Chapter 3

Assessing Psychological Disorders

 Clinical assessment
 Systematic evaluation and measurement
- Psychological
- Biological
- Social

 Diagnosis
 Degree of fit between symptoms and diagnostic criteria

 Purpose
 Understanding the individual
 Predicting behaviour
 Treatment planning
 Evaluating outcomes

 Funnel analogy
 Broad, multidimensional start
 Narrows to specific problems

Key Concepts in Assessment

Reliability

 Degree of consistency of a measurement

 Example: ‘Agreement’ between two different testing times or between
two different evaluators
Validity

 Does the test measure what it is supposed to?

 Several types:
- Concurrent: Comparison of results of one assessment with
another measure known to be valid
- Predictive: How well the assessment predicts outcomes
- Construct: Degree to which test or item measures the
unobservable construct it claims to measure (e.g. depression)

Standardisation

 Consistent use of techniques

 Provides normative population data
 Examples of things that are kept constant
- Administration procedures
- Scoring
- Evaluation of data
 The Clinical Encounter

Clinical encounter

 Assesses multiple domains

- Presenting problem
- Current and past behaviour
- Detailed history
- Attitudes and emotions
 Most common clinical assessment method
 Structured or semi structured.
 Example of semi structured interview: Anxiety Disorders Interview
Schedule for DSM-5 (ADIS-5) has modules pertaining to anxiety, mood
and related disorders, designed to assess DSM-5 criteria.

Mental State Examination

Mental state examination

 General appearance
 Cognition
 Mood and affect
 Reality testing and organisation
 Behaviour

Physical Examination

Physical examinations can be helpful in diagnosing mental health problems

 Understand or rule out physical aetiologies

- Toxicities
- Medication side effects
- Allergic reactions
- Metabolic conditions

Behavioural Assessment

Behavioural observation

 Identification and observation of target behaviours

- Target behaviour: Behaviour of interest (e.g. something that needs
to be increased or decreased)
 Direct observation conducted by assessor (e.g. therapist) or by individual
or loved one
 Goal: Determine the factors that are influencing target behaviours
 The ABCs of observation
- Antecedents
- Behaviour
- Consequences
  When individual observes self, it is called self-monitoring
 May be informal or formal (e.g. using established rating scales)
 The problem of reactivity
- Simply observing a behaviour may cause it to change due to the
individual’s knowledge of being observed

Psychological Testing

Psychological testing

 Specific tools for assessment of:

- Cognition
- Emotion
- Behaviour
 Include specialised areas such as personality and intelligence
 Psychological Testing: Projective Tests

Projective tests

 Rooted in psychoanalytic tradition

 Used to assess unconscious processes
 Project aspects of personality onto ambiguous test stimuli
 Require high degree of inference in scoring and interpretation

Examples

 The Rorschach inkblot test; Thematic Apperception Test (TAT)

Strengths

 May be useful icebreakers

 One way to gather qualitative data

Criticisms

 Hard to standardise
 Reliability and validity data tend to be mixed
 Objective Tests and Personality Inventories

Objective tests

 Roots in empirical tradition

 Test stimuli are less ambiguous
 Require minimal clinical inference in scoring and interpretation

Personality inventories

 Minnesota Multiphasic Personality Inventory (MMPI)

 Extensive reliability, validity and normative database

Psychological Testing

Minnesota Multiphasic Personality Inventory

 567 items (MMPI-2)

 True/false responses
 Example item: ‘I would like to be a singer’.
 Interpretation
- Individual scales
- Profiles

Psychological Testing and Objective Tests

Intelligence tests

 Nature of intellectual functioning and IQ

- Originally developed as a measure of degree to which children’s
performance diverged from others in their grade
 The deviation IQ
- Compare a person’s scores against those of other people who are
the same age
  Verbal and performance domains

Neuropsychological Testing

Purpose and goals

 Assess broad range of skills and abilities

 Goal is to understand brain-behaviour relations

Examples

 The Luria-Nebraska and Halstead-Reitan batteries

 Designed to assess for brain damage
 Test diverse skills ranging from grip strength to sound recognition,
attention, concentration

Problems with neuropsychological tests

 False positives: Mistakenly show a problem where there is none

 False negatives: Fail to detect a problem that is present

Neuroimaging and Brain Structure

Neuroimaging: Pictures of the brain

 Two objectives
- Understand brain structure
- Understand brain function

Neuroimaging of brain structure

 Computerised axial tomography (CAT or CT scan)

- Utilises X-rays
 Magnetic resonance imaging (MRI)
- Utilises strong magnetic fields
 - Better resolution than CT scan
 Positron emission tomography (PET)
 Single photon emission computed tomography (SPECT)
 Both involve injection of radioactive isotopes
- Isotopes react with oxygen, blood and glucose in the brain
 Functional MRI (fMRI) – brief changes in brain activity

Neuroimaging Advantages and Disadvantages

Chief advantage:

 Yield detailed information

 Lead to better understanding of brain structure and function

Disadvantages:

 Still not well understood

 Expense
 Lack adequate norms
 Limited clinical utility

Psychophysiological Assessment

Purpose

 Assesses brain structure, function and activity of the nervous system

Psychophysiological assessment domains

 Electroencephalogram (EEG) – brain-wave activity

- ERP – Event-related potentials = brain response to a specific
experience (e.g. hearing a tone)
 Heart rate and respiration – cardiorespiratory activity
 Electrodermal response and levels – sweat gland activity
Uses of routine psychophysiological assessment

 Disorders involving a strong physiological component

Examples

 PTSD, sexual dysfunctions, sleep disorders

 Headache and hypertension

Diagnosing Psychological Disorders: Foundations in

Classification

Diagnostic classification

 Classification is central to all sciences

 Assignment to categories based on shared attributes or relations

Idiographic strategy

 What is unique about an individual’s personality, cultural background or

circumstances?

Nomothetic strategy

 Often used when identifying a specific psychological disorder, to make a

diagnosis

Terminology of classification systems

 Taxonomy – classification in a scientific context

 Nosology – taxonomy in psychological/ medical phenomena
 Nomenclature – labels in a nosological system (e.g. ‘panic disorder’,
‘depressive disorder’)

Categorical and dimensional approaches

  Classical (or pure) categorical approach – strict categories (e.g. you either
have social anxiety disorder or you don’t)
 Dimensional approach – classification along dimensions (e.g. different
people have varying amounts of anxiety in social situations)
 Prototypical approach – combines classical and dimensional views

Widely used classification systems

 Diagnostic and Statistical Manual of Mental Disorders (DSM)

- Updated every 10 to 20 years
- Current edition (released May 2013): DSM-5
- Previous edition called DSM-IV-TR
 ICD-10
- International Classification of Diseases (ICD-10)
- Published by the World Health Organization (WHO)

History of the DSM

 Prior to 1980, diagnoses were made based on biological or

psychoanalytic theory
 Introduction of DSM-III in 1980 revolutionised classification
- Classification newly relied on specific lists of symptoms,
improving reliability and validity
- Diagnoses classified along five ‘axes’ describing types of problems
(e.g. disorder categories, health problems, life stressors)
 DSM-IV introduced in 1994
- Eliminated previous distinction between psychological and organic
mental disorders
- Reflected appreciation that all disorders are influenced by both
psychological and biological factors
  DSM-IV-TR (‘text revision’ of DSM-IV) incorporated new research and
slightly altered criteria accordingly

History of the DSM

 DSM-IV introduced in 1994

- Eliminated previous distinction between psychological and organic
mental disorders
- Reflected appreciation that all disorders are influenced by both
psychological and biological factors
 DSM-IV-TR (‘text revision’ of DSM-IV) incorporated new research and
slightly altered criteria accordingly
 Basic characteristics
- Removed axial system
- Clear inclusion and exclusion criteria for disorders
- Disorders are categorised under broad headings
- Empirically grounded, prototypic approach to classification

Adding New Diagnoses

 New disorder labels are created when groups of individuals are identified
whose symptoms are not adequately explained by existing labels
 Example: Premenstrual dysphoric disorder
- New disorder in DSM-5
- Relatively rare and severe emotional disturbance present during the
majority of premenstrual phases
 Example of new disorder that did not make it into the DSM-5: Mixed
anxiety–depression
- Insufficient research to justify the creation of a new label

Unresolved Issues in DSM-5

The problem of comorbidity

 Defined as two or more disorders for the same person

 High comorbidity is extremely common
 Emphasises reliability, maybe at the expense of validity (i.e. may
artificially ‘split’ diagnoses that are very similar)

Dimensional classification:

 DSM was intended to move towards a more dimensional approach, but

critics say it does not improve much from DSM-IV

Labelling issues and stigmatisation

 Some labels have negative connotations and may make patients less
likely to seek treatment

Summary of Clinical Assessment and Diagnosis

Clinical assessment and diagnosis

 Aims to fully understand the client

 Aids in understanding and relieving human suffering
 Based on reliable, valid and standardised information
 Chapter 6

OUTLINE

 Somatic Symptom and Related Disorders

- Somatic symptom disorder
- Illness anxiety disorder
- Psychological factors affecting medical condition
- Conversion disorder
- Functional somatic syndromes
 Dissociative Disorders
- Depersonalisation–derealisation disorder

FOCUS QUESTIONS

 What are the features of somatic symptom disorders?

 How are somatic symptom disorders managed?
 What are the features of dissociative disorders?
 How do dissociative disorders develop?

Somatic Symptom Disorders

 Somatic symptom disorders = excessive or maladaptive response to

physical symptoms or health concerns
 Soma = body
- Preoccupation with health or symptoms
- Physical complaints
- Usually no identifiable medical condition
 Types of disorders
- Somatic symptom disorder
- Illness anxiety disorder
 - Psychological factors affecting medical condition
- Conversion disorder
- Factitious disorder
 First identified by French doctor who noticed patients coming to him
with numerous complaints with no medical basis
 Formerly called Briquet’s syndrome
 Presence of one or more somatic symptoms
- Symptom is often medically unexplained
 Excessive thoughts, feelings and behaviours related to the symptoms
(e.g. excessive thoughts about seriousness of the symptom, frequent
complaints and requests for help, health-related anxiety, excessive
research)
 Substantial impairment in social or occupational functioning

DSM-5 Criteria: Somatic Symptom Disorder

A. One or more somatic symptoms that are distressing and/or result in

significant disruption of daily life.
B. Excessive thoughts, feelings and behaviours related to the somatic
symptoms or associated health concerns as manifested by at least one of
the following:
1. Disproportionate and persistent thoughts about the seriousness of
one’s symptoms.
2. High level of health-related anxiety.
3. Excessive time and energy devoted to these symptoms or health
concerns.
C. Although any one symptom may not be continuously present, the state of
being symptomatic is persistent (typically more than six months).
Specify if: With predominant pain (previously pain disorder): This specifier is
for individuals whose somatic complaints predominantly involve pain.

Specify current severity: Mild: Only one of the symptoms in Criterion B is

fulfilled.

Moderate: Two or more of the symptoms specified in Criterion B are fulfilled.

Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus
there are multiple somatic complaints (or one very severe somatic symptom).

Somatic Symptom Disorder

 Statistics
- Relatively rare condition
- Onset usually in adolescence
- More likely to affect unmarried women from lower socioeconomic
groups
- Runs a chronic course
 Research to date is limited due to recent redefinition of the disorder in
DSM-5

Illness Anxiety Disorder

 Very similar to DSM-IV hypochondriasis

 Clinical description:
- Severe anxiety about the possibility of having or acquiring a
serious disease
- Actual symptoms are either very mild or absent
- Strong disease conviction
- Medical reassurance does not seem to help

DSM-5 Criteria: Illness Anxiety Disorder

 A. Preoccupation with fears of having or acquiring a serious illness.
B. Somatic symptoms are not present or, if present, are only mild in
intensity. If another medical condition is present or there is a high risk for
developing a medical condition (e.g. strong family history is present), the
preoccupation is clearly excessive or disproportionate.
C. There is a high level of anxiety about health, and the individual is easily
alarmed about personal health status.
D. The individual performs excessive health-related behaviours (e.g.
repeatedly checks his or her body for signs of illness) or exhibits
maladaptive avoidance (e.g. avoids doctors’ appointments and hospitals).
E. Illness preoccupation has been present for at least six months, but the
specific illness that is feared may change over that period of time.
F. The illness-related preoccupation is not better explained by another
mental disorder, such as somatic symptom disorder, generalised anxiety
disorder or obsessive-compulsive disorder.

Specify whether: Care-seeking type: Medical care, including physician visits or

undergoing tests and procedures, is frequently used. Care-avoidant type:
Medical care is rarely used. From American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.

Illness Anxiety Disorder

 Affects approximately % 4-6 the general population

 Affects all ages approximately equally
 Often comorbid with anxiety and mood disorders

Culturally Specific Disorders

Koro = Fear in some Asian cultures of genitals retracting into the abdomen
Dhat = Symptoms (e.g. dizziness, fatigue) attributed to semen loss in some
Indian cultures

Kyol goeu = “Wind overload” among Khmer people of Cambodia.

 Fear that wind cannot circulate effectively through the body

 Dizziness, weakness, fatigue and trembling are seen as signs of this
illness

Causes of Somatic Symptom Disorders

 Consistent overreaction to physical signs and sensations

 Cause is unlikely to be found in isolated biological or psychological
factors
 Genetic component is present
 May have learnt from family to focus anxiety on physical sensations
 Three additional factors that may contribute to aetiology
- Stressful life events
- Illness in family during childhood
- Benefits of illness (e.g. sympathy, attention)

Schematic presentation: Somatic Symptom Disorders

 Example: Causes of Illness Anxiety Disorder

Somatic Symptom Disorder and Antisocial Personality Disorder

 Findings from family and genetic studies: Link between severe forms of
somatic symptom disorder and antisocial personality disorder
 Shared features
- Often begin early in life
- Chronic and difficult to treat
- More common in lower socioeconomic groups
- Linked to substance abuse and interpersonal problems
 Shared feature: disinhibition/impulsivity
- Individuals with somatic symptom disorder impulsively seek
sympathy and other benefits of illness
 Different manifestations of impulsivity
- Somatic symptom disorder: dependence
- Antisocial personality disorder: aggression
 Gender difference
 - ASPD much more common in males
- SSD more common in females

Management of Somatic Symptom Disorders

 Limited research to date

 Mild cases of illness anxiety disorder may benefit from detailed education
and some reassurance from medical professionals
 Cognitive-behavioural therapy can effectively treat illness anxiety
disorder
 Antidepressants may be helpful
 ‘Gatekeeper’ physician assigned to limit excessive use of medical
services
 Reduce supportive consequences of illness
- E.g. family members stop providing attention

Psychological Factors Affecting Medical Condition

 Diagnostic label useful for clinicians

 Indicates that psychological variables may be impacting a general
medical issue
 Examples:
- Patient’s concentration difficulties make it difficult to take
medication on time
- Patient fails to comply with medical advice due to being in denial
about diagnosis

Conversion Disorder

 Full name: Conversion disorder (functional neurological symptom

disorder)
 Key feature: Altered motor or sensory function that is inconsistent with
neural/medical conditions and not better explained by another disorder
- Often suggestive of neurological problem, but no such problem is
detected
 Must cause significant distress/impairment
 May display indifferent attitude towards symptoms (la belle indifference)
 Functioning may be mostly normal
 Not deliberately faking symptoms for the purpose of concrete gains
(malingering)

DSM-5 Criteria Summary: Conversion Disorder

 Conversion Disorder

 Rare condition, with a chronic intermittent course

 Often comorbid with anxiety and mood disorders
 Seen primarily in females
 Onset usually in adolescence
 Common in some cultural and/or religious groups

Conversion Disorder: Causes

 Not well understood

 Freudian psychodynamic view is still common, though unsubstantiated
- Past trauma or unconscious conflict is ‘converted’ to a more
acceptable manifestation, i.e. physical symptoms
 Primary/secondary gains
- Freud thought primary gain was the escape from dealing with a
conflict
- Secondary gains: Attention, sympathy, etc.
 Sociocultural factors
- More common in lower education, lower SES
- Patients likely to adopt symptoms with which they are already
familiar

Conversion Disorder: Management

 If onset after a trauma, may need to process trauma or treat posttraumatic

symptoms
 Remove sources of secondary gain
 Reduce supportive consequences of talking about physical symptoms

Factitious Disorders

 Purposely faking physical symptoms

 May actually induce physical symptoms or just pretend to have them
 No obvious external gains
- Only external gain may be benefit of ‘sick role’ (e.g. sympathy)
- Distinguished from malingering, in which physical symptoms are
faked for the purpose of achieving a concrete objective (e.g. getting
paid time off, avoiding military service)

DSM-5 Criteria Summary: Factitious Disorder

 Factitious Disorder Imposed on Another

 Formerly known as Munchausen’s syndrome by proxy

 Inducing symptoms in another person
- Typically a caregiver induces symptoms in a dependent (e.g. child)
 Purpose = receive attention or sympathy

Factitious Disorder Imposed on Another: Atypical Child Abuse

An Overview of Dissociative Disorders

 Severe alterations or detachments from reality

 Affect identity, memory or consciousness
 Depersonalisation – distortion in perception of one’s body or experience
(e.g. feeling like your own body isn’t real)
 Derealisation – losing a sense of the external world (e.g. sense of living in
a dream)
 Types of DSM-5 dissociative disorders
- Depersonalisation–derealisation disorder
- Dissociative amnesia
 - Dissociative trance disorder
- Dissociative identity disorder

Depersonalisation–Derealisation Disorder

 Recurrent episodes in which a person has sensations of unreality

of one’s own body or surroundings
 Feelings dominate and interfere with life functioning
 Only diagnosed if primary problem involves depersonalisation
and derealisation
- Similar symptoms may occur in the context of other
disorders, including panic disorder and PTSD

DSM-5 Criteria Summary: Depersonalisation–Derealisation

Disorder
 Depersonalisation–Derealisation Disorder

Facts and statistics:

 High comorbidity with anxiety and mood disorder

 1–3% of the population
 Onset is typically in adolescence
 Usually runs a lifelong chronic course
 Having a history of trauma makes this disorder more likely to manifest

Treatment:

 Research is very scarce

 No systematic research on psychological treatments
 Trial of antidepressant (fluoxetine) showed no effect above placebo

Dissociative Amnesia