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Chapter 4

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University of Guelph
PSYC 3390
Margaret Lumley

Chapter 4 CLINICALASSESSMENT • First a clinician must identify the presenting problem, or major symptoms or behaviours • An adequate assessment includes much more than the diagnostic label. For example, it should include an objective description of the persons behaviour • Assessment should include a description of any relevant long-term personality characteristics • It is also important to assess the social context in which the individual operates. The diverse and often conflicting bits of info about the individuals personality traits, behaviour patterns, environmental demands and so on, must then be integrated into a consistent and meaningful picture. Some clinicians refer to this picture as “dynamic formulation,” because it not only describes the current situation but also includes hypotheses about what is driving the person to behave in maladaptive ways. • Test results are only released to third party if release form is signed • When patients are given appropriate feedback on test results – they begin to improve- just from gaining a perspective on their problems from the testing • People who were provided with feedback showed significant decline in reported symtoms and an increase in measured self-esteem as a result of having a clearer understanding of their own resources • Aphysical examination consists of the kinds of procedures most of us have experienced in getting a “medical check up” • Because brain pathology is sometimes involved in some mental disorders, a specialized neurological examination can be administered in addition to the general medical examination. This may involve the clients getting an electroencephalogram (EEG) to assess brain wave patterns in awake and sleeping states.An EEG is a graphical record of the brains electrical activity. It is obtained by placing electrodes on the scalp and amplifying the minute brain wave impulses from various brain area; these amplified impulses from various brain areas; these amplified impulses drive oscillating pens whose deviations are traced on a strip of paper moving at a constant speed. • Significant divergences from the normal pattern can thus reflect abnormalities of brain function such as might be caused by a brain tumour or other lesions. When an EEG reveals a dysrhythmia (irregular pattern) in the brains electrical activity, other specialized techniques may be used in an attempt to arrive at a more precise diagnosis of the problem Anatomical Brain Scans • Radiological technology, such as computerized axial tomography (CAT scan) is one of the specialized techniques. Through the use of xrays, a CAT scan reveals images of parts of the brain that might be diseased • CAT scans have been increasingly replaced by magnetic resonance imaging (MRI). The images of the interior of the brain are frequently sharper with MRI because of its superior ability to differentiate subtle variations in soft tissue Pet Scans: AMetabolic Portrait • Another scanning technique is positron emission tomography , the PET scan.Although a CAT scan is limited to distinguished anatomical features such as the shape of a particular internal structure, a PET scan allows for an appraisal of how an organ is functioning. The PET scan provides metabolic portraits by tracking natural compounds, such as glucose, as they are metabolized by the brain or other organs The Functional MRI • The technique known as functional MRI (fMRI) has been used in the study of psychopathology for more than a decade. As original developed and employed the MRI could reveal brain structure but not brain activity. • The fMRI, however, is an alternative to PET scans. Simply put, in its most common form, fMRI measures changes in local oxygenation of specific areas of brain tissue that in turn depend on neuronal activity in those specific regions. Ongoing psychological activity, such as sensations, images, and thoughts, can thus be mapped, at least in principle, revealing the specific areas of the brain that appear to be involved in their neurophysiological mediation. • Both fMRI and MRI are quite sensitive to artifacts created by slight movements of the person being evaluated • Additionally, the results of fMRI studies are often difficult to interpret • fMRI is not considered a valid or useful diagnostic tool for mental disorders The Neuropsychological examination • behaviour and psychological impairments due to organic brain abnormalities may become manifest before any organic brain lesion is detechtable by scanning or other means. In these instances, reliable techniques are needed to measure any alteration in behavioural or psychological functioning that has occurred because of the organic brain pathology. This need is met by a growing cadre of psychologists specializing in neuropsychological assessment, which involves the use of various testing devices to measure a persons cognitive, perceptual and motor performance as clues to the extent and location of brain damage Assessment Interviews • an assessment interview, often considered the central element of the assessment process, usually involves a face to face interaction during which a clinician obtains info about the patients situation, behaviour, and personality • the interview may vary from a simple set of questions or prompts to a more extended and detailed format • it may be relatively open in character with an interviewer making moment to moment decisions about his or her next question • or it may be highly controlled and structured so as to ensure that a particular set of questions is covered. In the latter case, the interviewer may choose from a number of highly structured, standardized interview formats whose reliability has been established prior research Structured vs. unstructured assessments • the more controlled and structured type of assessment interview yields far more reliable results than the flexible format • the reliability of the assessment interview may also be enhanced by the use of rating scales that help focus inquiry and quantify the interview data The clinical observation of behaviour • the main purpose of direct observation is to learn more about the persons psychological functioning through the objective description of appearance and behaviour in various contexts. Clinical observation is the clinicians objective description of the persons appearance and behaviour • some practitioners and researchers use a more controlled, rather than a naturalistic, behavioural setting for conducting observations. These analogue situations, which are designed to yield information about the persons adaptive stratagies, might involve such taska as staged role-playing • in addition to making their own observations, many clinicians enlist their patients help by providing them instruction in self-monitoring: self-observation and objective reporting of behaviour, thoughts, and feelings as they occur in various natural settings Rating Scales • as in the case of interviews, the use of rating scales in clinical observation and in self reports helps both to organize info and to encourage reliability and objectivity • one of the rating scales most widely used for recording observations in clinical practice and in psychiatric research is the brief psychiatric rating scale (BRPS) • the BRPS provides a structured and quantifiable format for rating clinical symptoms such as somatic concern, anxiety, emotional withdrawal, guilt feelings, hostility, suspiciousness and unusual thought patterns • the BRPS has been found to be an extremely useful instrument in clinical research especially for the purpose of assigning patients to treatment groups on the basis of similarity in symptoms Psychological Tests • interviews and behavioural observation are relatively direct attempts to determine a persons beliefs, attitudes and problems. In contrast, psychological tests are a more indirect means of assessing psychological characteristics. • Scientifically developed psychological tests are standardized sets of procedures or tasts for obtaining samples of behaviour.An individuals responses to the standardized stimuli are compared with those of other people who have comparable demographic characteristics. From these comparisons, a clinician can then draw inferences about how much the persons psychological qualities differ from those who are in the reference group, typically a psychologically normal one • 2 general categories of psychological tests for use in clinical practice are intelligence tests and personality tests (projective and objective) Intelligence Test • The Wechsler Intelligence Scale for Children-Revised (WISC-IV) and the current edition of the Stanford-Binet Intelligence Scale are widely used in clinical settings for measuring the intellectual abilities of children • Probably the most commonly used test for measuring adult intelligence is the Wechsler Adult Intelligence scale • It includes 4 scales: verbal comprehension, perceptual reading, working memory and processing speed o Vocabulary: this subtest consists of a list of words to define, presented orally to the individual o Digit span (working memory): test is for shortterm memory, a sequence of numbers is administered orally. The individual is asked to repeat the digits in the order administered.Another task in this subset involves the individuals remembering the numbers, holding them in memory and reversing the sequence • In cases where intellectual impairment or organic brain damage is thought to be central to a patients problem, intelligence testing may be the most crucial diagnostic procedure in the test battery Projective personality tests • Projective tests are unstructured tests, in that they rely on various ambiguous stimuli, such as inkblots and vague pictures, rather than on explicit verbal questions, and in that the persons responses are not limited to the true, false or cannot say variety • Through their interpretations of these ambiguous materials, people reveal a good deal about their personal preoccupations, conflicts, motives, coping techniques and other personality characteristics • Such responses are akin to the childhood pastime of seeing objects or scenes in cloud formations, with the important exception that the stimuli in the case of tests are fixed and largely the same for all subjects The Rorschach Test • The test uses ten inkblot pictures to which a subject responds in succession after being instructed • Although generally considered an open-ended, subjective instrument, the rorshach has been adapted for computer interpretation • The Exner Comprehensive Rorschach System may answer the criticism that the Rorschach interpretation is unreliable, because of the use of standard norms can result in more reliable and invariant scoring of descriptors for any given set of Rorschach responses • The Rorschach was shown to ‘overpathologize’persons taking the test-that is, the test appears to show psychopathology even whn the person is normal The Thematic Apperception Test • The thematic apperception test (TAT) uses a series of simple pictures, some highly reprentational and others abstract, about which a subject is instructed to make up stories. • The content of the pictures, much of it depicting people in various contexts, is highly ambiguous about the actions and motives, so subjects are believed to project their own conflicts and worries onto it • Little evidence that they make a clinically significant contribution, time consuming • The TAT has been criticized on several grounds in recent years. There is a dated quality to the test stimuli: the pictures, were developed in the 1930s Sentence Completion Test • Another projective procedure that has proved useful in personality assessment is the sentence completion test • They
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