Anda di halaman 1dari 14

Chapter 3: Clinical Diagnosis and Assessment

TEXTBOOK NOTES OVERLAPPING WITH LECTURE

Diagnosing psychological disorders


o Diagnosis identification of nature of disorder, take symptoms and classify
them
1. Diagnose you
2. Administer series of tests to determine what is going on with you
o Made by assigning a patients symptoms to a specific classification
Classification of symptoms allows you to know more than what was
initially apparent
Diagnosis can suggest disorders possible causes, its course over time
and its possible treatments
Having a diagnosis might allow one to inter why they have developed
the disorder and whether the symptoms would be likely to shift in
frequency or intensity over time
Diagnosis indicates that certain types of treatment might be more
effective than other types of treatment
o Clinical assessment process of obtaining relevant information and making a
judgment about mental illness based on the information
Do assessment to figure out if you have disorder or if youre making
progress or if symptoms are worsening/lessening and to try and figure
out best course of treatment
Why diagnose?
o By categorizing, know more about patients symptoms and about how to treat
patient
o Provide type of shorthand that enables clinicians and researchers to use
small number of words than lengthy descriptions
o Allow clinicians and researchers to group certain abnormal thoughts,
feelings and behaviors into unique constellations
o Particular diagnosis may convey info useful for both clinicians and
researchers about etiology of disorder, its course, and indications for its
treatments
o Diagnosis can indicate that an individual is in need of attention (including
treatment, support, or benefits)
Cautionary note about diagnosis
o Diagnostic bias systematic error in diagnosis
Cause groups of people to receive a particular diagnosis
disproportionately, on the basis of an unrelated factor such as sex,
race, or age
Ex: In the USA, black patients more likely than white patients to be
diagnosed with schizophrenia instead of a mood disorder
Ex: women more likely than men to be diagnosed with anxiety
disorder

2 completely different patients exhibit completely different symptoms but along


same categories of symptoms
o Patients A and B have depression
*Cannot use mental illness as an out out of responsibility

ONLY LECTURE NOTES TUESDAY SEPTEMBER 30TH


Ted Talk Jon Ronson: Strange Answers to the Psychopath Test
URL:
http://www.ted.com/talks/jon_ronson_strange_answers_to_the_psychopath_test/transcript?langu
age=en

Being Sane in Insane Places Rosenhans study


o Based on assumptions on how we diagnose/categorize people
o Diagnosing someone could be incorrect or harmful
o Diagnoses are in the minds of the observers
o Diagnoses dont always reflect actual characteristics of person
o Rosenhan Study
8 undergraduate students who faked mental illness (auditory hallucination)
and admitted themselves in mental institute
Hearing voices empty hollow thud
Voices of the same sex
Covert participant observation person doesnt know observer is
observing you
As soon as they got admitted, they stopped pretending and they said they
were normal
They had to convince staff that they were now healthy
Though they acted normally, they were still considered as patients by
nurses
Other patients knew they werent insane
All of them released as schizophrenic in remission (forever schizophrenic,
on break but will have one sometime down the line) mental illness is
perceived as irreversible condition creating lifelong stigma than curable
illness
Why were they not found out?
Tendency for doctors to not want to assume someone is well when
they are not
Doctors play conservatively but when you slap label on someone,
it sticks
Is it possible to reverse diagnosis once someone has diagnosis? his
research questions
In the next 3 months, some patients will be faking psychiatric
illness
I want you (nurses) to rate whether they are faking or not on scale
of 1-10

193 people came through but NONE of the people were fake
patients
o 41 identified as fake
o Cant tell sane apart from insane
o Once you get diagnosis, you are attached to that diagnosis
o Our diagnosis system is subject to a lot of error and
therefore, diagnostic process cannot be too reliable
Labels are sticky
Staff fearful, hostile, suspicious towards the patients
Condescension
Walked away from patient
Did not answer patients questions
Privacy minimal going to bathroom even
Freedom of movement restricted stay where I can see you
Personal hygiene observed
Verbal/physical/sexual abuse
Talking about patients as if they arent present

TEXTBOOK NOTES OVERLAPPING WITH LECTURE

Reliability and validity in classification system


o Reliable property of classification systems (or measures) that consistently
produce the same results
Would every clinician diagnose her as having the same disorder? If
so, then classification system would be deemed reliable
If there were significant differences of opinion about her diagnosis
among the clinicians, the classification system they used probably is
not reliable
o Problems concerning reliability in diagnosis can occur when
Criteria for disorders are unclear and require clinician to use
considerable judgment about whether symptoms meet criteria
There is significant overlap among disorders, which can then make it
difficult to distinguish among them
o Valid property of classification systems (or measures) that actually
characterize what they are supposed to characterize
o Prognosis likely course and outcome of disorder
Diagnostic and Statistical Manual of Mental Disorders
o Criteria- kinds, number and duration of relevant symptoms
o DSM guide published by APA that describes the characteristics of many
psych disorders and identifies criteria for diagnosing each disorder
Classification system is categorical which means that someone either
has a disorder or not
o Comorbidity presence of more than 1 disorder at the same time in a given patient
Evolution of DSM-5
o Disorders as Categories, Not Continuous Dimensions

Criteria for disorders in DSM-5 structure so someone either has or


does not have a given disorderbut many disorders can exist along
continua so patients can have different degrees of a disorder
DSM-5 includes optional dimensional scale for disorders so clinicians
can rate severity of symptoms (from mild to severe) but ratings
optional and decision to diagnose patient is still categorical
o Psychological disorders are created to ensure payment
Increase in disorders reflect economic pressures for mental health
care industry (reflects economic pressures in mental health care
industry)
In order for mental health facility or provider to be paid or a patient
to be reimbursed by insurance companies, patients must have
symptoms that meet DSM-5 diagnosis
The more disorders included in a new DSM edition, more likely
patients treatment will be paid for or reimbursed by health insurance
companies
People who diagnose psychological disorders
o Clinical psychologists and counseling psychologist
Clinical psychologist: mental health professional who has a doctoral
degree (did dissertation) that requires several years of related coursework
and several years of treating patients while receiving supervision from
experienced clinicians
Counseling psychologist: mental health professional who has either PhD
degree from psychology program that focuses on counseling or an EdD
degree from a school of education
*both provide psychotherapy help cope with difficult thoughts and
behavior
o Psychiatrists, psychiatric nurses, and general practitioners
psychiatrist: mental health professional who has an MD degree and has
completed a residency that focuses on mental disorders, can prescribe
medication
psychiatric nurse: mental health professional who has an MSN degree,
plus a CS certificate in psychiatric nursing
o Mental health professionals with Masters degrees
social worker: mental health professional who has an MSW degree and
may have had training to provide psychotherapy to help individuals and
families
o Doctoral level psychologists clinical, counselinghave phd, psy d, EdD
o Medical personnel psychiatrist and GP (MD), psychiatric nurses
o Masters level mental health: social work (MSW), family therapist (MFT),
masters level counselors (MA)specific training in helping people with
problems in daily living or with mental illness
Assessing psychological disorders
o Complete clinical assessment can include various types of info regarding the
3 main categories that underlie neuropsychosocial model

Neurological/biological factors structure and functioning of brain


and body, history
Psychological behavior, emotion and mood, mental processes, affect
and contents, past and current ability to function
Social social context of patients problems, living environment and
community, family history and family functioning, history of the
persons relationships and level of financial resources and social
support available
Interpersonal functioning, community, where do they live
o Assessing neurological and other biological factors
o Assessing abnormal brain structures with MRIs
MRI neuroimaging technique that creates especially sharp images of
the brainmore precise diagnoses when brain abnormalities are
subtle
Ex: people with schizophrenia tend to have abnormally large
ventricles (fluid-filed spaces in the brain)
Crisp clear picture of the brain
Assessing Psychological Factors
o Clinical interview meeting between clinician and patient during which the
clinician asks questions related to the patients symptoms and functioning
Provides two types of information:
Content of the answers to the interview questions
Manner in which people answered them
Questions focus on symptoms, general functioning, degree and type of
impairment, patients relevant historyquestions way to understand
persons functioning
Semi-structured, structured, unstructured
Dept. of psych at UIC does interviews that fall between
structured and semi-structured
o Unstructured interview clinician asks whatever questions he or she deems
appropriate, depending on patients responses
Advantage: allows clinician to pursue topics and issues specific to the
patient
o Structured interview: clinician uses a fixed set of questions to guide interview
o Semistructured interview: specific questions guide the interview but the
clinician also has freedom to pose additional questions that may be relevant,
depending on patients answers to the standard questions

ONLY LECTURE NOTES TUESDAY OCTOBER 2ND

Blaming the Victim, Rosenhan (1975), On Being Sane in Insane Places


o Points to Remember (for exam)
Sticky labels
Stigma
Unreliability of diagnosis

As much as we would like to trust classification system (DSM-V),


the system is not as reliable as we would like it to be so we have to
be careful about diagnosing people in part because of stigma and
because diagnosing can be harmful
Self-fulfilling prophecy if people are given a diagnosis, they may
start to believe the diagnosis and reaffirm their beliefs
We never can be too sure about diagnosis system
We tend to stigmatize people who act different than us and get our
attention and draw conclusions about them if they are different
Ex: woman yelling loudly across street and talking to no
oneindicative of mental illness? We are not sure
Rosenhan the staff (including the psychiatrist) acted like they wanted
more distance between patients and themselves
Criticism rosenhan made: if your classification system was
reliable, then why did the staff label people as insane when they
werent insane and perfectly sane?
Criticisms on DSM
How reliable is this classification system?
o If a classification system was reliable, person A and B
could watch same scenario and if it was reliable, A and B
would come up with same diagnosis
o This is why we go for second opinion
o Reliability we want 2 separate independent clinicians
looking at same case make same diagnosis

Do not get reliability when classification data in the system is not


clear (lack of clarity in criteria!)
Overlap in symptoms between 2 different disorders
o Diagnosis A: A, B, C, D
o Diagnosis B: C, D, M, N
o Both have C and D!
*Not responsible for prevalence and incidence
Know prognosis
How reliable is this classification system?
o If a classification system was reliable, person A and B
could watch same scenario and if it was reliable, A and B
would come up with same diagnosis
o This is why we go for second opinion
o Reliability we want 2 separate independent clinicians
looking at same case make same diagnosis
Do not get reliability when classification data in the system is not
clear (lack of clarity in criteria!)
Overlap in symptoms between 2 different disorders
o Diagnosis A: A, B, C, D
o Diagnosis B: C, D, M, N
o Both have C and D!

*Not responsible for prevalence and incidence


Know prognosis
DSM V most widely used in North America (Canada + USA + Mexico)
Sometimes DSM is used to help people who might otherwise not get help
insurance companies will not cover the mental health disorder unless its
included in DSM
Insurance fraud if clinician assigns you a disorder thats covered
in DSM for insurance but you dont actually have
o Leads to ethical dilemma
Number of disorders increases with each DSM
Are we that sick or are we just becoming more intolerant of
variations in behavior? Are we identifying more behavior as
abnormal?
Are diagnostic criteria used in classification systems legitimate
unto themselves?
o Yes and No
o Is research valid or are becoming more intolerant of
difference?
Multiaxial system of DSM-IV-TR (has 5 axes)
o Axis I- clinical disorders
Mood disorders, schizophrenia
Includes majority of disorders
o Axis II- Personality disorders and mental retardation
Personality traits that are so inflexible and self-defeating that they impair
functioning
Aka characterogical issues
o Axis III- general medical conditions
Physical disorder/handicaps relevant to Axis I, II
Could a disorder here account for disorders I or II?
o Axis 4 and 5 we wont cover
o SYSTEM NOT USED ANYMORE!
o Ex: someone gets diagnosed with anxiety disorder on Axis I and also get
diagnosed with ADHD. Some people with ADHD have anxiety symptoms.
DSM V does not use axis system anymore
o Still uses criteria system (Checkmarks)
o No more axes
o Still use you are or you arent system
o Example
Aaron and Max carry diagnosis for schizophrenia. They both fall in cutoff
but Aaron is much less symptomatic than Max
Using DSM IV, theyd both be schizophrenic. Using DSM V,
theyd still be schizophrenic. BUT DSM V offers scales for
clinician to rate how severe persons symptoms are not in DSM IV
o Severity grading scale
Scale is a 5 point scale
Illustrate the advantage of DSM V

Classified as you are with little/moderate/severe


So can get a fuller picture
Move beyond Yes or No
Severity ratings are HOWEVER optional!!! (setback)
o DSM 5: allows you to rate severity of disorder
Know Who does the Diagnosing PhD vs Counseling psych vs social workers!!!
Reliability and validity want assessment tools to be reliable and valid
o For the longest time, participants in research was on white males and that research
was applied to other groups and genders
o Have to be sure that your assessment system is as applicable with one group as
with another group
Ex: based on research with white schizophrenic males, schizophrenia
medication is 50 mg and that dose will be administered to black females
Ex: Bern Sex Role inventory identify if your sex role is masculine,
feminine or androgynous (60 terms you have to rate on scale from 1 to 7)
Asians, Latin American, Black women were all similar to each
other in terms of femininity and androgyny
Researchers selected number of words and in 2nd part of study,
asked to give definition of terms
o Define passive
White: laid back
African American/Latino: not speaking your mind
o Measure is not valid because did not measure what you
intended to measure
o White male only research studies are basically non-existent now because not
validnow researchers develop measures on several populations

*only book reference is in intro textbook


*cite DSM-5!!!
TEXTBOOK NOTES OVERLAPPING WITH LECTURE

All types of interviews provide an opportunity for the clinician or researcher to observe
and make inferences about different aspects of a patient:
o Appearance
In addition to obvious aspects of appearance (whether the person has
bathed recently and is dressed appropriately), signs of disorder can
sometimes be noted by carefully observing subtle aspects of a persons
appearance
o Behavior
Patients body language, facial expression, movements, and speech can
provide insights into different aspects of psychological functioning
o Emotions

What emotions does patient convey? The clinician can observe patients
expression of distress (or lack thereof) and emotional state (upbeat, low,
intense, uncontrollable, inappropriate to the situation, or at odds with the
content of what the patient says)
o Movement
Patients general level of movement physical restlessness or a complete
lack of movementmay indicate abnormal functioning
o Speech
Clinicians observe the rate and contents of the patients speech
Speaking very quickly may suggest anxiety, mania, or certain
kinds of substance abuse; speaking very slowly may suggest
depression or other kinds of substance abuse
o Mental processes
Some behaviors reveal characteristics of mental processes
Do the patients mental processes appear to be unusual or abnormal?
Does the patient appear to be talking to someone not in the room which
would suggest that he or she is having hallucinations?
Can the patient remember what the clinician just asked?
Does the patient flit from topic to topic, unable to stay focused on
answering a single question?
o Clinician must keep in mind that unusual behavior should perhaps be interpreted
differently for patients from different cultural background
Patients own report of his experiences is crucial part of clinical assessment (self-report)
o At some point in the interview process, clinician will ask patients history (past
factors or events) and the patient will report such info about himself or herself
Clinician will ask about current and past psychological or medical problems and about
how the patient understands these problems and possible solutions to them
o Clinician will inquire about substance use, sexual or physical abuse or other
traumatic experiences, economic hardships, relationships with family members
and others and thoughts about suicide
o Patients answers help the clinician put the patients current difficulties in context
and determine whether his or her psychological functioning is maladaptive or
adaptive, given environmental circumstances
Some patients intentionally report having symptoms that they dont actually have or
exaggerate symptoms that they do have, either for material gain or to avoid unwanted
events (such as criminal prosecution) malingering (lying)
Semistructured interview
o Mental status exam set of questions to assess patients mental state at time of
interview
Clinician asks the patient to describe the problem, its history, and the
patients functioning in different areas of life
Probe the patients ability to reason, to perform simple mathematical
computations, and to assess possible problems in memory and judgment
Example
As part of the exam, asked whether they remember their own
name, date, year and who is president

More detailed questions involving different aspects of memory (if


the patient doesnt remember), may reflect underlying neurological
problem
Structured Clinical interview SCID, used when the interview is part of a
research project and is designed to assist the researcher in diagnosing
patients according to DSM criteria
Tests of psychological functioning
o Cognitive assessment
Intelligence test WAIS (Wechsler Adult Intelligence Scale) and
(Wechsler Intelligence Scale for Children) 4th edition
Yield an intelligence quotient
o Personality assessment
Inventories: assess general personality functioning
Questionnaire with items pertaining to many different problems
and aspects of personality
Indicates to clinician what problems and disorders might be most
likely for a given person
Contain test questions sorted into different scales with each scale
assessing a different facet of personality
o Most common MMPI (Minnesota Multiphasic Personality
Inventory)
Produces a profile
Consists of 567 questions about respondents
behavior, emotions, mental processes, mental
contents, and other characteristics
Respondent rates each question as being true or
false about himself
Projective tests: tool for personality assessment in which the patient is
present with ambiguous stimuli (such as inkblots or stick figures) and is
asked to make sense of and explain them
Assesses parts of patients personality that are less likely to emerge
in self-report
Rorshach test is a projective test consists of inkblots
o Patients are asked what each inkblot
o Based on the idea that test-taker imposes a structure onto
the ambiguous inkblot
o Patients responses are thought to reveal something about
himself
o Includes 10 inkblots
Ambiguity of shape allows patient to imagine what
shapes resemble
o Although it may provide info on some aspects of a patients
personality and mental functioning, it does not accurately
assess most aspects of psychological disorders
TAT Thematic Apperception Test

o Detailed black and white drawings that often include


people
o Patient is asked to explain the drawings in various ways
Clinician may ask patient what is happening in the
picture, what just happened, what will happen next
or what people in the picture might be thinking and
feeling
o TAT elicits responses that presumably reflect unconscious
beliefs, desires, fears, or issues

Assessing social factors


o How does the patient function in his or her home environment? Are there family
factors or community factors that might influence treatment decsions?
o Family functioning
In order to assess family functioning, clinicians may interview all or some
family members or ask patients about how the family functions
Some clinicians and researchers try to assess family functioning more
systematically than through interviews or observations
Family environment scale requires family members to answer set of
questions
Answers integrated to create a profile of the family environment
how the family is organized, different types of control and conflict,
family values and emotional expressiveness
Such info helps clinician or researcher to understand the patient within the
context of his or her family and identifies possible areas of family
functioning that could be improved
o Community
When making a clinical assessment, clinician should try to learn about
patients community in order to understand what normal functioning is in
that environment
People who have low SES are most likely to have psychological disorders
Live in fear due to high crime rates or stress
o Culture
To assess someones reports of distress or impairment, clinician must
understand persons culture
Different cultures have different views about complaining and how to
describe different types of distress or other symptoms, which influence the
amount and type of symptoms people will report to a mental health
clinician which, in turn, can affect the diagnosis a clinician makes
Notice how much higher the rates are in USA than in the other developed
and developing countries
One explanation for this discrepancy is that Americans are less
inhibited about telling strangers about their psychological
problems
People in other countries might have minimized the frequency or
severity of their symptoms
Assessment as an interactive process

o Mental health researchers and clinicians learn about patients from assessing
psychological and social factors and neurological and biological factors
o Information about each type of factor should not be considered in isolation but
rather should influence how the clinician understands the other types of
information
ONLY LECTURE NOTES TUESDAY OCTOBER 7TH

Assessment
o In schizophrenia, have abnormally large ventricles
Interviews
o SCID structured interview, determining whether someone meets criteria for
diagnosis
SCID interview question being asked on depression, weight loss, loss of
appetite, and emotional state
o Unstructured interview Andy and psychiatrist, not completely unstructured but
slightly structured
Taking the history
Making a risk assessment
Went where interview took her
Between semi-structured and structure
o Clinical interview make observations and follow up on observations
Look at persons appearance
Are they clean, dressed appropriately?
Anything unusual about persons appearance?
o Ex: guy in video looked fine in terms of appearance
Being dressed inappropriately, disheveled, smells
o Ex: women dressed in hat and coat in 95C weather
(**zoned out around 2:39 pm)
Behavior
Emotional state
What is the emotional state? Calm, angry?
How do they express their state?
Is what you are seeing proportionate to what the person is
presenting?
o Ex: representing something tragic in a flat, monotone voice
Whats their movement like?
Are they restless?
Is there a lack of movement?
Listening to their speech
Are they talking really fast or slow?
o Is it noticeably slow? (unusual)
Nonsensical talk indicative of something unusual going on
Assessing their memory
Can be related to mental health issue
Persons judgment making sound decisions?

Level of intellectual functioning has to be taken in account


History family history, important events in their life, development and
growing up
Informative in helping us understand if there were certain events
that might have contributed and partly influenced the situation the
person is currently in
Malingering = lying (patient lies)
Mental status exam- falls into realm of semi-structured interview
Thought content- what is client thinking? (mental processes)
Perception
Command hallucinations auditory halluciantions telling patient to
act certain way
Risk assessment risk to self and others
Does look play a role in assessment?
In addition to clinical interview, can also include testing
o Tests of intelligence
Famous one: WAIS Wexler adult intelligence scale (Latest version is 4)
Also an equivalence scale for children
o Assessments of personalities
MMPI Minnesota multiphasic personality inventory
More than 550 questions, takes long time to complete
Very thorough personality assessment includes lie scale
o Reveal whether you tend to lie or not
o Virtually 99% of people lie
o 90 minutes to complete
Rorschach popular
Projective test like a blank slate in front of you and in describing
what you are seeing in front of you, describing things about
yourself
o See something or make interpretation on something based
on you
What do you see?
Profile of responses given by people with psychiatric disorders
This test has validity and reliability problems but it is being used
less and less
o Not evidence on the projections it offers
Thematic apperception test (TAT)
Another projective test that uses cards and people have to say a
story
o Reveal something about motivations, feelings, issues
Objective vs subjective
o Subjective thoughts, feelings, mood ...you interpret the
facts, clinician interprets the facts
Problem with projective tests is that they are open
to subjective interpretation

o Objective- facts
*Rorschach, TAT, and MMPI are personality tests
Cognitive test- intelligence tests (WAIS)
MMPI-2 profile: anything in box is average, anything above and below
box would have clinical significance
o Social factors
Some cultures may describe symptoms differently
Asian and latino cultures describe anxiety as nerves
Native American describe depression broken-hearted
Some cultures may minimize symptoms or not describe them at all
America has a high percentage of people with mental disordervery high
percentage
In African cultures, confined schizophrenic man in hut and took care of
himdid not go to hospital
Cultures differ

Anda mungkin juga menyukai