Basics of Assessment

                Assessment: Process of gathering information about symptoms and possible causes
                                         .Also: Current symptoms, ways of stresscoping, recent events, substance abuse
                                          cognitive functioning, sociocultural background.

                Diagnosis: Label for a set of symptoms

• Validity:
  - Ability of a test to measure what it is intended to measure

• Reliability:
  - Indicates consistency of outcome

• Standardization:
  - Prevent extraneous factors from influencing responses
  - Administration and interpretation should be standardized à important for validity /reliability

Assessment Tools

• Clinical Interview:
  - Mental status exam: 5 types of information
                  1. Appearance and behaviour (Slow?)
                  2. Thought processes, speed of speech
                  3. Mood and affect
                  4. Intellectual functioning (memory/attention difficulty?)

                5. Orientation to place, time, person.

Structured interview: Format and sequence of questions is standardized

• Symptom Questionnaires:
  - quick assessment
  - cover wide variety of symptoms (BDI-Beck Depression Inventory)

• Personality Inventories:
  - Questionnaires that asses typical way of thinking, feeling, behaving.
  à Self-concept, attitudes, beliefs, well-being, coping strategies, perception of environment
       social resources, vulnerability
  - Minnesota Multiphasic Personality Inventory (MMPI) – 10 scales, 4 validity scales
                  - Problem with cross-cultural use

• Behavioral Observation and Self monitoring:
  - Clinician assesses specific behaviour (eg. Fights) and what precedes and follows them
  - Direct behavioural observation:
                  Problem: Individuals can alter behaviour when being watched (Hawthorne effect)

  Self-monitoring: Individuals keep track of the number and circumstances in which a specific
                                    behaviour occurs (eg. Alcohol use)

• Intelligence Tests:
  - Used when mental retardation or brain damage is suspected.
  - Tests: Wechsler Adult Intelligence Scale, Stanford-Binet, Wechsler Intel. Scale for Children
                  Problem: Do not asses talents in humanities + biased in favour of WEIRD middle,
                  upper class society.

• Neuropsychological Tests:
  - Used when neuropsychological impairment is suspected (memory – dementia)
  - Tests: Bender Gestalt Test (Draw and remember set of 9 drawings)
                  à does not identify specific type of damage
                  Halstead-Reitan Test
                  Luria-Nebraska Test
                  à Test for concentration, dexterity, speed of comprehension

• Brain-Imaing Techniques:
  - Good to identify specific deficits and brain abnormalities.
  - Clinicians: Injury / tumor
  - Researcher: Brain activity or structure

  Computerized tomography CT:
  - Function: Narrow X-Ray beams pass through head in diff. angles. Amount of absorption
                        of each beam is measured à slice of brain
  - Limitations: X-Ray
                            Image of brain structure, not activity

Positron-emission tomography PET:
- Function: Injection of radioactive isotope (eg. Fluorodeocyglucose FDG).
                      à accumulates in active parts of brain. Isotop decause, emits positrons which
                           collide with electrons. Both get annihilated à into photons.
                      Scanner detects photons at point of annihilation
- Limitation: Immage
- Variation:
                Single photon emission computed tomography SPEC: Different tracer substance
                à less accurated / expensive

Magnetic resonance imaing MRI fMRI:
- Advantages: No radiation, detailed pictures, any angle,
                           Structural MRI: Static image of brain structure
                           Functional MRI: Brain activity
- Function: Creates magnetic field, Hydrogen realigns. On/Off à hydrogen changes position
                      and emit magnetic signals

• Psychophysiological Tests:
  - Alternatives to CT, PET, SPECT, MRI
  - Can detect emotional and physiological changes.

  Electroencephalogram EEG:
  - Function: Measures electrical activitiy on scalp, (firing of neurons below)
                        Measure reponse to stimuli. Evoked potentials, event-related potentials
  - Use: To detect seizures, tumors, strokes.

  Lie detector:
  - Function: Measures electrodermal response (electrical conductivity on the skin)

• Projective tests:
  - People are shown pictures and the theory is that they interpret it according to their beliefs,
    concerns, feelings, relationships, desires.
  à uncover unconscious motives (if resistant or biased client)
  - Tests: Rorschach Inkblot Test à inkblots
                  Thematic Apperception Test TAT: Series of pictures à client tells a story
  - Used usually by psychodynamic therapists
  - Problems: Validity /reliability, cultural backgrounds differ
   

Challenges in assessment

• Resistance:
  - inability or unwillingness to provide accurate information
  - Forced teenagers, Strong interest in outcome of assessment (report only selected
    information),

• Evaluating Children:
  - cannot describe feelings or events very good. React to situations and emotions different
     than adults
  à Parents, Teachers are source of information
                  - Problem: Biased view. 63% difference in child/parent reason what problem is
                                      Teachers, Parents views differ, cause of different context

• Individuals across cultures:
  - Language problem.
  à Overdiagnosis: Assessor interprets unclear expression as more pathology
  à Underdiagnosis: Client cannot describe situation accurately
  - Solution:  Interpreter, but needs to be trained and well matched with sociocultural/economic status
    of client. (Dialect ect.)

  - Major difference of cultures: Reporting symptoms of psychopathology in emotions or
    somatic (physical) symptoms.

Diagnosis

                - Label for symptoms
                - Cultural variation in symptoms and presentation (emotional, somatic)

                Syndrome: Several symptoms form a syndrome
                                       - are not list of symptoms that occur in all disorders but co-occur

                Classification System: Set of syndromes and rules of determining if patients symptoms are
                                                            part of this set.

                Diagnostic and Statistical Manual of Mental Disorders, DSM: APA
                International Classification of Disease, ICD: Rest of the world

                Reification of diagnoses:  People tend to see it as real and existing, rather than a concept
                                                                    made out of judgement.

                Comorbidity: Criterias for one disorder are present in other disorder and lead to confusion
                                           which disorder is actually present (eg Schizophrenia/Depression and irritability)
                                           à not preventable because symptoms reflect problems in fundamental human
                                                  experience (sleep, emotion, cognition)
                                           à Leads to several diagnosis (primary/secondary) and problem with which to
                                                  deal first

• DSM:
  - DSM I (1952): vague descriptions, influenced by psychoanalytic theory
  - DSM II (1968): similar, only 54% reliability
  - DSM III (1980/87): 70% reliability, diagnosis relies heavily on clients statements,
                                          Axial approach: I : Clinical disorders
                                                                         II : Personality disorder, intellectual functioning
                                                                        III : Medical, psychosocial, environmental, childhood.
                                                                        IV : How does III affect diagnosis, treatment, prognosis
                                                                         V : Global assessment of functioning GAF-scale 0-100
  - DSM IV (1994/00): specific, concrete criteria for each disorder (behaviors, thoughts,
                                       feelings) à increase reliability through field trials à successful
  - DSM 5 (2013): Incorporation of continuum / dimensional model (noncategorical)
                  à Positive change: - How long symptoms must be present
                                                         - Symptoms must interfere with well-being and functioning
                                                         - Differentiation between disorders better established

                  à nonaxial approach: - To be more in line with ICD-System published by WHO
                                                              - Axes I-III integrated in overall diagnostic scheme
                                                              - Former Axes IV-V are no longer diagnostic criteria
                                                              à To provide index of global functioning, use WHODAS
                                                                                            à WHO Disability Assessment Schedule

• Danger of diagnosing:
  - Label leads clients and social surrounding to act according to their beliefs about the disorder
  à Power, control that can be abused
  - Psychologists made up Schizophrenia (Rosenhan 1973)
  à Discovered errors in diagnosis and hospital system

  - Benefits: Good communication between clinicians, facilitates research by standardization.

   

• Anxiety and Fear -  Fight or Flight?

     Fight or flight response:
   

   

  Posttraumatic Stress Disorder + Acute Stress Disorder

   

  PTSD: Result of experiencing expreme stress, traumatic experiences
              à death, injury, sexual abuse
              - women greater risk than men (gender related cultural experiences)
              - Withdrawal from activies that resemble event
              - Memory amnesia of details from event
              - Hypervigilance, chronic arousal
              - 20% of Vietnam veterans
              - 50% of sexual assault develop it

   Accute Stress Disorder /PTSD with prominent dissociative (depersonalization/derealization) symptoms
                  - Symptoms within 1 month after stressor and duration of symptoms = 4+ weeks
                  - Flashbacks, nightmares
                  - dissociative symptoms: Feeling that everything is unreal, a dream.

  Theory of PTSD:
  - Predictors: Severity, duration, proximity, social support
  - Chronic exposure to straining situations
  - Maladaptive coping styles (dissociation)
  - Culture influences manifestation: e.g. attaque de nervios
  Biological:
  - PET + MRI Scan = different brain activity (fight or flight), amygdala, hippocampus, PFC.
  à bad emotion regulation, overexposure to neurotransm. = shrinkage of hippocampus à bad sympathicus
       regulation.
  - Cortisol: Usually high levels à higher stressresponse, more time spend in reaction
  - Higher neurotransmitter use: epinephrine + norepinephrine. à HPA axis cant shut down
  - Genetics: Low cortisol is heritable

  Treatment of PTSD:
  CBT:
  - systematic desensitization
  - integration of events in self-concept
  stress-inoculation therapy: Therapist helps to cope with other problems that increase stress. à when
                                                         client is unable to expose to stimulus

  Drugs:
  - SSRI
  - Benzodiapezines

   

   

  Specific Phobias and Agoraphobia

        Specific Phobia: Irrational fear towards specific object or situations à most common disorder
  - 5 cathegories: animal, environment, situational, blood-injection-injury, other
   

  Agoraphobia:
  - Fear places where one cannot escape from or has trouble finding help
  - Fear that others can see nervousness or embarrass oneselve during panic attack.
  - more women than men. Start at early  20s.

  Theories of Phobias:
  - Freud = unconscious anxiety is displaced onto neutral object.
  - Behavioural: - classical conditioning leads to fear, operant conditioning maintains it. Negative reinforcement
  - prepared classical conditioning: Through evolutionary past. Conditioning can occur faster
  - Biological: First degree realtives = 4-5x more likely

  Treatment for Phobias:
  - Behavioural: systematic desensitization, modelling, flooding (injection inj. Blood= teach to rise blood pressure)
                                                                                                                            à applied tension technique
  - Drugs:
  - Benzodiapezines
   

   

  Social Anxiety Disorder

  - anxious and avoidant of social situations – fear of embarrassment, humiliation
  à somato experiences of stress à evtl panic attack
  - women more than men
  - develops in adolescence
  - Many comorbid disorders – Mood + other anxiety disorders

  Theories of Anxiety Disorder:
  - Genetic component
  - Cognitive perspective: irrealistically high standards for social performance, focus on negative aspects, self-evaluating
                                                  misinterpret everything in a self-defeating way, attention on own body sensations, ruminate

  Treatment of Social Anxiety Disorder:
  - SSRI
  - SNRI
  - CBT: exposure, relaxation, challenge beliefs, group therapy?
  - Mindfullnes based: less judgement
  - ACT: Acceptance and commitment
  - Future: Virtual reality exposure

  Panic Disorder

        Panic attacks: Short period of extreme physical stress response without environmental trigger or with specific trigger
  - 28 percent of adults at one time
  - Fear of life threatening illness or to go crazy
  - Co-occurrence with other disorders

  Theory of Panic Disorder:
  - Biological:
  - Heritability 50 %
  - Poor regulation of neurotransmitters à flight or fight response is poor
  - General arousal can trigger panic attacks
  - Dysregulation of neurotransmitters in the locus ceruleus: Can cause panic attacks cause connected to limbic system
  - Occurs postpartum or premenstrual periods
  - Cognitive:
  - Focus on bodily sensations
  - Misinterpret these
  - Engage in snowball catastrophic thinking
  - anxiety sensitivity:  belief that bodily symptoms have harmful consequences
  - interceptive awareness: awareness of bodily cues
  - interoceptive conditioning: bodily cues occurred at beginning of previous panic attack are now a cue.
                  even if not conscious
  - felt controllability decreases risk of panic attack

  Treatment for Panic Disorder

  - Drugs:
  - SSRI
  - SNRI
  - Benzodiapezines  à influence GABA

  - CBT:
  - 1. Relaxation techniques
  - 2. Identification of cognitions
  - 3. Practice relaxation techniques during experience of symptoms with therapist
  - 4. Challenge of catastrophizing cognitions
  - 5. Systematic desensitization
  - 90 % relief after 12 weeks

   

  Generalized Anxiety Disorder

   

        GAD: Excessive worry
  - more women than men
  - mostly chronic
  - beginning in childhood or adolescence
  - goes with comorbid disorders

  Theories of GAD:
  - Cognitive:
  - experience more intense negative emotions
  - highly reactive to negative events
  - feel that emotions are not controllable
  - chronicically high stress levels
  - maladaptive cognitions
  - hypervigilant
  - experienced high stress in past that was uncontrollable
  - cognitive avoidance model: worrying helps them to become aware of threats. This constant level of anxiety is better
                                                              than a sudden jump in anxiety and reduces reactivity to negative events

  - Biological:
  - Higher general activity of sympathetic system
  - Abnormality in GABA regulation (lack of thought inhibition)
  - heritable

  Treatments of GAD:

  CBT:
  - Challenge of cognitions
  -  Development of coping strategies

  Drugs:
  - Benzodiapezines
  - Tricyclic antidepressants

   

  Separation Anxiety Disorder

   

        - Occurs most often in childhood
  - physical symptoms in abdomen, nightmares, crying

  Theories of Separation Anxiety:
  Biological:
  - heritable. Behavioural inhibition: shy, fearful, irritable, cautious, quiet, introverted children

  Psychological:
  - Controlling and intrusive parents, + critical and negative
  - Give little control to children

  Treatment for Separation Anxiety:
  - Coping skills
  - Relaxation techniques
  - Parents need to learn it as well, also to teach their children

  Drugs:
  - Antidepressants
  - SSRI
  - Antianxiety: Benzodiapezines
  - Antihistamines

   

  Obsessive- Compulsive Disorder

   

        Compulsion: Repetitive acts that the individual “must” perform to get rid of obsessions or bad feelings
  Obsession: Intruding and disturbing thoughts (mostly aggressive, sexual, religious) (magical thinking)

  3 types: sexual-aggressive, order-symmetry, contamination

  subtypes: hoarding, hair-pulling, skin-picking, body dysmorphic disorder.
  - Begins at young age
  - Comorbid disorders: Panic attacks, phobias, substance abuse.

  Hoarding: cant throw away possessions, emotionally related to them (delusions)
  Hair pulling: relive of tension or pleasure. Automatic
  Body dysmorphic disorder: believe part of body is defective, preoccupied with hiding this. Bizarre, surreal.

  Theory of OCD:
  - Circuit in the brain: PFC à Basal Ganglia (striatum) à Hypothalamus à PFC
  - Hippocampus
  à inable to turn off primitive impulses
  - Children: Strep infection
  - genetical components

  Cognitive theory:
  - inability to control or disregard thoughts
  - Rigid, moralistic thinking
  - feel very responsible for everything
  - Belief they should be able to control every thought
  - Convulsions develop through operant conditioning

  Treatment of OCD:
  - Drugs:
  - Antidepressants: SSRI

  CBT:
  - exposure and response prevention: expose clients to stimulus but prevent response. Habituation.
  - Challenge negative cognitions à  60-90% success
  - habit reversal training: become aware of unhealthy behaviour, replace with more healthy one