Chapter 1 (revised)

Chapter 11: Strategic Leadership
Chapter 1
Psychological
Assessment &
Psychodiagnostics
Chapter 1Chapter 1
Psychological assessment andPsychological assessment and
psychodiagnosticspsychodiagnostics

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.

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.

cont.
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

• 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

• 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

• 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 5 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.

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 18 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.

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

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