Summary GGZ2030 Psychodiagnostics
Task 1: A difficult patient
What is the diagnostic process?
Clinical psychodiagnostics is based on three elements:
1. Theory development of the problem/complaints and problematic behavior
2. Operationalization and its subsequent measurement
3. Application of relevant diagnostic methods
This means that hypotheses about behavior, cognition and emotion/motivation are formulated
based on a theory, and are operationalized, measured, and tested using a step-by-step
diagnostic process.
First, the diagnostician analyzes the client’s request for help and the referrer’s request and formulates
the questions that arise during the first meet with the client. Based on these questions, the
diagnostician will construct a diagnostic scenario that contains a provisional theory about the client,
which describes what the problems are and how they can be explained. Testing this theory requires
five diagnostic measures:
1. Converting the provisional theory into concrete hypotheses
2. Selecting a specific set of research tools, which can either support or reject the formulated
hypotheses
3. Making predictions about the results or outcomes from this set of tools, to give a clear
indication as to when the hypotheses should be accepted or rejected.
4. Applying and processing instruments
5. Based on the results that have been obtained, giving reasons for why the hypotheses have
either been accepted or rejected. This results in the diagnostic conclusion.
Diagnostic cycle
Diagnostic cycle = structuring the diagnostic process to the empirical cycle of scientific research ->
this cycle is a model for answering questions in a scientifically justified manner:
1. Observation: collecting and classifying empirical materials, which provide the basis for forming
thoughts about the creation and persistence of problem behavior.
2. Induction: the formulation of theory and hypotheses about the behavior.
3. Deduction phase: testable predictions are derived from these hypotheses.
4. Testing phase: new materials are used to determine whether the predictions are correct or
incorrect.
5. Evaluation.
The diagnostic process from the application to the report
1. Application
2. Exploration:
a. Request
b. Request for help
c. The diagnosticians reflections:
o In all three steps the diagnostician can decide to stop, e.g.
because there request is more medical and the client should
be referred to the hospital.
3. Induction:
a. Diagnostic scenario -> subdivision of the five basic
questions
b. Hypotheses: converting the provisional theory into concrete
hypotheses
4. Deduction:
a. Selection of tools: choosing specific research tools, that can
either support or reject the formulated hypotheses.
b. Testable predictions: make predictions about the results or outcomes, to clarify how the
hypotheses can be accepted or rejected.
5. Testing:
a. Administration and processing: applying and processing instruments.
, 6. Evaluation:
a. Argumentation: explain why you accept or reject the hypotheses, based on the results.
7. Reporting
Application and exploration
Analyze and clarify the request and the request for help -> results in:
1. Information about the referrer:
a. Understanding the frame of reference = the referrer’s vision of the client’s behavior and
performance
b. Clarification of the relationship between the diagnostician and the referrer -> information
about the nature of the setting occasionally provides insight into the content and
seriousness of the problems and information on the purpose of examination.
c. It is important to make a distinction between the referrer in name and the actual referrer
d. Referrers differ from each other in terms of the nature and extent of the powers which
are available to them
2. Details about the type and content of the request -> aims to understand the type and
content of the request:
a. The referrer’s request may adhere to an open-ended format, where he will not formulate
any hypotheses regarding the problem, or closed format, where he will.
b. The contents of a request are partially connected to the setting from which the request
originates. In ambulant services and primary care centers, the requests are usually quite
specific. However, residential psychiatric centers often focus on more complex problems,
such as diagnostic categorization and exploring the underlying factors of a disorder.
c. Requests can be classified according to the five basic questions mentioned above.
The analysis is supported by:
o What the referrer already knows about the client: information on the client’s functioning
helps to examine the seriousness of the problems and to ascertain whether the referrer
and the client agree with each other about the client’s functioning.
o The analysis ultimately helps to determine whether the client presented himself to the
referrer and whether he consents to the examination.
Analyses of the request includes exploration of the client’s mindset:
During the first meeting, the client’s attitude to the examination is evaluated. The content of the
problem is also determined: does he have a well-defined request for help, what is the main
problem domain?
o The client is questioned about his complaints, how they arose, how they have developed
and the factors that have consequently played a role.
The client is asked who can best help him and what the result of an intervention should be ->
this exploration should preferably be carried out as openly as possible by means of an interview,
but broadband screening tools may also be used:
o Adults -> Multimodale Anamnese voor Psychotherapie (MAP)
o Children -> Child Behavior Checklist (CBCL)
When analyzing the application, the diagnostician will use the file data, such as reports from
previous psychodiagnostic or medical examinations, and information from such sources as
school, work, family and institutions.
The analysis of the application is followed by a reflection phase, in which due weight is given to each
of the various pieces of information.
The diagnostician should be aware of his potential biases in both general clinical judgment and
towards clients. There may be bias in relation to the applicant, e.g. regarding whether the
diagnostician is familiar with a specific type of problem, through which it may possibly be over-
diagnosed or under-diagnosed or the diagnostician’s preference for a specific type of research
tool.
The diagnostician also estimates the extent of his own knowledge of a problem and, on this
basis, may refer the client to a colleague if necessary.
In addition, the reflections involve any new questions about the problem that may have
occurred to the diagnostician.
During this reflection phase, the diagnostician will also be able to benefit from using the
literature and his own knowledge.
Induction
,In a diagnostic scenario, the diagnostician organizes all of the requester’s and client’s questions from
the application phase, all of the questions that have occurred to him and his knowledge of the problem.
Based on this information, he proposes an initial, tentative theory about the client’s problematic
behavior.
Five basic questions in psychodiagnostics:
1. Recognition: What are the problems; what works and what doesn’t?
o To obtain a better understanding of the client’s problem, the diagnostician identifies both
the complaints and adequate behavior of the client and/or his environment.
o Recognition includes (1) inventory and description, (2), organization and categorization in
dysfunctional behavior clusters or disorders, (3) examination of the seriousness of the
problem behavior
o The distinction between classification and diagnostic formulation is relevant in this
context:
Classification = clinical picture is assigned to a class of problems -> all-or-
nothing principle
Leads to labeling, which is limited and often forms the basis for
establishing comorbidity, but it does facilitate communication between
experts.
Diagnostic formulation focuses on the individual and his own unique clinical
picture -> (example: holistic theory)
Allows for the uniqueness of the individual, which helps the therapy
planning, but there is an occasional lack of empirical support.
o Diagnostic formulation usually involves simultaneous recognition and explanation.
o Recognition may occur after:
Criterion-oriented measurement: comparison to a predefined standard
Normative measurement: comparison to a representative comparison group.
Ipsative measurement: comparison to the individual itself (e.g. in previous
times)
2. Explanation: Why do certain problems exist and what perpetuates them?
o Answers the question of why there is a problem or a behavioral problem. It includes:
The main problem or problem component
The conditions that explain the problem’s occurrence
The causal relationship between the two points above
o Explanations may be classified according to:
The locus (the person or the situation): in the case of person-oriented
explanations, the explanatory factor lies in the person himself. In the event of a
well-known context, the explanation may be situation-oriented.
The explanatory events may (a) precede the behavior that is to be
explained or (b) follow it.
The nature of control:
Causes explain behavior -> determined by previous conditions.
Reasons make behavior understandable -> determined by a
voluntary/intentional choice
Synchronous and diachronous explanatory conditions:
Synchronous explanatory conditions coincide with the behavior that is
to be explained at the time.
Diachronous explanatory conditions precede this behavior.
Induced and persistent conditions:
Induced conditions give rise to a behavioral problem.
Persistent conditions perpetuate the behavioral problem.
3. Prediction: How will the client’s problems subsequently develop in the future?
o Involves making a statement about the problem behavior in the future -> it is a chance
statement
This chance plays a part in determining the treatment proposal.
o Prediction pertains to a relation between a predictor and a criterion. The predictor is the
present behavior, and the criterion is the future behavior.
However, relations are never perfect and we can consequently only determine the
chance that behaviors will collectively occur in a particular population (not in a
certain client) -> the term risk assessment is sometimes preferred.
4. Indication: How can the problems be resolved?
o Focuses on the question of whether the client requires treatment and, if so, which
caregiver and assistance are most suitable for this client’s complaints, problems, traits
and preferences.
, o Before indication, explanation and prediction must be completed. There are, however,
three additional elements:
Knowledge of treatments and therapists
Knowledge of the relative usefulness of the therapy
Knowledge of the client’s acceptance of the indication
There is an indication strategy that has been developed which takes the
client’s preferences into account -> contains four principles:
o The client’s perspective is examined and explicated.
o The diagnostician provides the client with information about the
courses of treatment, processes, and therapists.
o The client’s expectations and preferences are compared to those
that the diagnostician deems to be suitable and useful and, during
a mutual consultation, several possible treatments, which are
acceptable to both parties, are formulated.
o The client selects a therapist and a treatment.
5. Evaluation: Have the problems been adequately resolved because of the intervention?
o Establishes whether the therapy took account of the diagnosis and treatment proposal
and whether the process and the treatment have brought about a change in the client’s
behavior and experience -> can be established in two ways:
Establish whether the complaints or problems decreased to the desired degree
without discussing whether the changes were brought about by the therapy
Prove that the changes were caused by the therapy (with the help of n=1
designs)
Diagnostic formulation = a description of the unique individual and its context based on specific
characteristics, dimensions + specific modes of functioning -> helps with planning a therapy but is
often lacking in empirical support.
The diagnostic formulation often involves recognition and explanation.
Diagnostic examination
1. Hypothesis formulation -> diagnostician formulates some hypotheses based on the
diagnostic scenario
o De Groot defines a hypothesis as an assumption about a correlation in reality, which is
formulated in such a way that concrete, verifiable predictions may be derived from it.
o The diagnostician converts the tentative theory to hypotheses, i.e. assumptions can be
tested.
o The hypotheses are formulated in such a way, that the relationship between the
hypotheses is clear.
In the context of the recognition question, the hypotheses center on the presence
of psychopathology or a differential diagnosis -> can be a DSM-5 classification,
etc.
In the context of the explanation question, the hypotheses require a list of
explanatory factors and their predisposing or perpetuating roles
Predictive hypotheses are based on empirical knowledge of successful
predictors.
In the context of the indication question, hypotheses are assumptions about
which treatment and which therapist(s) are best suited to a client with a particular
problem.
o The hypotheses are founded on the conclusions that have been drawn from recognition,
explanation and prediction, but are also based on three points, which are also called the
client’s theory of illness, theory of healing and theory of health:
Theory of illness = how the client formulates his problem, how he views his
complaints and what the disease attributes.
Theory of healing = which type of help he expects to receive and the way he
expects to receive it.
Theory of health = what he hopes to achieve with the treatment.
2. Deduction:
a. Selection of examination tools
o The hypotheses must lead to testable statements about a person’s behavior or
experience. The selection of examination tools is linked to this.
The selection of examination tools is determined by the nature of the question,
the psychometric quality of the instruments and by the efficiency considerations
such as the duration of the examination and the scoring convenience.
Task 1: A difficult patient
What is the diagnostic process?
Clinical psychodiagnostics is based on three elements:
1. Theory development of the problem/complaints and problematic behavior
2. Operationalization and its subsequent measurement
3. Application of relevant diagnostic methods
This means that hypotheses about behavior, cognition and emotion/motivation are formulated
based on a theory, and are operationalized, measured, and tested using a step-by-step
diagnostic process.
First, the diagnostician analyzes the client’s request for help and the referrer’s request and formulates
the questions that arise during the first meet with the client. Based on these questions, the
diagnostician will construct a diagnostic scenario that contains a provisional theory about the client,
which describes what the problems are and how they can be explained. Testing this theory requires
five diagnostic measures:
1. Converting the provisional theory into concrete hypotheses
2. Selecting a specific set of research tools, which can either support or reject the formulated
hypotheses
3. Making predictions about the results or outcomes from this set of tools, to give a clear
indication as to when the hypotheses should be accepted or rejected.
4. Applying and processing instruments
5. Based on the results that have been obtained, giving reasons for why the hypotheses have
either been accepted or rejected. This results in the diagnostic conclusion.
Diagnostic cycle
Diagnostic cycle = structuring the diagnostic process to the empirical cycle of scientific research ->
this cycle is a model for answering questions in a scientifically justified manner:
1. Observation: collecting and classifying empirical materials, which provide the basis for forming
thoughts about the creation and persistence of problem behavior.
2. Induction: the formulation of theory and hypotheses about the behavior.
3. Deduction phase: testable predictions are derived from these hypotheses.
4. Testing phase: new materials are used to determine whether the predictions are correct or
incorrect.
5. Evaluation.
The diagnostic process from the application to the report
1. Application
2. Exploration:
a. Request
b. Request for help
c. The diagnosticians reflections:
o In all three steps the diagnostician can decide to stop, e.g.
because there request is more medical and the client should
be referred to the hospital.
3. Induction:
a. Diagnostic scenario -> subdivision of the five basic
questions
b. Hypotheses: converting the provisional theory into concrete
hypotheses
4. Deduction:
a. Selection of tools: choosing specific research tools, that can
either support or reject the formulated hypotheses.
b. Testable predictions: make predictions about the results or outcomes, to clarify how the
hypotheses can be accepted or rejected.
5. Testing:
a. Administration and processing: applying and processing instruments.
, 6. Evaluation:
a. Argumentation: explain why you accept or reject the hypotheses, based on the results.
7. Reporting
Application and exploration
Analyze and clarify the request and the request for help -> results in:
1. Information about the referrer:
a. Understanding the frame of reference = the referrer’s vision of the client’s behavior and
performance
b. Clarification of the relationship between the diagnostician and the referrer -> information
about the nature of the setting occasionally provides insight into the content and
seriousness of the problems and information on the purpose of examination.
c. It is important to make a distinction between the referrer in name and the actual referrer
d. Referrers differ from each other in terms of the nature and extent of the powers which
are available to them
2. Details about the type and content of the request -> aims to understand the type and
content of the request:
a. The referrer’s request may adhere to an open-ended format, where he will not formulate
any hypotheses regarding the problem, or closed format, where he will.
b. The contents of a request are partially connected to the setting from which the request
originates. In ambulant services and primary care centers, the requests are usually quite
specific. However, residential psychiatric centers often focus on more complex problems,
such as diagnostic categorization and exploring the underlying factors of a disorder.
c. Requests can be classified according to the five basic questions mentioned above.
The analysis is supported by:
o What the referrer already knows about the client: information on the client’s functioning
helps to examine the seriousness of the problems and to ascertain whether the referrer
and the client agree with each other about the client’s functioning.
o The analysis ultimately helps to determine whether the client presented himself to the
referrer and whether he consents to the examination.
Analyses of the request includes exploration of the client’s mindset:
During the first meeting, the client’s attitude to the examination is evaluated. The content of the
problem is also determined: does he have a well-defined request for help, what is the main
problem domain?
o The client is questioned about his complaints, how they arose, how they have developed
and the factors that have consequently played a role.
The client is asked who can best help him and what the result of an intervention should be ->
this exploration should preferably be carried out as openly as possible by means of an interview,
but broadband screening tools may also be used:
o Adults -> Multimodale Anamnese voor Psychotherapie (MAP)
o Children -> Child Behavior Checklist (CBCL)
When analyzing the application, the diagnostician will use the file data, such as reports from
previous psychodiagnostic or medical examinations, and information from such sources as
school, work, family and institutions.
The analysis of the application is followed by a reflection phase, in which due weight is given to each
of the various pieces of information.
The diagnostician should be aware of his potential biases in both general clinical judgment and
towards clients. There may be bias in relation to the applicant, e.g. regarding whether the
diagnostician is familiar with a specific type of problem, through which it may possibly be over-
diagnosed or under-diagnosed or the diagnostician’s preference for a specific type of research
tool.
The diagnostician also estimates the extent of his own knowledge of a problem and, on this
basis, may refer the client to a colleague if necessary.
In addition, the reflections involve any new questions about the problem that may have
occurred to the diagnostician.
During this reflection phase, the diagnostician will also be able to benefit from using the
literature and his own knowledge.
Induction
,In a diagnostic scenario, the diagnostician organizes all of the requester’s and client’s questions from
the application phase, all of the questions that have occurred to him and his knowledge of the problem.
Based on this information, he proposes an initial, tentative theory about the client’s problematic
behavior.
Five basic questions in psychodiagnostics:
1. Recognition: What are the problems; what works and what doesn’t?
o To obtain a better understanding of the client’s problem, the diagnostician identifies both
the complaints and adequate behavior of the client and/or his environment.
o Recognition includes (1) inventory and description, (2), organization and categorization in
dysfunctional behavior clusters or disorders, (3) examination of the seriousness of the
problem behavior
o The distinction between classification and diagnostic formulation is relevant in this
context:
Classification = clinical picture is assigned to a class of problems -> all-or-
nothing principle
Leads to labeling, which is limited and often forms the basis for
establishing comorbidity, but it does facilitate communication between
experts.
Diagnostic formulation focuses on the individual and his own unique clinical
picture -> (example: holistic theory)
Allows for the uniqueness of the individual, which helps the therapy
planning, but there is an occasional lack of empirical support.
o Diagnostic formulation usually involves simultaneous recognition and explanation.
o Recognition may occur after:
Criterion-oriented measurement: comparison to a predefined standard
Normative measurement: comparison to a representative comparison group.
Ipsative measurement: comparison to the individual itself (e.g. in previous
times)
2. Explanation: Why do certain problems exist and what perpetuates them?
o Answers the question of why there is a problem or a behavioral problem. It includes:
The main problem or problem component
The conditions that explain the problem’s occurrence
The causal relationship between the two points above
o Explanations may be classified according to:
The locus (the person or the situation): in the case of person-oriented
explanations, the explanatory factor lies in the person himself. In the event of a
well-known context, the explanation may be situation-oriented.
The explanatory events may (a) precede the behavior that is to be
explained or (b) follow it.
The nature of control:
Causes explain behavior -> determined by previous conditions.
Reasons make behavior understandable -> determined by a
voluntary/intentional choice
Synchronous and diachronous explanatory conditions:
Synchronous explanatory conditions coincide with the behavior that is
to be explained at the time.
Diachronous explanatory conditions precede this behavior.
Induced and persistent conditions:
Induced conditions give rise to a behavioral problem.
Persistent conditions perpetuate the behavioral problem.
3. Prediction: How will the client’s problems subsequently develop in the future?
o Involves making a statement about the problem behavior in the future -> it is a chance
statement
This chance plays a part in determining the treatment proposal.
o Prediction pertains to a relation between a predictor and a criterion. The predictor is the
present behavior, and the criterion is the future behavior.
However, relations are never perfect and we can consequently only determine the
chance that behaviors will collectively occur in a particular population (not in a
certain client) -> the term risk assessment is sometimes preferred.
4. Indication: How can the problems be resolved?
o Focuses on the question of whether the client requires treatment and, if so, which
caregiver and assistance are most suitable for this client’s complaints, problems, traits
and preferences.
, o Before indication, explanation and prediction must be completed. There are, however,
three additional elements:
Knowledge of treatments and therapists
Knowledge of the relative usefulness of the therapy
Knowledge of the client’s acceptance of the indication
There is an indication strategy that has been developed which takes the
client’s preferences into account -> contains four principles:
o The client’s perspective is examined and explicated.
o The diagnostician provides the client with information about the
courses of treatment, processes, and therapists.
o The client’s expectations and preferences are compared to those
that the diagnostician deems to be suitable and useful and, during
a mutual consultation, several possible treatments, which are
acceptable to both parties, are formulated.
o The client selects a therapist and a treatment.
5. Evaluation: Have the problems been adequately resolved because of the intervention?
o Establishes whether the therapy took account of the diagnosis and treatment proposal
and whether the process and the treatment have brought about a change in the client’s
behavior and experience -> can be established in two ways:
Establish whether the complaints or problems decreased to the desired degree
without discussing whether the changes were brought about by the therapy
Prove that the changes were caused by the therapy (with the help of n=1
designs)
Diagnostic formulation = a description of the unique individual and its context based on specific
characteristics, dimensions + specific modes of functioning -> helps with planning a therapy but is
often lacking in empirical support.
The diagnostic formulation often involves recognition and explanation.
Diagnostic examination
1. Hypothesis formulation -> diagnostician formulates some hypotheses based on the
diagnostic scenario
o De Groot defines a hypothesis as an assumption about a correlation in reality, which is
formulated in such a way that concrete, verifiable predictions may be derived from it.
o The diagnostician converts the tentative theory to hypotheses, i.e. assumptions can be
tested.
o The hypotheses are formulated in such a way, that the relationship between the
hypotheses is clear.
In the context of the recognition question, the hypotheses center on the presence
of psychopathology or a differential diagnosis -> can be a DSM-5 classification,
etc.
In the context of the explanation question, the hypotheses require a list of
explanatory factors and their predisposing or perpetuating roles
Predictive hypotheses are based on empirical knowledge of successful
predictors.
In the context of the indication question, hypotheses are assumptions about
which treatment and which therapist(s) are best suited to a client with a particular
problem.
o The hypotheses are founded on the conclusions that have been drawn from recognition,
explanation and prediction, but are also based on three points, which are also called the
client’s theory of illness, theory of healing and theory of health:
Theory of illness = how the client formulates his problem, how he views his
complaints and what the disease attributes.
Theory of healing = which type of help he expects to receive and the way he
expects to receive it.
Theory of health = what he hopes to achieve with the treatment.
2. Deduction:
a. Selection of examination tools
o The hypotheses must lead to testable statements about a person’s behavior or
experience. The selection of examination tools is linked to this.
The selection of examination tools is determined by the nature of the question,
the psychometric quality of the instruments and by the efficiency considerations
such as the duration of the examination and the scoring convenience.
