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Chapter 4

Classification and Assessment of Abnormal Behavior


CHAPTER OUTLINE
I.

II.

Basic issues in classification


A.

Diagnosis is important because it enables the clinician to refer to the knowledge base of a particular
set of problems.

B.

Diagnosis does not necessarily provide any information about cause.

C.

One important question is at what level (e.g., individual or family) should a problem be
conceptualized

D.

Categories versus dimensions


1.

Categorical approachdistinctions are qualitative; either in a category or not

2.

Dimensional approachattributes seen as falling on a continuum and continuous

3.

The DSM is a categorical classification system, but abnormal behavior can also be
conceptualized as dimensional.

Classifying abnormal behavior


A.

Brief historical perspective


1.

There are two widely used classification systems.


a. International Classification of Diseases (ICD), published by the World Health
Organization; currently ICD-10
b. Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the
American Psychiatric Association; currently DSM-5

B.

The DSM-5 system


1.

Basic characteristics
a. Disorders are grouped under broad headings (e.g., Anxiety Disorders).

b. Disorders are defined by inclusion and exclusion criteria as well as duration.


c. Contains diagnoses for over 200 disorders
C.

Culture and classification


1.

DSM-5 recognizes that cultural norms may influence the experience and
expression of emotional distress.

2.

DSM-5 recognizes culture-bound syndromes: sets of symptoms seen in


people of non-western cultures

3.

DSM-5 encourages clinicians to consider the influence of cultural factors in


both the expression and recognition of symptoms of mental disorders by including
discussions of cultural concepts of distress.
a. Culture-bound syndromes patterns of erratic or unusual thinking and
behavior that have been identified in diverse societies around the world and do not
fit easily into the other diagnostic categories
b. Ataques de nerviosinability to interrupt the dramatic sequence of emotion and
behavior; ataques are provoked by situations that disrupt the persons social
world
c. Bulimia nervosa is thought to be a culture-bound syndrome for Western societies.

III. Evaluating classification systems--DSM-5


A.

B.

Reliabilitythe consistency of a measurement (including diagnosis)


1.

Interrater reliabilityrefers to agreement of raters (in this case, clinicians) about


observations (diagnosis)

2.

Test-retest reliabilityrefers to the consistency with which a patient displays the diagnosable
symptoms between assessments

Validitythe usefulness, meaning, or importance of a measurement (diagnosis)


1.

Etiological validityconcerned with factors that contribute to the onset of the disorder

2.

Concurrent validityconcerned with current correlations between the disorder and other
symptoms or behaviors

C.

D.

IV.

3.

Predictive validityconcerned with the course and stability of the disorder over time

4.

Validity is not all or none; there are degrees of usefulness.

Problems and limitations of the DSM-5 system


1.

Optimal thresholds for diagnoses (e.g., of level of distress or impairment, number of


symptoms); existing thresholds between abnormal and normal behavior have been critisized as
being too vauge

2.

The DSM-5 is categorical; however, many disorders appear dimensional.

3.

Additional questions center around whether the DSM-5 organization is optimal


for designing treatments or research.

4.

The failure to make better use of information regarding the course of disorders over time

5.

The absence of a specific definition of social impairment is a practical issue.

6.

DSM-5 does not classify clinical problems into syndromes in the


simplest and most beneficial way.

The problem of comorbidity


1.

Defined as the simultaneous appearance of two or more disorders in the same person

2.

56 percent of those who met criteria for one disorder also meet criteria for at least one other
Disorder.

3.

When comorbidity is high, the validity (meaningfulness) of the diagnosis is weaker.

4.

Frequent comorbidity also highlights unanswered questions regarding the longitudinal


course of symptoms of one or more diagnoses.

Basic issues in assessment


A.

Purposes of clinical assessment


1.

Collecting and interpreting information that will be used to understand a person and make a
diagnosis.

2.

Primary goals are making predictions, planning interventions, and evaluating interventions

3.
B.

C.

Provide guideposts to measure treatment progress

Assumptions about consistency of behavior


1.

Consistencybehavior is consistent over time and across situations

2.

Levels of analysis (biological, psychological, or social) determine the type of assessment used;
assessment can focus on individual or social systems.

3.

Clinicians want to know if they can generalize the samples of behavior obtained during
assessment to natural settings.

Evaluating the usefulness of assessment procedures


1.

Reliability (consistency)
a. Test-retest reliability measures the consistency of an assessment procedure over time.
b. Split-half reliability measures the internal consistency of the items within a test.

2.

Validity (meaningfulness)
a. Addresses question of the meaning of a particular score on a test
b. Measures degree to which a scale accurately predicts future behavior
c. Cultural differences can make assessment procedures that are valid in one group
invalid in others.

V.

Psychological assessment procedures


A.

Psychological assessment procedures


1.

Interviews
a. Most frequently used assessment procedure
b. Allows direct gathering of information about clients subjective experience
c. Allows observation of appearance and important nonverbal behaviors
d. Other than when making decisions related to intellectual disability, the use of psychological

or biological tests are not required to use DSM-5 diagnostic categories.


e. Structured interviews begin with an overview of the current episode with open-ended
questions; then they procede by imposing more structure, creating a systematic framework
for collecting information.
f.

Advantages: interviewer can control interview, observe nonverbal behavior, and


cover a great deal in short time

g. Limitations: some people are unable or unwilling to provide information; clients


are influenced by social desirability; subjectivity and bias can enter in from the
client and/or the interviewer
2.

Observational procedures
a. Informal observations provide information from the natural environment or
controlled settings.
b. Rating scales allow an observer to make judgments and rate behavior on a scale.
c. Behavioral coding systems or formal observational schedules
1.) Focus on frequency of specific, targeted behavioral events
2.) Can include self-monitoring in which the client observes and records his/her
own behavior
d. Advantages: a more direct source of information; does not rely on self-report
e. Limitations: may be time-consuming and expensive; bias can still influence ratings;
behavior may be altered during observation, and observations do not necessarily
generalize to other situations

3.

Personality tests and self-report inventories


a. Data is collected in a standardized setting; underlying traits or abilities are assessed.
b. Personality inventories are "objective tests" containing clear statements that the person
endorses or rejects (objective refers to the scoring)
c. Minnesota Multiphasic Personality Inventory (MMPI-2) is the most widely used
psychological test

1.) 500+ statements rated by the test-taker as true or false for him/herself
2.) Includes validity scales to check whether the person is avoiding frank and
honest responses, being overly defensive, careless, or exaggerating problems
3.) Test interpretation is based on explicit rules derived from empirical research.
4.) Advantages: information concerning the client's test-taking attitude is
obtained; assesses a wide range of problems quickly in an objective manner,
and actuarial scoring provides comparisons with other patients
5.) Limitations: not sensitive to some forms of psychopathology; dependent on
the ability of a client to be able to complete a long and difficult test; data is not
available on all profiles, and profile types are not stable over time, which may
reflect a reliability problem or the tests sensitivity to change
4.

Projective personality tests


a. The person is presented with ambiguous stimuli (e.g., a picture or inkblots) and
asked to generate a response (a story or description)
b. Assumes responses will contain meaningful clinical information (i.e., the subject is
projecting hidden desires or conflicts) ; based on psychoanalytic theory
c. Intuitive scoring looks for recurrent themes; Exner created a more objective,
quantitative scoring system for the Rorschach, focusing primarily on the form of
responses rather than the content.
d. Advantages: they may provide useful information that may not be obtained by
other methods, they may reveal aspects of the person's view of the world and possibly
unconscious motives, and they may supplement information learned with other
assessment measures
e. Limitations: projective tests tend to have poor reliability and validity, lack
standardization in scoring and administration, have limited normative data
associated with them, and may be time-consuming
f.

Hermann Rorschach (18841922) developed the Rorschach test in 1921, which


consists of a series of 10 inkblots used to assess personality characteristics and
psychopathology.

g. Thematic Apperception Test (TAT) consists of a series of drawings that depict


human figures in various ambiguous situations.

VI.

Biological assessment procedures


1.

Brain imaging techniquesexamining the brain through X-ray type procedures


a. Static brain imagingdetailed pictures of the brain; magnetic resonance imaging
(MRI)provides clearer images, which can be more easily transformed into three
dimensions
b. Dynamic brain imagingPET and fMRI (functional MRI) images highlight brain
functioning as it is occurring
1.) Positron emission tomography scanning (PET)very expensive but
provides detailed images of the brain and reflects changes in activity of the
brain regions
2.) Computed tomography (CT) can provide a static image of specific brain
structures; usually the MRI has replaced the use of this technique in most research
facilities.
3.) Functional MRI (fMRI)-- rapid images of changes in brain activity obtained
through the measurement of oxygen flow; can measure momentary changes in
brain activity
c. Advantages: provides detailed information regarding brain structure and activity,
which may, in the future, have diagnostic or research value
d. Limitations: procedures are expensive; adequate norms have not yet been
established for these measures; very limited clinical utility; relationship between
brain activity and specific cognitive/emotional processes is not clear

2.

Psychophysiological assessment uses autonomic nervous system responses (e.g., heart


rate, perspiration, skin conductance) as a measure of psychological state
a. Results may be inconsistent with each other and with subjective reports
b. Anxiety responses and associated physiological reactivity have been measured
using this method.
c. Relationship characteristics in married couples can be identified using
physiological measures. For example, some husbands show a pattern of high
physiological response but little verbal expression of the arousal; this pattern is
associated with dissatisfaction with marriage and, ultimately, divorce.

d. Advantages: reduces or eliminates subjectivity or bias on the part of the interviewer


and client; measures can be taken while patients are doing other activities such
as sleeping
e. Limitations: equipment is expensive and can be intimidating; validity and
reliability of any one physiological measure is questionable

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