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Chapter 4


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Ayesha Khan

PSY240 CHAPTER 4 – CLINICAL ASSESSMENT Psychological assessment – procedure by which clinicians, using psychological tests, observation, and interviews, develop a summary of the client’s symptoms and problems Clinical diagnosis – process through which a clinician arrives at a general “summary classification” of the patient’s symptoms by following a clearly defined system *DSM-IV-TR or ICD-10] Assessment – ongoing process and may be important at other points during treatment - Establishing baselines for various psychological functions so that the effects can of treatment can be measured - Criteria based on these measurements may be established as part of treatment plan such that therapy is considered successful and terminated only when client’s behaviour meets predetermined criteria - Comparison of post-treatment with pretreatment assessment results – essential feature of many research projects designed to evaluate the effectiveness of various therapies THE BASIC ELEMENTS IN ASSESSMENT What does a clinician need to know? - Must be able to identify the presenting problem, or major symptoms and behaviour Taking a Social or Behavioural History - Clear understanding of individual’s behavioural history, intellectual functioning, personality characteristics, and environmental pressures and resources - Excesses, deficits, and appropriateness – key dimensions to note to understand particular disorder Personality Factors - Assessment should include any relevant long-term personality characteristics The Social Context - What kinds of environmental demands are placed on the person, and what supports or special stressors exist in their life situation - The information about individual’s personality traits, behaviour patterns, environmental demands must be integrated into a consistent and meaningful picture, referred to as “dynamic formulation” – only describes current situation but also includes hypotheses about what is driving the person to behave in maladaptive ways, formulation can allow clinician to develop hypotheses about client’s future behaviour - Which qualities does the patient bring to treatment that can enhance the chances of improvement - Assessment may involve coordinated use of physical, psychological, and environmental assessment procedures because wide range of factors can play important roles in causing and maintaining maladaptive behaviour The Influence of Professional Orientation - How clinicians go about assessment process depends on their basic treatment orientations - Certain types of assessments are more conductive than others to uncovering particular causal factors or for eliciting information about symptomatic behaviour central to understanding and treating a disorder within a given conceptual framework Trust and Rapport between the Clinician and the Client - Client being evaluated must feel comfortable with clinician PSY240 CHAPTER 4 – CLINICAL ASSESSMENT - Clinician should explain what will happen during assessment and how information gathered will help provide a clearer picture of problems client is dealing with - Clients need to be assured that feelings, beliefs, attitudes, and personal history that they are disclosing will be used appropriately, will be kept in strict confidence, and made available to only therapists or others involved in the case - * test results generally released to third party only if client signs an appropriate release form - Providing test feedback in clinical setting can be important element in treatment process - Clients tend to improve when given appropriate feedback on test results - Persons who were not provided psychological test feedback compared with those who were provided with feedback, latter group showed significant decline in reported symptoms and increase in measured self-esteem as result of having clear understanding of their own resources ASSESSMENT OF PHYSICAL ORGANISM Medical evaluation may include both a general physical examination and special examinations aimed at assessing structural (anatomical) and functional (physiological) integrity of brain as behaviourally significant physical system The General Physical Examination - Medical history is obtained, and major systems of the body are checked - Most clinicians insist on medical clearance before initiating psychosocially based interventions The Neurological Examination - Electroencephalogram [EEG] – assess brain wave patterns in awake and sleeping states o Graphical record of the brain’s electrical activity o Obtained by placing electrodes on scalp and amplifying the minute brain wave impulses from various brain areas; these amplified impulses drive oscillating pens whose deviations are traced on strip of paper moving at constant speed o Significant divergences from normal pattern can reflect abnormalities of brain function o When EEG reveals dysrhythmia [irregular pattern+in brain’s electrical activity, other specialized techniques may be used in attempt to arrive at more precise diagnosis of problem Anatomical Brain Scans - Computerized axial tomography [CAT] – specialized technique, through use of X-rays, reveals images of parts of the brain that might be diseased o Involves use of computer analysis applied to X-ray beams across sections of patient’s brain to produce images that neurologist can interpret o Limited to distinguishing anatomical features such as shape of a particular internal structure o Have been replaced by MRI - Magnetic resonance imaging [MRI] – images of interior of brain sharper because it has the ability to differentiate subtle variations in soft tissue, less complicated to administer, does not subject patient to ionizing radiation o Involves precise measurement of variations in magnetic fields that are caused by varying amounts of water content of organs and parts of organs o Visualization of all but most minute abnormalities of brain structure o Useful in confirming degenerative brain processes o Considerable potential to illuminate contribution of brain anomalies to “nonorganic” psychoses like schizophrenia PSY240 CHAPTER 4 – CLINICAL ASSESSMENT o Problem: some patients have claustrophobic reaction to being placed into narrow cylinder of MRI machine that is required to contain magnetic field and block out external radio signals Pet Scans: A Metabolic Portrait - Positron Emission Tomography [PET] – allows for an appraisal of how an organ is functioning o Provides metabolic portraits by tracking natural compounds, like glucose, as they are metabolized by brain or other organs o Enables medical specialist to obtain more clear-cut diagnoses of brain pathology o May be able to reveal problems that are not immediately apparent anatomically o Have been of limited value because of low-fidelity pictures obtained The Functional MRI - Functional MRI [fMRI] – used in study of psychopathology o Alternative to PET scans o Measures changes in local oxygenation (i.e. blood flow) of specific areas of brain tissue that depend on neuronal activity in those specific regions o Psychological activity (sensations, images, and thoughts) can be “mapped” revealing specific areas of the brain that appear to be involved in their neuropsychological mediation o Critically time-dependent o Requires development of high-speed devices for enhancing recording process and computerized analysis of incoming data o fMRI technique has the potential of adding to our understanding of early development of psychological disorder o illustrated effects of neuroleptic medication on schizophrenics and neuroanatomy of depression o sensitive to artifacts created by slight movements of person being evaluated o results of fMRI difficult to interpret, results do not provide specific information about processes studied The Neuropsychological Examination - neuropsychological assessment – involves use of various testing devices to measure person’s cognitive, perceptual, and motor performance as clues to the extent and location of brain damage - in instances of known or suspected organic brain involvement – clinical neuropsychologist administers a test battery to patient - person’s performance on standardized tasks can give valuable clues about any cognitive and intellectual impairment following brain damage - testing can provide clues of probable location of brain damage - neuropsychologists prefer administer highly individualized array of tests, depending on a patient’s case history and other available information - other neuropsychologists administer standard set of tests that have preselected to sample, in systematic and comprehensive manner - cases where psychological difficulty thought to result from nonorganic causes, psychological assessment is used 4.1 – Neuropsychological Examinations: Determine Brain-Behaviour Relationships  Halstead-Reitan battery – neuropsychological examination composed of several tests and variables from which an “index of impairment” can be computed  Provides specific information about subject’s functioning in several skills areas PSY240 CHAPTER 4 – CLINICAL ASSESSMENT  Used increasingly in neurological evaluations, because it yields great deal of useful information about individual’s cognitive and motor processes Made up of: 1) Halstead Category test – o Measures subject’s ability to learn and remember material o Provide clues as to their judgment and impulsivity o Subject presented with stimulus (on a screen) that suggests number between 1 and 4, subject presses button indicating number they believe was suggested, correct choice followed by sound of pleasant doorbell, incorrect choice by loud buzzer o Person required to determine from pattern of buzzers and bells what underlying principle of correct choice is 2) Tactual Performance test – o measures subject’s motor speed, response to unfamiliar, and ability to learn and use tactile and kinesthetic cues o test surface – board that has spaces for ten blocks for varied shapes o subject blindfolded (never seen the board) and asked to place blocks into correct grooves in board o later, subject asked to draw blocks and board from tactile memory 3) Rhythm test – o measures attention and sustained concentration through auditory perception task o subtest of Seashore’s test of musical talent o includes 30 pairs of rhythmic beats that are presented on tape recorder o subject asked whether the pairs are same or different 4) Speech Sounds Perception test – o Determines whether individual can identify spoken words o Nonsense words presented on tape recorder, and subject asked to identify presented word from a list of four printed words o Measures subject’s concentration, attention, and comprehension 5) Finger Oscillation task – o Measures speed at which individual can depress lever with index finger o Several trials given with each hand  Other tests, referred to as “allied procedures” may be used in neuropsychology laboratory PSYCHOSOCIAL ASSESSMENT Attempts to provide a realistic picture of individual in interaction with their social environment  Includes relevant information about individual’s personality makeup and present level of functioning, and information about stressors and resources in their life situation Psychological procedures that may be used: Assessment Interviews - Usually involves face-to-face interaction where clinician obtains information about patient’s situation, behaviour, and personality - May vary from simple set of questions or prompts to more extended and detailed format, may be open in character or tightly controlled and structured - Interviewer may choose from number of highly structured, standardized interview formats whose reliability has been established in prior research Structured and Unstructured Interviews - Research show that more controlled and structured type of assessment interview yields more reliable results than flexible format PSY240 CHAPTER 4 – CLINICAL ASSESSMENT - Reliability of assessment interview may be enhanced by use of rating scales that help focus inquiry and quantify interview data - Subject to error because they rely on human judgment to choose questions and process information o Evidence: different clinicians have often arrived at different formal diagnoses on basis of interview data elicited from particular patient Unstructured Interviews:  typically subjective and do not follow predetermined set of questions  beginning statements in interview usually general, and follow-up questions tailored for each client  content influenced by habits or theoretical views of interviewer  interviewer does not ask same questions of all clients; rather interviewer subjectively decides what to ask based on client’s response to previous questions  important criteria for DSM-IV diagnosis may be skipped  responses difficult to quantify or compare with responses of clients from other interviews  viewed by clients as being more sensitive to their needs or problems  spontaneous follow-up questions emerge in interview can provide valuable information Structured Interviews:  follow predetermined set of questions  beginning statements follow set procedures  themes and questions predetermined to obtain particular responses for all items  interviewer cannot deviate from question lists and procedures  all questions asked in present way  each question structured in manner to allow responses to be quantified or clearly determined  variation of structured interview (known as semistructured interview) includes structured questions asked in a standard way with option of following up responses with additional unstructured questions for purpose of clarification  clinical research studies often use semistructured interviews rather than fully structured interviews to establish diagnosis  take longer to administer and may include some seemingly tangential questions  patients can be frustrated by overly detailed questions in areas that are of no concern to them The Clinical Observation of Behaviour - direct observations of a patient’s characteristic behaviour - clinical observation – clinician’s objective description of person’s appearance and behaviour, takes place in natural environment, but more likely to take place upon admission to clinic or hospital - clinicians enlist 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 - helps to organize information and encourage reliability and objectivity - formal structure of scale likely to keep observer inferences to minimum - most useful – those that enable a rater to indicate presence or absence of trait or behaviour and its prominence or degree Brief Psychiatric Rating Scale [BPRS] - most widely used for recording observations in clinical practice and psychiatric research - provides structured quantifiable format for rating clinical syndromes PSY240 CHAPTER 4 – CLINICAL ASSESSMENT - contains 18 scales that are scored from ratings made by clinician following an interview with patient - enables clinicians to make standardized comparison of their patients’ symptoms with behaviour of other psychiatric patients - NOT widely used to making treatment or diagnostic decisions in clinical practice Psychological Tests Indirect means of assessing psychological characteristics, standardized sets of procedures or tasks for obtaining samples of behaviour, individual’s responses to standardized stimuli compared with those of other people who have comparable demographic characteristics, and from these comparisons, clinician can draw inferences about how much the person’s psychological qualities differ from those of a reference group [typically psychologically normal one] - More precise, and more reliable than interviewers or observational techniques - Value often depends on competence of clinician who interprets them Two general categories of psychological tests for use in clinical practice: Intelligence Tests Most common used for measuring adult intelligent – Wechsler Adult Intelligence Scale (WAIS-IV) - Includes four scales [verbal comprehension, perceptual reasoning, working memory, and processing speed] with total of 15 subsets - Vocabulary [verbal comprehension] – consists of list of words to define (presented orally), designed to evaluate knowledge of vocabulary - Digit Span [working memory] – test of short-term memory (presented orally), asked to repeat digits in order administered, individual’s remembering the numbers, and reversing order sequence Typically require two to three hours to administer, score, and interpret, not enough funding to administer these tests so portions of test can still provide useful information  Information about cognitive functioning can provide valuable clues to a person’s intellectual resources in dealing with problems Projective Personality Tests Can be projective or objective - Personality tests – unstructured tests, rely on various ambiguous stimuli rather than on explicit verbal questions, and person’s responses are not limited to “true” and “false” or “cannot say” - Through interpretations about their responses, people reveal a lot about their personal preoccupations, conflicts, motives, coping techniques, and other personality characteristics - Assumption underlying projective techniques – make sense out of vague, unstructured stimuli, individuals “project” their own problems, motives, and wishes into the situation - Aimed at discovering ways an individual’s past learning and personality structure may lead them to organize and perceive ambiguous information from the environment The Rorschach - Uses inkblots pictures and a subject responds in succession after being instructed - Use of this test is complicated and requires training - Results can be unreliable because of a subjective nature of test interpretations - No longer used because today’s mental health facilities require specific behavioural descriptions - But can be useful in discovering certain psychodynamic issues - Has been adapted for computer interpretation - Shown to “overpathologize” persons taking the test – test appears to show psychopathology even if the person is a “normal” person randomly drawn from the community - Extent to which this test provides valid information has not been demonstrated - Criticized as an instrument with low or negligible validity PSY240 CHAPTER 4 – CLINICAL ASSESSMENT Thematic Apperception Test - Uses series of simple pictures, some highly representational and others abstract, and a subject is instructed to make up sto
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