Chapter 4: Clinical Assessment, Diagnosis, & Treatment

Rapprochement Movement

A movement to identify a set of common factors or common strategies that run through all successful therapies

Treatment decisions begin with

Beginning with assessment info and diagnostic decisions to determine a treatment plan Use a combo of idiographic and nomothetic info

drawings

Client draws human figures and talk about them Evaluation is based on details and shape of the drawing Draw-a-person (DAP) test - ppl draw a person and then draw a person who isn't the same sex

Main focus of clinical practitioners

Clinical practitioners' main focus when faced with new clients is to gather idiographic or individual info about them

Clinical Picture

Clinicians use info from interviews, tests, and observations to construct an integrated picture of the factors that are causing and maintaining a client's disturbance

sentence-completion test

Complete a series of unfinished sentences Ex: "I wish ____" or "My father ___" Springboard for discussion and easy way to pinpoint topics to explore

strengths & weaknesses of Psychophysiological tests

Plays a key role in assessment of certain psychological assessments Require expensive equipment that must be tuned and maintained Laboratory equipment can arouse a participant's nervous system Can be inaccurate and unreliable Physiological responses may change when they are measured repeatedly in a single session

Clinical Test: Personality Inventories

Designed to measure broad personality characteristics Focus on behaviors, beliefs, and feelings Usually based on self-reported responses Clinicians use the responses to draw conclusions about the person's personality & psychological functioning Most widely used: Minnesota Multiphasic Personality Inventory For adults: MMPI (original) or MMPI-2 (1989 revision) For adolescents: MMPI-A

Is DSM-5 an effective classification system?

Predictive validity is most used clinically DSM-5 has greater validity than any previous edition Validity is still a concern (Gender or racial bias) reliability is questioned (Faulty procedures in development; insufficient field studies)

polygraph

Electrodes attached to various parts of a person's body detect changes in breathing, perspiration, and heart rate while person answers questions Answers control questions - questions whose answers are known to be yes and then person answers test questions If persons breathing, perspiration, and heart rate suddenly increase, person is suspected of lying

weaknesses of response inventories

Have strong face validity Have been created as a need arises w/o being tested for accuracy or consistency Not all have been subjected to careful standardization, reliability and or validity procedures Beck Depression Inventory and a few others are exceptions

Analogue Observations

If naturalistic observation is impractical, analogue observations are used and conducted in artificial settings Video camera or one-way mirror Focus on children interacting w/ their parents, married couples attempting to settle a disagreement, speech-anxious ppl giving a speech, and phobic ppl approach an object they scared of

DSM faces competition from two other diagnostic systems

In North America and around the world, the DSM faces competition from two other diagnostic systems: 1. International classification of disorders (ICD) Developed by World Health Organization Lists medical and psychological disorders, used in most other countries 2. Research domain criteria (RDoC)

Clinical Tests: Intelligence Tests

Intelligence is an inferred quality rather than a specific physical process → can only be measured indirectly Designed to indirectly measure intellectual ability Typically consist of a series of tests assessing both verbal and nonverbal skills General score is an intelligence quotient (IQ) Represents the ratio of a person's "mental" age to his or her "chronological" age

DSM-5

Lists of categories, disorders, and symptom descriptions, with guidelines for assignment, background info such as research findings Focus on clusters of symptoms (syndromes) Requires clinicians to provide categorical and dimensional info as part of a proper diagnosis

___ studies are more accurate than polygraphs

MRI studies are more accurate than polygraphs but some variability and false positive issues exist

Clinical Tests: Psychophysiological tests

Measure physiological response as an indication of psychological problems Includes heart rate, blood pressure, body temp, galvanic skin response, and muscle contraction Anxiety is accompanied by physiological changes - increased heart rate Polygraph (lie detector)

affective inventories (beck depression inventory)

Measure the severity of emotions - anxiety, depression, and anger Beck Depression inventory - ppl rate their level of sadness and its effect on their functioning

MMPI

Minnesota Multiphasic Personality Inventory For adults: MMPI (original) or MMPI-2 (1989 revision) For adolescents: MMPI-A Scores range from 0 to 120 Above 70 = deviant Graphed to create a "profile" Consists of self-statements to be labeled "true", "false" or "can't say" Covers mood, physical concerns, sexual behaviors, social activities Consists of 10 clinical scales Hypochondriasis (HS) Depression (D) Conversion hysteria (Hy) Psychopathic deviate (PD) Masculinity-femininity (Mf) Paranoia (P) Psychasthenia (Pt) Schizophrenia (Sc) Hypomania (Ma) Social introversion (Si) When the 10 scale scores are considered → profile (a pattern) which indicates person's general personality

can diagnosis & labeling cause harm?

Misdiagnosis and reliance on clinical judgements are concerns Clinicians are flawed info processors like all humans Overly influenced by info gathered early in assessment process Labeling may be a stigma and lead to self-fulfilling prophecy Ppl diagnosed as mentally disturbed may be perceived that way and reacted to correspondingly

DSM

Most widely used classification system in north america Written by american psychiatric association Current edition = DSM-5 - published in 2013

Clinical Tests: Clinical Observations

Naturalistic, analog observations, self-monitoring

Clinical tests: Neuroimaging & Neurophysiological tests

Neurological tests directly assess brain function by directly assessing brain structure and activity Some problems in personality/behavior are caused primarily by damage to the brain or by changes in brain activity Head injuries, brain tumors, alcoholism ex: EEG, PET scans, CT/CAT scans, MRI, fMRI

disadvantages of clinical observations

Not always reliable - various clinicians observing same person can observe dif things Observers may make errors that affect validity or accuracy of their observations Observer drift - steady decline in accuracy as a result of fatigue Observer bias Client's reactivity May lack Cross-situational validity - child aggressive at school might not be aggressive at home

Are particular therapies generally more effective?

Research shows each of the major forms of therapy to be superior to no treatment or placebo treatment No one form of therapy generally stands out over all others

cognitive inventories

Reveal a person's typically thoughts and assumptions and can help uncover counterproductive patterns of thinking

Thematic Apperception Test (TAT)

Shown cards w/ black and white pics of individuals and asked to tell a story about what you see Pictorial projective test Ppl identify with one of the characters on each card The stories are thought to reflect the individuals' own circumstances, needs, and emotions

differences btw DSM and ICD

Some differences btw the disorders listed in DSM and ICD and in their descriptions of criteria for various disorders

strengths & weaknesses of intelligence test

Strengths Among the most carefully produced of all clinical tests Highly standardized on large groups of subjects High reliability and validity High validity: children's IQ scores often correlate with their performance in school Weaknesses Performance can be influenced by nonintelligence Low motivation, high anxiety Tests may contain cultural biases in language or tasks Members of minority groups may have less experience and be less comfortable with these types of tests, influencing their results

strengths and weaknesses of Personality inventories

Strengths Easier, cheaper, and faster to administer than projective tests Objectively scored and standardized Appear to have greater validity than projective tests Weaknesses Can't be considered highly valid Measured traits often can't be directly examined Tests don't allow for cultural differences in responses

Strengths and weaknesses of clinical tests

Strengths Until the 1950s, the projective tests were most commonly used tests for personality assessment Now used to gain supplementary information Limitations Reliability and validity not consistently shown May be biased against minority racial and ethnic groups No members of these minority groups are represented in TAT pictures

is therapy generally effective?

Studies suggest that therapy often is more helpful than no treatment or than placebos Avg person who received treatment was better off than 75% of untreated ppl Studies suggest 3-15% of patients actually seem to get worse because of therapy

RDoC

The NIMH has developed its own neuroscience-focused classification tool (RDoC) Used as a primary classification guide by many researchers RDoC Guides researchers to identify disorders as clusters of underlying biological variables rather than as syndromes of specific clinical symptoms

Rorschach test

The images a viewer saw seemed to correspond in ways with their psychological condition Ppl diagnosed with schizophrenia tended to see images that differed from things described by ppl experiencing depression When administered properly can yield valid results

other factors that influence treatment decisions

Therapist's theoretical orientation Current research; guide to practice General state of clinical knowledge: currently focuses on empirically supported/evidence-based treatment

problems with neuroimaging/brain scanning

These techniques are sometimes unable to detect subtle brain abnormalities Clinicians often use a battery of tests each targeting a specific skill area

social skills inventories

Used particularly by behavioral and family-social clinicians Respondents indicate how they would react in a variety of social situations

clinical tests

Used to gather info about psychological functioning from which broader info is inferred includes: Projective tests, personality inventories, response inventories, psychophysiological tests, neuroimaging and neuropsychological tests, and intelligence tests

Clinical tests: Response Inventories

Usually based on self-reported responses Focus on one specific area of functioning ex: affective inventories, social skills inventories, cognitive inventories

A client's inability to profit from therapy may cause him or her to experience all of the following symptoms EXCEPT: a) neurocognitive symptoms. b) guilt. c) a reduced self-concept. d) a sense of failure.

a

Dr. Reed, a psychiatrist, has been asked by Sally's primary care physician to perform a _____ since her present complaints have no organic basis. a) clinical assessment b) research study c) physical examination d) treatment plan

a

In addition to paying attention to the themes and images of clients' responses, Rorschach testers today also pay attention to: a) style of the responses b) the time they take to answer c) nonverbal cues d) body language

a

John took the SAT, a reliable college admissions test. He received a high score on the verbal section of the test and a low score on the quantitative section. He decided to take it again the following week without studying. On his next administration, he can expect: a) a low quantitative score. b) verbal and quantitative scores that are similar to one another. c) a low verbal score. d) a high quantitative score.

a

Michael is fearful of public speaking and often experiences panic when faced with these situations. What kind of disorder might he be diagnosed with? a) anxiety disorder b) medical disorder c) depressive disorder d) mental disorder

a

Sheila has joined a task force of the American Psychological Association in a new movement called empirically supported treatment. The task force has been charged with identifying psychotherapies with proven efficacy and will seek to do all of the following EXCEPT: a) propose new research for therapies with little empirical evidence. b) identify therapies that have received clear research support for each disorder. c) spread information about research-supported treatments to clinicians. d) propose treatment guidelines for research-supported disorders.

a

The ACT, SAT, GRE, and other standardized tests that one takes to get into college or graduate school should be able to provide a moderate level of _____ for admissions officers to use when selecting students for their programs. a) predictive validity b) re-test reliability c) face validity

a

Tiana is conducting a clinical assessment using methods that assess her client's personality and probe for unconscious conflicts. Sara is most likely a _____ clinician. a) psychodynamic b) behavioralist c) humanistic d) none of the above

a

Treatment plans are often influenced by the therapist's theoretical model because: a. therapists are more likely to use models they are familiar with across different clients. b. therapists use the models with research support. c. they represent idiographic data. d. they represent nomothetic data.

a

What has the rapprochement movement tried to identify that makes all therapies effective? a) common strategies b) treatment modalities c) specific techniques d) particular therapies

a

standardizing a technique involves a) setting up common steps to be followed whenever it is administered b) accurately measuring what it is supposed to measure c) yielding the same results every time

a

PET scans

a computer-produced motion picture of chemical activity throughout the brain

Diagnosis

a determination that a person's problems reflect a particular disorder

Classification systems

a list of disorders, along w/ descriptions of symptoms and guidelines for making appropriate diagnoses Using all available info, clinicians attempt to paint a cluster of symptoms (syndrome) and make a diagnosis A determination that a person's psychological problems constitute a particular disorder Based on an existing classification system ex: DSM

empirically supported

a movement in the clinical field that seeks to identify which therapies have received clear research support for each disorder, to develop corresponding treatment guidelines and to spread such info to clinicians

MRI

a procedure that uses the magnetic property of certain hydrogen atoms in the brain to create a detailed picture of the brain's structure

Dimensional info (DSM-5)

a rating of how severe a client's symptoms are and how dysfunctional the client is across various dimensions of personality Assessment of current client disorder severity Rating scales for each disorder Cross-cutting symptom measure Emotional distress-depression scale

Test-retest reliability & example

a test yields the same results every time it is given to the same ppl Higher the correlation, the greater the test's reliability ex: If a woman's response on a particular test indicates she is a heavy drinker the test should produce a similar result when she takes it again a week later

predictive validity

a tool's ability to predict future characteristics or behavior

face validity

appears to be valid because it makes sense and seems reasonable

clinicians use the procedures of __ and __ to offer treatment

assessment and diagnosis

Bob is a clinician who developed a new measure to diagnose attention-deficit/hyperactivity disorder (ADHD). The assessment is designed to assess problems with attention, impulsivity, and hyperactivity. He gave it to a representative sample of children ages 6-18. For what purpose did Bob use the sample? a) reliability b) standardization c) validity

b

Dr. Hollis conducted a clinical interview of his client and gave the client a number of response inventories to complete. He provided both categorical and dimensional information when diagnosing the client. What information did he likely provide? a) severity rating and theory of abnormality b) category of disorder and severity rating c) category of disorder and theory of abnormality d) severity rating and treatment plan

b

One reason why sociocultural theorists believe individuals diagnosed with a mental illness often have difficulty getting jobs and having meaningful social relationships is that society: a) supports those with mental illness. b) attaches a stigma to abnormality. c) knows that those with mental illness are incapable of working and are socially withdrawn. d) is overly protective of the mentally ill.

b

Rajesh was diagnosed by his psychologist as having generalized anxiety disorder. He moved to another city in the United States and was diagnosed with social anxiety disorder by his new psychologist. He was confused by this, so he sought another opinion with a third psychologist, who diagnosed him with agoraphobia. This is an example of the reliability problems of: a. the ICD. b. the DSM-5. c. clinical psychologist training courses. d. clinicians' personal biases.

b

Ricardo is a marriage therapist. One of the clinical observation techniques he uses to better understand couples' problems is videotaping. He installs cameras in the couples' home for a week and then analyzes the recordings. This type of clinical observation is called: a) naturalistic observation b) analogue observation

b

____ began to reveal a number of tools were inaccurate and thus clinicians abandoned systematic assessment a) 1950s b) 1960s-1970s c) 1980s-1990s d) 2000s

b

nomothetic data

broad info about the nature and treatment of the disorder

Elizabeth scored in the top 10 percent on her SAT college admissions test and made good grades all through high school. She took a newly developed college admissions test on two separate occasions and received the same failing score on it both times. The new test can be considered: a) reliable and valid b) unreliable and not valid c) reliable but not valid

c

Katie conducted a clinical assessment and compared the information she acquired on her client to the DSM-5. Based on the profile of symptoms and the description, she determined that her client has major depressive disorder. The process Katie engaged in is referred to as: a) research. b) termination. c) diagnosis. d) treatment.

c

The biggest problem in determining the effectiveness of treatment is the: a) homogeneity of treatments. b) variety and simplicity of treatments. c) variety and complexity of treatments. d) common operational definitions of treatment success.

c

Clinical Assessment tools

clinical interviews, clinical tests, and clinical observations

Are particular therapies effective for particular problems?

cognitive-behavioral therapies appear to be most effective of all in treating phobias drug therapies seems to be the single most effective treatment for schizophrenia some clinical problems may respond better to combined approaches (depression & anxiety: psychopharmacologist & psychologist/social worker)

Assessment

collection of relevant info to reach a conclusion; idiographic info

fMRI

converts MRI pics of brain structures into detailed pics of neuron activity thus offering a picture of the functioning brain Much clearer than PET scan images

Characteristics of Assessment tools are: a) standardization b) reliability c) validity d) all of the above

d

Clinicians use the information from interviews, tests, and observations to construct a(n) _____ of the factors that are causing and maintaining a client's disturbance. a) idiographic understanding b) syndrome c) diagnosis d) clinical picture

d

Janice is applying for a State Department job that will involve access to sensitive compartmented information (SCI). As part of her security clearance examination, a polygraph (lie detector test) will be administered. This is a _____ variety of clinical test. a) neuropsychological b) response inventory c) projective d) psychophysiological

d

Josefina conducted a comprehensive literature review and identified almost 100 controlled studies of humanistic clinical therapy used to treat depression. She combined and collectively analyzed the effects found in the individual studies. What Josefina did is called a(n): a) structured investigation. b) double-masked study. c) standardization. d) meta-analysis.

d

Kristoff was recently diagnosed with depression after reporting symptoms such as a loss of interest in activities, poor concentration, loss of appetite, difficulty sleeping, and fatigue. He was referred for therapy. At his first session, he took a test for depression composed of items about sadness and crying. His scores indicated that he was not depressed. Which statement is true about the test? a) It has low reliability. b) It accurately assesses depressive symptoms. c) It is trustworthy. d) It may only have face validity.

d

Ramone Walker is a licensed clinical social worker who consults with Dr. Robinson, a psychiatrist who is treating his client for depression using an antidepressant medication. Ramone sees his client once a week for therapy, whereas the psychiatrist follows up with him once a month. This collaboration is called a(n): a. experimental approach. b. placebo. c. collaborative approach. d. combined approach.

d

in order for an assessment tool to be useful it must be a) standardized b) have clear reliability c) have validity d) all of the above

d

janine has been experiencing persistent and chronic sadness for about two years. She also has feelings of anxiety and worry about a number of things. The DSM-5 is used to diagnose her. Her clinical presentation would suggest: a) her symptoms defy classification. b) her symptoms can be classified as an acute disorder. c) her symptoms will continue to worsen over time. d) people sometimes receive more than one diagnosis.

d

limitations of clinical interviews a) lack of validity or accuracy b) interviewer bias or mistakes in judgement c) lack of reliability d) all of the above

d

concurrent validity

degree to which the measures gathered from one tool agree with the measures gathered from other assessment techniques

Emil Kraepelin

developed the first classification system for abnormal behavior and his categories formed the foundation for the Diagnostic and Statistical Manual of Mental Disorders (DSM)

interrater (interjudge) reliability and example

different judges independently agree on how to score and interpret a particular tool ex:

clinical interviews

face-to-face encounter, basic background data gathered w/ specific theoretical focus, person's problems, feelings, lifestyle, relationship, personal history

An understanding of a particular individual is called:

idiographic

Idiographic

info about a particular individual as opposed to a larger population

Clinical Assessment

info used to determine whether, how, and why a person is behaving abnormally and how that person may be helped - idiographic - also enables clinicians to evaluate ppl's progress after they have been in treatment for a while

Neuroimaging/brain scanning

neurological tests that provide images of brain structure or activity:

Naturalistic observations

occur in everyday environments - homes, schools, institutions (hospitals, prisons) Focus on parent-child, sibling-sibling, teacher-child interactions & on fearful, aggressive, or disruptive behavior Observations are generally made by "participant observers" and reported to a clinician Participant observers = key ppl in client's environment Reliability and validity are a concern

Self-Monitoring

ppl observe themselves and carefully record the frequency of certain behaviors, feelings, or cognitions as they occur over time Useful in assessing infrequent or overly frequent behaviors that is unlikely to be seen during other kinds of observations Provides a means of measuring private thoughts or perceptions Validity is often a problem - ppl don't always manage or try to record their observations accurately

unstructured clinical interview

primarily open-ended Lack of structure allows the interviewer to follow leads and explore relevant topics that couldn't have been anticipated before the interview Typically psychodynamic and humanistic clinicians

structured clinical interviews

primarily specific Mental status exam - a set of interview questions and observations designed to reveal the degree and nature of a client's abnormal functioning Evaluates client's awareness, attention span, mood, memory Typically cognitive-behavioral clinicians

important role of clinical assessment

proper diagnoses and effective treatment rests on accurate clinical assessment

EEG

records brain waves, the electrical activity that takes place within the brain as a result of neurons firing Electrodes placed on scalp send brain-wave impulses to a machine that record them Doesn't pinpoint precisely where in the brain this activity occurs

Projective tests

require client interpretation of vague or ambiguous stimuli or open-ended instruction (ppl will "project" aspects of their personality); psychodynamic orientation ex: rorschach test, thematic appreciation test (TAT), sentence completion test, drawings

what factors may limit the use of assessment tools?

rising costs, health insurance concerns, economic factors

Therapy outcome studies

studies that measure and compare the effects of various treatments and typically ask 1 of 3 questions: 1. is therapy in general effective? 2. are particular therapies generally effective? 3. are particular therapies effective for particular problems?

validity

the accuracy of a tool's results An assessment tool must accurately measure what it is supposed to measure Three specific types: face validity, predictive validity, concurrent validity

Reliability

the consistency of an assessment measure A good tool will always yield the same results in the same situation Two main types: Test-retest reliability & Interrater (interjudge) reliability

Categorical info (DSM-5)

the name of the category (disorder) indicated by the client's symptoms ex: Anxiety disorders Generalized anxiety disorder, social anxiety disorder, panic disorder, separation anxiety disorder ex: Depressive disorders Major depressive disorder, persistent depressive disorder, premenstrual dysphoric disorder

Standardization

the process in which a test is administered to a large group of ppl whose performance then serves as a standard or norm against which any individual's score can be measured One must standardize administration, scoring, and interpretation

the combination of nomothetic and idiographic data is used to form a ___

treatment plan

comorbid disorders

when ppl receive 2 or more diagnoses

CT/CAT scans

x rays of the brain's structure are taken at dif angles & combined