Kring11e PPT ch03

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Chapter 3
Diagnosis and Assessment
Abnormal Psychology, Eleventh Edition
by
Ann M. Kring, Gerald C. Davison, John M. Neale,

& Sheri L. Johnson
Diagnosis and Assessment

Diagnosis
The classification of disorders by symptoms and signs.
Advantages of diagnosis:
Facilitates communication among professionals
Advances the search for causes and treatments
Cornerstone of clinical care
Copyright 2009 John Wiley & Sons, NY
Reliability
Consistency of measurement
Inter-rater
Observer agreement
Test-retest
Similarity of scores across repeated test administrations or
observations
Alternate Forms
Similarity of scores on tests that are similar, but not identical
Internal Consistency
Extent to which test items are related to one another
Validity
How well does a test measures what it is supposed to
measure?
Content validity
Extent to which a measure adequately samples the domain of
interest e.g., all of the symptoms of a disorder.
Criterion validity
Extent to which a measure is associated with another measure (the
criterion)
Concurrent
Two measures administered at the same point in time
Hopelessness scale and diagnosis of depression
Predictive
Ability of the measure to predict another variable measured at some future
point in time
College GPA and annual salary after graduation
Validity
Construct validity (Cronbach & Meehl, 1955)
A construct is an abstract concept or inferred attribute
Involves correlating multiple indirect measures of the attribute
e.g., self-report of anxiety correlated with increased HR, shallow breathing, racing thoughts.
Important method for evaluating diagnostic categories
DSM-IV-TR
Diagnostic System
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)
4th edition revised
Published by American Psychiatric Association
Multiaxial system
Diagnosis based on 5 axes or dimensions.
Five Axes of DSM-IV

AXIS DESCRIPTION
I
II
III
IV
V
All diagnostic categories except personality

disorders and mental retardation
Personality disorders and mental retardation
General medical conditions
Psychosocial and environmental problems
Global assessment of functioning scale (GAF)
Selected Axis I
Diagnostic Categories
Disorders usually first diagnosed in infancy, childhood or

adolescence
Learning Disorders
Pervasive Developmental Disorders
Substance-related disorders
Alcohol-related and Amphetamine-related Disorders
Schizophrenia and other Psychotic Disorders

Anxiety disorders
Panic, Generalized Anxiety, Obsessive-Compulsive Disorders
Mood disorders
Major Depressive and Bipolar Disorders
Eating Disorders
Anorexia Nervosa and Bulimia Nervosa
Example: Multiaxial Diagnosis of

Carol S.
Axis I
Major Depressive Disorder
Axis II
Borderline Personality Disorder
Axis III
Thyroid disease
Axis IV
Axis V
Problems with primary support group: marital

separation
GAF = 60 Moderate difficulty in social and
occupational functioning
Early Foundations: Emil Kraepelin

(1856-1926)
Pioneered classification of mental illness based on biological causes
Published 1st psychiatry text (1883)
Mental illness as syndrome
Cluster of symptoms that co-occur
Proposed two major syndromes

Dementia praecox
Manic-depressive psychosis
10
Improvements in the
DSM-IV-TR
1.
Specific diagnostic criteria
2.
Less vague, more explicit and concrete than DSM-II (see Table 3.2)
More extensive descriptions
Essential features
Associated features (e.g., lab findings)
Differential diagnosis
11
Improvements in the
DSM-IV-TR
3. Increasing number of diagnostic
categories
4. Issues and possible diagnostic
categories in need of further study
Caffeine withdrawal or Premenstrual Dysphoric
Disorder
12
Table 3.2 Descriptions of Mania in

DSM-II vs. DSM-IV-TR
13
Ethnic & Cultural Considerations

Mental illness universal
Culture can influence:
Risk factors
Types of symptoms experienced
Willingness to seek help
Availability of treatments
DSM-IV-TR includes:
Enhanced cultural sensitivity

Appendix of 25 culture-bound syndromes
Koro
Amok
Some researchers endorse looking for commonalities rather than

differences across cultures
14
Table 3.4 Twelve month prevalence of the most

common diagnoses by country
15
Table 3.3 Number of Diagnostic

Categories per Edition of DSM
16
Figure 3.1 Categorical vs.

Dimensional Systems
Categorical
Presence/absence of a disorder
Either you are anxious or you are not
anxious.
Dimensional
Rank on a continuous quantitative dimension
Degree to which a symptom is present
How anxious are you on a scale of 1 to 10?
Dimensional systems may better capture an

individuals functioning
Categorical approach has advantages for
research and understanding
17
Figure 3.2 Interrater Reliability

Extent to which clinicians
agree on the diagnosis.
18
Inter-Rater Reliability of Selected

DSM Diagnoses
For most DSM
diagnostic
categories, reliability
is good
Reliability in
everyday settings
may be lower than in
formal research
settings
Diagnosis
Bipolar Disorder
Major Depression
Schizophrenia
Alcohol Abuse
Any Eating Disorder
Panic Disorder
Avoidant PD
Dependent PD
Kappa
.84
.80
.79
1.0
.77
.65
.97
.86
19
Validity of Diagnostic Categories

Construct validity of highest
concern
Diagnoses are constructs
For most disorders, no lab test
available to diagnose with
certainty
Strong construct validity

predicts wide range of
characteristics
20
Table 3.5 Rates of marital distress and missed work

days among people with mental illness in the past year
21
Criticisms of Classification
Stigma against mental illness
Treated differently by others
Difficulty finding a job
Categories do not capture the uniqueness of a

person.
The disorder does not define the person.
She is an individual with schizophrenia, not a schizophrenic
Classification may emphasize trivial similarities

Relevant information may be overlooked.
22
Possible Changes for DSM-IV

Including a Personal Health Index
Reorganizing categories based on overlap
Dimensional approach to diagnoses
Organizing diagnoses by causes
Defining disability
23
Psychological Assessment
Techniques employed to:
Describe clients problem
Determine causes of problem
Arrive at a diagnosis
Develop a treatment strategy
Monitor treatment progress
Ideal assessment involves multiple measures and methods

Interviews, personality inventories, etc.
24
Table 3.7 Major Psychological

Assessment Methods
25
Characteristics of Clinical Interviews

Interviewer attends to how questions are answered
Is response accompanied by appropriate emotion?
Does client fail to answer question?
Paradigm influences information sought
CBT interviewer focuses on current, rather than early childhood,

events.
Good rapport essential
Empathy and accepting attitude
Formal (structured) vs. informal

Structured interviews
All interviewers ask the same questions in a predetermined order
Structured Clinical Interview for Axis I of DSM (SCID)
26
Figure 3.4 Sample Item

from SCID
27
Assessment of Stress
Social Readjustment Rating Scale (SSRS)
Holmes & Rahe (1967)
Relies on retrospective ratings
Stressfulness ratings fixed
Assessment of Daily Experiences (ADE)
Stone & Neale (1982)

Monitor and record thoughts and events on a daily basis
Bedford College Life Events and Difficulties Schedule

(LEDS)
Semi-structured interview
Evaluates stressors within the context of each individuals
circumstances
28
Figure 3.5 Sample of

Assessment of Daily
Experience Scale
29
Figure 3.6 LEDS Life Events Timeline
30
Three Types of Psychological Tests

Self-report personality Inventories
Minnesota Multiphasic Personality Inventory (MMPI)

Yields profile of psychological functioning
Specific subscales to detect lying and faking good or bad
Projective Tests
Rorshach Inkblot Test and Thematic Apperception Test (TAT)

Projective hypothesis
Responses to ambiguous stimuli reflect unconscious processes
Intelligence tests
Wechsler Adult Intelligence Scale, 3rd Ed (WAIS-III); Wechsler Intelligence Scale

for Children, 3rd Ed (WISC-III)
Assesses current mental ability
31
Figure 3.7 Hypothetical MMPI-2 Profile
32
Figure 3.8 Rorschach Inkblot Test
33
Behavioral Observation
Observe behavior as it occurs
Sequence of behavior divided into segments
Antecedents and consequences
Observation often conducted in lab setting

e.g., romantic partners discuss relationship problem
Interaction observed through one-way mirror or videotaped for later
coding
34
Self-Observation
Self monitoring
Individuals observe and record their own behavior
e.g., moods, stressful events, thoughts, etc.
Ecological Momentary Assessment (EMA)

Collection of data in real time using diaries or PDAs
Reactivity
The act of observing ones behavior may alter it
Desirable behaviors tend to increase whereas undesirable
behaviors decrease
35
Self-report Inventories & Cognitive

Assessment
Format often similar to personality tests
Dysfunctional Attitude Scale (DAS)
Identifies maladaptive thought patterns
People will think less of me if I make mistakes
Articulated Thoughts in Simulated Situations (ATSS)

Assesses immediate thoughts in specific situations
36
Neurobiological Assessment: Brain

Imaging
Computerized Axial Tomography (CT or CAT scan)
Reveals structural abnormalities by detecting differences in tissue

density.
e.g., enlarged ventricles
Magnetic Resonance Imaging (MRI)

Similar to CT but higher quality
fMRI (functional MRI)
Images reveal function as well as structure

Measures blood flow in the brain
(BOLD; blood oxygenation level dependent)
Positron Emission Tomography (PET scan)

Brain function
37
Neurobiological Assessment:
Neurotransmitter Assessment
Postmortem studies
Metabolite assays
Metabolite levels
By-products of neurotransmitter breakdown found in urine, blood serum or cerebral
spinal fluid
May not reflect actual level of neurotransmitter

Correlational studies
38
Neurobiological Assessment:
Neuropsychological Assessment
Neuropsychologist
Studies how brain abnormalities affect thinking, feeling, and

behavior
Neuropsychological Tests
Reveal performance deficits that can indicate areas of brain

malfunction
Halstead-Reitan battery
Tactile Performance Test - Time
Tactile Performance Test - Memory
Speech Sounds Perception Test
Luria-Nebraska battery
Assesses motor skills, tactile & kinesthetic skills, verbal & spatial skills,
expressive & receptive speech, etc.
39
Psychophysiological Assessment
Psychophysiology
Study of bodily changes that accompany psychological

characteristics or events
Electrocardiogram (EKG)
Heart rate measured by electrodes placed on chest
Electrodermal responding (skin conductance)
Sweat-gland activity measured by electrodes placed on hand.
Electroencephalogram (EEG)
Brains electrical activity measured by electrodes placed on scalp.
40
Cultural Bias in Assessment

Measures developed for one culture or ethnic group may not be valid
or reliable for another.
Not simply a matter of language translation
Meaning may be lost
Cultural bias can lead to minimizing or exaggerating psychological

problems
41
Strategies to Avoid Bias

Increase graduate students sensitivity to cultural issues
Insure participants understanding of task
Establish rapport
Distinguish cultural responsiveness from cultural stereotyping
(Lopez, 1994)
42
COPYRIGHT
Copyright 2009 by John Wiley & Sons, New York, NY. All
rights reserved. No part of the material protected by this
copyright may be reproduced or utilized in any form or by
any means, electronic or mechanical, including
photocopying, recording or by any information storage and
retrieval system, without written permission of the
copyright owner.
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PowerPoint Lecture Notes

Ann M. Kring, Gerald C. Davison, John M. Neale,

Diagnosis and Assessment

Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY

Important method for evaluating diagnostic categories

Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY

Five Axes of DSM-IV

All diagnostic categories except personality

Copyright 2009 John Wiley & Sons, NY

Disorders usually first diagnosed in infancy, childhood or

Alcohol-related and Amphetamine-related Disorders

Schizophrenia and other Psychotic Disorders

Panic, Generalized Anxiety, Obsessive-Compulsive Disorders

Major Depressive and Bipolar Disorders

Anorexia Nervosa and Bulimia Nervosa

Copyright 2009 John Wiley & Sons, NY

Example: Multiaxial Diagnosis of

Major Depressive Disorder

Borderline Personality Disorder

Problems with primary support group: marital

Early Foundations: Emil Kraepelin

Proposed two major syndromes

Copyright 2009 John Wiley & Sons, NY

Specific diagnostic criteria

More extensive descriptions

Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY

Table 3.2 Descriptions of Mania in

Copyright 2009 John Wiley & Sons, NY

Ethnic & Cultural Considerations

Enhanced cultural sensitivity

Some researchers endorse looking for commonalities rather than

Copyright 2009 John Wiley & Sons, NY

Table 3.4 Twelve month prevalence of the most

Copyright 2009 John Wiley & Sons, NY

Table 3.3 Number of Diagnostic

Copyright 2009 John Wiley & Sons, NY

Figure 3.1 Categorical vs.

How anxious are you on a scale of 1 to 10?

Dimensional systems may better capture an

Copyright 2009 John Wiley & Sons, NY

Figure 3.2 Interrater Reliability

Copyright 2009 John Wiley & Sons, NY

Inter-Rater Reliability of Selected

Copyright 2009 John Wiley & Sons, NY

Validity of Diagnostic Categories

Strong construct validity

Copyright 2009 John Wiley & Sons, NY

Table 3.5 Rates of marital distress and missed work

Copyright 2009 John Wiley & Sons, NY

Categories do not capture the uniqueness of a

She is an individual with schizophrenia, not a schizophrenic

Classification may emphasize trivial similarities

Copyright 2009 John Wiley & Sons, NY

Possible Changes for DSM-IV

Copyright 2009 John Wiley & Sons, NY

Ideal assessment involves multiple measures and methods

Copyright 2009 John Wiley & Sons, NY

Table 3.7 Major Psychological

Copyright 2009 John Wiley & Sons, NY