Chapter 4: Clinical Assessment, Diagnosis, and Treatment

MOST countries outside the United States use what classification system for mental disorders? DSM-IV ICD DSM-5 CCMD

ICD

Henry is a freshman student who attended the university counseling center because he was feeling anxious. The psychologist, Dr. Walker, conducted a clinical assessment to gather information about Henry's background, including his family life, academic performance, current functioning, and psychiatric history. The type of information gathered in this assessment is considered: absolute. formative. nomothetic. idiographic.

idiographic

Which item would be LEAST likely to be included in a mental status exam? . "How are you doing these days?" "Are you upset about anything?" "What day is it today?" "Do you remember the picture I showed you?"

"How are you doing these days?"

Treatment: how might the client be helped?

- OVER THE COURSE of 10 months, Franco was treated for depression and related symptoms. He improved considerably during that time, as the following report describes: - Clearly, treatment helped Franco, and by its conclusion he was a happier, more functional person than the man who had first sought help 10 months earlier. But how did his therapist decide on the treatment program that proved to be so helpful?

is DSM-5 an effective classification system?

- A classification system, like an assessment method, is judged by its reliability and validity. Here reliability means that different clinicians are likely to agree on the diagnosis when they use the system to diagnose the same client. Early versions of the DSM were, at best, moderately reliable. In the early 1960s, for example, four clinicians, each relying on DSM-I, the first edition of the DSM, independently interviewed 153 patients (Beck et al., 1962). Only 54 percent of their diagnoses were in agreement. Because all four clinicians were experienced diagnosticians, their failure to agree suggested deficiencies in the classification system. - The framers of DSM-5 followed certain procedures in their development of the new manual to help ensure that DSM-5 would have greater reliability than the previous DSMs (Zachar et al., 2019; APA, 2013). For example, they conducted extensive reviews of research to pinpoint which categories in past DSMs had been too vague and unreliable. In addition, they gathered input from a wide range of experienced clinicians and researchers. They then developed a number of new diagnostic criteria and categories, expecting that the new criteria and categories would be reliable. Although some studies have indeed found enhanced reliability in DSM-5, others have not - Why are the reliability findings less than stellar? Critics point to faulty procedures used in the development of DSM-5. They suggest, for example, that the framers failed to run a sufficient number of field studies to test the merits of the new criteria and categories. In turn, DSM-5 may have retained several of the reliability problems found in past editions of the DSM. - The validity of a classification system is the accuracy of the information that its diagnostic categories provide. Categories are of most use to clinicians when they demonstrate predictive validity — that is, when they help predict future symptoms or events. A common symptom of major depressive disorder is either insomnia or excessive sleep. When clinicians give Franco a diagnosis of major depressive disorder, they expect that he may eventually develop sleep problems even if none are present now. In addition, they expect him to respond to treatments that are effective for other depressed persons. The more often such predictions are accurate, the greater a category's predictive validity. - DSM-5's framers tried to also ensure the validity of this edition by conducting extensive reviews of research and consulting with numerous clinical advisors (Zachar et al., 2019). As a result, according to several studies, its criteria and categories do appear to have stronger validity than those of the earlier versions of the DSM, but other research clarifies that the manual's validity is still less than desirable (Allsopp et al., 2019; Bakker, 2019). Among other validity issues, some of DSM-5's criteria and categories may reflect gender or racial bias. - Indeed, one very important organization has concluded that the validity of DSM-5 is lacking and is acting accordingly. The National Institute of Mental Health (NIMH), the world's largest funding agency for mental health research, no longer gives financial support to clinical studies that rely exclusively on DSM-5 criteria. And, more generally, the agency has developed its own neuroscience-focused classification tool, called the Research Domain Criteria (RDoC), which is now used as a primary classification guide by many researchers (NIMH, 2020a). Proceeding from the basic premise that mental disorders are best understood as a biological phenomenon, RDoC guides researchers to identify disorders as clusters of underlying biological variables rather than as syndromes of specific clinical symptoms (Cuncic, 2019). Critics of RDoC worry that it minimizes environmental and psychological factors at the expense of its focus on genetics, brain scans, cognitive neuroscience, and related areas of study. - Clearly, DSM-5 has raised concerns among many clinical practitioners and researchers (see InfoCentral). In addition to the possible reliability and validity limitations described above, critics argue that some of its criteria and categories are ill-advised and can, on occasion, lead to problems for clients. Some of the DSM-5 features that have raised significant concern are the following: - It calls for a diagnosis of "major depressive disorder" for some recently bereaved people, which many clinicians consider inappropriate (see Chapter 7). - It includes a category of "premenstrual dysphoric disorder" that many consider unfounded and sexist (see Chapter 7). - It includes a category of "somatic symptom disorder" that may, in some cases, be assigned to people who are understandably anxious about their serious medical problems (see Chapter 9). - It considers "gambling disorder" to be an addictive disorder in the same vein as substance use disorders, which some clinicians consider inappropriate (see Chapter 11). - It includes a category of "mild neurocognitive disorder" that may, in some cases, be misapplied to normal age-related forgetfulness (see Chapter 17).

Clinical Assessment: How and Why does the client behave abnormally?

- ASSESSMENT IS SIMPLY the collecting of relevant information in an effort to reach a conclusion. It goes on in every realm of life. We make assessments when we decide what cereal to buy or which presidential candidate to vote for. College admissions officers, who have to select the "best" of the students applying to their college, depend on academic records, recommendations, achievement test scores, essays, interviews, and application forms to help them decide. Employers, who have to predict which applicants are most likely to be effective workers, collect information from résumés, interviews, references, and perhaps on-the-job observations. - Clinical assessment is used to determine whether, how, and why a person is behaving abnormally and how that person may be helped. It also enables clinicians to evaluate people's progress after they have been in treatment for a while and decide whether the treatment should be changed. The hundreds of clinical assessment techniques and tools that have been developed fall into three categories: clinical interviews, tests, and observations. To be useful, these tools must be standardized and must have clear reliability and validity.

Characteristics of Assessment Tools

- All clinicians must follow the same procedures when they use a particular type of assessment tool. To standardize such a tool is to set up common steps to be followed whenever it is administered. Similarly, clinicians must standardize the way they interpret the results of an assessment tool in order to be able to understand what a particular score means. They may standardize the scores of a test, for example, by first administering it to a group of research participants whose performance will then serve as a common standard, or norm, against which later individual scores can be measured. The group that initially takes the test must be typical of the larger population for whom the test is intended. If an aggressiveness test meant for the public at large were standardized on a group of professional football players, for example, the resulting "norm" might turn out to be misleadingly high. - Reliability refers to the consistency of assessment measures. A good assessment tool will always yield similar results in the same situation (Frick, Barry, & Kamphaus, 2020; Miller & Lovler, 2019). An assessment tool has high test-retest reliability, one kind of reliability, if it yields similar results every time it is given to the same people. If a woman's responses on a particular test indicate that she is generally a heavy drinker, the test should produce a similar result when she takes it again a week later. To measure test-retest reliability, participants are tested on two occasions and the two scores are correlated. The higher the correlation (see Chapter 2), the greater the test's reliability. - An assessment tool shows high interrater (or interjudge) reliability, another kind of reliability, if different judges independently agree on how to score and interpret it. True-false and multiple-choice tests yield consistent scores no matter who evaluates them, but other tests require that the evaluator make a judgment. Consider a test that requires the person to draw a copy of a picture, which a judge then rates for accuracy. Different judges may give different ratings to the same drawing. - finally, an assessment tool must have validity: it must accurately measure what it is supposed to measure. Suppose a weight scale reads 12 pounds every time a 10-pound bag of sugar is placed on it. Although the scale is reliable because its readings are consistent, those readings are not valid, or accurate. - A given assessment tool may appear to be valid simply because it makes sense and seems reasonable. However, this sort of validity, called face validity, does not by itself mean that the instrument is trustworthy. A test for depression, for example, might include questions about how often a person cries. Because it makes sense that depressed people would cry, these test questions have face validity. It turns out, however, that many people cry a great deal for reasons other than depression, and some extremely depressed people do not cry at all. Thus an assessment tool should not be used unless it has high predictive validity or concurrent validity (Frick et al., 2020; Miller & Lovler, 2019). - Predictive validity is a tool's ability to predict future characteristics or behavior. Let's say that a test has been developed to identify elementary schoolchildren who are likely to take up cigarette smoking in high school. The test gathers information about the children's parents — their personal characteristics, smoking habits, and attitudes toward smoking — and on that basis identifies high-risk children. To establish the test's predictive validity, investigators could administer it to a group of elementary school students, wait until they were in high school, and then check to see which children actually did become smokers. - Concurrent validity is the degree to which the measures gathered from one tool agree with the measures gathered from other assessment techniques. Participants' scores on a new test designed to measure anxiety, for example, should correlate highly with their scores on other anxiety tests or with their behavior during clinical interviews. - Before any assessment technique can be fully useful, it must meet the requirements of standardization, reliability, and validity. No matter how insightful or clever a technique may be, clinicians cannot profitably use its results if those results are uninterpretable, inconsistent, or inaccurate. Unfortunately, more than a few clinical assessment tools fall short, suggesting that at least some clinical assessments, too, miss their mark.

What are the limitations of clinical interviews?

- Although interviews often produce valuable information about people, there are limits to what they can accomplish. One problem is that they sometimes lack validity, or accuracy. Individuals may intentionally mislead in order to present themselves in a positive light or to avoid discussing embarrassing topics. Or people may be unable to give an accurate report in their interviews. Individuals who suffer from depression, for example, take a negative view of themselves and may describe themselves as poor workers or inadequate parents when that isn't the case at all. - Interviewers too may make mistakes in judgments that slant the information they gather (Segal, June, & Pifer, 2019). They usually rely too heavily on first impressions, for example, and give too much weight to unfavorable information about a client. Interviewer biases, including gender, race, and age biases, may also influence the interviewers' interpretations of what a client says. - Interviews, particularly unstructured ones, may also lack reliability (Miller, 2019). People respond differently to different interviewers, providing, for example, less information to a cold interviewer than to a warm and supportive one. Similarly, a clinician's race, gender, age, and appearance may influence a client's responses - Because different clinicians can obtain different answers and draw different conclusions even when they ask the same questions of the same person, some researchers believe that interviewing should be discarded as a tool of clinical assessment. As you'll see, however, the two other kinds of clinical assessment methods also have serious limitations.

the effectiveness of treatment

- Altogether, hundreds of forms of therapy are currently practiced in the clinical field (Buchanan & Haslam, 2019; Grohol, 2019b). Naturally, the most important question to ask about each of them is whether it does what it is supposed to do. Does a particular treatment really help people overcome their psychological problems? On the surface, the question may seem simple. In fact, it is one of the most difficult questions for clinical researchers to answer. - The first problem is how to define "success." If, as Franco's therapist implies, he still has much progress to make at the conclusion of therapy, should his recovery be considered successful? The second problem is how to measure improvement. Should researchers give equal weight to the reports of clients, friends, relatives, therapists, and teachers? Should they use rating scales, inventories, therapy insights, observations, or some other measure? - Perhaps the biggest problem in determining the effectiveness of treatment is the variety and complexity of the treatments currently in use. People differ in their problems, personal styles, and motivations for therapy. Therapists differ in skill, experience, orientation, and personality. And therapies differ in theory, format, and setting. Because an individual's progress is influenced by all these factors and more, the findings of a particular study will not always apply to other clients and therapists - Proper research procedures address some of these problems. By using control groups, random assignment, matched research participants, and the like, clinicians can draw certain conclusions about various therapies (Comer & Bry, 2019). Even in studies that are well designed, however, the variety and complexity of treatment limit the conclusions that can be reached - Despite these issues and difficulties, the job of evaluating therapies must be done, and clinical researchers have plowed ahead with it. Investigators have, in fact, conducted thousands of therapy outcome studies, studies that measure and compare the effects of various treatments (see MindTech). The studies typically ask one of three questions: (1) Is therapy in general effective? (2) Are particular therapies generally effective? (3) Are particular therapies effective for particular problems?

personality inventories

- An alternative way to collect information about individuals is to ask them to assess themselves. Respondents to a personality inventory answer a wide range of questions about their behavior, beliefs, and feelings. In the typical personality inventory, individuals indicate whether each of a long list of statements applies to them. Clinicians then use the responses to draw conclusions about the person's personality and psychological functioning - By far the most widely used personality inventory is the Minnesota Multiphasic Personality Inventory (MMPI) (Sellbom, 2019). Two adult versions are available — the original test, published in 1945, and the MMPI-2, a 1989 revision that was itself revised in 2001. There is also a widely used, streamlined version of the inventory called the MMPI-2-Restructured Form and a special version of the test for adolescents, the MMPI-A. Still another version, MMPI-3, is scheduled for publication in the near future. - The MMPI consists of more than 500 self-statements, to be labeled "true," "false," or "cannot say." The statements cover issues ranging from physical concerns to mood, sexual behaviors, and social activities. Altogether the statements make up 10 clinical scales, on each of which an individual can score from 0 to 120. When people score above 70 on a scale, their functioning on that scale is considered deviant. When the 10 scale scores are considered side by side, a pattern called a profile takes shape, indicating the person's general personality. The 10 scales on the MMPI measure the following: - Hypochondriasis Items showing abnormal concern with bodily functions ("I have chest pains several times a week.") - Depression Items showing extreme pessimism and hopelessness ("I often feel hopeless about the future.") - Hysteria Items suggesting that the person may use physical or mental symptoms as a way of unconsciously avoiding conflicts and responsibilities ("My heart frequently pounds so hard I can feel it.") - Psychopathic deviate Items showing a repeated and gross disregard for social customs and an emotional shallowness ("My activities and interests are often criticized by others.") - Masculinity−femininity Items that are thought to separate male and female respondents ("I like to arrange flowers.") - Paranoia Items that show abnormal suspiciousness and delusions of grandeur or persecution ("There are evil people trying to influence my mind.") - Psychasthenia Items that show obsessions, compulsions, abnormal fears, and guilt and indecisiveness ("I save nearly everything I buy, even after I have no use for it.") - Schizophrenia Items that show bizarre or unusual thoughts or behavior ("Things around me do not seem real.") - Hypomania Items that show emotional excitement, overactivity, and flight of ideas ("At times I feel very 'high' or very 'low' for no apparent reason.") - Social introversion Items that show shyness, little interest in people, and insecurity ("I am easily embarrassed.") - The MMPI and other personality inventories have several advantages over projective tests (Frick et al., 2020; Williams et al., 2019). Because they are computerized or paper-and-pencil tests, they do not take much time to administer, and they are objectively scored. Most of them are standardized, so one person's scores can be compared with those of many others. Moreover, they often display greater test-retest reliability than projective tests. For example, people who take the MMPI a second time after a period of less than two weeks receive approximately the same scores - Personality inventories also appear to have more validity, or accuracy, than projective tests (Frick et al., 2020; Sellbom, 2019). However, they can hardly be considered highly valid. When clinicians have used these tests alone, they have not regularly been able to judge a respondent's personality accurately (Braxton et al., 2007). One problem is that the personality traits that the tests seek to measure cannot be examined directly. How can we fully know a person's character, emotions, and needs from self-reports alone? - Another problem is that despite the use of more diverse standardization groups by the MMPI-2 designers, this and other personality tests continue to have certain cultural limitations. Responses that indicate a psychological disorder in one culture may be normal responses in another. With this in mind, a new version of the MMPI, the MMPI-3, has recently been developed and is scheduled for publication in the near future, as noted earlier. Among other improvements and updates, the MMPI-3 will include significant changes in a number of items and scoring scales — changes based on the responses of standardization groups that align very closely with the recent U.S. Census findings of population diversity across the United States. - Despite such criticisms of the personality inventories, they continue to be popular. Research indicates that they can help clinicians learn about people's personal styles and disorders as long as they are used in combination with interviews or other assessment tools

Intelligence Tests

- An early definition of intelligence described it as "the capacity to judge well, to reason well, and to comprehend well" (Binet & Simon, 1916, p. 192). Because intelligence is an inferred quality rather than a specific physical process, it can be measured only indirectly. In 1905, French psychologist Alfred Binet and his associate Théodore Simon produced an intelligence test consisting of a series of tasks requiring people to use various verbal and nonverbal skills. The general score derived from this and later intelligence tests is termed an intelligence quotient (IQ). There are now more than 100 different intelligence tests available. As you will see in Chapter 16, intelligence tests play a key role in the diagnosis of intellectual disability and they can also help clinicians identify other problems (Holdnack, 2019). - Intelligence tests are among the most carefully produced of all clinical tests (Bowden et al., 2011). Because they have been standardized on large groups of people, clinicians have a good idea how each individual's score compares with the performance of the population at large. These tests have also shown very high reliability: people who repeat the same IQ test years later receive approximately the same score. Finally, the major IQ tests appear to have fairly high validity: children's IQ scores often correlate with their performance in school, for example. - Nevertheless, intelligence tests have some key shortcomings. Factors that have nothing to do with intelligence, such as low motivation or high anxiety, can greatly influence test performance (Ganuthula & Sinha, 2019). In addition, IQ tests may contain cultural biases in their language or tasks that place people of one background at an advantage over those of another background (Shuttleworth-Edwards, 2016). Similarly, members of some minority groups may have little experience with this kind of test, or they may be uncomfortable with test examiners of a majority ethnic background. At the same time, test examiners may hold biases about various minority groups that can have a negative impact on test administration or scoring. Any or all of these variables can lead to IQ scores that are inaccurately low for members of some racial and ethnic minority groups.

self monitoring

- As you saw earlier, personality and response inventories are tests in which individuals report their own behaviors, feelings, or cognitions. In a related assessment procedure, self-monitoring, people observe themselves and carefully record the frequency of certain behaviors, feelings, or thoughts as they occur over time. How frequently, for instance, does a drug user have an urge for drugs or a headache sufferer have a headache? Self-monitoring is especially useful in assessing behavior that occurs so infrequently that it is unlikely to be seen during other kinds of observations. It is also useful for behaviors that occur so frequently that any other method of observing them in detail would be impossible — for example, smoking, drinking, or other drug use. Finally, self-monitoring may be the only way to observe and measure private thoughts or perceptions. As you read in Chapter 3, more and more people in treatment are recording such private experiences on smartphone apps as they are occurring — observations that can be sent immediately to their therapists or collectively reported in their treatment sessions - Like all other clinical assessment procedures, however, self-monitoring has drawbacks (Bartels et al., 2019; Schat et al., 2017). Here too, validity is often a problem. People do not always manage or try to record their observations accurately. Furthermore, when people monitor themselves, they may change their behaviors unintentionally. Smokers, for example, often smoke fewer cigarettes than usual when they are monitoring themselves, and teachers give more positive and fewer negative comments to their students.

Diagnosis: Does the Clients syndrome match a known disorder?

- CLINICIANS USE THE INFORMATION from interviews, tests, and observations to construct an integrated picture of the factors that are causing and maintaining a client's disturbance, a construction sometimes known as a clinical picture (Frick et al., 2020; Miller & Lovler, 2019). The clinical picture also may be influenced to a degree by the clinician's theoretical orientation. The psychologist who worked with Franco held a cognitive-behavioral view of abnormality and so produced a picture that emphasized modeling and reinforcement principles and Franco's expectations, assumptions, and interpretations: - With the assessment data and clinical picture in hand, clinicians are ready to make a diagnosis (from the Greek word for "a discrimination") — that is, a determination that a person's psychological problems constitute a particular disorder. When clinicians decide, through diagnosis, that a client's pattern of dysfunction reflects a particular disorder, they are saying that the pattern is basically the same as one that has been displayed by many other people, has been investigated in a variety of studies, and perhaps has responded to particular forms of treatment. They can then apply what is generally known about the disorder to the particular individual they are trying to help. They can, for example, better predict the future course of the person's problem and the treatments that are likely to be helpful.

clinical tests

- Clinical tests are devices for gathering information about a few aspects of a person's psychological functioning from which broader information about the person can be inferred. On the surface, it may look easy to design an effective test. Websites, for example, regularly present new tests that supposedly tell us about our personalities, relationships, sex lives, reactions to stress, or ability to succeed. Such tests might sound convincing, but most of them lack reliability, validity, and standardization. That is, they do not yield consistent, accurate information or reveal where we stand in comparison with others. - More than 1,000 clinical tests are currently in use around the world (EBSCO, 2020). Clinicians use six kinds most often: projective tests, personality inventories, response inventories, psychophysiological tests, neuroimaging and neuropsychological tests, and intelligence tests.

additional information

- Clinicians also may include other useful information when making a diagnosis. They may, for example, indicate special psychosocial problems the client has. Franco's recent breakup with his girlfriend might be noted as relationship distress. Altogether, Franco might receive the following diagnosis: - Diagnosis: Major depressive disorder with anxious distress - Severity: Moderate - Additional information: Relationship distress - Each diagnosis also has a numerical code that clinicians must state — a code listed in ICD-11, the international classification system mentioned earlier. Thus if Franco were assigned the DSM-5 diagnosis indicated above, his clinician would also state a numerical code of F32.1 — the code corresponding to major depressive disorder, moderate severity.

drawings

- On the assumption that a drawing tells us something about its creator, clinicians often ask clients to draw human figures and talk about them (Parente, 2019). Evaluations of these drawings are based on the details and shape of the drawing, the solidity of the pencil line, the location of the drawing on the paper, the size of the figures, the features of the figures, the use of background, and the comments made by the respondent during the drawing task. In the Draw-a-Person (DAP) test, the most popular of the drawing tests, individuals are first told to draw "a person" and then are instructed to draw a person who is not the same sex.

psychophysiological tests

- Clinicians may also use psychophysiological tests, which measure physiological responses as possible indicators of psychological problems. This practice began three decades ago, after several studies suggested that states of anxiety are regularly accompanied by physiological changes, particularly increases in heart rate, body temperature, blood pressure, skin reactions (galvanic skin response), and muscle contractions. The measuring of physiological changes has since played a key role in the assessment of certain psychological disorders (Comer et al., 2020; Cooper-Vince et al., 2017). As you read in Chapter 3, for example, low-profile, wearable, mobile devices with sensors are increasingly being used to remotely monitor clients' psychophysiological activity throughout their day-to-day lives. - One psychophysiological test is the polygraph, popularly known as a lie detector (Cook & Mitschow, 2019). Electrodes attached to various parts of a person's body detect changes in breathing, perspiration, and heart rate while the person answers questions. The clinician observes these functions while the person answers "yes" to control questions — questions whose answers are known to be yes, such as "Are both your parents alive?" Then the clinician observes the same physiological functions while the person answers test questions, such as "Did you commit this robbery?" If breathing, perspiration, and heart rate suddenly increase, the person is suspected of lying. - Like other kinds of clinical tests, psychophysiological tests have their drawbacks (Cook & Mitschow, 2019). Many require expensive equipment that must be carefully tuned and maintained. In addition, psychophysiological measurements can be inaccurate and unreliable (see Trending). The laboratory equipment itself — elaborate and sometimes frightening — may arouse a participant's nervous system and thus change their physical responses. Physiological responses may also change when they are measured repeatedly in a single session. Galvanic skin responses, for example, often decrease during repeated testing

can diagnosis and labeling cause harm?

- Even with trustworthy assessment data and reliable and valid classification categories, clinicians will sometimes arrive at a wrong conclusion (Lazarus, 2019). Like all human beings, clinicians are flawed information processors. Studies show that they are overly influenced by information gathered early in the assessment process. In addition, they may pay too much attention to certain sources of information, such as a parent's report about a child, and too little to others, such as the child's point of view. Finally, their judgments can be distorted by any number of personal biases — gender, age, race, ethnicity, and socioeconomic status, to name just a few. Given the limitations of assessment tools, assessors, and classification systems, it is small wonder that studies sometimes uncover shocking errors in diagnosis, especially in hospitals - Beyond the potential for misdiagnosis, the very act of classifying people can lead to unintended results. As you read in Chapter 3, for example, many family-social theorists believe that diagnostic labels can become self-fulfilling prophecies. When people are diagnosed as mentally disturbed, they may be perceived that way and reacted to correspondingly. If others expect them to take on a sick role, they may begin to consider themselves sick as well and act that way. Furthermore, our society attaches a stigma to abnormality (Lim, Goh, & Chan, 2019). People labeled mentally ill may find it difficult to get a job, especially a position of responsibility, or to be welcomed into social relationships. Once a label has been applied, it may stick for a long time. - Because of these problems, some clinicians would like to do away with diagnoses. Others disagree. They believe we must simply work to increase what is known about psychological disorders and improve diagnostic techniques. They hold that classification and diagnosis are critical to understanding and treating people in distress.

categorical information

- First, the clinician must decide whether the person is displaying one of the hundreds of psychological disorders listed in the manual. Some of the most frequently diagnosed disorders are the anxiety disorders and depressive disorders. - Anxiety disorders People with anxiety disorders may experience general feelings of anxiety and worry (generalized anxiety disorder); fears of specific situations, objects, or activities (phobias); anxiety about social situations (social anxiety disorder); repeated outbreaks of panic (panic disorder); or anxiety about being separated from one's parents or from other key individuals (separation anxiety disorder). - Depressive disorders People with depressive disorders may experience an episode of extreme sadness and related symptoms (major depressive disorder), persistent and chronic sadness (persistent depressive disorder), or severe premenstrual sadness and related symptoms (premenstrual dysphoric disorder). - Although people may receive just one diagnosis from the DSM-5 list, they often receive more than one. Franco would likely receive a diagnosis of major depressive disorder. In addition, let's suppose the clinician judged that Franco's worries about his teachers' opinions of him and his later concerns that supervisors at work would discover his inadequate skills were really but two examples of a much broader, persistent pattern of excessive worry, concern, and avoidance. He might then receive an additional diagnosis of generalized anxiety disorder. When an individual receives two or more separate diagnoses, they are said to have comorbid disorders. Alternatively, if Franco's anxiety symptoms did not rise to the level of generalized anxiety disorder, his diagnosis of major depressive disorder might simply specify that he is experiencing some features of anxiety (major depressive disorder with anxious distress).

Treatment decisions

- Franco's therapist began, like all therapists, with assessment information and diagnostic decisions. Knowing the specific details and background of Franco's problem (idiographic data) and combining this individual information with broad information about the nature and treatment of depression (nomothetic data), the clinician arrived at a treatment plan for him. - Yet therapists may be influenced by additional factors when they make treatment decisions. Their treatment plans typically reflect their theoretical orientations and how they have learned to conduct therapy (Wedding & Corsini, 2019). As therapists apply a favored model in case after case, they become more and more familiar with its principles and treatment techniques and tend to use them in work with still other clients. - Current research may also play a role. Most clinicians say that they value research as a guide to practice (Castonguay, Constantino, & Beutler, 2019). However, not all of them actually read research articles, so they cannot be directly influenced by them (Tasca, 2020). In fact, according to surveys, therapists gather much of their information about the latest developments in the field from colleagues, professional newsletters, workshops, conferences, websites, books, and the like (Castonguay et al., 2019; Farrell & Shaw, 2018). Unfortunately, the accuracy and usefulness of these sources vary widely. - To help clinicians become more familiar with and apply research findings, there is an influential movement in North America, the United Kingdom, and elsewhere toward empirically supported, or evidence-based, treatment (Wiltsey-Stirman & Comer, 2019). Proponents of this movement have formed task forces that seek to identify which therapies have received clear research support for each disorder, to propose corresponding treatment guidelines, and to spread such information to clinicians. The movement has gained considerable momentum over the past few decades.

Rorschach Test

- INKBLOT - In 1911 Hermann Rorschach, a Swiss psychiatrist, experimented with the use of inkblots in his clinical work. He made thousands of blots by dropping ink on paper and then folding the paper in half to create a symmetrical but wholly accidental design, such as the one shown in Figure 4-1. Rorschach found that everyone saw images in these blots. In addition, the images a viewer saw seemed to correspond in important ways with their psychological condition. People diagnosed with schizophrenia, for example, tended to see images that differed from those described by people experiencing depression. - Rorschach selected 10 inkblots and published them in 1921 with instructions for their use in assessment. This set was called the Rorschach Psychodynamic Inkblot Test. Rorschach died just 8 months later, at the age of 37, but his work was continued by others, and his inkblots took their place among the most widely used projective tests of the twentieth century. - Clinicians administer the "Rorschach," as it is commonly called, by presenting one inkblot card at a time and asking respondents what they see, what the inkblot seems to be, or what it reminds them of. In the early years, Rorschach testers paid special attention to the themes and images that the inkblots brought to mind (Erdberg, 2019; Mihura et al., 2019). Testers now also pay attention to the style of the responses: Do the clients view the design as a whole or see specific details? Do they focus on the blots or on the white spaces between them?

what lies ahead?

- IT IS CLEAR from this chapter that proper diagnoses and effective treatments rest on the shoulders of accurate clinical assessment. Correspondingly, before the 1950s, assessment tools were a highly regarded part of clinical practice. However, as research in the 1960s and 1970s began to reveal that a number of the tools were inaccurate or inconsistent, many clinicians abandoned systematic assessment. Today, respect for assessment is on the rise once again. One reason for this renewal of interest is the drive by researchers for more rigorous tests to help them select appropriate participants for clinical studies. Still another factor is the growing belief in the field that brain-scanning techniques may soon offer assessment information about a wide range of psychological disorders. Along with heightened respect for assessment has come increased research in this area. - Ironically, just as clinicians and researchers are rediscovering systematic assessment, rising costs and economic factors may be conspiring to discourage the use of assessment tools. As you read in Chapter 1, insurance parity and treatment coverage, including assessment coverage, for people with psychological problems had been improving during the twenty-first century as a result of federal parity laws and the Affordable Care Act (see page 19). However, with different health care priorities now unfolding in Congress and in some states, many experts fear that clinical assessment will receive only limited insurance support in the future. Which forces will ultimately have a stronger influence on clinical assessment — promising research or economic pressure? Only time will tell.

dimensional information

- In addition to deciding what disorder a client is displaying, diagnosticians assess the current severity of the client's disorder — that is, how extensive are the symptoms and how much do they impair the client's functioning? For each disorder, DSM-5 suggests various rating scales for evaluating the severity of the disorder (APA, 2013). Using a depression rating scale, for example, Franco's therapist might assign a severity rating of moderate to the young man's depression, meaning his symptoms are quite frequent and disabling but not as extreme and incapacitating as those found in the most severe cases of depression. DSM-5 is the first edition of the DSM to consistently seek both categorical and dimensional information as equally important parts of the diagnosis, rather than categorical information alone

clinical observations

- In addition to interviewing and testing people, clinicians may systematically observe their behavior. In one technique, called naturalistic observation, clinicians observe clients in their everyday environments. In another, analog observation, they observe them in an artificial setting, such as a clinical office or laboratory. Finally, in self-monitoring, clients are instructed to observe themselves.

sentence completion test

- In the sentence-completion test, first developed in the 1920s (Payne, 1928), the test-taker completes a series of unfinished sentences, such as "I wish ..." or "My father ..." The test is considered a good springboard for discussion and a quick and easy way to pinpoint topics to explore

response inventories

- Like personality inventories, response inventories ask people to provide detailed information about themselves, but these tests focus on one specific area of functioning. For example, one such test may measure affect (emotion), another social skills, and still another cognitive processes. Clinicians can use the inventories to determine the role such factors play in a person's disorder. - Affective inventories measure the severity of such emotions as anxiety, depression, and anger. In one of the most widely used affective inventories, the Beck Depression Inventory, people rate their level of sadness and its effect on their functioning. For social skills inventories, used particularly by behavioral and family-social clinicians, respondents indicate how they would react in a variety of social situations. Cognitive inventories reveal a person's typical thoughts and assumptions and can help uncover counterproductive patterns of thinking. - Both the number of response inventories and the number of clinicians who use them have increased steadily in the past 35 years. At the same time, however, these inventories have major limitations. With the notable exceptions of the Beck Depression Inventory and a few others, many of the tests have not been subjected to careful standardization, reliability, and validity procedures (Reis et al., 2019). Often they are created as a need arises, without being tested for accuracy and consistency.

clinical interviews

- Most of us feel instinctively that the best way to get to know people is to meet with them face-to-face. Under these circumstances, we can see them react to what we do and say, observe as well as listen as they answer, and generally get a sense of who they are. A clinical interview is just such a face-to-face encounter (Segal, 2019). If during a clinical interview a man looks as happy as can be while describing his sadness over the recent death of his mother, the clinician may suspect that the man actually has conflicting emotions about this loss.

naturalistic and analog observations

- Naturalistic clinical observations usually take place in homes, schools, institutions such as hospitals and prisons, or community settings. Most of them focus on parent-child, sibling-sibling, or teacher-child interactions and on fearful, aggressive, or disruptive behavior (Frick et al., 2020; Moens et al., 2018). Often such observations are made by participant observers — key people in the client's environment — and reported to the clinician. - When naturalistic observations are not practical, clinicians may resort to analog observations, often aided by special equipment such as a video camera or one-way mirror. Analog observations often have focused on children interacting with their parents, married couples attempting to settle a disagreement, speech-anxious people giving a speech, and phobic people approaching an object they find frightening. - Although much can be learned from actually witnessing behavior, clinical observations have certain disadvantages. For one thing, they are not always reliable. It is possible for various clinicians who observe the same person to focus on different aspects of behavior, assess the person differently, and arrive at different conclusions (Cherry, 2019d; Meersand, 2011). Careful training of observers and the use of observer checklists can help reduce this problem. - Similarly, observers may make errors that affect the validity, or accuracy, of their observations (Frick et al., 2020; Wilson et al., 2010). The observer may suffer from overload and be unable to see or record all of the important behaviors and events. Or the observer may experience observer drift, a steady decline in accuracy as a result of fatigue or of a gradual unintentional change in the standards used when an observation continues for a long period of time. Another possible problem is observer bias — the observer's judgments may be influenced by information and expectations they already have about the person - A client's reactivity may also limit the validity of clinical observations; that is, their behavior may be affected by the very presence of the observer (Cherry, 2019d). If schoolchildren are aware that someone special is watching them, for example, they may change their usual classroom behavior, perhaps in the hope of creating a good impression. - Finally, clinical observations may lack cross-situational validity. A child who behaves aggressively in school is not necessarily aggressive at home or with friends after school. Because behavior is often specific to particular situations, observations in one setting cannot always be applied to other settings

are particular therapies effective for particular problems?

- People with different disorders may respond differently to the various forms of therapy (Cuijpers et al., 2019; Schweiger et al., 2019). In an oft-quoted statement, influential clinical theorist Gordon Paul said a half-century ago that the most appropriate question regarding the effectiveness of therapy may be "What specific treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances?" (Paul, 1967, p. 111). Researchers have investigated how effective particular therapies are at treating particular disorders, and they often have found sizable differences among the various therapies. Cognitive-behavioral therapies, for example, appear to be the most effective of all in treating phobias (Antony, 2019), whereas drug therapy seems to be the single most effective treatment for schizophrenia - As you read previously, studies also show that some clinical problems may respond better to combined approaches. Drug therapy is sometimes combined with certain forms of psychotherapy, for example, to treat depression or anxiety (Cuijpers et al., 2020). In fact, it is now common for clients to be seen by two therapists — one of them a psychopharmacologist, a psychiatrist who primarily prescribes medications, and the other a psychologist, social worker, or other therapist who conducts psychotherapy. Obviously, knowledge of how particular therapies fare with particular disorders can help therapists and clients alike make better decisions about treatment. We will keep returning to this issue as we examine the various disorders throughout the book.

projective tests

- Projective tests require that clients interpret vague stimuli, such as inkblots or ambiguous pictures, or follow open-ended instructions such as "Draw a person." Theoretically, when clues and instructions are so general, people will "project" aspects of their personality into the task. Projective tests are used primarily by psychodynamic clinicians to help assess the unconscious drives and conflicts they believe to be at the root of abnormal functioning (Fournier, 2018). The most widely used projective tests are the Rorschach test, the Thematic Apperception Test, sentence-completion tests, and drawings.

neuroimaging and neuropsychological test

- Some problems in personality or behavior are caused primarily by damage to the brain or by changes in brain activity. Head injuries, brain tumors, brain malfunctions, alcoholism, infections, and other disorders can all cause such impairment. If a psychological dysfunction is to be treated effectively, it is important to know whether its primary cause is a physical abnormality in the brain. - A number of techniques may help pinpoint brain abnormalities. Some procedures, such as brain surgery, biopsy, and X ray, have been used for many years. More recently, scientists have developed a number of neuroimaging, or brain-scanning, techniques, which are designed to measure brain structure and activity directly. One neuroimaging technique is the electroencephalogram (EEG), which records brain waves, the electrical activity that takes place within the brain as a result of neurons firing. In an EEG, electrodes placed on the scalp send brain-wave impulses to a machine that records them. Although an EEG is helpful in identifying the presence of electrical activity across different regions of the brain, it does not offer enough resolution to pinpoint precisely where in the brain this activity is occurring. - Other neuroimaging techniques offer higher resolution "pictures" of brain structure or brain activity that provide for more precise pinpointing of activity in the brain. These techniques include computerized axial tomography (CT scan or CAT scan), in which X rays of the brain's structure are taken at different angles and combined; positron emission tomography (PET scan), a computer-produced motion picture of chemical activity throughout the brain; and magnetic resonance imaging (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. - One version of the MRI, functional magnetic resonance imaging (fMRI), converts MRI pictures of brain structures into detailed pictures of neuron activity, thus offering a picture of the functioning brain. Partly because fMRI-produced images of brain functioning are so much clearer than PET scan images, the fMRI has generated enormous enthusiasm among brain researchers since it was first developed in 1990. - Though widely used, these techniques are sometimes unable to detect subtle brain abnormalities. Clinicians have therefore developed less direct but sometimes more revealing neuropsychological tests that measure cognitive, perceptual, and motor performances on certain tasks; clinicians interpret abnormal performances as an indicator of underlying brain problems (Allen & DeLuca, 2019). Brain damage is especially likely to affect visual perception, memory, and visual-motor coordination, so neuropsychological tests focus particularly on these areas. The famous Bender Visual-Motor Gestalt Test, for example, consists of nine cards, each displaying a simple geometrical design. Patients look at the designs one at a time and copy each one onto a piece of paper. Later they try to redraw the designs from memory. Notable errors in accuracy by individuals older than 12 are thought to reflect organic brain impairment. Clinicians often use a battery, or series, of neuropsychological tests, each targeting a specific skill area (Riegler, Guty, & Arnett, 2020; Allen & DeLuca, 2019).

Is therapy generally effective?

- Studies suggest that therapy often is more helpful than no treatment or than placebos. A pioneering review examined 375 controlled studies, covering a total of almost 25,000 people seen in a wide assortment of therapies (Smith, Glass, & Miller, 1980; Smith & Glass, 1977). The reviewers combined the findings of these studies by using a special statistical technique called meta-analysis. According to this analysis, the average person who received treatment was better off than 75 percent of the untreated persons. Other meta-analyses have found similar relationships between treatment and improvement - Some clinicians have concerned themselves with an important related question: Can therapy be harmful? A number of studies suggest that 3 to 15 percent of patients actually seem to get worse because of therapy (Hardy et al., 2019). Their symptoms may become more intense, or they may develop new ones, such as a sense of failure, guilt, reduced self-concept, or hopelessness, because of their inability to profit from therapy.

thematic apperception test

- The Thematic Apperception Test (TAT) is a pictorial projective test (Frick et al., 2020; Morgan & Murray, 1935). People who take the TAT are commonly shown 30 cards with black-and-white pictures of individuals in vague situations and are asked to make up a dramatic story about each card. They must tell what is happening in the picture, what led up to it, what the characters are feeling and thinking, and what the outcome of the situation will be. - Clinicians who use the TAT believe that people always identify with one of the characters on each card. The stories are thought to reflect the individuals' own circumstances, needs, and emotions. For example, a female client seems to be revealing her own feelings when telling this story about a TAT picture similar to the image shown in Figure 4-2:

DSM-5

- The effort to produce DSM-5 took more than a decade. After years of preliminary work by a DSM-5 task force and numerous work groups, whose goal was to develop a DSM that addressed the limitations of previous DSM editions, the new diagnostic and classification system was published in 2013. The categories and criteria of DSM-5 are featured throughout this textbook - DSM-5 lists more than 500 mental disorders (see Figure 4-3). Each entry describes the criteria for diagnosing the disorder and the key clinical features of the disorder. The system also describes features that are often but not always related to the disorder. The classification system is further accompanied by background information such as research findings; age, culture, or gender trends; and each disorder's prevalence, risk, course, complications, predisposing factors, and family patterns. - DSM-5 requires clinicians to provide both categorical and dimensional information as part of a proper diagnosis. Categorical information refers to the name of the distinct category (disorder) indicated by the client's symptoms. Dimensional information is a rating of how severe a client's symptoms are and how dysfunctional the client is across various dimensions of personality and behavior.

Conducting the interview

- The interview is often the first contact between client and clinician. Clinicians use it to collect detailed information about the person's problems and feelings, lifestyle and relationships, and other personal history. They may also ask about the person's expectations of therapy and motives for seeking it. The clinician who worked with Franco began with a face-to-face interview: - Beyond gathering basic background data of this kind, clinical interviewers give special attention to those topics they consider most important (Segal, 2019). Psychodynamic interviewers try to learn about the person's needs and memories of past events and relationships. Cognitive-behavioral interviewers try to identify information about the stimuli that trigger responses, consequences of the responses, and/or assumptions and interpretations that influence the person. Humanistic clinicians ask about the person's self-evaluation, self-concept, and values. Biological clinicians look for signs of biochemical or brain dysfunction. And sociocultural interviewers ask about the family, social, and cultural environments. - Interviews can be either unstructured or structured. In an unstructured interview, the clinician asks mostly open-ended questions, perhaps as simple as "Would you tell me about yourself?" The lack of structure allows the interviewer to follow leads and explore relevant topics that could not have been anticipated before the interview. - In a structured interview, clinicians ask prepared — mostly specific — questions. Sometimes they use a published interview schedule — a standard set of questions designed for all interviews. Many structured interviews include a mental status exam, a set of questions and observations that systematically evaluate the client's awareness, orientation with regard to time and place, attention span, memory, judgment and insight, thought content and processes, mood, and appearance (Renn & John, 2019). A structured format ensures that clinicians will cover the same kinds of important issues in all of their interviews and enables them to compare the responses of different individuals. - Although most clinical interviews have both unstructured and structured portions, many clinicians favor one kind over the other (Frick et al., 2020; Miller, 2019). Unstructured interviews typically appeal to psychodynamic and humanistic clinicians, while structured formats are widely used by cognitive-behavioral clinicians, who need to pinpoint behaviors or thinking processes that may underlie abnormal function.

Jerell is having a test today that is a neuroimaging technique that uses the magnetic property of certain hydrogen atoms in his brain to create a detailed picture of his brain's structure. Which test is he having? CAT scan EEG MRI PET scan

MRI

classification systems

- The principle behind diagnosis is straightforward. When certain symptoms occur together regularly — a cluster of symptoms is called a syndrome — and follow a particular course, clinicians agree that those symptoms make up a particular mental disorder. If people display this particular pattern of symptoms, diagnosticians assign them to that diagnostic category. A list of such categories, or disorders, with descriptions of the symptoms and guidelines for assigning individuals to the categories, is known as a classification system. - In 1883, Emil Kraepelin developed the first modern classification system for abnormal behavior (see Chapter 1). His categories formed the foundation for the Diagnostic and Statistical Manual of Mental Disorders (DSM), the classification system currently written by the American Psychiatric Association. The DSM is the most widely used classification system in North America. The content of the DSM has been changed significantly over time. The current edition, called DSM-5, was published in 2013. It features a number of changes from the previous editions. Most other countries rely primarily on a system called the International Classification of Diseases (ICD), developed by the World Health Organization, which lists both medical and psychological disorders. The newest edition of this system, ICD-11, was published in 2018. - Although there are some differences between the disorders listed in the DSM and ICD and in their descriptions of criteria for various disorders (the DSM's descriptions are more detailed), the numerical codes used by DSM-5 for all disorders match those used by the ICD-11, a matching that produces uniformity when clinicians fill out insurance reimbursement forms.

are particular therapies generally effective?

- The studies you have read about so far have lumped all therapies together to consider their general effectiveness. Many researchers, however, consider it wrong to treat all therapies alike. Some critics suggest that these studies are operating under a uniformity myth — a false belief that all therapies are equivalent despite differences in the therapists' training, experience, theoretical orientations, and personalities - Thus, an alternative approach examines the effectiveness of particular therapies. Most research of this kind shows each of the major forms of therapy to be superior to no treatment or to placebo treatment (APA, 2020b). A number of other studies have compared particular therapies with one another and found that no one form of therapy generally stands out over all others across the full spectrum of mental health problems - If different kinds of therapy have similar successes, might they have something in common? People in the rapprochement movement have tried to identify a set of common factors, or common strategies, that may run through all effective therapies, regardless of the clinicians' particular orientations (Cuijpers et al., 2019). Surveys of highly successful therapists suggest, for example, that most give feedback to clients, help clients focus on their own thoughts and behavior, pay attention to the way they and their clients are interacting, and try to promote self-mastery in their clients. In short, effective therapists of any type may practice more similarly than they preach.

what are the merits of projective tests?

- Until the 1950s, projective tests were the most commonly used method for assessing personality. In recent years, however, clinicians and researchers have relied on them largely to gain "supplementary" insights. One reason for this shift is that practitioners who follow the newer models have less use for the tests than psychodynamic clinicians do. Even more important, the tests have not consistently shown much reliability or validity. - In reliability studies, different clinicians have tended to score the same person's projective test quite differently. Similarly, in validity studies, when clinicians try to describe a client's personality and feelings on the basis of responses to projective tests, their conclusions often fail to match the self-report of the client, the view of the psychotherapist, or the picture gathered from an extensive case history - Another validity problem is that projective tests are sometimes biased against minority racial and ethnic groups (see Table 4-1). For example, people are supposed to identify with the characters in the TAT when they make up stories about them, yet no members of these minority groups are represented in the TAT pictures. In response to this problem, some clinicians have developed other TAT-like tests with African American or Hispanic figures

summing up

- the practitioners task: Clinical practitioners are interested primarily in gathering idiographic information about their clients. They seek an understanding of the specific nature and origins of a client's problems through clinical assessment and diagnosis - clinical assessment: To be useful, assessment tools must be standardized, reliable, and valid. Most clinical assessment methods fall into three general categories: clinical interviews, tests, and observations, each of which has certain merits and limitations. A clinical interview may be either unstructured or structured. Types of clinical tests include projective, personality, response, psychophysiological, neuroimaging, neuropsychological, and intelligence tests. Types of observation include naturalistic observation, analog observation, and self-monitoring. - diagnosis: After collecting assessment information, clinicians form a clinical picture and decide on a diagnosis. The diagnosis is chosen from a classification system. The system used most widely in North America is the Diagnostic and Statistical Manual of Mental Disorders (DSM). Most other countries rely primarily on a system called the International Classification of Diseases (ICD), which lists both medical and psychological disorders. The current editions of these classification systems are DSM-5 and ICD-11. Alternatively, many researchers use a more neuroscience-focused classification tool called RDoC - DSM-5: The most recent version of the DSM, known as DSM-5, lists more than 500 disorders. DSM-5 contains numerous additions and changes to the diagnostic categories, criteria, and organization found in past editions of the DSM. The reliability and validity of this revised diagnostic and classification system have been receiving considerable clinical review and, in some circles, criticism - dangers of diagnosis and labeling: Even with trustworthy assessment data and reliable and valid classification categories, clinicians will not always arrive at the correct conclusion. They are human and so fall prey to various biases, misconceptions, and expectations. Another problem related to diagnosis is the prejudice that labels arouse, which may be damaging to the person who is diagnosed - treatment: The treatment decisions of therapists may be influenced by assessment information, the diagnosis, the clinician's theoretical orientation and familiarity with research, and the state of knowledge in the field. Determining the effectiveness of treatment is difficult. Nevertheless, therapy outcome studies have led to three general conclusions: (1) people in therapy are usually better off than people with similar problems who receive no treatment, (2) the various therapies do not appear to differ dramatically in their general effectiveness, and (3) certain therapies or combinations of therapies do appear to be more effective than others for certain disorders. Some therapists currently advocate empirically supported treatment — the active identification, promotion, and teaching of those interventions that have received clear research support

Of people in the United States, _____ percent qualify for three or more DSM diagnoses during their lives. 17.3 10.4 53.6 18.7

17.3

In terms of test-retest reliability, people who take the MMPI a second time within _____ of taking it the first time are more likely to receive about the same score each time. 6 months 2 months 2 weeks 1 year

2 weeks

The most recent DSM was published in: 2011. 2009. 2008. 2013.

2013.

A number of studies suggest that from _____ percent of clients actually seem to get worse because of therapy. 50 to 60 3 to 15 35 to 45 20 to 30

3 to 15

Altogether, more than _____ forms of therapy are currently practiced in the clinical field. 100 1,000 200 400

400

Henry is a freshman student who attended the university counseling center because he was feeling anxious. The psychologist, Dr. Walker, conducted a clinical assessment to gather information about Henry's background, including his family life, academic performance, current functioning, and psychiatric history. The type of information gathered in this assessment is considered: idiographic. nomothetic. absolute. formative.

idiographic

To be useful, clinical assessment tools should have each of the following characteristics EXCEPT: valid. idiographic. reliable. standardized.

idiographic

Security personnel at airports, as well as clinical observers, may experience a steady decline in accuracy of observation—as a result of fatigue or as a result of a gradual, unintentional change in the standards used when an observation continues for a long period of time. This is known specifically as observer: reactivity bias overload drift.

drift

Oswaldo was diagnosed with hypochondriasis due to his anxiety about illness. According to the DSM-5, the name of his disorder has changed to: dementia. manic-depressive disorder. illness anxiety disorder. multiple personality disorder.

illness anxiety disorder.

To which type of information does idiographic refer? . performance individual past group

individual

In order to help clinicians become more familiar with and apply research findings, there is an ever-growing movement in the United States, the United Kingdom, and other parts of the world toward _____ treatment. experientially based empirically supported experimentally supported exponentially based

empirically supported

Which of the following factors contributes MOST to therapy outcomes? therapist factors specific therapy techniques client factors events in the client's life

events in the client's life

Jim is using the current and most widely used classification system for abnormal behavior in the United States. What is he using? DSM-III-R DSM-IV-TR DSM-IV DSM-5

DSM-5

Which of the following is an argument for doing away with diagnoses? Online feedback played too great a role in the development of DSM-5. Classification systems are expensive to develop. Diagnostic labels can be self-fulfilling prophecies. DSM-5 appears to have strong validity.

Diagnostic labels can be self-fulfilling prophecies.

He developed the first modern classification system for abnormal behavior in 1883. Josef Breuer Alfred Binet Sigmund Freud Emil Kraepelin

Emil Kraepelin

What is one of the problems of the mobile mental health movement—mHealth, as it is called? The movement has not attracted many software-producing firms. The majority of mental health apps can only be obtained with a prescription. Few apps have been researched and shown to be effective. Over time, mental health app users become heavily dependent on the apps.

Few apps have been researched and shown to be effective.

Which of the following is NOT a known drawback to polygraph testing? Some participants may be able to control the measured responses. There is low interrater reliability. Galvanic skin responses increase with repeated testing. The equipment is expensive.

Galvanic skin responses increase with repeated testing.

This neuroimaging technique provides a computer-produced motion picture of chemical activity throughout the brain. PET scan EEG CAT scan MRI

PET scan

Dr. Jones believed she had selected the best anxiety assessment for her study because it made sense and seemed reasonable. This is known as: face reliability. face validity. concurrent validity. predictive validity.

face validity

Dr. Barret believed she had selected the best assessment for her study into social media usage of employees at work, because the assessment made sense and seemed reasonable. This is known as face reliability. face validity. concurrent validity. predictive validity

face validity.

Martha is a psychodynamic therapist. She has just had her first session with a client who is suffering from schizophrenia and is convinced he died several months ago. What is the BEST approach Martha could take with this client? She could refer the client to a psychopharmacologist. She could ask the client to explain why he thinks he died. She could administer a Rorschach test or other projective test. She could encourage the client to think of himself as deserving of life.

She could refer the client to a psychopharmacologist.

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 low quantitative score. verbal and quantitative scores that are similar to one another. a low verbal score. a high quantitative score.

a low quantitative score.

This type of projective test involves people making up dramatic stories about 30 black-and-white pictures of individuals in vague situations. Rorschach test Differential Aptitude Test Draw a Person Test Thematic Apperception Test

Thematic Apperception Test

What is the relationship between the DSM-5 and the ICD-11? The DSM-5 has greater validity and reliability. The ICD-11 includes treatment recommendations. The ICD-11 goes into greater detail about each disorder. They generally agree and use the same numerical codes.

They generally agree and use the same numerical codes.

The National Institute of Mental Health (NIMH) refuses to fund clinical studies that rely exclusively on DSM-5 criteria for which of the following reasons? They have concluded that the DSM-5 lacks validity. They do not have money to fund DSM-5 research. They prefer the ICD to the DSM. They have concluded that the DSM-5 lacks reliability.

They have concluded that the DSM-5 lacks validity.

_____ means that a test measures what it is supposed to measure. Reliability Validity Interrater reliability Test-retest reliability

Validity

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 high quantitative score. a low verbal score. verbal and quantitative scores that are similar to one another. a low quantitative score.

a low quantitative score.

Steven attended therapy for six months. During the process, he became increasingly withdrawn, began to feel hopeless, and was more depressed than when he first presented for therapy. Steven represents the 5-10 percent of patients who: . do not enjoy therapy. have an inability to profit from therapy. profit from therapy. get better after they feel worse.

have an inability to profit from therapy.

Two months ago, Jennifer took a personality test that is highly reliable, and the results indicated that she was open and agreeable. When she takes the test again in the upcoming week, the results will likely indicate that she is: disagreeable. closed-minded. agreeable. not open to new experiences.

agreeable

Two months ago, Jennifer took a personality test that is highly reliable, and the results indicated that she was open and agreeable. When she takes the test again in the upcoming week, the results will likely indicate that she is: . agreeable. not open to new experiences. closed-minded. disagreeable

agreeable

Bresha is a humanistic clinician. She has scheduled a clinical interview with a new client where she will focus on asking questions about his self-concept and values. Which type of interview is Bresha MOST apt to use? an unstructured interview a structured interview a clinical test a standardized test

an unstructured interview

Brianna has scheduled an appointment with a new client. She will start with some open-ended questions and let the client's answers dictate where the conversation goes from there. What is the term for this kind of therapist-client interaction? . a structured interview an unstructured interview a personality inventory a projective test

an unstructured interview

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 polygraph. analog observation. naturalistic observation. self-monitoring.

analog observation.

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

anxiety disorder

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: . is overly protective of the mentally ill. knows that those with mental illness are incapable of working and are socially withdrawn. attaches a stigma to abnormality. supports those with mental illness.

attaches a stigma to abnormality.

Of the following, which technique is more promising and seems to be more accurate at detecting lies than polygraph tests are truth serum electric shocks solitary confinement brain scanning

brain scanning

When deciding which specific psychological disorder an individual is displaying, clinicians first use: dimensional information. insurance company guidelines. categorical information. parity health laws.

categorical information.

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? category of disorder and severity rating category of disorder and theory of abnormality severity rating and theory of abnormality severity rating and treatment plan

category of disorder and severity rating

A clinical picture is an integrated picture of factors that are: improving a client's disturbance. biological in nature. causing and maintaining a client's disturbance. diagnostic in nature.

causing and maintaining a client's disturbance.

A list of disorders, descriptions of symptoms, and guidelines for making appropriate diagnoses is known as a: classification system. syndrome cluster. diagnosis. symptom.

classification system.

Dr. Goldman used the DSM-5 to locate descriptions of anxiety disorder so that he could compare his client's symptoms to the syndrome profile outlined in the manual. His ability to figure out what condition his client had was due to this: theoretical model. classification system. treatment manual. therapy.

classification system.

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

clinical assessment

Dr. Terry, a psychiatrist, has been asked by Billie's primary care physician to perform a _____ as the physician has not been able to find a medical explanation for Billie's current complaints. research study treatment plan physical examination clinical assessment

clinical assessment

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 idiographic understanding syndrome diagnosis clinical picture

clinical picture

After several sessions, Dr. Zujan ascertained that Sylvia's fear of germs developed when she was young and watched her father struggle through a severe bout of pneumonia. During one session, Sylvia mentioned nightmares about being unable to breathe. Dr. Zujan believes that Sylvia's fear of germs is reinforced in her current profession as a health inspector. Dr. Zujan is putting together a set of integrated factors to explain Sylvia's disturbance. Such a construction is called a: classification system. set of naturalistic observations. clinical picture. projective assessment.

clinical picture.

An understanding of a particular individual is called: . holistic. universal. idiographic. nomothetic.

idiographic

After several sessions, Dr. Zujan ascertained that Sylvia's fear of germs developed when she was young and watched her father struggle through a severe bout of pneumonia. During one session, Sylvia mentioned nightmares about being unable to breathe. Dr. Zujan believes that Sylvia's fear of germs is reinforced in her current profession as a health inspector. Dr. Zujan is putting together a set of integrated factors to explain Sylvia's disturbance. Such a construction is called a: . projective assessment. clinical picture. set of naturalistic observations. classification system.

clinical picture.

Rodney has a fear of open spaces. His therapist is working with him and using the therapy that seems to be MOST effective for treating phobias. Which type of therapy is he using? client-centered cognitive-behavioral drug psychodynamic

cognitive-behavioral

Meta-analysis allows clinical researchers to better understand the effectiveness of similar treatments by: disseminating the findings of individual studies. combining the findings from treatment studies. reviewing the findings of studies. reporting the findings of individual studies.

combining the findings from treatment studies

Effective therapists know that strategies such as giving feedback to clients and trying to promote self-mastery help clients regardless of the therapist's theoretical orientation. These strategies are considered: common strategies. specific techniques. particular therapies. treatment modalities.

common strategies.

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: . termination. research. treatment. diagnosis.

diagnosis

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: diagnosis. treatment. termination. research.

diagnosis.

In a classic study where a clinical team was asked to reevaluate the records of 131 patients at a mental hospital in New York, conduct interviews with many of these persons, and arrive at a diagnosis for each one, there were notable differences between the clinician diagnoses and the diagnosis in the medical record, reflecting a problem in: diagnostic interrater reliability. interpretation. clinical conformity. test-retest reliability.

diagnostic interrater reliability.

Dr. Brown is a family clinician who has a client who meets DSM-5 criteria for schizophrenia. However, she is reluctant to diagnose the client due to her belief that: . the client will benefit from the diagnosis. diagnostic labels will not stick for a long time. the client will drop out of treatment. diagnostic labels can become self-fulfilling prophecies.

diagnostic labels can become self-fulfilling prophecies.

Unstructured interviews may lack reliability because people respond: in a way the clinician does not expect. differently to different interviewers. the same to different interviewers. the same to the same interviewer.

differently to different interviewers

Asking a person about the severity of her symptoms and asking how functional she is in her social and work lives are examples of: a diagnosis .a syndrome. dimensional information. categorical information.

dimensional information.

For the latest Alzheimer's research study, raters were trained to score the Alzheimer's Disease Assessment Scale the same way for all of the subtests in an effort to achieve: interrater reliability. standardization. test-retest reliability. test-retest validity.

interrater reliability

For the latest happiness research study, in an effort to achieve _____, evaluators were trained to score the Happiness Assessment Scale the same way for all of the subtests. interrater reliability standardization test-retest validity test-retest reliability

interrater reliability

The Research Domain Criteria (RDoC), which is expected to eventually be the primary tool used by researchers, is criticized for all of the following reasons EXCEPT that it: is more valid than the DSM-5. focuses excessively on genetics, brain scans, and cognitive neuroscience. minimizes psychological factors in its classifications. minimizes environmental factors in its classifications.

is more valid than the DSM-5.

The limitations of clinical interviews include all of the following EXCEPT the: lack of accuracy. lack of structure. lack of reliability. lack of validity.

lack of structure

A polygraph test is also known as a _____ test. Rorschach projective cognitive lie detector

lie detector

What technique is being used when researchers combine the findings of several outcome studies? clinical interview psychological survey structured interview meta-analysis

meta-analysis

Beatriz's grandmother has been showing signs of confusion and memory problems. The problems are not severe, but Beatriz recognizes that there is something different about her grandmother's mind. In the past, this would have been referred to as mild dementia, but with the changes in the DSM-5, her grandmother would probably be diagnosed with: . major neurocognitive disorder. mild neurocognitive disorder. somatic symptom disorder. delirium.

mild neurocognitive disorder.

Studies suggest that therapy often is _____ no treatment or the use of placebos. minimally helpful compared with equally as helpful as more helpful than less helpful than

more helpful than

The International Classification of Diseases (ICD) is used most often used by therapists in: . most countries in the world besides the United States. the United States and European Union countries. the European Union countries only. the United States.

most countries in the world besides the United States

Nadia is conducting a study with men in prison. She has trained a man who is an inmate to record the behavior and conversation topics of other men during breakfast, lunch, and dinner times. This clinical observation method is called: analog observation. a polygraph. self-monitoring. naturalistic observation.

naturalistic observation

These types of tests detect brain impairment by measuring a person's cognitive, perceptual, and motor performances. neuropsychological neurological projective intelligence

neuropsychological

When looking at a late-nineteenth-century photograph of the baseball team at the Homeopathic Asylum for the Insane in Middletown, New York, most observers assume the players are: . staff. patients. ill. happy.

patients

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: her symptoms can be classified as an acute disorder. her symptoms will continue to worsen over time. people sometimes receive more than one diagnosis. her symptoms defy classification.

people sometimes receive more than one diagnosis.

Joel is generally happy, but he worries about his financial situation to the point where it interferes with his day-to-day activities and relationships. Joel suffers from: generalized anxiety disorder. social anxiety disorder. panic disorder. phobia.

phobia

Cognitive-behavioral clinicians prefer structured to unstructured interviews because they need to: ask mostly open-ended questions to explore behaviors. be able to follow leads and explore unanticipated topics. explore unconscious wishes or impulses that influence abnormal behavior. pinpoint thinking or behaviors that underlie abnormal behavior.

pinpoint thinking or behaviors that underlie abnormal behavior

Proponents of empirically supported treatment have formed task forces in response to a problem among clinical practitioners. What is this problem? . practitioners' underuse of available research results difficulty making diagnoses as a step toward treatment underappreciation of research as a guide to practice lack of research that practitioners would find helpful

practitioners' underuse of available research results

The SAT college admissions test has a moderately high correlation with first-year college grade point average (GPA). This measure is considered to have: interrater reliability. predictive validity. face validity. concurrent validity.

predictive validity

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: propose new research for therapies with little empirical evidence. identify therapies that have received clear research support for each disorder. propose treatment guidelines for research-supported disorders. spread information about research-supported treatments to clinicians.

propose new research for therapies with little empirical evidence.

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: propose treatment guidelines for research-supported disorders. spread information about research-supported treatments to clinicians. identify therapies that have received clear research support for each disorder. propose new research for therapies with little empirical evidence.

propose new research for therapies with little empirical evidence.

A psychopharmacologist is a _____ who primarily prescribes medications. social worker nurse psychiatrist psychologist

psychiatrist

Lee is a psychopharmacologist, which is a _____ who primarily prescribes medications. psychiatrist psychologist social worker nurse

psychiatrist

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. . biological psychodynamic cognitive-behavioral sociocultural

psychodynamic

A psychiatrist that primarily prescribes medication is a ______. general practitioner nurse psychologist psychopharmacologist

psychopharmacologist

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. psychophysiological response inventory neuropsychological projective

psychophysiological

A(n) _____ has emerged in an effort to identify a set of common strategies that may run through the work of all effective therapists, regardless of the clinicians' particular orientation. uniformity myth rapprochement movement uniformity movement approachment movement

rapprochement movement

Gloria has been a therapist for many years, and she has developed a model for treatment of clients that she uses successfully in case after case. At times, she needs to learn about new techniques in her field. If she is a typical therapist, what is the LEAST likely way in which Gloria learns new techniques? . discussions with colleagues attending conferences reading and applying research findings reading newsletters

reading and applying research findings

Dr. Jenkins uses the Diagnostic Interview Scale, which is a published interview schedule, to help her diagnose posttraumatic stress disorder. Each of the following statements is true EXCEPT that the questions: are prepared. reflect the clinician's theoretical orientation. can be used with all clients. are mostly specific.

reflect the clinician's theoretical orientation

Dr. Jenkins uses the Diagnostic Interview Scale, which is a published interview schedule, to help her diagnose posttraumatic stress disorder. Each of the following statements is true EXCEPT that the questions: . are mostly specific. reflect the clinician's theoretical orientation. can be used with all clients. are prepared.

reflect the clinician's theoretical orientation

According to the text, research has shown that drug therapy approaches are most effective in treating: . schizophrenia. eating disorders. phobias. trauma.

schizophrenia

If a test is reliable, what kind of results can one expect when giving the test a second time under similar circumstances? different inaccurate dissimilar similar

similar

In these inventories, which are used particularly by behavioral and family-social clinicians, respondents are asked how they would react in a variety of situations. psychosocial social skills cognitive affective

social skills

In this process, a test is administered to a large group of people, whose performance then serves as a norm against which any individual's score can be measured. standardization validity validation reliability

standardization

A mental status exam is an example of a(n) _____ interview. open-ended free-flowing unstructured structured

structured

Cathy is conducting research into why people get tattoos. She is using an interview schedule. Which type of interview uses this? open-ended unstructured structured free-flowing

structured

A cluster of symptoms that usually occur together is known as a: classification system .symptom. diagnosis. syndrome.

syndrome

Meredith gave the NEO-III personality inventory to a representative sample on Monday and then gave the same test to the same participants under the same circumstances two weeks later. The scores on both administrations were highly correlated, establishing that the test had high _____ reliability. . interrater alternative forms test-retest internal consistency

test-retest

Dr. Chamberlain discovered that the latest anxiety instrument lacked _____; in other words, the results varied every time the test was given to the same people. interrater reliability test-retest reliability test-retest validity standardization

test-retest reliability

Dr. Kelvin administers a test for identifying PTSD to a large group of emergency first responders. When he repeats the test with the same group three months later, he finds that many individuals who scored as having PTSD in the first round do not do so the second time, and vice versa. This implies that the test lacks: . face validity. test-retest reliability. standardization. concurrence.

test-retest reliability

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: . the DSM-5. clinical psychologist training courses. the ICD. clinicians' personal biases.

the DSM-5.

Is therapy generally effective? Are particular therapies generally effective? Are particular therapies effective for particular problems? These three questions are asked in _____ outcome studies. experimental diagnostic therapy assessment

therapy

Clinical assessment techniques and tools fall into _____ categories two five three four

three

This is a FALSE belief that all therapies are equivalent despite differences in therapists' training, experience, theoretical orientations, and personalities. multiformity myth triformity myth conformity myth uniformity myth

uniformity myth