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Department of Applied PsychologySchool of Social SciencesBeaconhouse National University

October, 2008Hand out number: 3

Psychopathology I

Course code: PSY 205 / PSY 520Course instructor: Madiha Anas

Clinical Assessment and Diagnosis (DSM)

Clinical Assessment A procedure in which a clinician evaluates a person in terms of the psychological,

physical, and social factors that influence the individual's functioning. A - Clinical Interviews

Interview formats Mental Status Examination

B - Clinical Tests Characteristics of tests (standardization etc.) Projective Tests (Rorschach, TAT) Objective Tests (self-report inventories, Neuropsychological tests Psychophysiological tests

C - Clinical Observations------------------------------------------------------------------------------------------------------------

A - Clinical Interview most commonly used assessment tool for developing an understanding of

The client Nature of the client's current problems History and future aspirations

Family history covers major events in the lives of the client’s relatives

Personal history includes important events and relationships in the client’s life.

Unstructured interview involves a series of open-ended questions.

Structured interview consists of a standardized series of questions with predetermined wording and order.

Information sought through interviews: Reasons for being in treatment Symptoms Health status Family background Life history Expectations from treatment

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Limitations of clinical interviews Information pre-selected by client Distorted perception of client (due to health reasons) Interviewer’s subjectivity Different client ---- different interviewer

Mental Status Exam A term used by clinicians to describe what the client talks and thinks about and

how he/she acts. Clinicians use the mental status examination to assess a client's behavior and

functioning, with particular attention to the symptoms associated with psychological disturbance.

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B - Clinical TestsDevices used for gathering information about a few aspects of a person’s psychological

functioning, from which broader information about the person can be inferred.

1 - Characteristics of Tests Reliability

Consistency in measurement Validity

What the test measures and how well it does so Accuracy

Standardization A test should go through the Standardization process Has to be administered to a large group of subjects whose performance then

serves as a common standard, or norm, against which any individual’s score can be measured

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2 - Projective Tests Project aspects of personality onto ambiguous stimuli Have roots in psychoanalytic tradition 2a. Inkblot Tests - Rorschach Inkblot Tests

1911 – Herman Rorschach People with schizophrenia saw different images from people with anxiety

disorders 1921 - Set of ten inkblots

5 black and white 5 colored

Stages of assessment: Rorschach Inkblot Free association/Performance phase

Say it! Inquiry phase

Why did you say it? Testing the limits

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Others said it, do you agree? Rorschach Interpretation

Normal people- Whole designs- But focus on details in at least ½ inkblots Depressed people- Give few responses- Do not mention color at all Impulsive people- Respond intensely to color

2b. Thematic Apperception Test (TAT 1935 – Henry A. Murray

– 30 black and white pictures– Clinicians choose appropriate ones– CAT – children’s apperception test

2c. Sentence-Completion Test “I wish ___________________________” “My father ________________________” “A home is ________________________”

Sample #1: Assessment of a sentence-completion testFamilial Attitudes

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The client appears to be well-adjusted with her family and her perceptions about her parents appear to be secure. To the stimulus of “The happiest time”, the client responded with “sitting near the heater in winters with family” (Item # 2). Hence, it may be assumed her contact with the parental figures and even the siblings is a source of comfort for her. This assumption can further be substantiated by her response to the stimulus of “A mother”, to which the client said, “is the most reliable thing you can get on the face of the earth” (Item # 11). In addition, to “My father”, the client said, “is a soft, nice guy” (Item # 35). However, there is conflict regarding the death of parental figures. In two places, the client identified her greatest worry and fear as her parents “dying on” her (Items # 13 and 39).

2d. Drawings “Draw a person” (DTP) “HTP” (House-Tree Person) Evaluations of drawing

Quality and shape of drawing Solidity of the pencil line Location of the drawing on the paper Size of the figures Use of background Comments made by the respondent

Sample analysis of HTP“…The client’s need for intellectual achievement and physical achievement were noted with the drawing of the tree’s branches going upward and outward. The long and muscular arms of the human figures, which are out of proportion to the rest of the body, substantiate this need.

The omission of the male figure’s foot, as it appears to be extended in imagination off the bottom of the page reflects the client’s need for autonomy and achievement. The ground-line upon which the house rests and the absolute symmetry of the house are reflective of the client’s need for inner balance and security…”

3. Objective Tests

3a. Objective Tests

3b. Objective Personality Tests/Self-report inventories

– MMPI and MMPI-2

– Q-sort

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– BDI

3c. Objective Intelligence Tests

– Nature of intellectual functioning and IQ

3a. Objective Tests

– Test stimuli are minimally ambiguous

– Roots in empirical tradition

3b. Objective Personality Tests: MMPI

Original instrument developed in late 1930s

Most widely used and extensively researched of all psychological tests

Revised in 1989 – MMPI-2

MMPI CLINICAL SCALE DEVELOPMENT

Hathaway and McKinely, University of Minnesota

Selected a pool of over 1000 items from a variety of sources, psychology

tests, interviews, and their own clinical experience

Deleted duplicate items and eliminated those not useful for their purposes,

leaving a pool of 504 items.

MMPI-2

Original items obsolete, politically incorrect or offensive

Eliminated and/or reworded items, added items such as substance abuse

and marital relationships

Final version consists of 567 items

3b. Self-report inventory: Q- Sort

A method Carl Rogers employed to study the changes in client’s concept

of him/herself before during and after therapy.

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Assumption:

– At start of therapy there will be a large difference between clients

perception of what they are like (the self) and

– what they feel they should be or want to be.

Q-sort

Q-sort measures this difference.

– Client asked to sort 100 or so statements on cards (I am lazy, I feel guilty a

lot) into piles ranging along a continuum “very characteristic of me”…”not at all

characteristic of me.”

Correspondence between two sorts can be computed statistically.

Any discrepancy should decrease as client-centered therapy progresses.

3b. Self-report inventory: Beck Depression Inventory (BDI-II)

The Beck Depression Inventory is a self-report measure of the presence and

severity of depressive symptoms.

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Trait vs. State

A personality trait is a durable disposition to behave in a particular way in a variety of

situations. A state is a temporary condition that an individual is in at a particular point in

time, and can respond well to psychotherapy

3c. Intelligence Testing

Intelligence Quotient:

A method of quantifying performance on an intelligence test.

Originally:

Intelligence Testing

First intelligence test by Binet.

Revised as the Stanford-Binet.

Wechsler scales now more widely used.

Wechsler introduced deviation IQ to replace mental/chronological age ratio.

Psychological Testing and Neuropsychology

Neuropsychological Tests

– Assess broad range of skills and abilities

– Goal is to understand brain-behavior relations

– Used to evaluate a person’s assets and deficits

– Examples include

• Luria-Nebraska

• Halstead-Reitan Batteries

Clinical Test: Bender Visual-Motor Gestalt Test

= Mental AgeChronological Age X 100I.Q

.

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Neuroimaging and Brain Structure

Neuroimaging:

– Pictures of the Brain

• Allows examination of brain structure and function

– Imaging Brain Structure

• Computerized axial tomography (CAT or CT scan)

• Magnetic resonance imaging (MRI)

• Positron emission tomography (PET)

• Functional MRI (fMRI)

Advantages and Limitations

– Provide detailed information regarding brain function

– Procedures are expensive

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– Procedures have limited clinical utility (especially for therapist)

Diagnosis Diagnosis is an important step in the process of identifying and classifying

a clinical condition. It is a label that we attach to a set of symptoms that tend to occur together

and this set of symptoms is referred to as a syndrome. Classification

For centuries, humans have tried to organize the confusing array of psychological symptoms into a limited set of syndromes.

This set of syndromes and the rules for determining whether an individual’s symptoms are part of one of these syndromes are called a classification system.

One of the first classification systems for psychological symptoms was proposed by Hippocrates which was based on the categories like mania, melancholia, paranoia and epilepsy.

In 1939, the World Health Organization added mental disorders to the International List of Causes of Death which was later expanded to become the International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD).

Although this nomenclature was unanimously adopted but mental health section failed to be widely accepted. Ultimately in 1952, American Psychiatric Association published its own Diagnostic and Statistical Manual.

The Diagnostic and Statistical Manual of Mental Disorders

Brief History

DSM I was published in 1952 and had about 60 different disorders. DSM II was published in 1968. Both of these editions were strongly influenced

by the psychodynamic approach. In 1980, with DSM-III, the psychodynamic view was abandoned and the

biomedical model became the primary approach, introducing a clear distinction between normal and abnormal.

In 1987 the DSM-III-R appeared as a revision of DSM-III. Many criteria were changed.

In 1994, it evolved into DSM-IV. This work is currently in its fourth edition. Some new syndromes are presented for future inclusion. List of defense mechainsms is given for making it an additional axis.

The most recent version is the 'Text Revision' of the DSM-IV, also known as the DSM-IV-TR, published in 2000. The vast majority of the criteria for the diagoses were not changed from DSM-IV.

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http://en.wikipedia.org/wiki/2000



http://en.wikipedia.org/wiki/Biomedical_model


http://en.wikipedia.org/wiki/Psychodynamic_psychotherapy


Basic Features of DSM IV

A Multiaxial Approach

Today practitioners make use of a multiaxial classification system which is designed to summarize the diverse information relevant to an individual case rather than to provide a single label.By using this approach clinicians can describe an individual in terms of a set of clinically important factors, or axes. The first multiaxial system was presented in 1980 in DSM III.

A multiaxial system is primarily concerned with the description of clinical problems. Its categories take note of the etiology, or cause, of the disorder as well as the subjective experiences of the client and their assests and liabilities. DSM IV Provides information about the context in which abnormal behavior occurs as well as the description of the behavior.

The axis of DSM IV provide information about the biological, psychological, and social aspects of a person’s situation.

Axis I: Clinical Syndromes

Axis I reports most of the disorders or conditions in the classification system except personality disorders and mental retardation. When necessary to accurately describe a given individual, more than one disorder can be listed on Axis I. In such a case, the principal diagnosis is listed first.

Disorders listed on Axis IDisorders usually diagnosed in infancy, childhood, or adolescence:Attention –deficit hyperactivity disorderConduct and oppositional disorderSeparation anxiety disorderPervasive developmental disordersLearning disordersFeeding, tic, and elimination disordersDelirium, dementia,and amnestic or other cognotive disordersSubstance related disordersSchizophrenia and other psychotic disordersMood disordersAnxiety disordersSomatoform disordersFactitious disordersDissociative disordersSexual and gender anxiety disorders Eating disordersSleep disordersAdjustment disorders

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Other conditions that may be focus of clinical attention

Axis II: Developmental and Personality Disorders

Axis II deals with lifelong disorders that pervade every area of the person’s life. Personality disorders and mental retardation, both of which begin in childhood or adolescence and usually persist into adult life are reported on Axis II.

Disorders Listed on Axis IIMental RetardationPersonality disordersParanoid Personality disorderSchizoid Personality disorderSchizotypal Personality disorderAntisocial Personality disorderBoderline Personality disorderHistrionic Personality disorderNarcissistic Personality disorderAvoidant Personality disorderDependent Personality disorderObsessive-compulsive Personality disorder

Axis III: Physical Conditions

Axis III describes general medical conditions that may or may not directly related to the psychological problems of the individual.

Axis IV: Psychosocial Stressors

Axis IV describes psychosocial and environmental problems (eg housing problems, a negative life event, or family stress). In some cases, these problems may stem from adjustment difficulties created by the disorder.

Axis IV Psychosocial and Environmental Problems to NoteProblems with primary support groupProblems related to the social environmentEducational ProblemsOccupational Problems Housing Problems

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Economic ProblemsProblems with access to health care servicesProblems related to interaction with the legal system and to crime.

Axis V: Global Assessment Functioning

Axis V is a global assessment of the individual’s psychological, social, and occupational functioning. The clinician makes a global assessment of functioning on a rating scale from 1 to 100. Low ratings indicate that individuals pose dangers to themselves and to others. High ratings indicate good or superior functioning.

Code Axis V Global Assessment of Functioning100 Superior functioning in a wide range of areas90 Absence or minimal symptoms; good functioningin all areas.80 If symptoms present, they are transient and expectable reactions to psychosocial

stressors; only slight impairment in functioning.70 Some mild symptoms or difficulty in functioning.60 Moderate symptoms and difficulty in functioning.50 Serious symptoms and difficulty in functioning.40 Some impairement in reality testing or communication or major impairment in

several domains.30 Considerable delusions and hallucinations or serious impairment in

communication and judgment. 20 Some danger of hurting self or others or gross impairment in communication.10 Persistent danger of severely hurting self or others.

The Major Diagnostic Categories

This section provides us with a brief description of the major diagnostic categories of Axis I and II.

Disorders Usually First Diagnosed In Infancy, Childhood, Or Adolescence

Within this broad-ranging category are the intellectual, emotional, and physical disorders that usually begin in infancy, childhood, or adolescence. Disorders in this category include:

Attention deficit hyperactivity Disorder. Conduct and Oppositional Defiant. Pervasive Developmental Disorder. Learning Disorders.

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Separation Anxiety Disorder. Feeding, Tic and Elimination Disorder. Motor Skills Disorder. Communication Disorders.

Substance-Related Disorders

Conditions marked by adverse social, behavioral, psychological, and physiological effects caused by seeking or using one or more substances, for example alcohol, cocaine and amphetamines. Disorders in this category include:

Alcohol-Related Disorder. Amphetamine-Related Disorders. Caffeine-Related Disorders. Cannabis-Related Disorders. Cocaine-Related Disorders Hallucinogen-Related Disorders. Inhalant-Related Disorders. Nicotine-Related Disorders Opioid-Related Disorders. Phencyclidine-Related Disorders. Sedative-,Hypnotic-, or Anxiolytic-Related Disorders Other Substance-Related Disorders Schizophrenia and Other Psychotic Disorders

Significant distortion in the perception of the reality; impaired capacity to reason, speak and behave rationally and spontaneously with appropriate affect. Disorders in this category include:

Schizophrenia (Paranoid, Disorganized, Catatonic, Undifferentiated and Residual) Schizophreniform Disorder. Schizoaffective Disorder. Delusional Disorder Brief Psychotic Disorder Shared Psychotic Disorder Psychotic Disorder due To General Medical condition. Shared Psychotic Disorder Psychotic Disorder NOS

Mood DisordersAbnormal mood characterized by depression, mania, or both symptoms in an

alternating fashion. Disorders in this category include: Depressive Disorders(Major Depressive, Dysthymic Disorder, Depressive

Disorder NOS) Bipolar Disorders(Bipolar I, Bipolar II, Cyclothymic, Bipolar NOS) Other Mood Disorders(General Medical Condition, Substance Induced, NOS)

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Anxiety DisordersHigh levels os anxiety, tension and worry over extended periods of time that may

be accompanied by avoidance of feared situations, ritual acts or repetitive thoughts. Disorders in this category include:

Panic Disorders(with and without agoraphobia) Phobias.(Specific and Social) Obsessive-Compulsive Disorders. Generalized Anxiety Disorder. Post Traumatic Stress Disorder. Acute Stress Disorder. Substance Induced Anxiety Disorder Anxiety Disorder Due to General Medical Conditions. Anxiety Disorder NOS

Somatoform DisordersCharacterized by physical symptoms for which no medical cause can be found;

persistent worry abiout having a physical illness; exaggerated concern about minor or imagined physical defects in an otherwisw normally appearing person. This Category includes:

Somatization Disorder Conversion Disorder Pain Disorder Hypochondriasis Body Dysmorphic Disorder Somatoform Disorder NOS

Factitious DisordersPhysical or behavioral symptoms that are voluntarily produced by the individual,

apparently in order to play the role of patient. Disorder includes: Factitious Disorder Factitious Disorder NOS.

Dissociative DisordersTemporary, often sudden disruptions in the normal functions of Consciousness

and this category includes: Dissociative Amnesia Dissociative Fuge Dissociative Identity Disorder Delirium Dementia Dissociative Disorder NOS

Mental Disorders Due to General medical Conditions Not Elsewhere Classified

Catatonic Disorder due to a general medical condition

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Personality Change Due to a General Medical Condition Mental Disorders NOS to a General Medical Condition

Sexual And Gender Identity Disorders:Difficulty in the expression of normal sexuality. This category includes following

disorders: Sexual Desire Disorders Sexual Arousal Disorders. Orgasmic Disorders Sexual Pain Disorders Paraphilias Gender Identity Disorders. Other Sexual Disorders.

Eating Disorders This category is characterized by significant disturbances in eating patterns and

include: Anorexia Nervosa Bulimia Nervosa Eating Disorder NOS

Sleep DisordersDisturbances in sleep process e.g., difficulty in going to sleep , excessive day time

sleep and disturbances of sleep-wake cycle. This category includes: Dyssomnias Parasomnias Sleep Disorders Related to Another Mental Disorders Other Sleep Disorders.

Impulse-Control Disorders Not Elsewhere ClassifiedRepeated expression of impulsive acts that lead to physical or financial damage to

the individual or another person and often result in a sense of relief or release of tension. Disorders include:

Intermittent Explosive Disorder Kleptomania Pyromania Pathological Gambling Trichotillomania Impulse-Control Disorder NOS

Adjustment DisordersPersistent emotional or behavioralreactions in response to an identifiable stressor.

The reactions may be dominated by anxiety, depression or withdrawal. Disorders in this category includes:

Adjustment Disorder With Depressed Mood

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With Anxiety With Disturbance of Conduct

Personality DisordersPervasive and enduring patterns of maladaptive behavior and thought that begin

by early adulthood, often interfers with normal relationships and rerduce personal effectiveness. Subjective distress may or may not be present. Personality disorders specified in DSM IV include:

Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder Antisocial Personality Disorder Boderline Personality Disorder Histrionic Personality Disorder Narcissitic Personality Disorder Avoidant Personality Disorder Dependent Personality Disorder Obsessive-Compulsive Personality Disorder Personality Disorder NOS

Mental RetardationDisorders marked by delays in development in many areas. These disorders are

predominantly characterized by pervasive impaired intellectual functioning as well as specific learning problems. Retadation levels rane from mild to profound.

Other Conditions That may be focus of Clinical AttentionThios category comprises of conditions that are not regarded as menta disorders

but still may be a focus of attention or treatment. This category includes : Psychological factors Affecting a medical condition Problems related to Abuse or Neglect Relational ProblemsSome other conditions may include, Noncompliance with Treatment, Malingering,

Antisocial Behavior, Boderline Intellectual Functioning, Age related Cognitive Decline, Bereavement, Academic Problem, Occupational Problems, Identity Problems, Religious or Spiritual Problems, Acculturation Problem and Phase of Life Problems.

Issues And Possible Categories In Need Of Further Study

One of Dsm-IV’s appendix is entitled “Criteria Sets and Axes Provided for Further Study”. It contains several proposals for new categories that the DSM-IV task force considers promising but not sufficiently established by data as to merit inclusion on DSM-IV. By listing and describing these categories of disorders, the DSM task forces encourages professionals to consider whether a future DSM contains any of these syndromes or axes as official ways of classifying mental disorders. Possible new syndromes are:

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Caffeine Withdrawal Mixed Anxiety-Depressive Disorder Pervasive-Aggressive Personality Disorder Depressive Personality Disorder

References

American Psychiatrist Association: Diagnostic and Statistical Manual of Mental Disorders, Ed 4. American Psychiatric Association, Washington, 1994.

Carson, R.C, Butcher, J.N & Coleman, J.C. (1998) . Abnormal psychology and modern Life. USA: Scott Foresman and Company.

Davison, G.C & Neal, J.M. (1998). Abnormal Psychology (7th ed). New York: John Wiley & Sons, Inc.

Nolen-Hoeksema,S. (2001). Abnormal Psychology. New York: McGraw HillsCompanies, Inc.

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