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Lecture

PSYC*3390 Ch 4.doc

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Department
Psychology
Course
PSYC 3390
Professor
Mary Manson
Semester
Fall

Description
Tuesday, September 25, 2012 Chapter 4: Clinical Assessment - clinical diagnosis is the process through which a clinician arrives at a general “summa- ry classification” of the patient’s symptoms by following a clearly defined system such as DSM-IV-TR - in the initial clinical assessment, an attempt is made to identify the main dimensions of a client’s problem and to predict the probable course of events under various condi- tions - deacons are to be made such as what treatment approach is to be offered, whether the problem will require hospitalization, to what extent family members will need to be included as co-clients The Basic Elements in Assessment - first the clinician must identify the Presenting Problem or the major symptoms The Relationships between Assessment and Diagnosis - it is important to have an adequate classification of the presenting problem for several reasons: it is necessary for health coverage, it can help plan treatment Taking a Social or Behavioural History - more important that a formal classification - excesses, deficits and appropriateness of behaviour are key - long-term personality characteristics - what kinds of environmental demands are typically placed on the person and what supports or special stressors exist in his or her life situation - the personality traits, behaviour patterns and environmental demands must then be in- tegrated into a consistent and meaningful picture called the dynamic formulation - this should explain behaviour and help predict future behaviour The Influence of Professional Orientation - a biologically oriented clinician (psychiatrist) is likely to focus on biological assessment methods aimed at determining any underlying organic malfunctioning - a psychoanalytically oriented clinician may choose unstructured personality assess- ment techniques - a behaviorally oriented clinician will rely on techniques such a behavioural observation Tuesday, September 25, 2012 Trust and Rapport between the Clinician and the Client - the client must feel comfortable and that testing will help the practitioner gain a clear understanding of her or his problems and must understand how the tests will be used and how the psychologists will incorporate them into the clinical evaluation - clients need to be assured that what they are disclosing will be use appropriately, will be kept in strict confidence and made available only to therapists involved in the case - when patients are given appropriate feedback they tend to improve just from gaining perspective on their problems from the testing Assessment of the Physical Organism - the medical evaluation may include both a general physical examination and special examinations aimed at assessing the structural and functional integrity of the brain The General Physical Examination - consists of the kinds of procedures most of us have experienced in a checkup - a medical history is obtained and the major systems of the body are checked The Neurological Examination - may involve an EEG to asses brain wave patterns in awake and sleeping states - when an EEG reveals dysrhythmia (irregular pattern) other techniques can be used, it may mean ADHD Anatomical Brain Scans - CAT scans reveal parts of the brain that may be diseased - MRIs have replaced CAT scans, measures magnetic fields, have potential to illuminate the contribution of brain anomalies to “nonorganic” psychoses such as schizophrenia PET Scans: A Metabolic Portrait - allows for an appraisal of how an organ is functioning - can pinpoint sites responsible for epileptic seizures, trauma from a head injury and brain tumors The Functional MRI - an alternative to PET scans, measures changes in local oxygenation - ongoing psychological activity such as sensations, images, and thoughts can be “mapped” revealing areas of the brain that are involved in them - fMRI studies have shown that the impaired time estimation found in schizophrenics might result form dysfunction in the thalamus and prefrontal cortex Tuesday, September 25, 2012 - the results are often difficult to interpret and the test is very sensitive to movement - at this point, it is not considered a valid or useful diagnostic tool for mental disorders The Neuropsychological Examination - involves the use of various testing devices to measure a pertness’ cognitive, perceptu- al, and motor performance as clues to the extent and location of brain damage - in many instances, a clinical neuropsychologist administers a test battery Psychosocial Assessment - attempts to provide a realistic picture of an individual in interaction with his or her so- cial environment - this picture includes relevant information about the individual’s personality makeup and present level of functioning as well as information about the stressors and resources in her or his life situation Assessment Interviews - considered the central element of the assessment process, involving a face-to-face in- teraction where the clinician obtains information about the patient’s situation, behaviour and personality Structured and Unstructured Interviews - research shows that the more controlled and structured type of assessment interview yields far more reliable results than the flexible format - reliability may be enhanced by the use of rating scales that help focus inquiry and quantify the interview data The Clinical Observation of Behaviour - one of the traditional and most useful assessment tools that a clinician has available is direct observation of a patient’s characteristic behaviour - the main purpose is to learn more about the person’s psychological functioning through the objective description of appearance and behaviour in various contexts - may be in a natural environment or in a clinic or hospital - some use Analogue Situations which might involve role-playing, event re-enactment, family interaction assignments or think-aloud procedures - clinician’s enlist their patients’ help by providing them instruction in self-monitoring: self-observation and objective reporting of behaviour, thoughts and feelings Rating Scales Tuesday, September 25, 2012 - the formal structure of a scale is likely to keep observer inferences to a minimum - the Brief Psychiatric Rating Scale provides a structured and quantifiable format for rat- ing clinical symptoms such as somatic concern, anxiety, emotional withdrawal, guilt feel- ings, hostility, suspiciousness and unusual thought patterns Psychological Tests - a more indirect means of assessing psychological characteristics - standardized sets of procedures or tasks for obtaining samples of behaviour - tests can measure coping patterns, motive patterns, personality characteristics, role behaviours, values, levels of depression or anxiety and intellectual functioning - there are 2 general categories: Intelligence Tests - Stanford-Binet Intelligence Scale - Whittler Adult Intelligence Scale - verbal comprehension and working memory Projective Personality Tests - projective tests are unstructured tests in that they rely on various ambiguous stimuli such as inkblots and vague pictures - in trying to make sense out of the vague, unstructured stimuli, individuals “project” their own problems, motives and wishes into the situation The Rorschach - use is complicated and requires considerable training - results can be unreliable because interpreters might disagree on the symbolic signifi- cance of response - popularity has diminished due to its questionable validity The Thematic Apperception Test (TAT) - uses a series of simple pictures, some highly representational and others quite ab- stract and the subjects is instructed to make up stories about them - scoring and interpretation systems have been developed to focus on different aspects of a subject’s stories, such as expressions of needs, the person’s perception of reality - most often a clinician simply makes a qualitative and subjects determination of how the story content reflects the person’s underlying traits, motives and preoccupations Sentence Completion Test - consist of the beginnings of sentences that a person is asked to complete - test stimuli are more standard but interpretation is usually subjective and unreliable Objective Personality Tests - structured, typically questionnaires, self-report inventories or rating scales Tuesday, September 25, 2012 - one virtue of such quantification is its prevision which enhances reliability The MMPI - Minnesota Multiphasic Personality Inventory was the prototype and standard - today it is the most widely used personality test for both clinical assessment and psy- chopathology research The Clinical Scales of the MMPI - ten scales, by drawing a line connecting the scores for different scales, a clinician can construct a profile that shows how far from normal a patient’s performance is on each of the scales - the schizophrenia scale for example is made up of the items that schizophrenic pa- tients consistently answered in a way that differentiated them from normal people Criticisms of the MMPI - is superficial and does not adequately reflect the complexities of an individual taking the test, too oriented toward unobservable constructs Advantages and Limitations of Objective Personality Tests - self-report inventories are cost-effective, highly reliable, and objective - the also can be scored and interpreted by a computer - criticisms are that they are too mechanistic, patients who are illiterate cannot take it - the individual’s cooperation is required and a person can distort their answers - computer-based MMPI interpretation systems typically employ powerful Actuarial Pro- cedures - descriptions of actual behaviour or other characteristics of many subjects with particular patterns of test scores have been stored in the computer - accumulations of precise actuarial data is difficult, time-consuming and expensive - sometimes the different paragraphs generated by the computer have inconsistencies A Psychological Case Study: Esteban - a young man who presented a complicated clinical picture that was substantially clari- fied through psychological and neuropsychological assessment - this is an unusual case because the young man’s problems were quite severe and in- volved both psychological and organic elements, it involved cross-cultural considera- tions, and a number of specialists participated in the assessment study Social History - Esteban, a 21 year old student from Columbia had been enrolled in an English-lan- guage program at a university in the greater Toronto area - he had become disruptive in school and with his roommates and was expelled Tuesday, September 25, 2012 - he also had severe headaches and confused thinking - after extensive medical and neurological examinations Esteban was diagnosed as hav- ing some “diffuse” brain impairment but otherwise healthy - the neurologists recommended a psychological and neuropsychological examination because he suspected that Esteban’s mild neurological condition would acount for his extreme psychological and behavioural symptoms Interviews and Behaviour Observations - Esteban was disorganized and distractible, he talked incessantly, often loudly - his behaviour resembled a hyperactive child - excitable, impulsive and immature - he expressed frequent complains about headaches, tensions and sleeping problems - he tended to say socially inappropriate things and get frustrated and lose his temper Family History - father was a Spanish-Columbian banker in his sixties, passive and warm - had 2 heart attacks, business problems and re
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