Chapter 1 (revised)

Chapter 11: Strategic Leadership

Chapter 1

Psychological Assessment &

Psychodiagnostics

Chapter 1Chapter 1

Psychological assessment Psychological assessment and psychodiagnosticsand psychodiagnostics

Viv O'Neill

I'm not sure what the final chapter title is?


Section 1: Introduction • Abnormal behaviours are diverse and pervasive;

need a sub-discipline in psychology.• Abnormal behaviour: Any behaviour that deviates

from social and statistical norms and that is maladaptive and causes distress.

• Psychopathology: Derived from the words ‘psyche’ (mind or soul) and ‘pathology’ (disease or illness) = mind illness.

• Psychological disorder: • Psychological dysfunction within an individual• associated with distress or impairment in

functioning• and a response to this that deviates from that

individual’s culture.


Statistical deviance• Determine what is normal (far from normal = ‘abnormal’).• Norm is influenced by cultural/social perspectives.• What is considered normal is not necessarily healthy.

Maladaptiveness • Behaviours that prevent individual adapting for the good of

individual/group are considered abnormal (e.g. depression).• Relative to culture.

Personal distress• Psychopathology often accompanied by distress and

suffering.• Diagnosis of abnormality set in person’s context (e.g.

‘normal’ distress from bereavement).

Defining criteria for abnormal behaviour


The pre-scientific era• Initial belief that abnormal behaviour was caused by

supernatural forces.• Hippocrates – first biological view

• Brain is the centre of wisdom, consciousness, intelligence, and emotion.

• Changes in behaviour = changes in the brain.• Abnormal behaviour = result of physical disease.

• Galen: 4 humours of the brain. • Galenic-Hippocratic tradition

• Linked abnormality with brain chemical imbalances.

• Foreshadowed modern views.

A brief history of mental illness


The pre-scientific era, cont.• Middle Ages: Move away from biological views -

mental illness considered punishment for sin (thus people had to be exorcised).

• Some still believe this today (e.g. HIV/AIDS).• Institutionalisation on the increase – inhumane

treatment in ‘asylums’.• Around 1800: reforms in treatment of mentally ill

(Pinel; Tuke).

A brief history of mental illness, cont.



The scientific era• Shift back to a biological approach.• Noted that syphilis produced same symptoms as

mental disorder but cause = biological (bacterial micro-organism).• Supported view that mental illness = physical

illness (John Grey).• Provided a biological basis for madness.

• Kraepelin: • Classification system• Dementia Praecox

• Development of variety of psychological theories.



The scientific era, cont.• Sigmund Freud - disorder the result of:

• conflict of different personality structures.• over-reliance on certain defence mechanisms.

• Behavioural theory (John Watson; Pavlov; Skinner):• Disorder the result of learned behaviour.

• The 1950s:• Medications becoming increasingly available.• Included neuroleptics (antipsychotics, e.g.

reserpine) and major tranquillizers.


Psychology in South Africa• South Africa was the scene of ongoing conflict

between various world powers.• Led to subjugation of white Afrikaner and black

South Africans.• Racial segregation was formalised by H.F

Verwoerd (‘father of apartheid’).• Use of culturally biased psychological tests to

endorse racial oppression.• SA still dealing with colonial and apartheid

legacy.


• Indigenous theories of illness: • Personal problems are caused by difficulties in social

relationships.• Many people in Southern Africa consult indigenous

healers.• Religious healing also common in Southern Africa.• Western-trained mental-health practitioners can learn

from indigenous healers in order to work with people from different cultures.

• Client-centered approach useful: • Takes person’s own cultural perspective

• Multi-dimensional approach: • Many different models of psychopathology

Additional and cross-cultural views


• Term introduced by David Cooper.• ‘Illness’ is a physical concept therefore cannot

be applied to any psychological disorder that has no signs of physical pathology.

• This puts patients in a passive role; leads to inhumane treatment of patients (as objects).

• Anti-authoritarian position against the use of:• psychiatric diagnoses• drug treatments• electro-convulsive treatments• involuntary hospitalisation

Anti-Psychiatry Movement


Two classifications of mental illness:International Classification of Diseases (ICD)• Published by WHO.• Includes a section on psychiatric conditions.

The Diagnostic and Statistical Manual of Mental Disorders (DSM):

• Published by APA. • Solely focused on mental health disorders.

Aim of the manuals:• Develop replicable and clinically useful categories

and criteria.• Facilitate consensus and agreed standards.

Classification of mental illness


Classification of mental illness, cont.

Problems associated with these systems: • Diagnostic categories based on particular

psychiatric theories and data – not truly theoretical.

• Categories are broad and are specified by numerous possible combinations of symptoms.

• Many categories overlap.• Were originally intended as a guide to experienced

clinicians.


Background and history• 1952: 1st DSM.• Number of disorders grew to 400 by DSM-IV.• Anti-Psychiatry Movement critically viewed DSM

diagnoses as labels constructed by society in order to silence deviance.

• DSM-III and DSM-IV criticised for their approach to diagnoses:• Minimum number of symptoms from a list

determines the presence or absence of the disorder.

The Diagnostic Statistical Manual of Mental Disorders

(4th ed.) (Text Revision)


• DSM-IV-TR based on biomedical model:• Signs and symptoms grouped together to identify the

pathological cause or syndrome.

DSM-IV-TR: Multi-axial diagnostic system


DSM-5

• DSM-5 also attempts to address the structural problems of previous editions.

• In answer to the criticism levelled at the large number of narrow diagnostic categories in the previous editions, DSM-5 makes use of scientific indicators to inform new groupings of related disorders within the existing categorical framework.

• Ongoing revisions of DSM-5 ‘will make it a living document, adaptable to future discoveries in neurobiology, genetics and epidemiology.’ (American Psychiatric Association, 2014, p. 13).


DSM-5• DSM-5 is organized on developmental and lifespan

considerations, beginning with disorders that first manifest in early childhood, followed by disorders that manifest in adolescence and early adulthood, and ending with disorders relevant to adulthood and later life (American Psychiatric Association, 2014).In contrast to previous editions that made use of a multiaxial system of diagnosis, DSM-5 utilises a nonaxial documentation of diagnosis (previously axes I, II and III),

• Allows separate notations for key psychosocial and contextual factors (previously axis IV) and disability (previously axis V).

• This addresses the criticism that previous editions implied that medical conditions were unrelated to behavioural and psychosocial factors.


• Only describes disorders (lack of focus on aetiology).

• Has evolved into a biomedical system.• Adopts an individualistic approach.• Often criticised for creating diagnostic categories

that have a Western cultural perspective.• Concerns about validity of the DSM-IV system.• Reliability of DSM-IV system also questioned.• Caution: A diagnosis does not describe the

person, but only a set of behaviours associated with the person’s problem.

Criticisms of the DSM-IV system


Background and history• 1893: Jacques Bertillon introduced Bertillon Classification of

Causes of Death in Chicago.• 6th revision: Classification system now two volumes.• Included morbidity and mortality conditions.• Title modified to: Manual of International Statistical

Classification of Diseases, Injuries and Causes of Death (ICD).

• 1960s: WHO became actively engaged in improvement in diagnosis and classification of mental disorders.

• Extensive consultation process: Numerous proposals to improve classification of mental disorders led to eighth revision of International Classification of Diseases (ICD-8).

The International Classification of Diseases (ICD)


The ICD has 3 axes:• AXIS I: Clinical diagnoses (mental disorders, physical

disorders, and personality disorders).• AXIS II: Description of any activity, limitation, or

participation restrictions in specific areas of functioning (including personal care; occupation; family and household; and functioning in the broader social context).

• AXIS III: Used to describe contextual factors (environmental/lifestyle factors) relevant to pathogenesis and course of the patient’s illness.

• ICD includes personality disorders on the same axis as other mental disorders, unlike DSM.

• ICD-10 also attempts to be more culture-sensitive than the DSM-IV-TR.

ICD, cont.


• The most reliable of diagnostic criteria are not necessarily valid (they do not measure what they are supposed to measure).

• NB problem = single-word diagnoses: Do not necessarily help understanding of the person’s problems (complex personal meanings contained in a simple diagnosis).

• Criticism of ICD and DSM different nosologies (schemes of classification) proposed to replace current descriptive model of mental disorders:• Dimensional model (mental disorders lie on a

continuum)

Classification systems: Comparison and critique


Classification systems: Comparison and critique, cont.

Criticism of ICD and DSM, cont.• Holistic model (equal emphasis on social,

spiritual, and pharmacological treatments)• Essential/Perspectival model (Johns Hopkins)

• disease (physical disease or damage)• dimensions (cognitive or emotional

weaknesses)• behaviours (e.g. alcoholism)• life story (life experiences)

• Each perspective has its own approach to treatment.


Classification systems: Comparison and critique, cont.

DSM-IV categories ICD-10 categories

Neurodevelopmental Disorders(Childhood emotional disorders are incorporated under Depressive Disorders, Anxiety Disorders, Obsessive-Compulsive Disorders, Trauma and Stressor Related Disorders, Feeding and Eating, Elimination and Disruptive, Impulse Control and Conduct Disorders)

Behavioural and emotional disorders with onset usually occurring in childhood and adolescenceMental retardationDisorders of psychological development

Neurocognitive Disorders Organic, including symptomatic, mental disorders

Substance-related and Addictive Disorders Mental and behavioural disorders due to psychoactive substance use

Schizophrenia Spectrum and other psychotic disorders Schizophrenia, schizotypal, and delusional disorders

Bipolar and Related DisordersDepressive Disorders

Mood (affective) disorders

Anxiety disordersObsessive-Compulsive and Related DisordersTrauma- and Stressor Related DisordersSomatic Symptom Disorders Dissociative disorders

Neurotic, stress-related, and somatoform disorders

Feeding and Eating DisordersSleep – Wake DisordersSexual DysfunctionGender Dysphoria

Behavioural syndromes associated with physiological disturbances and physical factors

Personality disordersDisruptive, Impulse Control and Conduct Disorders

Disorders of adult personality and behaviour


• Abnormal behaviour criteria:• statistical deviance• maladaptiveness• personal distress

• Broader political, socio-cultural and historical factors are important in understanding the nature of normality and abnormality.

• In South Africa, we need to embrace a more critical perspective on abnormal behaviour.

Section 1: Conclusion


• Clinical assessment:• The evaluation and measurement• of psychological, biological, and social factors• in individuals who present with possible

psychological disorders.• Diagnosis = process whereby:

• A clinician determines whether the particular problem with which the individual presents meets all criteria for psychological disorder as described in the DSM-IV-TR or ICD-10.

• Clinician begins with collecting a wide range of information.

Section 2: Introduction


Section 2: Introduction, cont.

• Three basic concepts to help establish the value of assessments:• reliability• validity• standardisation

• There are a number of procedures in assessment:• clinical interview• physical examination• behavioural observation and assessments• psychological tests


• First step: Ask patient what is wrong (establish presenting problem).

• If more than one, rank problems from most important to least.

• Take full history and record other relevant facts.• Note observable signs (e.g. fidgeting, eye contact,

etc.).• Must identify any evidence of medical condition

that could explain the problem before diagnosis of psychological disorder.

Basic steps in the diagnostic process


Basic steps in the diagnostic process, cont.

• May need to do a neurological examination.• Determine individual’s mental condition (state):

• Orientation to time/place/person• Attention span, concentration, and memory• Helps make provisional diagnosis

• From list of possible (differential) diagnoses, diagnostician identifies most likely diagnosis, based on symptoms (subjective) and signs (objective).


The clinical interview• 1st step of process

• Allows the diagnostician to obtain:• detailed description of presenting problem• history of patient’s life, current situation, and

social history• info about attitudes, emotions, and current

and past behaviour• family history• info about when problem started, significant

events around that time

Interviewing & observations


Interviewing & observations, cont.

Viv O'Neill

Can the figure number be updated to Figure 1.8?


Mental Status Examination (MSE)• Involves systematic observation of patient’s behaviour.• Structured and detailed (but quite quick).• Five categories:

• appearance and behaviour (e.g. dress; posture; appearance)

• thought processes (e.g. conversation; rate/flow of speech)• mood and affect (mood is subjective; affect is what the

clinician observes)• intellectual functioning (abstractions; understanding of

metaphors; memory)• sensorium (awareness of surroundings: orientation -

time/person/place)• Enables diagnostician to establish which areas of patient’s

behaviour and condition should be assessed in more detail.



Behavioural assessment• Direct observation in order to assess formally an individual’s

thoughts, feelings, and behaviour in specific contexts.• Sometimes used for someone who is not old enough or is

unable to report their problems or experiences.• Could be at workplace or home; role play.• Identify specific behaviour one wants to observe (target

behaviour).• Focus on ABC:

• antecedent (before the target behaviour)• behaviour itself• consequences of behaviour

• Self-monitoring.• Behaviour rating scales (initial behaviour and changes).• Awareness of being observed can distort any observational

data.



Medical assessments

Physical examination• Many medical conditions can mimic symptoms of

psychological disorder (e.g. overactive thyroid symptoms look like anxiety disorder).

Neuro-imaging• Accurate images of the brain’s structure and

function:• structure = size or shape of various parts;

damage• function = metabolic activity and blood flow


Neuro-imaging, cont.• Structure

• CAT scan = non-invasive; useful for locating brain tumours/ injuries; takes 15 mins; some risk of cell damage.

• MRI = better resolution; very expensive; not for patients with claustrophobia.

• Function• PET = patient injected with tracer substance that interacts

with glucose, blood, or oxygen; supplements MRI and CAT scans.

• SPECT = less expensive than PET scan so used more often; but less accurate.

• fMRI = preferred means of brain mapping (advanced; quick); pictures of brain at work; does not expose patient to radiation; minimally invasive; widely available.

Medical assessments, cont.


Psycho-physiological assessment• Measurement of nervous system changes that may

reflect emotional and psychological events.• Measurement can be taken directly from brain or

other parts of the body (e.g. skin).• EEG measures brain activity - can be done asleep or

awake.• Other measures: Individual’s heart rate,

electrodermal activity (sweat gland activity), and respiration.

Medical assessments, cont.


• Determine emotional, behavioural, or cognitive responses that could be associated with specific disorder.

• SA history: Inappropriate use of norms on sub-groups.

• All behavioural and personality-based assessments must be carried out by registered psychologists (or others) with skills and experience in assessment in cross-cultural context.

• If assessment used incorrectly, test may produce false negatives or false positives.

Psychological testing


Psychological testing, cont.

• Use of psychological tests regulated by HPCSA (only trained and/or registered psychologists may use certain tests).

• Advanced tests include intelligence tests, personality tests, projective, and other diagnostic tests.

• These can only conducted by registered psychologists.

• Some tests can be conducted by:• psychometrists (under direct supervision) • trained allied professionals (e.g. social workers)

(trained and supervised)


Culture and assessment• Major challenge for psychological testing is

influence of cultural factors on test results.• Culture-free test: Minimise effects culture may

have on a person’s performance.• Culture-fair test: Aims to be free of culture bias (no

culture has advantage over another):• Designed to assess intelligence, personality,

attitudes, etc., without relying on knowledge specific to any individual cultural group.



Intelligence tests• Intelligence = global concept involving the ability to:

• act with purpose• to think in a rational manner• to deal with the environment in an effective way (Wechsler)

• Includes:• abstract thinking• learning from experience• solving problems through insight• adjusting to new situations • focusing and sustaining the ability to achieve a desired goal

• IQ tests = very good predictors of academic performance.

• However, emotional intelligence is also important for successful functioning in society.



Intelligence tests, cont. Wechsler Adult Intelligence Scale (WAIS)• Used for assessment of intellectual functioning or

intellectual disability.• WAIS-III has SA norms.• WAIS-III contains:

• Verbal scales: Knowledge of facts; vocabulary; verbal reasoning; short-term memory; and abstract thinking

• Performance scales: Psychomotor ability; ability to learn new relationships; planning ability; and non-verbal reasoning

Raven’s Standard Progressive Matrices (RSPM)• non-verbal test • assesses abstract reasoning• can supplement WAIS



Personality inventories• Basic components of personality = traits.• If one can identify someone's personality type,

one can identify causes of (and predict) person’s future behaviour.

• A personality disorder is a mental illness with consequences similar to other major psychiatric disorders (e.g. Schizophrenia).

• One can evaluate personality by clinical interviews and by administrating personality tests.



Personality inventories, cont.Minnesota Multiphasic Personality Inventory II

(MMPI-II)• Broad range of self-descriptions; scored to give quantitative

assessment of individual’s level of emotional adjustment and attitude toward test-taking.

• Can be administered to people 16 years and older.• ‘True or false’ statements.• Content: Psychological, neurological, psychiatric, and

physical symptoms.• Pattern of responses compared to response patterns from

groups of individuals with specific disorders.• Scales measure personality traits.• Extremely reliable; good validity.



Personality inventories, cont.Millon Clinical Multiaxial Inventory III (MCMI-III)• Assesses personality, emotional adjustment, and attitude toward

taking tests.• Standardised self-report questionnaire (175 true/false

statements).• Pattern of responses compared to response patterns of groups

of individuals with specific disorders.• 28 scales that are divided into 5 categories:

• modifying indices• clinical personality patterns• severe personality pathology• clinical syndromes• severe syndromes

• Can be administered to individuals 18 years or older.• Focuses on personality disorders together with associated

symptoms.



Projective tests• Unconscious processes can influence psychological

disorders.• Present wide range of ambiguous stimuli - person asked to

describe what they see or asked to draw something.

Rorschach Inkblot Test• Ten cards with bilaterally symmetrical inkblots.• Individual must tell the clinician what they see.• Assesses structure of the personality (how individual

constructs their experience).• Individual organises responses according to own needs,

motives, conflicts, etc.• Indicates how person will confront other ambiguous situations.• Critique: Subjective interpretation/reliability/validity.• Exner scoring system addressed critique.



Projective tests, cont.Thematic Apperception Test• 20 cards (19 pictures; 1 blank).• More structured stimuli than Rorschach.• Individual must tell story of what is happening in the picture;

what characters might be thinking and feeling.• Reveals emotions, drives, and conflicts.• May reflect individual’s current life situation rather than

underlying personality structure.• Elicits rich, varied, multifaceted info, as well as unconscious

personal info. • Subjective interpretation; reliability improves using

quantitative scoring methods.



Neuropsychological assessment• Screen for neuropsychological and brain

dysfunction:• Necessary if individual has suffered head injury• Eligibility for:

• workman's compensation• disability grant• compensation from road accident fund

• Depression; dementia• Performing badly in school or work




Neuropsychological assessment, cont.The Luria-Nebraska Neuropsychological Battery

(LNNB)• 11 scores: Motor Functions; Rhythm; Tactile

Functions; Visual Functions; Receptive Speech; Writing; Reading; Arithmetic; Memory; and Intellectual Processes

• Score compared to critical level appropriate for that person’s age and education level.

• Controversy surrounding reliability and validity.


Neuropsychological assessment, cont.The Halstead-Reitan Neuropsychological Battery• 7 tests (5-6 hours to complete).• Able to discriminate between individuals with frontal lobe or

other lesions and normal individuals.• Evaluates wide range of nervous system and brain functions.• Provides useful info re brain damage: Causes, site, time (e.g.

childhood), deterioration.• Fixed test battery: Category Test; Tactual Performance Test;

Rhythm Test; Speech Sounds Perception Test; Finger Tapping Test; Trail Making Test; Aphasia Screening Test

• Needs skilled administration and interpretation.• Results can be affected by testee’s demographic factors.• Critique: Controversy surrounding reliability and validity; no

specific test of memory.



False positives, false negatives and malingering

• False positives: Test results indicate a problem when there is no problem.

• False negatives: Test results indicate that there is no problem when some difficulty does exist.

• Malingering = deliberately falsifying a test result• Use Rey 15-item test or Forced Choice test to

detect malingering.



Arriving at a diagnosis: The use of diagnostic classification systems

• Ultimate goal of assessment: Arrive at multiaxial diagnosis.

• Need: Minimum number and duration of symptoms.

• There is often overlap between symptoms in disorders.

• Differential diagnosis: List all possible disorders; often includes comorbid disorders.

• Final diagnosis communicates information to other professionals about patient, treatment, and prognosis.


The DSM-IV-TR & ICD-10 • Ultimate goal of assessment is to arrive at a multi-axial

diagnosis.

Arriving at a diagnosis, cont.

Viv O'Neill

Please change figure number to Fig 1.12


Section 2: Conclusion

• Assessment and diagnosis involves complex and time-consuming procedures.

• Requires:• investigative and deductive reasoning• technical skills• sensitivity to person’s cultural background

• Thus, training (and experience) are essential to avoid misdiagnosis.

• Diagnosis:• provides guide to treatment• helps understand prognosis

Education

Chapter 1 (revised)