Lecture 5 - Abnormal Psychology PDF

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Claudia Fox 2019...

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Lecture 5: Clinical Assessment Clinical assessment  Aims to chart cognitive, emotional, personality and behavioural factors associated with psychopathology  Assessment can be used to: o Make a diagnosis o Identify targets for therapeutic interventions  E.g. aggression  target that issue and recommend group/individual treatment o Monitor effects of treatment over time o Conduct research aimed at learning more about psychopathology  Wide range of uses Methods of assessment E.g. clinical observation, psychological tests, personality/trait inventories, neurological tests, biological based assessment, clinical interviews Clinical interviews  An interview is any interpersonal encounter in which language is used to gather information about a client o About them, their issues  Clinical interviewer o Pays attention to how a respondent answers questions  Or if they do not respond o Will be sensitive to emotion associated with a particular topic  Emotions described, or the lack of emotion  Influence of paradigm o Type of information sought o How it is obtained o How it is interpreted  Psychodynamic interviewer o Likely to remain sceptical of verbal reports o Based on the notion that most significant aspects have been repressed into unconscious therefore sceptical of conscious verbalising of individual  CBT interviewer o Focus on circumstances, thoughts and emotions o Semantic content  Regardless of theoretical stance, important to: o Develop rapport o Obtain trust o Empathise with client (facilitate discussion) o Respond using head nods, verbal cues, reflection – help to develop report, obtain trust, empathise  give more detailed information o Basic counselling skills  Interviews vary in structure o Quite open o May depend on theoretical stance  Generally clinicians tend to conduct using ‘vague’ outlines o Open ended questions rather than closed questions

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Basic counselling skills important for individuals to explain problems fully

Assessment example  Client appearance/speech & sensory perception o Client’s appearance, body language and behaviour; speech pitch/pace impediments?  How are they presenting themselves?  Case study of woman who was well dressed, looked okay on outside  The way someone speaks, moves o Disability?  Client emotions o Client’s predominant mood/emotions? Do these vary/alter?  Do they feel like this all the time? Or is there a change? o What is it that they are describing? o Suicide ideation?  Important to have in mind  Risk assessment idea  History o Has there been counselling before? When, where, whom, outcome?  If they have had a bad experience it may affect therapeutic relationship  If they have never had counselling they might feel nervous  Their feelings are important, how do they respond to the counsellor’s feelings? o Support outside of counselling relationship?  Friends, family – support  Do they know any other sources of support? o Is any medication being taken? Will this interfere with the client’s ability to engage in our work?  Useful to know  Can give an idea of their struggles if for example they have been to the GP for depression and given antidepressants o Are there any boundary issues with other professionals? (consider confidentiality, other contracts)  Previous counselling, ongoing counselling  Perhaps under the care of a psychiatrist  Draw up a contract about how you are going to work together  Could be confusing for client to see more than one professional at one time o Are there any obvious indications against counselling? (alcohol/drug dependency, suicide risk, hospitalisation)  Specialised services to help for particular problems which are more effective and appropriate  Suicide risk – is it appropriate to engage in someone who is seriously ill, do they need to be referred?  Concerning counselling (tailored more for person-centred counselling) o Does the client have capacity for insight? Are they motivated?  Will they take responsibility?  Are they self-referred?  In schools where they are sent for counselling questions motivation o Client’s ability to connect/empathise?  Have to talk about feelings, theirs and the counsellor’s o Presenting problem? Including any client goals  Anything they want to achieve from the counselling

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Concerning the therapist o Do I feel competent to work with the issues the client brings? o What thoughts and feelings do I have when I am with this client? o Development of the problem. How will I work with this client? o Generating understanding

Limitations of the clinical interview  Unstructured nature  Reliability o Low giving unstructured nature o The work of 2 clinicians will be different  Merit of info provided by client o Relying on information clients provide o There are some diagnoses where clients may deliberately lie to you e.g. borderline PD, antisocial PD  Interviewer bias: o Primacy effect – placing too much emphasis on first impressions o Prioritising negative information (Meehl, 1996) o Influence of client demographics – gender, ethnicity, sexual orientation may be irrelevant in terms of issues but being biased on these can be an issue Structured interviews  Not all clinical interviews are unstructured  Making a diagnosis these can be helpful  Gathering particular, structured information  Generally demonstrate good interrater reliability (Blanchard & Brown, 1998) Structured Clinical Interview (SCID) for Alex 1 DSM IV   Sample item (Spitzer, Gibbon & Williams, 1996)  Pre-determined fashion  The response will determine the next question you ask  Detailed instructions for the interviewer  Give a score of ?, 1, 2 or 3

Inter-rater reliability of selected DSM 4 diagnoses for SCID This tends to be generally good

Proportion of agreement expected above chance Anything above .8 means agreement

Psychological tests  Structured ways about gathering info  Method of administration o Traditionally, client would fill in paper and pencil test o Nowadays, seeing increasing numbers of online questionnaires, verbally  Psychometric approach o Stable underlying characteristics or traits exist at different levels in everyone  Exist in all of us e.g. anxiety, depression, compulsiveness  Everyone experiences these but they are just in different levels according to this approach o Assessment of psychopathology symptoms, intelligence and neurological or cognitive deficits  Advantages: o Rigid response requirements  Moving away from open-ended responses  Individuals respond a pre-determined response  Helps to score an individual  helpful  standardise the tests o Assess client one or more specific characteristics/traits or individual pathology o Rigorously tested  Reliable, valid o Standardisation  Establish norms  Comparison to normal distribution – what is clinical and what is not?  Estimate of meeting diagnostic criteria (e.g. CBOCI Clark & Beck 2003)  Score that takes an individual over a threshold to lead to a clinical diagnosis 1. Personality inventories 2. Trait inventories 3. Projective Tests 4. Intelligence Tests 5. Neurological impairment tests 1. Personality inventories  Minnesota Multiphasic Personality Inventory (MMPI) o Most well-known inventory used by psychologists o Gives you an idea of a wide range of problems o Originally developed with 800 psychiatric and 800 non-psychiatric patients (Hathaway & McKinley, 1943) o Included only Qs that differentiate the two groups  Updated by Butcher, Dahlstrom, Graham, Tellegen et al (1989) o MMPI-2 o Consists of 567 self-statements re: mood, physical concerns, social attitudes etc (true, false, cannot say) o 10 clinical sub-scales

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 Wide range of aspects tested 4 validity scales   Allow estimation of whether client has provided false information Range of scores: 0-120 Above 70 indicative of psychopathology

Responses plotted on graph o

Advantages and disadvantages:  Utility of validity scales – can be useful  Internal reliability and clinical validity – corresponds accurately with clinical diagnoses and ratings of symptoms by clinicians and familial members (Ganellan 1996, Graham 1990, Vacha-Hasse, Kogan, Tani & Woodall 2001)  Time consuming to administer - 567 questions  Short versions available (Dahlstrom & Archer, 2000)

2. Specific Trait Inventories  State Trait Anxiety Inventory (STAI)  o Spielberger, Gorsuch & Lushene (1970) o The higher the score, the higher the anxiety o Add up individual score  Eating Disorders (Eating Disorder Inventory (EDI-3)) o Garner et al (2004)  Depression (Beck Depression Inventory (BDI-II)) o Beck et al (1996)  Advantages and disadvantages o Useful as research tools o Some valuable with good psychometric properties o Potential diagnostic and theoretical value o Some relatively underdeveloped o Majority fail to include ‘validity’ scales as MMPI  Self-report measure 3. Projective Tests  Derived from psychodynamic paradigm  Paradigm

‘A group of tests usually consisting of a standard fixed set of stimuli that are presented to clients, but which are ambiguous enough for clients to put their own interpretation on what the stimuli represent’(Davey, 2008) Stimuli interpreted according to unconscious processes revealing true attitudes, motivations and modes of behaviour – projective hypothesis Rorschach Inkblot Test o Projective personality test using inkblots o Client asked to react to each inkblot, one at a time o Client is believed to ‘project’ her personality onto it – information about the individual provided o Show client ask what they see (free association stage) o Ask again and ask them to list everything they see (enquiry stage) o Responses systematically scored according to:  Vagueness/synthesis of multiple images  Location  Variety of determinants (shape, colour, texture etc.)  Form quality (faithfulness to actual form)  Content  Degree of mental organising activity  Illogical/incongruous or incoherent aspects  (Exner & Weiner, 1995) Thematic Apperception Test (TAT) o Projective personality test consisting of black and white pictures of people in vague/ambiguous situations o Client asked to tell the story behind each (Morgan & Murray, 1935) o What is going on, what happened before, what are they feeling, what will happen after o Clients usually identify with one of the individuals in the picture called the ‘hero’  acts as a vehicle for the client to express their own feelings and thoughts Sentence Completion Test o First developed in 1920s o Provides clients with the first part of an uncompleted sentence:  ‘I like…’  ‘I think of myself as…’  ‘I feel guilty when…’ o Allows identification of  Topics that can be further explored with clients  Ways in which an individual’s psychopathology might bias his/her thinking  Ways in which he/she processes information Using the sentence completion test to identify trauma-relevant thinking biases in combat veterans with PTSD (Kimble et al 2001) o Ps given 33 sentences to complete o Items generated so could be completed with military/nonmilitary content  ‘he was almost hit by a…’  ‘the night sky was full of…’  ‘the air was heavy with the smell of…’  ‘the silence was broken by the…’ o

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Those with PTSD responded with more military words Biases in their coding and retrieval, trauma related information Suggests that the sentence completion test may be useful to differentiate those that have a mental health problem and those who don’t Problems with projective tests: o Use over the years has declined o Relevance to the psychodynamic approach – also declined o Reliability of such tests (Lilienfeld, Wood & Gard 2000)  Relying on client’s response and the clinician’s interpretation  Low reliability o Cultural bias of traditional TAT pictures – no ethnic minorities presented however now there are more contemporary pictures o Clinician training  Extensive o Time consuming to administer and score o Some projective tests can infer psychopathology in the absence of other convincing evidence (Hamel, Shaffer & Erdberg 2000)  Inkblot test to 100 schoolchildren none of whom had any history of MHPs  Results of test were interpreted that in almost all cases there was evidence of faulty reasoning that might be indicative of SZ or mood disorder  Given inkblot test  Need to be careful o o o

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4. Intelligence Tests  Regularly used by clinicians in a variety of settings for a variety of reasons o In combination with other measures of ability  Intellectual and learning difficulties o Identify intellectually gifted children o Assessment of needs of individuals with learning, developmental or intellectual difficulties o As part of neuropsychological evaluation o Can be used to track someone’s dementia for example and track their degeneration  Weschler Adult Intelligence Scale (WAIS) o Provides scores on a range of different abilities:  Vocabulary  Arithmetic abilities  Digit span  Information comprehension  Letter-numbering sequences  Picture completion ability  Reasoning ability  Symbol search  Object assembly ability  Problems with IQ tests: o Intelligence as a construct – purely hypothetical, no agreed upon definition o Current concepts of intelligence may be too narrow  Musical ability/physical skill? (Gardner 1998, Mayer, Salovey & Caruso 2000) o Cultural biases of IQ tests  Based on limited views of what is adaptive (Gopaul-McNichol & Armour Thomas, 2002) o Measurement of capacity to learn (Grigorenko & Strenberg 1998)

 Getting a snapshot of the individual at that one time (if they didn’t get enough sleep or are having a bad day) 5. Neurological Impairment Tests  Assessment as a result of structural and functional damage of brain o Traumatic injury o Stroke o Degenerative brain disorder e.g. Alzheimer’s  Can cause changes in personality, deficits in cognitive functioning  Rationale behind these tests: o We have different psychological functions (e.g. motor skills, memory, language, planning, executive functioning) localised in different areas of the brain o If we can find out where the deficit is, we can put in place a treatment plan to help and support the individual  Assessment in Clinical Neuropsychology o Determining the nature and location of any deficits o Providing information about onset, severity and progression of symptoms o Helping to discriminate between neurological and psychiatric symptoms o Helping to identify the focus for rehabilitation programmes  Types of neuropsychological test o Adult Memory and Information Processing Battery (AMIPB) Trail-Making Task – letters (Coughlan & Hollows, 1985) and numbers, connect by  Widely used in the UK drawing lines e.g. 1A2B –  Comprises two tests of speed of information anything over 91 seconds processing, verbal memory tests (list learning and indicates a brain impairment. story recall) and visual memory tests (design learning Requires a lot of tasks at and figure recall) once. o Halstead-Reitan Neuropsychological Test Battery (Broshek & Barth 2000)  More commonly used in the US  Compiled to evaluate brain and nervous system functioning across a fixed set of eight tests o Test battery – not just a questionnaire – lots of tests that form part of this assessment  Extensive  Can be time-consuming  Short forms can arise o Mini Mental State Examination (MMSE) (Folstein et al, 1975)  Overall levels of cognitive and mental functioning  Short form – 30 item screen for dementia Biologically Based Assessment  Psychophysiological Tests e.g. o Electrodermal responding (GSR)  Monitoring skin conductance response o Stimuli that elicit anxiety (Cuthbert et al 2003) o Particular psychopathology  APD – might see less reaction and less response o Ability of clients to cope following treatment intervention  Bobadilla & Taylor 2007; Grillion et al 2004  Test and monitor how clients are coping during/after treatment

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Neuroimaging techniques o Anatomical and structural info o Info re: brain activity and functioning o E.g. schizophrenia

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Clinical observation o Can supplement other o Analogue observations – carried out in a controlled environment e.g. two way mirror o Direct observation of a client’s behaviour  E.g. looking at interactions with others o Self-observation/monitoring  Client observes and records own behaviour/thoughts – noting frequency of their feelings for example  Ecological momentary assessment (EMA) (Stone & Shiffman, 1994) – electronic diaries for example to collect data in real time, overcomes bias associated with recall as it is recorded there and then  Gaining insight can be therapeutic in itself ABC Charts o Coding sheets o A: The antecedents of behaviour o B: The behaviour itself (what individual did) o C: The consequences of behaviour o Breaks down what is going on o Helps to work out what is going on and what provoked the behaviour Examples of Observational Coding Forms o Sample checklist for coding child behaviour 

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Clinical Observation advantages & disadvantages:

Observer effect – would they be acting how they are acting if they weren’t being observed?

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Cultural Biases in Assessment Most assessment have been developed on Caucasian populations o Therefore, many tests may be culturally biased

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Clinicians need to be aware of these biases in their judgements and diagnoses

Examples of Cultural Anomalies 1. Some ethnic groups score differently on assessment tests than others o E.g. MMPI o American Asians score higher than white Americans 2. Alcoholism and Schizophrenia o Garb, 1998 o Black Americans score higher than white Americans 3. SES Background o Bentacourt & Lopez, 1993; Robbins & Regier 1991 o Described as more disturbed Causes of Cultural Anomalies o Mental health symptoms may manifest differently in different cultures o Language differences between clinician and client can affect diagnosis o Cultural stereotypes can affect the perception of what is ‘normal’ behaviour in ethnic groups o Cultural differences in religious and spiritual beliefs can affect the expression of psychopathology o Cultural differences can affect client-clinician relationships Addressing Cultural Anomalies o Clinicians need proper education and training when assessing and diagnosing minority persons (Hall, 1997) o DSM-IV-TR has made some attempt to identify potential cultural anomalies in diagnosis o Appendix on culture o When clinicians were asked, half didn’t know it existed o DSM-5 Cultural Formation Interview (CFI)...