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Chapter 4 - Chapter 4 Chapter 4 Clinical Assessment I 0 A...

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Unformatted text preview: Chapter 4 Chapter 4 Clinical Assessment I 0. A. Basic elements of assessment 1. B. Assessment of the physical organism A. Clinical Assessment 2. Range of assessment problems: 0. Learning disorders, depression, panic attacks, ADHD, custody, dangerousness, suicide risk, brain damage, epilepsy, retardation, sexual dysfunction, eating disorder, addiction, senility, psychosis, insomnia, etc. 3. Range of factors to account for: 1. Physical, psychological, social, cultural Assessment vs diagnosis 4. Assessment: procedure by which clinicians use tests, observations, interviews, etc. to develop a summary of a client’s problems and symptoms 5. Diagnosis: process by which clinicians arrive at ‘general classification’ of symptoms following a defined system such as DSM IV or ICD­10 The Initial Clinical Assessment 6. In the initial clinical assessment an attempt is made to 2. Identify the main dimensions of a client’s problem 2. 3. Predict the likely course of events under various conditions (e.g. dangerousness) 4. Establish baselines for psychological functions so that the effects of treatment can be measured (define criteria for improvement) Assessment Information: Sources and Modes 7. Source 5. Client 6. Others: spouse, parents, teacher 8. Mode 7. Face to face 8. Via telephone etc. 9. Direct via interview; indirect via tests Assessment Information 9. (What the clinician is trying to learn during psychological assessment) 0. Psychological assessments include: 0. 1. Identifying and describing symptoms (presenting problem) 1. 2. Determining the chronicity and severity of problems 0. (continued) Assessment Information 1. Psychological assessments include 2. 3. Evaluating the potential causal factors in the person’s 2. background 1. Internal and external 2. Chronic and acute duration 3. Proximal and distal 3. 4. Exploring the individual’s personal resources that might be assets in treatment 4. liabilities and assets 0. (continued) Assessment Information 10.Psychological assessments include: 10. 5. A social history noting: 0. A. Personality factors 0. Predispositions 1. Problem solving strategies 1. B. The social context 2. Family stresses and supports 3. Social support and difficulties 2. C. Environmental demands and assets Goals of Assessment 11.1. To develop a good picture of the client – past and present; strengths and weaknesses 12.2. To get a good description of behavior 11. What it is, appropriateness, context 3. (continued) Goals of assessment 13.3. To develop an hypothesis about what is going on and what to do about it 12. Based on psychological ‘picture’ of the client 4. Past and present stressors and experiences 14.4. To find explanations based on causes, 14. consequences 15.5. To establish goals for changing the situation The Assessment Process 16.How clinicians go about the assessment process often depends on their basic treatment orientations 13. Medical/biological 14. Psychological 5. 6. 7. 8. Psychodynamic Behavioral Cognitive­behavioral Humanistic 15. Social/interpersonal The Assessment Process 17.For psychological assessment to proceed effectively, the client must feel comfortable with the clinician 16. 17. 18. Trust and rapport Understanding Confidentiality The Assessment Process 18.Psychological assessment is: 19. Essential for helping the client 20. Varies from client to client 21. Is on­going throughout treatment B. Physical assessment 19.Biological/physiological orientation 20.Medical personnel 20. Assessment of the Physical Organism (Medical) 21.Many psychological problems have physical components either as 22. Causal factors 23. Symptom patterns 22.Therefore, it is often important to include a medical examination in the psychological assessment Assessment of the Physical Organism (Medical) 23.If organic brain damage is suspected, neurological tests can aid in determining the site and extent of organic brain disorder 24.The neurological examination may include 24. 25. 26. 27. An EEG (brain waves) A CAT scan (structure) A PET scan (function) A functional MRI (function) Assessment of the Physical Organism (Medical) 25.EEG: electroencephalogram 25. 28. Assess brainwave patterns 29. If abnormal, may point to neurological prob. 26.CAT/MRI: anatomical brain scan 30. Location and extent of structural abnormality 27.PET: functioning of brain 31. Metabolic activity (epileptic seizures) 28.Functional MRI: blood flow 32. Mapping of neurological activity Assessment of the Physical Organism (psychological) 29.The neuropsychological examination involves the use of an expanding array of testing devices to measure a person’s cognitive, perceptual, and measure a person motor performance as clues to the extent and location of brain damage Assessment of the Physical Organism (psychological) 30.Sometimes there may be psychological and behavioral problems without evidence of brain pathology yet caused by brain pathology 31.Psychological assessment may identify location and extent of brain pathology Assessment of the Physical Organism (psychological) 32.One popular neuropsychological examination, the Halstead­Reitan battery, is composed of the following tests: 33. 34. 35. 36. 37. Halstead Category Test (learning & memory) Tactual Performance Test (motor) Rhythm Test (attention & concentration) Speech Sounds Perception Test Finger Oscillation Test (motor speed) Clinical Assessment II 33.C. Psychosocial assessment 38. (Psychological testing) 38. 34.D. Classifying abnormal behavior C. Psychosocial assessment 35.Conducted by psychologists 36.Who take a Psychological/social orientation 37.Using direct and indirect methods Psychosocial Assessment (direct) 2. Psychosocial assessment attempts to provide a realistic picture of an individual in interaction with his or her social environment 3. Includes information on personality functioning, stressors, resources, etc. 4. Involves gathering information in order to form hypothesis Psychosocial Assessment (direct) 5. Two direct procedures commonly used in psychosocial assessments include: 4. Assessment interviews 5. Central to process of assessment 6. May be structured or unstructured 7. May be supplemented with observation 5. Clinical observation of behavior 8. Observe client’s behavior, appearance 9. May be in office, home, school 10. May be open (natural) or controlled (analogue) Psychological Tests (indirect) 38.In addition to direct methods of assessment, 38. psychologists may utilize indirect methods of assessment through psychological tests 39.Tests are standardized procedures or tasks to obtain samples of behavior 39. Allows for comparisons with others 40. Involves interpretation by clinician Psychological Tests (indirect) 40.Two general categories of psychological tests for use in clinical practice are 41. Intelligence tests such as the WISC­III and WAIS­III 9. 11 subtests: verbal and performance 10. 2­3 hours to administer 11. Can assess brain injury, intellectual functioning 42. Personality tests 12. Projective 13. Objective Psychological Tests (indirect) 41.Two general categories of personality tests for use in clinical practice are: 43. Projective 44. Objective Psychological Tests (projective) 45. In projective personality tests 14. Unstructured stimuli are presented to a subject 4. Ambiguous stimuli 15. The subject projects meaning or structure onto the 15. stimuli 5. Underlying assumption of 'tests' 16. These projections reveal hidden motives Psychological Tests (projective) 46. Projective personality tests include 17. The Rorschach ­ 10 ink blots 6. Complicated scoring; very subjective 18. The Thematic Apperception Test (TAT) 7. Series of pictures; client makes up stories 19. Sentence completion tests 8. Beginning of sentences which client completes Psychological Tests (objective) 42.In objective personality tests 47. Structured questionnaires; self­report inventories; rating scales 48. A subject is required to read and respond to itemized statements or questions 43.Objective personality tests include 49. The MMPI­2 50. The MMPI­A 50. Psychological Tests (objective) 44.MMPI 51. First edition (MMPI­1) in 1943 20. Empirically derived 21. 550 items 22. Created by administering pool of items to patients with diagnoses and choosing those items which identify diagnosis 23. 10 clinical scales that create profile 24. 3 validity scales to check for faking 25. Multiple special scales Psychological Tests (objective) 45.MMPI 52. Second edition (MMPI­2) 26. Most widely used personality test 27. 565 items 53. Criticized as mechanistic and superficial 28. Focuses on traits, not behavior 29. Requires cooperation of patient 54. Advantages: cost effective, reliable, objective, can be computerized The Integration of Assessment Data 46.Clinician must integrate biological, psychological, 46. observational, testing data into clinical picture to make diagnosis and to formulate treatment 47.Assessment is both an initial and ongoing process throughout treatment The Integration of Assessment Data 55. Ethical issues in assessment include 30. Potential cultural bias in instrument and/or clinician 31. Theoretical orientation of the clinician may result in different focus and conclusions 32. Under­emphasis of the external situation if focus is on personality 33. Insufficient validation due to subjectivity of observation and testing (projective) 34. Inaccurate data or premature evaluation leading to misunderstanding of problem D. Classifying Abnormal Behavior 56. Classification involves the attempt to delineate meaningful sub­varieties of maladaptive behavior 57. The benefits of classification include 35. The introduction of order­ making sense out of chaos 36. The enabling of communication ­ understanding 37. The enabling of statistical research 38. Insurance issues Classifying Abnormal Behavior 58. Classification involves generalizations that go beyond observation 39. Inferences that may be flawed or incomplete 40. May ignore individual's uniqueness 59. A classification system’s usefulness depends 59. largely on its reliability and validity 41. Reliability: consistency in ratings 42. Validity: does it measure what it says it does 43. Validity presupposes reliability Classifying Abnormal Behavior 48.Three basic approaches include 60. The categorical approach– a patient is healthy or disordered, but there is no overlap (discrete & homogenous) 61. The dimensional approach– the patient may fall along a range from superior functioning to absolutely impaired functioning (degree of strength or intensity) 62. The prototypal approach– a conceptual entity depicts an idealized combination of characteristics, some of which the patient may not have Classifying Abnormal Behavior 63. The Diagnostic and Statistical Manual of Mental Disorders (DSM) purports to be categorical, but it is in fact prototypal: 44. May be impossible to utilize categories 64. Prototypes identify general characteristics 45. Individual may not have all characteristics of type 46. Individual needs only to have some characteristics to be included 47. Problems with prototypes in DSM: overlap, vagueness, poor differentiation History of DSM 65. Six decades of development of DSM 65. 48. Efforts at increased refinement and precision 49. DSM I: 1952 (from WWII) 50. DSM II: 1968 (from post war research) 51. DSM III: 1980 avoiding jargon, increases in reliability, reduction in vagueness, operational 52. DSM IV: more reliable, more objective, more operational 53. Factors behind changes: insurance, economy, politics The Five Axes of the DSM­IV­TR 54. Axis I: The clinical syndromes or other conditions that may be the focus of clinical attention 9. Schizophrenia, anxiety, substance abuse etc. 55. Axis II: Personality disorders 10. Problems in ways of relating to world ­ maladaptive 56. Axis III: General medical conditions 11. Relevant to case (e.g. depression from pain) 57. Axis IV: Psychosocial & environmental problems 12. Stressors contributing to problem (e.g. family, work) 58. Axis V: Global assessment of functioning 13. 100 point scale or patient's ability to function Two major classification systems 49.International Classification of Disease Symptoms (ICD) by WHO 50.Diagnostic and Statistical Manual (DSM) 66. Text follows DSM IV 59. Symptoms are complaints by patient 60. Signs are objective observations by clinicians 61. Both are used to make diagnosis Diagnostic terms Diagnostic terms 51.Duration 67. Acute – under 6 months 68. Chronic – over 6 months 52.Intensity 69. Mild, moderate, severe Etiological alternative to DSM­IV­TR 53.Groupings based on etiology of problem 70. 71. 72. Disorders due to organic brain damage Disorders due to substances Disorders of psychological or sociocultural origin 62. E.g. anxiety, depression, somatoform, personality 73. Disorders arising during childhood 63. Retardation, learning disabilities 74. (more consistent with medical approaches) The Issue of Labeling 75. Diagnosis is only a label applied to a category of problematic behavior 76. Mental health professionals should be aware of the downsides of labeling 64. It may close off further inquiry ­ it is too easy to accept a accurate and complete 65. Patients may play out the expectations of their “role” which is assigned to them due to label 66. Others may stigmatize the labeled person since labels can be pejorative The Issue of Labeling 77. Nevertheless, arriving at such a diagnosis is usually 77. required before the commencement of clinical services ­ it is a first step 78. A diagnosis is usually required by insurance 79. Assessment typically goes beyond diagnosis 67. Gathering information 68. Developing and testing hypotheses 69. Developing and monitoring treatment End of Chapter 4 ...
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