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Chapter 4 CLINICAL ASSESSMENT
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
A physical 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: A Metabolic 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
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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)
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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
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