Lecture notes with Psychodiagnostics at the Leiden University

Lecture 1

The history of psychological testing

- In 2200 BC, Chinese emperors examined officials for fitness for office. Only 3% passed the test. They tested civil law, military affairs, agriculture, revenue and geography.

- Physiognomy was a method of psychological testing based on assessment of a person’s outward appearance. 

- Phrenology is an example of this. It assumes that the reading of bumps on the head can be used to measure characteristics of the individual.

- On average, people can’t detect lies on the basis of someone’s facial expression. Only certain experts were able to detect lies by detecting micro expressions.

- Early experimental psychology originated in the early 1800s. They primarily looked at sensory processes using objective procedures.

- Francis Galton is seen as the ‘father of mental testing’. He introduced objective assessment to detect individual differences in for example intelligence.

- Alfred Binet was however the first to develop an actual intelligence test: Simon-Binet intelligence test. According to him, intelligence should be measured not only by focusing on sensory processes. 

- Binet introduced the concept of ‘mental age’ and the Intelligence Quotient (IQ); which is still used today.

- Over the years, researchers also gained interest in aptitude, projective, personality and neuropsychological tests and interest inventories.

- All these methods of testing have life-long relevance (in all different stages of life).

Different types of psychological tests

- Psychological tests are either criterion-referenced or norm-referenced. Criterion-referenced tests compare individual scores to a certain cut-off score; so they are able to measure the ability level of the individual. Norm-referenced tests compare individual scores to a relevant standardization sample; the norm group.

What is psychodiagnostics?

- Psychodiagnostic testing makes use of the empirical circle; observation -> induction -> deduction -> testing -> evaluations. In psychodiagnostics, it is called the diagnostic cycle.

- The diagnostic cycle:

1. Assessment of the client’s complaints (intake interview, anamnesis, client’s request for help).

2. Assessment of client’s problems (establishing the link between the complaints and problems, clustering of problems and cross-referencing of the problems with scientific knowledge of (mental) illness).

3. Diagnosing (formulate hypothesis, test it, choose the test, evaluate the results and integrate those).

4. Indication (determining goal for intervention, type of help and a recommendation).

- In Youth Diagnostics, we normally have an intake, an interview with informants (like the parents or teachers) and an interview with the child itself.

- We typically use classification systems such as the DSM-V to make a diagnosis.

- However, this system fails to detect a disorder in people who have multiple different problems yet who do not reach the diagnostic threshold. 

- Also, not all disorders in childhood fit in homogenous categories.

- Needs-based assessment model integrates multiple steps: 

1. Intake 

2. Strategy 

3. Testing/diagnosis

4. Needs-assessment (Do we adhere to the request of help? Or do we need to reconsider our treatment and go back to earlier steps?)

5. Recommendations

- NBA is a goal-directed diagnostic process. It targets relevant risks and protective factors. It is scientist-practitioner oriented, since it combines scientific knowledge with coaching skills. It increases the clinical relevance of assessment data by translating information into recommendations for intervention.

- A proper diagnosis conveys information about strength, weaknesses, etiology and best choices for remediation and treatment.

Bullet-point summary

• This lecture focuses on the history of psychological testing; which started in 2200 BC in China. Later on, the field of physiognomy arose. Early experimental psychology originated in the 1800s. Sensory processes were viewed as objective measures.
• Alfred Binet was the first to develop an intelligence test. Before that, intelligence was measured by someone's ability level on sensory test. Binet introduced the Intelligence Quotient.
• Psychological tests can either be criterion-referenced or norm-referenced.
• Needs-based assessment consists of the following procedural steps: intake -> formulation of strategy -> testing and diagnosing -> evaluation -> recommendation

Lecture 2

- Behavioral assessment gathers information on what a person does, rather than assessing how the person feels. We assess in an objective manner the behavior on a day-to-day basis.

- The goal of behavioral assessment is to provide relevant information for treatment and the possibility for educational/developmental improvement of the child.

- Observable behavior (data) is the primary means of evaluation of the behavior.

- Behavioral assessment takes place through the stages as described in the Needs-Based Assessment Model. Today, we will focus on the intake stage.

- During the intake, we focus on the antecedents of (atypical) behavior and its consequences. We identify the reinforcement history (what factors have sustained the behavior). Why has the behavior not responded to change? What are the attributions with respect to the problem behavior?

- Antecedents are the triggers of the target behavior. The ABC theory is as follows: Antecedent --> Behavior --> Consequences.

- SORC model for behavioral interviewing: S (stimulus; antecedents), O (organismic variables), R (response) and C (consequences).

- Behavioral assessment is generally viewed as more objective than a personality inventory. It has a lower level of interference for its interpretations. 

- A response set is the normative data on responses of a standardized sample.

- Behavioral assessment has pitfalls: Feelings are for example not always congruent with behavior. Externalizing behavior is more obvious and easier to assess than internalizing behaviors. Behavioral assessment is sensitive to response sets. Researchers should also consider that participants may present overly positive (social desirability) or negative presentations (cry for attention) of behavior.

Types of tests and assessment:

- Controlled direct observations (are ethical, but have low validity)

- Naturalistic direct observations (are high in validity, but raise an ethical dilemma since there is no consent from the individual)

- Behavioral observation (counting behaviors)

- Observational sampling methods:

--> During event sampling, the researcher keeps track of specific behavior and uses coding schemes. The advantage is that the data is quantitative. A disadvantage is that other possibly relevant behaviors are not taken into consideration.

--> During time sampling, the researcher reports behavior during specific time intervals. The advantage is that reduces the number of observational moments; qualitative data. A disadvantage is that observations might not be representative. Interesting or relevant behaviors may be missed.

Types of behavioral tests:

- Maximum performance test measure the ability of the test taker.

- Typical response tests provide an index of constructs as personality, behavior, attitudes and interests.

- Behavior rating scales reflect for example aggression, hyperactivity, depression or anxiety. They tell us how common or rare certain behaviors are in the general population. These scales are time-efficient and cheap. Objectivity is however an important concern; parents or teachers may over- or underestimate behavior.

--> The Child Behavior Checklist (CBCL) is a standardized questionnaire to assess problem behavior in children. It provides an index of externalizing and internalizing problems. CBCL makes use of parent, teacher and self-reports. 

--> We should keep in mind that the CBCL is a screener of problem behavior; and diagnosis based on solely this instrument is not possible.

--> The CBCL consists of two sections. Section 1 considers information about the child’s activities and competencies. Section 2 considers information of the child’s problem behavior.

- Domain-specific rating scales focus on one specific syndrome or set of symptoms.

- Psychophysiological assessment is for example done using a polygraph; which is a lie detector test that measures changes in heart rate, respiration and skin conductance. Electroencephalograms (EEG) measure brain activity with high temporal precision. 

- Neuro-feedback training is effective on very specific areas of the brain.

- The psychologist has many tasks during the assessment process. He or she must provide a diagnosis in a limited time period, have a good overview of background information, understand and formulate the case characteristics and make therapeutic recommendations. 

- Psychologists should keep in mind that diagnostic criteria change over time.

- The goal of the intake process is to get insight into the origin of the problem behavior, to clarify the request for help, understand the problems, get to know the parents (to get an idea of the child’s environment), preliminary development of assessment process, and to build a framework to interpret the test results. It also serves to provide building blocks for a good client-therapist relationship, give insight to subsequent steps and procedures, and end with agreement for treatment or referral.

- The client-therapist relationship is essential for good therapy. During the intake, the first moment of contact takes place. The therapist should have emphatic abilities and be aware of the message that his or her verbal as well as nonverbal behavior conveys. Good (non-)verbal therapist behavior relates to active listening by expressing certain body language, paraphrasing of what the client says, et cetera.

- Steps in the intake process: 

1. Specify the amnesis (uncover pattern of complaints, when did these surface, what preceded them, what are the consequences and what is the client’s attitude towards them. Why is the client asking for help at this moment?)

2. Specify the current level of functioning on different areas in life and the client’s developmental anamnesis. You should look for clusters of symptoms.

3. To offer adequate psychological counseling. A request for help needs to be clarified. What are the wishes and expectancies of the client?

- Then, after finalizing the intake process, the therapist considers what the adequate strategy is going to be. He describes and clusters the child’s characteristics, clusters those relevant to a certain context and chooses a strategy based on these findings.

- Risk assessment considers the age appropriateness of behavior, their duration, the frequency, the intensity and the circumstances in which the behavior occurs.

- If the child characteristics have been clarified and clustered, then research questions and hypotheses can be formulated. Diagnostic hypotheses can also be translated into questions. Hypotheses need to be derived/justified from and formulated based on scientific theories or evidence. They also need to be testable. There are different fashions in which hypotheses can be formulated.

Bullet-point summary

• Behavioral assessment follows the same steps as needs-based assessment. This lecture mainly focused on the intake stage.
• The ABC theory: Antecedent --> Behavior --> Consequences
• There are different methods of assessment; controlled direct observation, naturalistic direct observation, behavioral observation and observational sampling.
• There are also different types of behavioral tests; maximum performance tests, typical response tests, behavioral rating scales (such as the CBCL), domain-specific rating scales and psychophysiological assessment.
• The goal of the intake process is to get insight into the origin of the problem behavior, to clarify the request for help, understand the problems, get to know the parents, preliminary development of assessment process, and to build a framework to interpret the test results. It also serves to provide building blocks for a good client-therapist relationship, give insight to subsequent steps and procedures, and end with agreement for treatment or referral.
• A good client-therapist relationship is essential.
• Steps in the intake process are: 1. specify the amnesis, 2. specify the current level of functioning, 3. clarify request for help
• Hypotheses are formulated after the symptoms have been clarified and clustered.

Lecture 3

- There is not one general accepted definition of intelligence. Generally, we say that intelligence reflects one’s ability to learn from it’s environment and adapt to it.

- Galton assumed that intelligence was governed by sensory abilities. The more perceptive our senses are, the larger is the field upon which our judgment and intelligence can act. However, sensory processing speed is significantly affected in individuals with low intelligence levels.

- Spearman thought that there is one general factor that captures our intelligence; the g factor. The g factor captures different sub-factors of intelligence.

- Cattell-Horn-Carroll’s (CHC) theory of intelligence stated that intelligence consists of pervasive, broad and narrow abilities. At the top of all these abilities, in striatum III, is the g factor. This model is still used today.

- The CHC theory distinguishes fluid intelligence (high level reasoning that is used for novel tasks, which cannot be performed automatically) and crystallized intelligence (acquired cultural knowledge).

- Gardner states that we have multiple intelligences that normal intelligence tests would not distinguish: Think of musical intelligence, naturalistic intelligence and creative intelligence. Gardner states that what we consider intelligence is dependent on cultural values.

- Someone has an intellectual disability when the IQ is below 70 and significant limitations in adaptive functioning occur. These limitations should have their onset prior to the age of 18 years.

- Intelligence testing is used in enrollment in academic trajectory, diagnosing intellectual disabilities, academic difficulties or giftedness.

- General IQ does however not explain the unique individual functioning of a person. A detailed analysis of the intelligence subtest can in this case shed more light on the specific strengths and weaknesses of the person.

- The Wechsler Intelligence Scales are the general scales we use nowadays to determine intelligence. The WAIS test consists of a verbal IQ scale and a performance IQ scale, which are both subdivided into more sub-scales.

- The WISC intelligence test for children is very much based on the CHC theory. It gives insight into the relative strengths and weaknesses of the child. The test measures fluid reasoning, visual spatial abilities, verbal comprehension, the working memory index, and the processing speed index. We compare the results of these different subtests by standardizing the test scores into normed scores. We can then accurately compare them.

- It is important to think about how you communicate the results of intellectual functioning test to parents and teachers.

- It is also important to keep in mind that we cannot solely base a diagnosis on an intelligence test.

- When assessing a child’s cognitive functioning, you also measure cooperation, attention, persistence, ability to sit still, and social responsiveness to an assessment situation, Behavioral observations are therefore just as important as the test results of an intelligence test. 

- Test scores obtained during infancy show poor predictive validity of older ages. 

- As a clinician, you may get questions from clients dealing with their developmental delay, relative strengths and weaknesses in cognitive functioning, and what to expect in terms of development. Also: is there a chance on full recovery? 

- Sometimes it is impossible to apply a standard IQ test to a client, for example because the IQ is too low: Standard intelligence tests are too difficult; IQ tests have poor discriminative ability of subtest due to too low performance. Also, verbal deficits hamper administration of some verbal subtests of an IQ test.

- Underestimating and overestimating are important pitfalls a clinician should consider. 

Bullet-point summary:

• Intelligence is one's ability to learn from and adapt to its environment.
• Galton thought intelligence could be measured by measuring sensory processing. Later on, Spearman came up with the idea that the g factor is the overarching factor of intelligence.
• Cattell-Horn-Carroll’s (CHC) theory of intelligence stated that intelligence consists of pervasive, broad and narrow abilities.
• Gardner states that we have multiple intelligences that normal intelligence tests would not distinguish.
• A general IQ does not specify the relative strengths and weaknesses of a person.
• The Wechsler and WICS methods for measuring intelligence are commonly used today.
• We cannot base a diagnosis solely on the results of an intelligence test.
• Test scores obtained during infancy show poor predictive validity of older ages. 

Lecture 4

- Child neuropsychology studies the relationship between behavior and the functioning of the brain during ongoing development.

- Child neuropsychologists try to infer associations between atypical child behavior and brain dysfunction.

- In split-brain patients we can clearly observe the specializations of the two hemispheres.

- Neuropsychological assessment focuses on IQ, sensory perception, attention, information processing, verbal memory, visual memory, executive functioning, language, and social cognition. Standard psychological assessment on the other hand only focuses on IQ, educational achievement, socio-emotional disturbances, and the DSM. It focuses on the discrepancy between IQ and educational achievement.

- Brain dysfunction influence neurocognitive functions, which influence behavior and behavioral problems. The environment facilitates or compromises these processes. 

- Neuropsychological assessment is required in cases of autism, developmental disorders, attentional disorders, (neuro-)psychiatric disorders, memory disorders, traumatic brain injury, substance abuse, infections, and radio/chemotherapy. It is also assessed in cases of brain-related cognitive dysfunction, evaluations of rehabilitation processes, when we explore possibilities for educational support, when there is a disharmonic intelligence profile, or when there is a prominent decline in (education) performance.

- Important questions that clinicians may receive are: What are the chances of (complete) recovery? And; what are the consequences of brain injury / chemotherapy / infections on cognitive functioning.

- Brain development is associated with a decrease in grey matter volume.

- The brain area that controls executive functions such as controlling impulses and weighing long-term consequences is one of the last brain areas to fully mature. 

- The premorbid level of functioning refers to the level of functioning prior to the brain trauma, infection or chemotherapy. Hold tests are the least sensitive to brain trauma; such as vocabulary tests, reading tests and tests of abilities that are (largely) automatized. This gives us a problem since most cognitive abilities are not that automatized yet in children. This is why these test are usually used for adults.

- The size of the tumor or lesion does not always imply more or less severe cognitive deficits. The location is however often decisive with regard to the severity. Brain development also plays an important role: During what stage of brain development did the tumor or lesion occur?

- Disruptions in brain development during early development typically have more global affects on cognitive functioning. These disruptions can occur as a result of genetic deficits, infections, oxygen depletion or substance abuse by the mother. Traumatic brain injury at a very early age can also have detrimental consequences.

- Young brains are more plastic, but this does not necessarily mean that they recover more quickly or better from brain trauma. There is for example strong evidence that young children under the age of 7 have a smaller chance on reasonable recovery than older children. 

- Psychosocial problems within the family environment can have a negative consequence for the chances of recovery. This is referred to as the double hazard hypothesis.

- Brain injury does not only affect cognition, but in some cases personality as well.

- Some effects of a tumor become visible only after a certain period of time. It often becomes evident during a task where one expects adequate performance given the age of a child. Executive functioning deficits reveal itself when the child is expected to possess certain cognitive control functions given the developmental level of the child.

- Behavior that is adequate or appropriate for a certain age may be inadequate of inappropriate for another age. For this reason, a neuropsychologist is required to have sufficient theoretical knowledge about the typical brain functioning throughout development.

- Problem assessment results in testable hypotheses about either atypical development or brain dysfunction. Hypotheses will be tested by using tests that index neurocognitive functions.

- Profile analysis is characterizing strengths and weaknesses in neurocognitive functioning. Profile analysis is done by translating raw subtest scores into standardized scores. Clinicians should be aware of situational factors that might have influence the testing and interpretation of the scores, and be aware of neurocognitive fractional functions. Test scores are then clustered with respect to their neurocognitive function. Large differences between test scores are most meaningful in this case.

- Clinicians never make a diagnosis based on a single test.

- Interventions are aimed at minimizing the functional impairments resulting from the cognitive dysfunctions.

- The ultimate goal of the strengths and weaknesses profile is to engage in theory-driven thinking about brain-behavior associations that yield an individual explanatory theory. Causal, threatening and facilitating factors are discussed.

- The Mini Mental State Exam is a 5-10 minute screening test that yields an objective index of cognitive functioning.

- Subtest performance on intelligence scales can be related to brain (dys)function: Subtest that index fluid intelligence are mostly related to frontal brain and executive funciton. Subtest that index crystallized intelligence are mostly related to temporal and parietal brain regions. Most working memory tasks demonstrate a close relation with fluid intelligence.

- Full scale IQ is the most important measure to predict future functioning. Subtest provide insight in strengths and weaknesses in neurocognitive functioning.

- Perception contains five sensory modalities; auditory, visual, somatosensory (touch), gustatory (taste) and olfactory (smell).

- The perceptual system is dependent on individual specialization and integration with other neural networks.

- Early after birth, perception of orientation, form and movement develops, just as facial recognition and preference for facial configurations. From 6 months, the perception of color and hand-eye coordination (the dorsal stream) develops. Grasping for objects occurs somewhere between the age of 6 to 12 months.

- Perception can be assessed by the Block Design WISC or WAIS (measuring visuo-spatial construction), the visuomotor integration Beery VMI test, and visuo-spatial perception is measured with the Benton Line Orientation Test.

- Unilateral visual neglect and hemi-spatial neglect are disorders of perception.

- Cerebral Palsy is a motor disorder that is often diagnosed within the first 12 months of age and it has a clear neurological cause. Developmental Coordination Disorder often does not have a clear neurological cause, and diagnosis occurs at a later age. It is a disorder of fine motor function, which is initially perceived as clumsiness.

- Language is composed of its form (phonology, morphology and syntaxis), its content (semantics and lexicon) and its use (pragmatics).

- Broca’s aphasia is caused by damage to Broca’s area; which is a small region in the left hemisphere in front of the motor area. It is a disorder of language production, characterized by a telegram style of speech. Understanding spoken or written language is however often intact.

- Wernicke’s aphasia is caused by damage to Wernicke’s area; a small region in the upper left temporal lobe. It is a disorder of language comprehension. Patients speak fluently but cannot associate words with their underlying meaning.

- Clinical Evaluation of Language Fundamentals (CELF-4-NL) is an evaluation of the cause and severity of language disorders in children and adolescents. The language level, and the receptive and expressive language function are assessed.

- Assessment of the memory in baby’s is quite difficult, since language is still in development and the use of language is often still absent. Assessment of the implicit memory is also quite difficult since it requires motor responses, of which the quality is still limited at that age.

- Clinicians may ask whether there are complications in daily-life functioning and for how long the client has been experiencing memory problems. The clinician consider whether the memory problems are age-appropriate and whether they can be explained by other factors than brain damage.

- The visual recognition memory can be testing with the K-ABC method. The visual spatial memory can be tested with the Corsi Block Tapping Test. The long-term memory can be tested with the 15 Word Test.

- Factors that influence the memory are intelligence, acquired knowledge, attention, sense of time, motivation, perception and visual-constructive abilities.

- Attention is the process of detecting and selecting information for further processing. Executive functions consist of regulatory cognitive functions needed to initiate efficient and goal-directed behavior.

- In the Day-Night Task, 3-7 year old children can be tested on their executive functioning; and more specifically their inhibition and response interference.

- The Tower of London Task ask the child to more the balls from the start position to the goal situation in as few steps as possible.

- The Wisconsin Card Sorting Task provides an important index of deficiencies in cognitive flexibility.

- The Test of Everyday Attention for Children (TEACH) is an attention test for children from 6-16 years old. It focuses on attentional control. It consists of 9 subtest, of which 4 are aimed to screen the client.

- Topographical Disorientation is a complex disorder that is characterized by deficits in orienting in space. Visual and verbal functions and intelligence are however intact. – In the case of egocentric disorientation, the patient is unable to estimate the distance of an object to him-/herself. He or she experiences difficulties in grasping objects due to failure to estimate the distance. The visual recognition memory is intact. There is a deficit in the posterior parietal cortex.

- In Landmark Agnosia, the patient is unable to cognitively represent salient landmarks in his or her environment. Patients are however able to draw an accurate layout or map of their home There is a deficit in the lingual gyrus.

- In Anterograde Disorientation, patients are not able to draw a cognitive map of their environment. They are however able to recollect cognitive maps formed before the onset of their illnesses.

- Developmental Topographical Disorientation was recently discovered. It has not been linked to neurological deficits. It is characterized by significant impairments in navigating the environment from early childhood onwards.

- Virtual navigation tasks can assess the visual functions and visual spatial memory.

Bullet-point summary:

• Child neuropsychologists try to infer associations between atypical child behavior and brain dysfunction.
• Important questions that clinicians may receive are: What are the chances of (complete) recovery? And; what are the consequences of brain injury / chemotherapy / infections on cognitive functioning.
• The brain area that controls executive functions such as controlling impulses and weighing long-term consequences is one of the last brain areas to fully mature.
• What is important in the case of brain lesions is in what stage of development it occurred and what the location is.
• Young brains are more plastic, but this does not necessarily mean that they recover more quickly or better from brain trauma.
• Problem assessment results in testable hypotheses about either atypical development or brain dysfunction.
• Profile analysis is characterizing strengths and weaknesses in neurocognitive functioning.
• The ultimate goal of the strengths and weaknesses profile is to engage in theory-driven thinking about brain-behavior associations that yield an individual explanatory theory
• Subtest performance on intelligence scales can be related to brain (dys)function.
• The perceptual system is dependent on individual specialization and integration with other neural networks.
• Clinical Evaluation of Language Fundamentals (CELF-4-NL) is an evaluation of the cause and severity of language disorders in children and adolescents.
• Assessment of the memory in baby’s is quite difficult.
• The clinician consider whether memory problems are age-appropriate and whether they can be explained by other factors than brain damage.
• The Day-Night Task, Tower of London Task and Wisconsin Card Sorting Task test executive functions.
• The TEACH tests for attentional control in children.
• Topographical Disorientation is a complex disorder that is characterized by deficits in orienting in space. It can be egocentric disorientation, landmark agnosia, or anterograde disorientation.

Lecture 5

- From this lecture on, we will focus on the psychological assessment of adults.

- Scientology claims that psychiatry and the psychodiagnostic system is designed just to make profit. They state that the DSM has no scientific foundation.

- Psychodiagnostics is multidimensional: On one level, we assess clusters of behaviors and symptoms. On another level, we assess the current situation and context of the patient. On the third domain, we assess explicit cognitive schemes, coping skills and mental representations of the self and others. On the fourth level, we assess implicit schemes; that can indicate neurotic or psychotic deficiencies. On the fifth domain, we assess the early experiences and context of the patient. On the sixth domain, we assess the temperament of the patient and his/her stable personality characteristics.

- In this lecture, we will focus on the assessment and diagnosing part of the diagnostic cycle.

- The first information that a clinician receives is usually a referral letter. Through initial assessment and an interview, we make a case formulation, from which we can deduce a treatment indication.

- In online self-tests, people can ‘diagnose’ themselves according to for example the DSM criteria. Based on the outcome of such a test, a person may decide to see a doctor.

- Clinicians often receive referral letters from doctors, but these are mostly quite vague. The assessment is up until now still of poor quality.

- Clinicians choose to let their client do an online assessment. It assesses one’s traits, psychological complaints, and one’s personality. 

- The reliability and validity of these online assessments are however not assured. Clinicians also have a lack over control over the test situation. Another issue with computerized testing is that some clients may have high reactivity on the test. Another problem: how does the clinician know for sure that the right person has filled out the test?

- Questionnaires require self-reflection. However, not every person is able to self-reflect which leads to a bias: referred to as the Dunning-Kruger effect. These people aren’t aware that they can’t self-reflect.

- Clinicians also have an interview with their client. The goal is to obtain information from the patient and to establish a working relationship: Most clinicians who do the intake end up also treating that patient. 

- In the interview, information is gathered via open-ended questions, closed-questions and simultaneous observations of the client.

- We watched an example intake interview of Bart Verkuijl with one of his clients.

- In an interview, we focus on the origin of the problem by looking at the client’s history in many areas of his life; e.g. family history, developmental history, substance use, et cetera.

- In general, clinicians focus on two major characteristics during assessment: the vulnerability or strength of the patient, and his/her externalizing and internalizing behaviors.

- Next to an interview, clinicians also systematically observe their client. Clinicians measure specific target behavior, which is formulated very specifically. It is a standardized procedure, during which time and place are also reported. The method of scoring is also specified. 

- The RCISS (Rapid Couple Interaction Scoring System) is a method of systematic observation. It aims to observe the interaction habits of husband and wife. It has been found that the RCISS can predict whether a divorce will happen.

- Mental status examination focuses on a patient’s general appearance, his/her mood and affect, and thought patterns (how is the client’s orientation).

- The solution focused perspective focuses on the goal of the treatment, and the goals and needs of the patient. The method of needs-based assessment by Pameijer is a good example of this. 

- A client may be asked the question what would be different when he or she would wake up, a miracle would have happened and all the problems of his life would have disappeared: What would be the cues for the client to notice that a miracle has happened?

- Eventually, we try to come up with a case formulation. It is a provisional explanation or hypothesis of how an individual comes to present with a certain disorders or circumstances at a particular point in time. It includes biological, psychological and systematic factors of the client’s life.

- We watched a clip from Dr. Phil in which a girl tells her story. We were encouraged to theorize about her disorder and her case in general.

- The psychodynamic perspective states that in the case of psychological problems, there is a conflict between the self and the situation.

- The systematic perspective focuses on all the factors around the client.

- Verbal information, test scores and observations eventually lead to a case formulation. Clinicians may use a statistical approach and look at the data they have obtained. They can also use a clinical approach, and use their clinical intuition and experience to guide their choice for treatment.

- We tend to believe that clinicians’ intuition are better at making case formulation; however, mechanical / computerized predictions tend to be more accurate.

- There is low agreement on the causal factors or explanatory mechanisms of a disorder. The DSM provides a higher rate of agreement; so it is very useful.

- The function of diagnosis is to guide treatment decisions.

- As a clinician, it is critical to keep in the back of your mind that not everyone has sufficient intelligence to answer certain questions.

- Very little research has been done towards the use of assessment in predicting treatment outcomes. However, one study has determined some factors that predict whether behavioral treatment or medical treatment will be more useful for a patient.

- The Behavioral Avoidance Test tests the level of fear and disgust in a patient.

- We can systematically monitor the progress or outcome of the treatment and obtain feedback by applying a test to the client. Clinicians can on the basis of this reconsider their treatment.

Bullet-point summary:

• Through initial assessment and an interview, a clinician makes a case formulation, from which he/she can deduce a treatment indication.
• Clinicians often receive referral letters from doctors, but these are mostly quite vague.
• Clinicians choose to let their client do an online assessment. It assesses one’s traits, psychological complaints, and one’s personality. Computerized assessments does have disadvantages.
• Clinicians also have an interview with their client. The goal is to obtain information from the patient and to establish a working relationship.
• In an interview, we focus on the (possible) origin of the problem by looking at the client’s history in many areas of his life.
• In general, clinicians focus on two major characteristics during assessment: the vulnerability or strength of the patient, and his/her externalizing and internalizing behaviors.
• Next to an interview, clinicians also systematically observe their client.
• Mental status examination focuses on a patient’s general appearance, his/her mood and affect, and thought patterns (how is the client’s orientation).
• Eventually, we try to come up with a case formulation. It is a provisional explanation or hypothesis of how an individual comes to present with a certain disorders or circumstances at a particular point in time. It includes biological, psychological and systematic factors of the client’s life.
• We tend to believe that clinicians’ intuition are better at making case formulation; however, mechanical / computerized predictions tend to be more accurate.
• Very little research has been done towards the use of assessment in predicting treatment outcomes.
• We can systematically monitor the progress or outcome of the treatment and obtain feedback by applying a test to the client. Clinicians can on the basis of this reconsider their treatment.

Lecture 6

- Personality assessment is important for the explanation of how symptoms manifest. Resilience, vulnerability factors, an explanation for the life course and coping styles are assessed. 

- Examples of top-down test construction are using constructs like self-esteem, introversion, rigidity, et cetera. 

- The lexical approach of test construction used the method of asking a large number of persons has been asked to rate themselves or other on statement about personality. These statements have been clustered. The BIG 5-factor model of normal personality (OCEAN) is an example.

- The MMPI is an example of a bottom-up test construction: For this test, items were selected that differentiated depressives from healthy individuals. The original aim was to measure psychiatric disorders. It was only later that the MMPI assessed personality as well. The consequence was that item overlap occurred in several scales. Saturation of the clinical scales with a general demoralization factor was the result.

- The PSY-5 was formulated from the MMPI: It distinguishes 5 general traits; namely affective instability, introversion, aggression/negative affectivity, impulsivity and psychoticism. 

- Personality questionnaires are useful, because they are simple to administer, they are easy to score, information is gathered and processed in a standardized manner, response bias can be easily detected, and there is a low burden for respondents.

- Personality questionnaires are used in a clinical setting before treatment, during treatment and as comprehensive assessment to inform treatment. They are also used in a forensic setting to assess the mental state of suspected offender. Personality questionnaires are used in a work setting for employee selection and to advice how to help people with burn out symptoms or with a stalled professional career.

- The DICS is a 2x2 theory. On the y-axis are outgoing to reserved. On the x-axis is the continuum of task-oriented to people-oriented.

- The Severity Index of Personality Pathology-118 is a top-down assessment method. It has 227 items, on 16 facets, on 5 clinical scales: self-control, identity integration, relational capacities, social concordance, and responsibility.

- The SCID-P is a semi-structured interview based on the DSM-5. It is often used in clinical practice and trials and is specifically aimed at indication for treatment.

- Psychological assessment is communication from a patient to clinician with the use of an instrument. The results are interpreted and the conclusion is discussed and a treatment indication is given.

- What determines the quality of assessment is 1) the characteristics of the patient, 2) the psychometric characteristics of the instrument, 3) the quality of the interpretation system, and 4) the expertise and skills of the clinician.

- The pitfall of self-report is that they are sensitive to social desirability. The validity of a self-report questionnaire depends on the client’s self-insight. Self-report are sensitive to the client’s state; depression, trauma, psychosis, et cetera.

- All personality questionnaires assess what the subject is able or willing to report. As a clinician, you should keep this in mind.

- Indirect performance-based measures are for example observations, biographies, information from others, and projective techniques.

- The projective hypothesis states that unstructured, vague, ambiguous stimuli provide ideal circumstances for revelations about inner aspects of the personality. 

- An example of a projective technique is the Thematic Apperception Test; the clinician makes a formal analysis of how the patient tells a story. It gives an indication about clarity and coherence of thought processes. The content of the story is also analyzed; what emotional themes are salient?

- In a sentence completion test. the patient is asked to complete half-finished sentences. Salient themes are uncovered; as the clinicians tries to analyze how the client fills in empty spaces.

- An advantage of projective testing is that it is an appealing method. Disadvantages are the cost-effectiveness, validity and reliability, and they are not transparent.

- Diagnostic results inform major decisions about a patient. To avoid damage, there is a great necessity for ethical rules.

- We should watch out that psychological assessment truly belongs to the field of academically trained psychologists.

- In writing a report, it is important to first determine the ordering party. Then, a clinician formulates clear questions and chooses the appropriate instruments. The clinician provides the patient with information on the nature, duration, aim and procedure of the assessment and discusses how the results will be conveyed. The optimal context is a pleasant environment in which the client is adequately supported. The context is always under the responsibility of the psychologist.

- In the interpretation of test results, the clinician should avoid summing up the results and describing them only in general terms. Clinicians should combine and compare the test results. 

- The integration of results in a report should always mention the date of the assessment, the patient data, the questions, the used instruments and the observations. The report should also mention the history, results, summary and conclusions that are tailored to the patient, the duration of validity of the report and the statement that the report may be used only for these specific questions. The report is signed by the responsible psychologists. The report is strictly confidential and perishable.

- Beware that a report is a concept-report as long as it has not been discussed with the patient yet. Clinicians should always keep in mind what the goal of the assessment is.

- The patient has the right on extensive debriefing, the right on reading the report before release, the right on completion, correction and removal of data, the right on receiving a copy, and the right on blocking the release of the report.

- The assessment results are strictly confidential and the psychologist has a strict obligation to secrecy.

- Each report needs to contain the test data. The patient does not receive the completed tests. External parties can receive the report under specific circumstances.

- The Dutch WGBO law regulates patients’ rights. The goal is to have informed consent. The law includes rules for filing the patients’ data.

- The BIG regulates the necessity of training of professionals, the qualifications and the quality of training. BIG-registered professionals have to comply to the disciplinary code. Those who seriously and repeatedly infringe the code may be deposed.

- In addition to formal legislation, the professional association of psychologists (NIP) also has its own disciplinary code. Unprofessional acting may result in a warning, a reprimand, a temporary dismissal or expulsion from the association.

- Finally, a patient may sue the psychologist and claim financial compensation for sustained damage or harm. A professional psychologist therefore will always have the proper insurances.

Bullet-point summary:

• Personality assessment methods have a top-down construction, bottom-up construction, or a lexical approach.
• Personality assessment techniques can be used in the clinical setting, in the forensic setting and in work settings.
• What determines the quality of assessment is 1) the characteristics of the patient, 2) the psychometric characteristics of the instrument, 3) the quality of the interpretation system, and 4) the expertise and skills of the clinician.
• The pitfall of self-reports is that they are sensitive to social desirability.
• Indirect performance-based measures are for example observations, biographies, information from others, and projective techniques.
• There are several important ethical rules clinicians abide by when writing a client's report. Patients have several rights.
• The Dutch WGBO, BIG register, NIP register provide clinicians with rules. 

Lecture 7

- The topics of this lecture are (predictive validity and reliability, GMA tests and personality questionnaires, assessment centers; roleplaying, fact-finding, et cetera, structured interviews, and assessment and diversity.

- The quality of a selection instrument depends on its validity and reliability or, in other words, its accuracy.

- Psychological assessment should be objective: It should predict future job performance by assessing whether an applicant meets the required competences. 

Competences are a mixed bag of observable and measurable knowledge, skills, abilities and personal attributes that contribute to enhanced employee performance and ultimately result in organizational success.

- A six-factor model of elementary competencies and dimensions distinguishes 1) problem solving, 2) organizing and planning, 3) drive, 4) consideration or awareness of others, 5) communication, and 6) influencing others.

- A more practically competencies assessment distinguishes four themes: conceptual (analytical thinking, creative thinking and vision), relational (customer-oriented, leadership, coaching), operational (results, decisiveness, initiative, organizing), personal (flexibility, stress resistance, self-confident).

- To predict one’s ability to do a certain job or predict his or her future behavior we use cognition tests such as the TMA and aptitude tests, personality tests, and behavioral tests.

- Components of an assessment are GMA tests, personality and other questionnaires, simulations, structured interviews with psychologists, and feedback.

- A GMA is a General Mental Ability test: it consists of speed tests (many items of the same difficulty; the goal is to have as many answers as possible in a limited time span), power tests (items increase in difficulty; the speed is less relevant), and adaptive tests (comparable with power tests).

- In simulations, the behavior of the person is assessed without role-playing. Standardization of the results is however quite difficult, and this type of assessment is also relatively expensive. 

- In corrective coaching interviews, there is role-playing.

- For interviews with a psychologist, we should keep in mind that there is a primacy effect; a first impression, that is influential. For example, women with a firm hand shake received substantially higher ratings that did men with a handshake of the same firmness.

- There is also a fear of false positives: What if we hire someone that is in fact not fit for the job?

- In the future, we will likely start to use big data and algorithms to assess personality.

- For applicants with a migrant background, we should remember that GMA tests also measure someone’s acquaintance with the culture. Intelligence is an interaction between natural ability and environment; thus also culture. Another pitfall is that personality questionnaires rely too much on language skills. 

Bullet-point summary:

• The quality of a selection instrument depends on its validity and reliability or, in other words, its accuracy.
• Psychological assessment should be objective: It should predict future job performance by assessing whether an applicant meets the required competences. 
• Components of an assessment are GMA tests, personality and other questionnaires, simulations, structured interviews with psychologists, and feedback.
• A GMA is a General Mental Ability test consisting of speed, power, and adaptive tests.
• There are a few general pitfalls of interviews with a psychologists. There are also some biases when assessing applicants with a migrant background.

Lecture 8

- This lecture will focus on the recent advances in the field of psychodiagnostics.

- Some important notes on the exam were made: We should study the book, literature, and lecture sheets. The exam guide on BlackBoard explains which tests are the most important. There are practice exams that have been made available.

- Estimates of prevalence of a mental disorder depends on the sensitivity and specificity of (diagnostic) screening instruments.

- Sensitivity refers to the ability of a test to correctly identify positive cases; people who truly have the disorder. Specificity refers to the ability of a test to correctly identify non-cases; people who don’t have the disorder are correctly assessed as well. The higher the sensitivity and specificity, the lower the rate of misclassification.

- With relatively rare disorders and our limited variety of tests to assess these, false positives are more likely.

- We should remain critical when new biomarkers are promoted in the media.

- While for mental disorders reliable brain-biomarkers are not yet discovered or maybe even absent; brains can be severely affected and psychological testing plays a critical role in determining strengths and weaknesses of the functioning of these brains. Neuropsychological testing accounts for this.

- Neuropsychological assessment can be useful to assess neurocognitive impairments due to for example Alzheimers disease, excessive alcohol abuse, Korsakov, Parkinsons disease, aphasia, Creutzfeldt-Jacob, excessive drug use, multiple sclerose, poisening, traumatic brain injury, or tumors.

- Social constructionism states that psychiatric disorders are only created by cultures or for social purposes. We should be aware of the social and cultural background of a patients in relation to your own context.

- Classification methods of disorders such as the DSM are practical, because they give a reliable diagnosis, a prognosis, provide a framework for treatment selection, and seek for risk factors.

- The mechanistic property clusters (MPC) approach claims that there are “more or less stable patterns of complex interactions between behavior, environment and physiology”. “In this view, mental disorders represent sets of symptoms, connected through a system of causal relations. These associations are thought to explain to co-occurrence of different symptoms and are furthermore assumed to span several levels, requiring explanatory pluralism”. “To examine to notion of symptoms impacting on each other, special methodology collecting frequently repeated measures of mental states underlying symptoms is required; such as the Experience Sampling Method”.

Bullet-point summary:

• Some important notes on the exam were made: We should study the book, literature, and lecture sheets. The exam guide on BlackBoard explains which tests are the most important. There are practice exams that have been made available.

• Estimates of prevalence of a mental disorder depends on the sensitivity and specificity of (diagnostic) screening instruments. The higher the sensitivity and specificity, the lower the rate of misclassification .
• We should remain critical when new biomarkers are promoted in the media.
• Neuropsychological assessment can be useful to assess neurocognitive impairments due to various diseases.
• Social constructionism states that psychiatric disorders are only created by cultures or for social purposes. We should be aware of the social and cultural background of a patients in relation to your own context.
• Classification methods of disorders such as the DSM are practical, because they give a reliable diagnosis, a prognosis, provide a framework for treatment selection, and seek for risk factors.
• According to the MPC approach, disorders are clusters of symptoms that represent stable connections between behavior, environment and physiology.