Clinical Assessment, Interpretation and Diagnosis

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which a clinician evaluates a person in terms of the psychological,

1 Clinical Assessment, Interpretation and Diagnosis Madiha Anas Lecturer Beaconhouse National University Clinical Assessment A procedure in which a clinician evaluates a person in terms of the psychological, physical, and social factors that influence the individual's functioning. 1

Clinical Assessment A - Clinical Interviews 1. Interview formats 2. Mental Status Examination B - Clinical Tests 1.

Self-report inventories/objective Tests 4. Neuropsychological tests 5.

commonly used assessment tool for developing an understanding of The client Nature of the client's current

2 Clinical Assessment A - Clinical Interviews 1. Interview formats 2. Mental Status Examination B - Clinical Tests 1. Characteristics of tests (standardization etc.) 2. Projective Tests (Rorschach, TAT) 3. Self-report inventories/objective Tests 4. Neuropsychological tests 5. Neuroimaging and Brain function Domains of Clinical Assessment: A - Clinical Interview Clinical interview most commonly used assessment tool for developing an understanding of The client Nature of the client's current problems History Family history covers major events in the lives of the client s relatives future aspirations. Personal history includes important events and relationships in the client s life. 2

3 Interview The unstructured interview involves a series of open-ended questions. Information sought through interviews: Reasons for being in treatment Symptoms Health status Family background Life history Expectations from treatment The structured interview consists of a standardized series of questions with predetermined wording and order. Limitations of clinical interviews Information pre-selected by client Distorted perception of client (especially those suffering from psychotic disorders) Interviewer s subjectivity Different client ---- different interviewer 3

Domains of Clinical Assessment: Mental Status Exam A term used by clinicians to describe what the client talks and thinks about and how he/she acts.

4 Domains of Clinical Assessment: Mental Status Exam A term used by clinicians to describe what the client talks and thinks about and how he/she acts. Clinicians use the mental status examination to assess a client's behavior and functioning, with particular attention to the symptoms associated with psychological disturbance. Mental Status Exam Components of the mental status exam 4

5 Sample Mental Status Exam Task Instructions Scoring Date orientation Tell me the date? One point each for year, day, season, date and month. 5 5 Place orientation Where are you? One point each for state, country, town, building and floor 5 5 Register 3 objects Name three objects slowly and clearly. Ask the client to repeat them. One point for each item correctly repeated 3 3 Recall 3 objects Ask the client to recall the objects mentioned above. One point for each item correctly remembered 3 1 Writing Ask the client to write a sentence. One point if the sentence has a subject, a verb and makes sense 1 1 Drawing Ask the client to copy a figure of interesting pentagons on to a piece of paper. One point if the figure has ten corners and two intersecting lines 1 1 Scoring A score of 24/30 or above is considered normal X X Domains of Clinical Assessment: B - Clinical Tests Devices used for gathering information about a few aspects of a person s psychological functioning, from which broader information about the person can be inferred. 5

1 - Characteristics of Tests Reliability Consistency in measurement Validity What the test measures and how well it does so Accuracy Standardization A test should go through the

6 1 - Characteristics of Tests Reliability Consistency in measurement Validity What the test measures and how well it does so Accuracy Standardization A test should go through the Standardization process Has to be administered to a large group of subjects whose performance then serves as a common standard, or norm, against which any individual s score can be measured 6

psychoanalytic tradition Clinical Projective Tests: 2a.

7 Domains of Clinical Assessment: 2 - Projective Tests Projective Tests Project aspects of personality onto ambiguous stimuli Have roots in psychoanalytic tradition Clinical Projective Tests: 2a. Inkblot Tests This inkblot resembles the ambiguous figures presented in the Rorschach test. 7

Rorschach Inkblot Tests 1911 Herman Rorschach People with schizophrenia saw different images from people with anxiety disorders 1921 - Set of ten inkblots 5 black and white 5

8 Rorschach Inkblot Tests 1911 Herman Rorschach People with schizophrenia saw different images from people with anxiety disorders Set of ten inkblots 5 black and white 5 colored Stages of assessment: Rorschach Inkblot Free association/performance phase Say it! Inquiry phase Why did you say it? Testing the limits Others said it, do you agree? 8

9 Clinical Projective Tests: Rorschach Inkblot Rorschach Interpretation Normal people - Whole designs - But focus on details in at least ½ inkblots Depressed people - Give few responses - Do not mention color at all Impulsive people - Respond intensely to color 9

10 Clinical Test: 2b. Thematic Apperception Test TAT 1935 Henry A. Murray 30 black and white pictures Clinicians choose appropriate ones CAT children s apperception test 10

11 Clinical Projective Tests: 2c. Sentence-Completion Test I wish My father A home is Sample #1: Assessment of a sentence-completion test Familial Attitudes The client appears to be well-adjusted with her family and her perceptions about her parents appear to be secure. To the stimulus of The happiest time, the client responded with sitting near the heater in winters with family (Item # 2). Hence, it may be assumed her contact with the parental figures and even the siblings is a source of comfort for her. This assumption can further be substantiated by her response to the stimulus of A mother, to which the client said, is the most reliable thing you can get on the face of the earth (Item # 11). In addition, to My father, the client said, is a soft, nice guy (Item # 35). However, there is conflict regarding the death of parental figures. In two places, the client identified her greatest worry and fear as her parents dying on her (Items # 13 and 39). 11

12 Sample # 2: Assessment of a sentence-completion test General Traits Most of the conflict areas of this client revolve around his incapacity to work productively due to his illness. To mujhay pasand hai, he responded with mai juld sehet yaab ho jaon, he wants to know what he is suffering from, he believes he cannot function properly because he is sick, he needs to get well, that it is hard for him to remain lying down all day with nothing to do, he hopes to get discharged soon, and also that he gets better soon (Items # 1, 3, 15, 25, 31 and 32). Hence, his present consciousness is dominated by the thought of his sickness as it overshadows other important areas of his life. Perhaps the voice of conscience and religious morality is rather strong in him and he expresses that his the best time is that which is spent in the memory of God (Item # 2). Types of Respons e Omission Conflict Scoring Sentence Completion Tests Code O C1 C2 Numerical Value 4 5 Score Frequen cy Percentage (%) Score Numeri cal Value (39/39-2) x 113 = C Positive P P P Neutral N Σ =

13 Drawings: Clinical Projective Tests: 2d. Drawings Draw a person (DTP) HTP (House-Tree Person) Evaluations of drawing Quality and shape of drawing Solidity of the pencil line Location of the drawing on the paper Size of the figures Use of background Comments made by the respondent 13

Sample analysis of HTP The client s need for intellectual achievement and physical achievement were noted with the drawing of the tree s branches going upward and outward.

14 Sample analysis of HTP The client s need for intellectual achievement and physical achievement were noted with the drawing of the tree s branches going upward and outward. The long and muscular arms of the human figures, which are out of proportion to the rest of the body, substantiate this need. The omission of the male figure s foot, as it appears to be extended in imagination off the bottom of the page reflects the client s need for autonomy and achievement. The ground-line upon which the house rests and the absolute symmetry of the house are reflective of the client s need for inner balance and security Questions on the HTP (Note: These questions were relative to the content of the drawing and are not standard questions). How old is this house? It s older than I am. I was born here. Who lives in this house? Five people live here. What are the people like? They are nice people. The father is soft and the mother is strong. Not too may deaths have occurred here. Anything else you would like to say about this house? It s not any unhappy house, sometimes it is airconditioned. It s an ordinary house sort of shabby it s certainly not the best house around. When I was young, there were charpayees outside the house. 14

15 Sample analysis 2 of HTP The client s personality accessibility and openness may be gathered from the adequate number of doors and windows of good size in the house and the partly two-dimensional branches of the tree. The relaxed position of the arms of the human figures depicts her good adjustment and adaptability. Next Class 15

Domains of Clinical Assessment: 3. Objective Tests 3a. 3a. Objective Tests 3b. Objective Personality Tests/Self-report inventories MMPI and and MMPI-2 Q-sort BDI BDI 3c.

16 Domains of Clinical Assessment: 3. Objective Tests 3a. 3a. Objective Tests 3b. Objective Personality Tests/Self-report inventories MMPI and and MMPI-2 Q-sort BDI BDI 3c. 3c. Objective Intelligence Tests Nature of of intellectual functioning and and IQ IQ 3a. Objective Tests Test stimuli are minimally ambiguous Roots in empirical tradition 16

3b. Objective Personality Tests MMPI Original instrument developed in late 1930s Most widely used and extensively researched of all psychological tests Revised in 1989 MMPI-2 MMPI CLINICAL SCALE

17 3b. Objective Personality Tests MMPI Original instrument developed in late 1930s Most widely used and extensively researched of all psychological tests Revised in 1989 MMPI-2 MMPI CLINICAL SCALE DEVELOPMENT Hathaway and McKinely, University of Minnesota Selected a pool of over 1000 items from a variety of sources, psychology tests, interviews, and their own clinical experience Deleted duplicate items and eliminated those not useful for their purposes, leaving a pool of 504 items. 17

18 MMPI: Some Basic Scales Depression Conversion Hysteria Paranoia Schizophrenia Social Introversion MMPI-2 Original items obsolete, politically incorrect or offensive Eliminated and/or reworded items, added items such as substance abuse and marital relationships Final version consists of 567 items 18

19 3b. Self-report inventory: Q- Sort A method Carl Rogers employed to study the changes in client s concept of him/herself before during and after therapy. Assumption: At start of therapy there will be a large difference between clients perception of what they are like (the self) and what they feel they should be or want to be. 3b. Self-report inventory: Q- Sort 19

20 Q-sort Q-sort measures this difference. Client asked to sort 100 or so statements on cards (I am lazy, I feel guilty a lot) into piles ranging along a continuum MOST characteristic of me LEAST characteristic of me Q-sort Correspondence between two sorts can be computed statistically. Any discrepancy should decrease as clientcentered therapy progresses. 20

21 3b. Self-report inventory Beck Depression Inventory (BDI-II) The Beck Depression Inventory is a selfreport measure of the presence and severity of depressive symptoms. Trait vs. State A personality trait is a durable disposition to behave in a particular way in a variety of situations A state is a temporary condition that an individual is in at a particular point in time, and can respond well to psychotherapy. 21

22 3c. Intelligence Testing Intelligence Quotient: A method of quantifying performance on an intelligence test. Originally: I.Q. = Mental Age Chronological Age 22

23 Intelligence Testing First intelligence test by Binet. Revised as the Stanford-Binet. Wechsler scales now more widely used. Wechsler introduced deviation IQ to replace mental/chronological age ratio. I.Q. = Mental Age Age X 100 Chronological Age Age The distribution of IQ scores across the population fits a normal curve. 23

Domains of Clinical Assessment: Psychological Testing and Neuropsychology Neuropsychological Tests Assess broad range of skills and abilities Goal is to understand

24 Domains of Clinical Assessment: Psychological Testing and Neuropsychology Neuropsychological Tests Assess broad range of skills and abilities Goal is to understand brain-behavior relations Used to evaluate a person s assets and deficits Examples include Luria-Nebraska Halstead-Reitan Batteries Clinical Test: Bender Visual-Motor Gestalt Test 24

25 BGT report Normal Person The standard score of 80 on the client s BGT suggests absence of pathology or organicity. However, general observation of the client while she made the drawing and specific features of her drawing, project aspects of her personality which would otherwise be difficult to gauge. BGT report Organic Problem In at least one figure, perceptual rotation has been observed which is common in patients with history of organicity. Overlapping difficulty has been noted, which is generally associated with brain dysfunction of the right hemisphere. Tremors have been observed which are linked to brain damage, usually involving centers such as the cerebellum. 25

BGT - Psychopathology The downward slope of Figure 1 may speak for depressive tendencies. Some circles instead of dots suggest poor impulse control.

26 BGT - Psychopathology The downward slope of Figure 1 may speak for depressive tendencies. Some circles instead of dots suggest poor impulse control. The flattening of the point in Figure 3 is representative of difficulty in handling aggression. There are problems with the angles of Figures 6 and 8, which reflect regression of ego, back to the early childhood states. Domains of Clinical Assessment: Neuroimaging and Brain Structure Neuroimaging: Pictures of the Brain Allows examination of brain structure and function Imaging Brain Structure 1. Computerized axial tomography (CAT or CT scan) 2. Magnetic resonance imaging (MRI) 3. Positron emission tomography (PET) 4. Functional MRI (fmri) 26

27 Domains of Clinical Assessment: Neuroimaging and Brain Function (cont.) Advantages and Limitations Provide detailed information regarding brain function Procedures are expensive Procedures have limited clinical utility (especially for the therapist) NEXT CLASS 27

28 Diagnosis Classification systems DSM IV-TR Issues And Possible Categories In Need Of Further Study Classification What is Classification? Hippocrates s classifications. 28

29 Brief History of DSM DSM I (1952) 60 disorders DSM II (1968) Psychoanalytically Oriented DSM III (1980) Biomedical Model Brief History of DSM DSM-III-R (1987) Revised Criteria. DSM IV(1994) New Syndromes+ Defense Mechanisms. DSM-IV-TR (2000) Updated Criteria 29

30 The Multiaxial Approach Multiaxial Approach Five Axis Axis I Clinical Disorders Axis II Life long Conditions Axis III Medical conditions Axis IV Psychosocial Stressors Axis V GAF 30

31 Axis I: Clinical Disorders Examples of Disorders listed on Axis I Disorders usually diagnosed in infancy, childhood, or adolescence Somatoform disorders Delirium, dementia,and amnestic or other cognotive disorders Substance related disorders Schizophrenia and other psychotic disorders Mood disorders Anxiety disorders Factitious disorders Dissociative Disorders Axis II: Developmental and Personality Disorders Examples of Disorders Listed on Axis II Mental Retardation Personality disorders Schizotypal Personality disorder Antisocial Personality disorder Boderline Personality disorder Dependent Personality disorder Obsessive-compulsive Personality disorder 31

32 Axis III: Physical Conditions Axis III describes general medical conditions that may or may not be directly related to the psychological problems of the individual. Axis IV: Psychosocial Stressors Axis IV Psychosocial and Environmental Problems to Note Problems with primary support group Problems related to the social environment Educational Problems Occupational Problems Housing Problems Economic Problems Problems with access to health care services Problems related to interaction with the legal system and to crime. 32

33 Axis V: Global Assessment Functioning Code Axis V Global Assessment of Functioning Superior functioning in a wide range of areas Absent or minimal symptoms; good functioning in all areas. If symptoms are present, they are transient and expectable reactions to psychosocial stressors; only slight impairment in functioning. Some mild symptoms or difficulty in functioning. Moderate symptoms and difficulty in functioning. Serious symptoms and difficulty in functioning. Some impairement in reality testing or communication or major impairment in several domains. 30 Considerable delusions and hallucinations communication and judgment. or serious impairment in Some danger of hurting self or others or gross impairment in communication. Persistent danger of severely hurting self or others. Example Axis I Panic Disorder Axis II Dependent Personality Disorder Axis III Diabetes Axis IV Psychosocial and environmental stressors: recent bereavement Axis V GAF: 60 33

34 Example 2 Tentative Diagnosis Axis I Major Depression, single episode, Moderate severity Axis II V No diagnoses Axis III Diarrhea, unspecified Axis IV Problems with primary support group (health problems in family) Axis V GAF: 60 MAJOR DIAGNOSTIC CATEGORIES 34

35 Major Major Diagnostic Categories Categories Disorders of Infancy and Childhood Substance Related Disorders Schizophrenia and related Psychotic Disorders Mood Disorders Major Major Diagnostic Categories Anxiety Disorders Somatoform Disorders Factitious Disorders Dissociative Disorders 35

36 Major Major Diagnostic Categories Sexual and Gender Identity Disorders Eating Disorders Sleep Disorders Impulse Control Disorders Not Elsewhere Classified Major Major Diagnostic Categories Adjustment Disorders Personality Disorders Mental Retardation 36

37 POSSIBLE CATEGORIES IN NEED FOR FURTHER STUDY Caffeine Withdrawal Mixed Anxiety Depressive Disorder Passive-Aggressive Personality Disorder Depressive Personality Disorder THANK YOU 37

Outline/Overview. Diagnosis. Psychological Disorders (Psych 335) Chapter 4: Classification, Diagnosis, & Assessment. Reasons for diagnosing:

Outline/Overview. Diagnosis. Psychological Disorders (Psych 335) Chapter 4: Classification, Diagnosis, & Assessment. Reasons for diagnosing: Psychological Disorders (Psych 335) Chapter 4: Classification, Diagnosis, & Assessment Outline/Overview DSM-IV (and III) multiaxial system DSM5 new system Reliability Validity Psychological Assessment