ADIS, CAPS, and Clinical Significance

DSM-IV-TR Diagnosis & formulation

Diagnoses founded in behavioral descriptors Behavioral descriptors = behavioral excesses or deficits Through description of problem, it can be understood Through understanding, the problem can begin to be predicted to occur under certain circumstances and conditions (its lawful) Prediction lends itself to theoretical control, through the control of conditions that predict the problem behavior Therefore, diagnosis is the foundation for formulation and treatment Interviewing description or formulation of problem prediction intervention or control over problem

Open/closed-ended questions: Is the writing on the wall?

Unstructured interviewing validly obtains info.
What is obtained?

However, is it reliable?
reliability vs. validity

Structured interviewing has been established as both reliable and valid. What about therapeutic relationship effects?
Research re: Structure-driven therapists

Structured interviewing: Friend or foe?

Managed care: Limiting treatment to reduce costs (i.e., pencil-pushing/actuarial phenomenon). Accountability: Practicing within supported boundaries (e.g., empirically evaluated, supported, and evidence-based). Research-needs: Screening research subjects in / out. This stated / realized: Feelings about diagnosis? ( + / - )

Semi - & structured - interviewing: Benefits to the beginning interviewer & therapist
With experience structure Provides guidelines for what to do/say next Improved reliability provides variance due to chance Improved hits provide increased rates correct conceptualization, in turn leading to correct treatment

 decisions, decisions so many decisions, so little time what to do oh, what to do?!?!?!?

ADIS IV: Anxiety Disorders Interview Schedule for DSM-IV

Developed because psychosocial treatments for anxiety disorders have become highly specific SCID lacked depth and detail Again, systematic/detailed questioning necessary for a reliable differential diagnosis ADIS provides accurate diagnosis & functional analysis of problems/symptoms

Bennies of the ADIS

Asks some dichotomous questions (yes/no answers) Asks dimensional questions, which are important for diagnostic clarity, comparativeness, and as an outcome prognostic indicator Depth of detail assists clinical judgment more than others; nonetheless, all require not only familiarity with the respective instruments, but also of the DSM-IV since their decision-tree line of questions are based upon DSM descriptors and templates of disorders ADIS carries added advantage to researchers, especially for anxiety disorders

ADIS structure & form

Utilizes a semi-structured format, allowing for both a structured format for accuracy and reliability, but also for clarification Incorporates introduction section and summary sections Provide standard questions, which in the ADIS are bold Starts with dichotomous questions, and then funnels down to specific dimensional questions

ADIS structure
All modules start with the INITIAL INQUIRY questions, which are typically dichotomous in nature; This allows the interviewer to decide whether to proceed into the module At the end of the interview, the Hamilton scales (anxiety and depression) are administered Hamiltons are followed by a summary section, where the patient is asked what the primary issue is they want help with, as well as whether they feel like there was anything the interviewer missed and/or didnt ask about

Clinical significance and reliable change

Question: How do you gauge change? Better Q: What constitutes change?

How to measure change in psychotherapy

Change used to be artifact of clinical opinion
Tx thought or felt pt was better/worse Reliability non-existent & meaningless validity

No meaningful (statistical) legitimacy

Stronger change indicators demanded by MHC

Pure statistical change not useful either

What does 25% or 35% (responder) change mean? Without a sense of whether it matters, it is useless

More usable ways to monitor change needed

How compare with non-clinicals (normals)?

What is normal versus not?

Human functioning located on range of instrument of interest
Typically, hi score worse and low score better

Monitor score behavior over treatment and follow-up data points

Determine how patient compares to average joes

Teaching statistics to non-researchers

Lab couch gap
Chasm unacceptable

Average tx is stats aversive

Math anxiety rampant

Simple formulas better Illustrations critical Use tx own cases

Clinical decision-making and change indexes

Three easily definable/quantifiable C targets
1. Cross clinical threshold C dont stop until
a. a. b. a. Once passed C: Ok to begin to fade Introduce relapse prevention & generalization training Discuss importance of maintenance & mentor programs Offer booster sessions ( 3 in 6-12 months)

2. Within 1 std dev alright to begin termination/stop

3. At non-clinical (normal) mean, stop

4. Below normal --- just bennie

Reliable change: Dont consider fading, or discussions of termination until RCI 1.96

PTSD: Tracking progress for CS and RCI

Clinicals PTCI 1

C PTCI 1

A science of clinical psychology

Since 1600s the cornerstone of testability has served as foundation of scientific practice With increasing specialization/sophistication, people understand less and less about many techniques and underlying concepts Opposition to ESTs not on basis of evidence but by denial of efficacy of rational inquiry or insistence upon equal epistemic merit of alternatives Flight from- and rejection of- reason = danger

Is psychological science an oxymoron?

Subversion of reason and knowledge is leaving clinical psychology without a formal guiding, scientific compass/foundation
Snake oil gains acceptability & credibility

Derogation of science is old, and people are aligning away from logic, reason, and truth
Humanism gains, science loses

Under light of reason, superstition can be burned away to reveal a truly rational society
In such rational truth, charlatanism cannot hide

Beliefs, myths, and behaviors

Inactive / less active ingredients detract from optimal progress / outcome because detracts time afforded more active / effective pieces
Worst case, become equivalent of safety bhrs

Faith: A belief not supported by logical proof or material evidence

Equivalent to superstition, myth, and outright lies

Act in non-scientific/anti-scientific ways

Subordinates truth-seeking to subjective preference, inclination, expediency, or opportunistic consideration

Dodo-Bird Verdict (1936)

All treatments are effective, and equally so Everyone has won, and all must have prizes Should actively ingredient treatments be held as equivalents of everything from less active to sham treatments?

When a true genius appears in the world, you may know him by this sign, that the dunces are all in confederacy against him Jonathan Swift

Conclusions
Without understanding the issues that bring your patient to see you, you might misapply treatment.

Learn how to systematically and critically think about your patients. Dont be a Prof. Gallagher
Pendant