Lecture 6

1. Lecture 6 Introduction to Assessment

2. Why do we Diagnose? To plan treatments: particularly for some disorders (e.g., depression) where enough research is available that can inform us which treatments work best for which types of individuals. To conduct research: allows psychologists to tests theories and treatments. As a means of communication between mental health professionals: a diagnosis is a helpful shorthand summary of behavior

3. How do we Diagnose a Disorder? At the most simple level, the clinician uses signs and symptoms. Signs are the observations that the clinician makes. Symptoms are the conditions that the client reports. Can you think of signs vs. symptoms of depression?

4. Important Issues in Diagnosis Diagnostic Reliability Refers to the extent with which clinicians agree on which signs and symptoms signal a specific disorder Diagnostic Validity Consists of the capacity of a diagnostic system to identify and predict disorders accurately Diagnostic Bias Consists of biases or prejudices by clinicians that affect the reliability and validity of the diagnostic process

5. Early History of the DSM 1946 representatives from the military as well as state and veteran hospitals met to draft the DSM 1952 DSM-I was published and contained approximately 100 diagnoses – very vague and unreliable 1968 DSM-II published – not much of an improvement

6. A Revolution: DSM-III 1970s Psychology moved toward better research methods on diagnoses and a completely new diagnostic system was put in place. 1980 The DSM-III was published It contained almost 300 diagnoses. Each diagnosis was organized around diagnostic criteria, which described signs and symptoms. Criteria were based much more on empirical data and the system was atheoretical DSM-III introduced the multi-axial system

7. The Current Diagnostic System 1987 Some minor revisions were made and the DSM-III-R was published 1994 After several years of data collection on a variety of disorders and several task forces of experts, the DSM-IV This most recent edition of the DSM contains over 300 diagnoses, and is more sensitive to gender, ethnic, and socioeconomic background than previous editions. Therefore, it is less likely to have diagnostic bias. Although the system is by no means perfect, researchers and clinicians have made a lot of progress towards a better diagnostic system.

8. The Multi-Axial System Axis I: Clinical disorders (e.g., major depression) Axis II: Personality disorders & Mental retardation (e.g., mild mental retardation) Axis III: General medical conditions (e.g., seizures) Axis IV: Psychosocial and environmental problems (e.g., family discord) Axis V: Global assessment of functioning (see handout)

9. Diagnostic Reliability likelihood that the same dx will be assigned to a pt who exhibits the same sx Types of reliability: indices of temporal stability: test-retest reliability -- index of consistency across time –Pearson’s r equivalent-forms reliability -- index of consistency across time that is NOT as vulnerable to a practice effect –Pearson’s r If you use a steel ruler, you can be reasonably sure that the ruler is consistent in measuring distances. However, a cloth tape measure would not provide the same consistency. If you use a steel ruler, you can be reasonably sure that the ruler is consistent in measuring distances. However, a cloth tape measure would not provide the same consistency.

10. Diagnostic reliability cont. Types of reliability cont. 2. indices of internal consistency split-half reliability -- test arbitrarily split in half and the halves are correlated -- Pearson’s r. internal consistency -- the average of all possible split-half reliabilities is computed -- Cronbach’s Alpha or Kuder-Richardson-20. interrater/interjudge reliability -- index of the degree of agreement between 2 or more raters or judges of a trait -- Pearsons r, intraclass correlation, or Kappa. Internal consistency = (do all the items appear to be measuring the same variable?): Internal consistency = (do all the items appear to be measuring the same variable?):

11. Validity A determination of whether or not the test measures what it claims to measure need a valid set of criteria for a disorder (e.g., depression) before you can start planning tx. Diagnostic validity is constrained by diagnostic reliability--reliability puts a ceiling on validity. (e.g., for tx planning, generating hypotheses about etiology) including something like panic attacks on the BDI would be a mistake, and it would cloud our view of what depression is. A valid test should be composed of questions relevant to what is being assessed, should correspond to theoretical constructs, and should accurately predict real-world performance in the relevant domain. (e.g., for tx planning, generating hypotheses about etiology) including something like panic attacks on the BDI would be a mistake, and it would cloud our view of what depression is. A valid test should be composed of questions relevant to what is being assessed, should correspond to theoretical constructs, and should accurately predict real-world performance in the relevant domain.

12. Types of validity Face validity: items on a test “look right”; there is a consensus that a measure represents a particular concept - according to common sense, some the questions on the test belong there. Content validity: the degree to which the content of a test is representative of the domain it’s supposed to cover. For example, if for the first midterm, we ask questions about the historical events surrounding the composition of Tchaikovsky’s 1812 Overture, you’d be upset because the question doesn’t make sense in a psychology class - but if we asked that same question for a test in 19th century music history, then it would have face validity. For example, if for the first midterm, we ask questions about the historical events surrounding the composition of Tchaikovsky’s 1812 Overture, you’d be upset because the question doesn’t make sense in a psychology class - but if we asked that same question for a test in 19th century music history, then it would have face validity.

13. Types of validity cont. Predictive validity: the degree to which test scores can predict behavior or tests scores that are observed at some point in the future. Concurrent validity: the degree to which test scores are correlated with a related, but independent, set of test scores or behaviors.

14. Types of validity Construct validity: the degree to which test scores are correlated with other measures or behaviors in a logical and theoretically consistent way determines the extent to which a measure represents concepts it should represent (convergent validity) and does not represent concepts it should not represent (discriminant validity).

15. The Normal Distribution A symmetrical frequency of scores; most scores are clustered around the mean and the number of scores above and below the mean is approximately the same Standard Deviation: a measure of the amount of variation among scores in a distribution. If most of the scores are clustered near the mean, the standard deviation will be small; when scores are spread out, the standard deviation will be large. In a normal distribution, approximately 68% of the scores fall within one standard deviation above or below the mean. Approximately 95% of the scores fall within two standard deviations above or below the mean.If most of the scores are clustered near the mean, the standard deviation will be small; when scores are spread out, the standard deviation will be large. In a normal distribution, approximately 68% of the scores fall within one standard deviation above or below the mean. Approximately 95% of the scores fall within two standard deviations above or below the mean.

16. Diagnostic instruments should have the following types of validity: content: all important aspects included in the diagnosis or scale?; unimportant ones not there? concurrent: a person who is severely depressed should receive a high score on the BDI; low scorer should not be depressed predictive: if the BDI is a good instrument, a high score at time one should predict future depressive episodes; however, this is not entirely true (complicated by the fact that depression runs many courses--some people only have a single episode)

17. Dimensional vs. Categorical assessment Categorical assessment: one means of distinguishing between common human experience and clinical disorder Differences are qualitative A CATEGORICAL SYSTEM PROVIDES US WITH DISCRETE ENTITIES (E.G., MELANCHOLIC DEPRESSION), WHICH THEN ALLOWS US TO PROCEED TO DISCUSSIONS OF ETIOLOGY AND TREATMENT; YOU NEED A DISORDER BEFORE YOU CAN TALK ABOUT HOW IT CAME TO BE AND HOW TO TREAT IT.

18. Advantages of Categorical Assessment: convenient way to summarize and convey important information about a person’s difficulties; communicate with other clinicians, researchers, insurance company’s etc

19. Disadvantages of Categorical Assessment loss of information: not all a person’s essential qualities fit within a diagnostic category: person with heart disease is not fully explained by heart disease; more important: use language “people with social phobia” not “social phobics” loss of information about severity: person gets MDD diagnosis; how depressed? just enough to have be down most of the day nearly every day or actively suicidal?; person doesn’t meet threshold and still is quite depressed

20. 2. Comorbidity: lots of overlap among disorders, especially personality disorders; in the National Comorbidity Study, 56% with one lifetime disorder had two or more disorders--led some mental health professionals to question the utility of a categorical system

21. comorbidity is not random - with some disorders (e.g., anxiety and depression) more often comorbid than others (e.g., anxiety and ASPD); comorbidity may be artifactual when the different diagnoses really address the same disorder; one disorder may develop as a secondary condition of another; two disorders (e.g., MDD and GAD) may share a common diathesis (e.g., genetic); those with comorbid conditions generally have a more chronic and complicated course, poorer prognosis, lessened response to treatment

22. 3. Heterogeneity: DSM diagnostic criteria often reflect multiple symptom dimensions (e.g., criteria for depression include sx related to mood, motivation, and affect); two people meeting criteria for a disorder may have few symptoms in common--e.g., is the person who has 5 sx of depression different from the person who has 12 sx? They may be given the same diagnostic label; A dimensional system would account for a different number of symptoms

23. mixed symptom presentations that fall between diagnostic boundaries given NOS diagnoses which are very common (e.g., PD NOS is the most common PD diagnosis) atypical and boundary diagnoses such as schizoaffective disorder present challenges to a categorical system

24. 4. Organizational Problems in the DSM-IV: Axis I vs. Axis II, validity of the distinction is questionable; examples include the separation of schizotypal PD from schizophrenia, avoidant PD from social phobia; no compelling reason for their separation; little support for separation based on information about etiology, structure of psychopathology, or temporal stability

25. 5. Implications for Change in the Taxonomy: number of diagnoses has grown in each DSM; comorbidity may signal incompatibility between psychopathology and categorical taxonomies; subtyping and adding new categories make the system more cumbersome

26. Dimensional Assessment: symptomatology assessed on a linear continuum of graded severity; dimensional system has the advantages of smaller set of dimensions vs. 300 diagnoses; dimensional and categorical systems are not a dichotomy--e.g., they can be combined in what the book calls the prototypical approach

27. Advantages of dimensional assessment Allows clinician to specify degree to which someone has a disorder (distinguishes between individuals who have 2 vs. 6 sx). Consistent with the complexity of sx patterns that are observed clinically More info is retained Allows for ID of sub-threshold patients

28. Disadvantages of dimensional assessment If normal behavior and psychopathology exist on a continuum, where do you draw the line?

29. Overview of the assessment process: Referral Assessment starts with a referral question... for example... “Why is Johnny having trouble in school?” “Why do I have so many problems with thinking?” “Why does Frankie beat up other kids and steal things?” “Is this mother capable of taking care of her kids?” Can be self-referred, brought in by a parent. or referred by an agency (e.g., the courts, DHS, school system, etc.).

30. Very important to thoroughly understand the referral question before the assessment proceeds so that time is not wasted on inappropriate procedures. Is the client interested in a recommendation for treatment? Do they wish to rule out certain hypotheses? E.G., adult ADHD cases.

31. Referral cont. This will change what tests you do and how you ultimately frame the report. - If person is not interested in treatment, I will make no reference to what scores or other information might mean towards treatment - If person is primarily interested in their ability to think, more testing will be done in that area. Many things to test: ability, personality, psychopathology

32. Referral cont. After getting a good understanding of the referral question.... A) Interviewing B) Psychological Testing C) Other Data Collection, e.g., old psych reports, school reports D) Drawing Conclusions/Report Writing As you can see, information is gathered from numerous sources if at all possible.As you can see, information is gathered from numerous sources if at all possible.

33. Psychological Assessment Tools A. Clinical Interviews Measures of Intelligence Neuropsychological Tests Tests of personality Behavioral Assessment/Observation

34. The job of a clinician is to piece it all together (biopsychosocial model), to add psychological test data to the other information and make a final report answering the referral question.

35. The Clinical Interview Types of interviews: structured vs. unstructured structured: a standard set of questions and follow-up probes that are asked in a specified sequence. Typically diagnostic interview. Reliable, thorough, but time consuming and hurt rapport? unstructured: clinician ask any questions that come to mind (but with goals). Efficient, natural (rapport), allows for clinician to confirm, clarify, explore hypotheses about the person as they emerge. But highly unreliable and vulnerable to clinician’s theoretical perspective or biases. Think you know what’s going on so ask question to confirm rather than disconfirm your biases. Mostly unstructured except in research or with inexperienced interviewers.Think you know what’s going on so ask question to confirm rather than disconfirm your biases. Mostly unstructured except in research or with inexperienced interviewers.

36. Intake-admission interview: Two purposes: to determine why the patient/client has come to the clinic. to determine whether the clinic’s facilities, policies, and focus of competence will meet the needs of the client.

37. Case-history interview: Clinician elicits a personal & social history of client that is as complete as possible. the main purpose is to provide a context within which to view the client and his/her presenting problem. range of material covered is broad -- often includes childhood, adulthood, educational, occupational, sexual, medical, parental, religious, and psychiatric history.

38. Mental status interview: Conducted to assess the presence of cognitive, emotional, or behavioral problems. the clinician looks assesses the following: general presentation (appearance, behavior, attitude) state of consciousness (alert, hyperalert, lethargic) attention &concentration speech (clarity, goal-directedness, language deficits) orientation (to person, place, or time: time, day, month, year) mood and affect thought problems Like a functional assessment, how bad off is the person. Useful in hospital settings, residential settings. Like a functional assessment, how bad off is the person. Useful in hospital settings, residential settings.

39. Diagnostic Interview Used to formulate a formal DSM-IV diagnostic picture of the client. Ex: SCID: Structured Clinical Interview for the DSM-IV. - Features standardized questions in standardized format/order, covering all DSM-IV diagnoses - Lengthy, but the interviewer doesn’t ask a question about every symptom of every disorder. rather, inclusion and exclusion criteria are used. Ex 2: DIS: Diagnostic Interview Schedule (DIS) - Structured interview designed to allow a lay person to make a DSM diagnosis. Mainly a research tool, large scale epidemiology. - No decisions are made often unstructured (i.e., free-form), but these interviews can be quite unreliable. Different people ask different questions today, many clinicians use structured interviews to diagnose clients these interviews are sometimes even administered by computers. - SCID developed after the DSM-III came out. Clear inclusion and exclusion criteria made a structured, predictable interview possible. Lengthy, but the interviewer doesn’t ask a question about every symptom of every disorder. rather, inclusion and exclusion criteria are used first to quickly determine if the person does or does not have a disorder. Starts with questions that have Yes or No reply, then asks person to elaborate so that clinical can judge severity of symptom. - Clinical can select parts of the SCID, substance abuse, personality dis. DIS: person follows a flow-chart of questions that can be read just as they are written. - Can be computerized Weakness: Unstructured quicker, and often have good idea what to ask. often unstructured (i.e., free-form), but these interviews can be quite unreliable. Different people ask different questions today, many clinicians use structured interviews to diagnose clients these interviews are sometimes even administered by computers. - SCID developed after the DSM-III came out. Clear inclusion and exclusion criteria made a structured, predictable interview possible. Lengthy, but the interviewer doesn’t ask a question about every symptom of every disorder. rather, inclusion and exclusion criteria are used first to quickly determine if the person does or does not have a disorder. Starts with questions that have Yes or No reply, then asks person to elaborate so that clinical can judge severity of symptom. - Clinical can select parts of the SCID, substance abuse, personality dis. DIS: person follows a flow-chart of questions that can be read just as they are written. - Can be computerized Weakness: Unstructured quicker, and often have good idea what to ask.

40. Crisis Interview/Assessment Goal of Crisis Clinic: Crisis management. Time: 10 minutes. Maybe one open-ended question “How can I help you today?”, the rest direct. Suicide: Assessing ‘dangerousness’. How to assess for suicide. Is there a plan? Time, place, note, method Are the means for committing suicide readily available? What to do Stay with person, have someone stay with person Contact relatives, close friends, clinician, anyone else. Bring to ER. Contract, promise not to do it Can call 911 Assessment: Referral Question still crucial as in all assessment. What does the person want? Identify what you can do for the person today. Just listen? Refer to counseling? Encourage them to go to hospital? Solicit contract to keep self safe, not kill self? Crises: Need food, shelter, chronically mentally ill ‘touching base’, parents whose kids ran away, kids who have ran away. Persons in mental health crises such as a spouse who just committed suicide, or a person who is planning to commit suicide. - Many people have thought about commiting suicide in a “what if” sort of way, or “I think about it but I would never ever do it”. - Many depressed people think about it an awful lot - Thinking ? Planning ? Attempting ? Completing. Hard to predict these things - Important to ask about it (assess), helpful to do and not at all harmful.Assessment: Referral Question still crucial as in all assessment. What does the person want? Identify what you can do for the person today. Just listen? Refer to counseling? Encourage them to go to hospital? Solicit contract to keep self safe, not kill self? Crises: Need food, shelter, chronically mentally ill ‘touching base’, parents whose kids ran away, kids who have ran away. Persons in mental health crises such as a spouse who just committed suicide, or a person who is planning to commit suicide. - Many people have thought about commiting suicide in a “what if” sort of way, or “I think about it but I would never ever do it”. - Many depressed people think about it an awful lot - Thinking ? Planning ? Attempting ? Completing. Hard to predict these things - Important to ask about it (assess), helpful to do and not at all harmful.

41. Elements of the Interview: the setting: a private, quiet, non-distracting place is ideal video- and audio-recording: should never be done without a client’s consent note-taking: often important in order to remember the details of the interview but too much can get in the way of rapport some clinics tape interviews for research, training purposes, or for diagnostic purposes. should strive for middle ground -- enough to remember the essential details, but not so much as to detract from your understanding of the client.some clinics tape interviews for research, training purposes, or for diagnostic purposes. should strive for middle ground -- enough to remember the essential details, but not so much as to detract from your understanding of the client.

42. Rapport refers to the quality and the nature of the clinician-client relationships things that can get in the way of rapport: clinician nervousness or anxiety, coldness or harshness appearance of clinician incompetence things that support good rapport: in general, attitudes of understanding, respect, acceptance, sincerity, and empathy good rapport is imperative for an efficient, profitable interview. good rapport is imperative for an efficient, profitable interview.

43. Communication beginning a session: can be helpful to start with some casual conversation to increase rapport and relaxation language: at client’s level, understandable silence: can be disturbing to clinicians look at the meaning and function in context listening: actively listen to and encode what client’s say failure to do this will decrease rapport

44. Questioning open-ended: gives the client responsibility for responding “Would you tell me about your time in college?” facilitative: encourages flow of conversation “Can you tell me a little more about that?” clarifying: encourages clarity and amplification “It sounds like you’re saying...?” confronting: challenges inconsistencies “before when you said . . . ?” direct: can be effective after rapport has been established “What did you do when your girlfriend dumped you?” Good to start with this, helps rapport, speaking has something like inertia, once they start harder to stop. Good to start with this, helps rapport, speaking has something like inertia, once they start harder to stop.

45. Interviewing exercise Pair up with an unknown classmate Conduct an interview Try out the styles of questioning Practice active listening Switch roles 5 minutes each Attempt to be keen observers of each others behaviors