorders z Focuses on signs and symptoms to the exclusion of other facets of the disorder

How to Fix the DSM

z Emphasize environmental influences z Move from disorder to discorder

Why Use the DSM-IV

z Provides appropriate terminology z Common language among health service providers z 500-lb gorilla

z Changes to expect:
{Conform with ICD {Maybe change diagnosis {Maybe change theoretical orientation {Maybe increased emphasis on testing and assessment

New WHO Diagnostic Schematic

z Two parts, each with two components:
{Functioning and Disability
z Body functions and structures z Activities and Participation

{Contextual Factors
z Environmental Factors z Personal Factors

z Practice comes from medicine z Diagnosis is the assignment of a label that serves as shorthand for a cluster of related behavioral features which may or may not be related to demonstrable organic varibles z Psychological diagnoses arent yet to the level of medical diagnoses

Categorical versus Dimensional Conditions

60 Frequency 40 20 0 1 3 5 7 9 11 13 15 17 19 Scores

(A) Dichotomy There are only two levels, and all people are at one of those two levels

Categorical versus Dimensional Conditions

60 Frequency Frequency 40 20 0 1 3 5 7 9 11 13 15 17 19 Scores 60 40 20 0 1 3 5 7 9 11 13 15 17 19 Scores

(B) Dimensional Considerable variety across population

Categorical versus Dimensional Conditions

60 Frequency Frequency 40 20 0 1 3 5 7 9 11 13 15 17 19 Scores 60 40 20 0 1 3 5 7 9 11 13 15 17 19 Scores

60 Frequency 40 20 0 1 3 5 7 9 11 13 15 17 19 Scores

(C) Bimodal Distribution Variability within each category

Problems With/Abuses of Diagnostic Terms/Labels

z Self-fulfilling prophesy z Distorting diagnoses to get insurance coverage z Label viewed as immutable z Circular use of label z Disagreement of diagnoses z Inconsistency in the definition of the label

Problems With/Abuses of Diagnostic Terms/Labels

z Careless assignment of labels z Potentially harmful effects on a person z Political and economic exploitation z confidentiality

Positive Uses for Diagnostic Labels

z Facilitate communication z Prevent confusion z Classify clients for definition of treatment issues z Used in:
{Clinical communities {Insurance companies {Research {Statistical purposes

Methods of Assessment
z Clinical Interview
{Most widely used method {Covers:
z Identifying data z Presenting Problem z Psychosocial History z Psychiatric History z Medical History

Methods of Assessment
{Interview Formats:
Structured Increased reliability and validity Decreased flexibility May miss idiosyncratic info May increase defensiveness and resistance Allows comparability Used in research & clinical settings Computer admin & scoring Unstructured Decreased reliability and validity Increased flexibility Picks up idiosyncratic info Increases rapport Creates favorable changes

Methods of Assessment
{Interview vs. Conversation
z Interview designed to achieve certain goals z Interview may require discussion of unpleasant things z Interviewer directs and controls the flow of the interview z One-sided z Time Limited

Methods of Assessment
z Mental Status Exam
{Appearance and behavior {Thought processes {Mood and affect {Intellectual functioning {Sensorium

z Physical Exam

Methods of Assessment


Methods of Assessment
z Psychological Tests
{Used to evaluate reasonably stable traits such as intelligence and personality {Standardized {Two important concepts:
z Validity
The extent to which a test measures what it purports to measure

z Reliability
The extent to which a test obtains comparable scores across time

Three Concepts Determine the Value of Assessment

Methods of Assessment
{Intelligence Tests
z Stanford Binet z Wechsler Scale z Deviation IQ score

{Self-Report Personality Tests

z Objective tests z Empirically derived z MMPI-2 z MCMI


Methods of Assessment

Methods of Assessment

This inkblot resembles the ambiguous figures presented in the Rorschach test

Methods of Assessment
{Projective Personality Tests
z Rationale for these z Validity z Rorschach Inkblot Test z Thematic Apperception Test

{Neuropsychological Assessment
z Bender Visual Motor Gestalt Test z Halstead-Reitan Neuropsychological Battery z Luria Nebraska Battery


Methods of Assessment
{Behavioral Assessment
z Functional analysis z Self-monitoring

z Analogue Measures z Behavioral Rating Scales

{Cognitive Assessment {Physiological Measurement


Methods of Assessment
z EEG z EMG z Brain Imaging

Science and Abnormal Behavior

z Nature of Science
{ Way of knowing the world unlike normal everyday ways of knowing { Science values empiricism, objectivity, and replicability { Science demands rigorous standards of proof { Science is a means for testing hypotheses and theoretical claims { Science as a human enterprise is often value laden, not value free


Science and Abnormal Behavior

z Questions Driving a Science of Psychopathology
{What problems cause distress or impair functioning? {Why do people behave in unusual ways? {How can we help people behave in more adaptive ways?

Basic Components of Research

z Starts with a Hypothesis or Educated Guess
{ Not all hypotheses are testable { Hypotheses in science are formulated so that they are testable

z Research Design
{ A method to test hypotheses { Independent variable The variable that causes or influences behavior { Dependent variable The behavior influenced by the independent variable

Considerations in Research Design

z Balancing Internal vs. External Validity
{ Internal validity Confidence that effects are due to the independent variable { External validity Extent to which the findings are generalizable

z Ways to Increase Internal Validity by Minimizing Confounds

{ Use of control groups { Use of random assignment procedures { Use of analog models

z Relation Between Internal and External Validity


Statistical Methods and Clinical Meaningfulness

z Statistical Methods
{ Branch of mathematics { Helps to protect against biases in evaluating data

z Statistical vs. Clinical Significance

{ Statistical significance Means that the results are beyond chance or coincidence { Clinical significance Refers to whether the results are clinically meaningful { Statistical significance does not imply clinical meaningfulness

Statistical Methods and Clinical Meaningfulness

z Balancing Statistical vs. Clinical Significance
{Evaluate effect size {Evaluate social validity

z Generalizability and the Patient Uniformity Myth

Types of Research
z Case Study z Correlational Study z Experimental Study
{Single Case Experimental Design {Genetic Studies {Studying Behavior Across Time {Studying Behavior Across Cultures