4. Clinical Assessment: Methods and purpose Flashcards
what are methods of clinical assessment?
- Clinical interview
- Personality Assessments
- Questionnaires
- Corroborative reports
- Self-report
- Self-monitoring forms
- Observation
- Measuring Process and Outcome of therapy
what are the purposes of clinical interviews?
- Mental Status Examination
- Diagnosis
- Risk assessment
- Formulation
- Understand client’s goals for assessment or therapy
- Understand process issues that might guide the course of therapy
- Demographics
- evidence based
what is mental status examination in clinical interviews?
o doesn’t give you a diagnosis
o just gives to a pathology
what is diagnosis in clinical interviews?
does not give you full information, so you wouldn’t base the therapy entirely on the diagnosis. But is very important and informative in guiding a treatment plan
what is risk assessment in clinical interviews?
risk to self-harm, suicide and to others
what is formulation in clinical interviews?
case conceptualisation or explanation of what psychological processes a person has had
what are demographics in clinical interviewing?
age, level of education
what links into treatment plans?
diagnosis, formulation, risk assessment, demographics, evidence based
what are the three phases of a semi-structured clinical interview?
opening, middle, end
what is involved in the opening of a semi-structured clinical interview?
o warm up and rapport building
o assess the suffering, empathise
what is involved in the middle of a semi-structured clinical interview?
history, mental status, assessment, determine client’s level of insight
what is involved in the end of a semi-structured clinical interview?
o summarise conclusions
o focus on goals and hope for future
what are the areas covered by a clinical interview?
- Ask about presenting problem (what brings them in today)
- Explore current psychological functioning and symptom formation (identify diagnoses and differential diagnoses)
- Mental Status Examination throughout interview
- Risk assessment
- Personal history, including critical developmental incidents, as well as family, educational, medical, psychiatric and social histories – looking for psychological mechanisms as well as events
- Current social systems
- Strengths, competencies and abilities
- Client’s goals for assessment or therapy
what is involved in Mental status examination?
A structured summary of your own observation of the client
what are aspects that you should observe in mental status examination?
o Appearance o Behaviour o Thought Form o Thought Content o Perception o Affect\Mood o Orientation o Judgement o Insight o Intelligence
what do you observe when observing appearance and behaviour?
• Dress • Self-care • Eye contact • Motor activity o Agitation o Retardation • Movements
what do you observe when observing mood and affect and behaviour?
Cues: behaviour, appearance, facial expression, expression, presentation
what do you observe when observing thought and behaviour?
content and form
what do you observe when observing perception and behaviour?
• Sensory distortions and illusions • Hallucinations: o hearing o vision (implications) o smell, taste and touch • Other abnormal perceptions • Depersonalisation and derealisation
what do you observe when observing cognition and behaviour?
- Orientation to time, place and person
- Attention and concentration
- Capacity for abstraction and reasoning
- Current functioning in relation to previous functioning
- Tools – MMSE, proverbs, serial 7s
what do you observe when observing insight and behaviour?
• Understanding and Attitudes:
o towards the problem
o towards the consequences and limitations imposed by the problem/disorder
o towards any help offered
what does affect refer to in MSE?
• Affect refers to characteristics communicated during the interview – the interpersonal dimension in the here and now.
what observing thought and behaviour what does the content aspect observe?
o Unusual content
o Overvalued ideas
o Delusions
what observing thought and behaviour what does the form aspect observe?
o Rate, responsivity and spontaneity o Coherence – use of standard grammatical forms and sentence structure o Capacity to sustain train of thought o Circumstantiality o Tangentiality o Flight of ideas o Thought block o Word salad o Unusual word usage – neologisms
when assessing attention and concentration when observing cognitions is MSE what are you looking for?
o distraction due to intrusive thoughts
o impaired reasoning
o impaired concentration
• Memory and whether a good historian
when assessing attention and concentration when observing cognitions is MSE what are you looking for?
o distraction due to intrusive thoughts
o impaired reasoning
o impaired concentration
• Memory and whether a good historian
what are risk factors observed in suicide risk assessment?
o Ideation, Plans, Intent to act, Means, o Acute stress o Depression o Impulse control problems o Humiliation/embarrassment o Hopelessness o Use of substances o Previous models of self-harm
what are protective factors in suicide risk assessment?
o Beliefs (eg moral or religious)
o Family (eg children)
o Social Support
o Upcoming positive experiences to look forward to
what is the purpose of a diagnosis?
- Description of levels of psychopathology
- Communication
- Guide Treatment
- Inform prognosis
- Guides Research
- Identifying capacity of someone to stand trial
- Cognitive or functional impairment
what are the key questions for a diagnosis?
- What are the primary symptoms?
- What is the approximate duration of the disorder?
- How severe are the symptoms?
- Has a specific cause or precipitant for the symptoms been identified?
- Are there differential diagnoses?
what is involved in diagnostic reasoning
cues, inferences, patterns, hypothesis, inquiry conclusion and formation which all lead to evidence
what are the categories of mental disorders?
Normative/statistical
what are mental disorders?
A significant behaviour that occurs in an individual that is associated with distress or disability, or an increased risk for suffering death, pain, disability, or an important loss of freedom. This syndrome must not be due to a culturally sanctioned response.
what, generally, are examples of mental disorders?
- Impaired functioning/adaptability
* Distress
what are categorical classification/system of mental disorders?
Presence/absence of a disorder
• Either you are anxious or you are not anxious.
what are dimensional classification/system of mental disorders?
o Rank on a continuous quantitative dimension
• How anxious are you on a scale of 1 to 10?
why are dimensional systems preferred when assessing mental disorders
Dimensional systems may better capture an individual’s functioning but the categorical approach has advantages for research and understanding
when was DSM 1 made?
1952
what did DSM 1 reflect?
Myers psychobiological view that Disorders are cause by personality “REACTION”
when was DSM 2 made?
1968
what does DSM 2 reflect?
same as DSM 1 but the reference to ‘reaction’ was removed
when was DSM 3 published
1980
Hoe does DSM 3 differ from DSM 1 and 2?
It is Free from theories of etiology and Initiates use of Multi-axis system
when was DSM 3-R published?
1987
why was DSM 3-R published?
revision made to clarify diagnoses
when was DSM 4 published?
1994
what were the characteristics of DSM 4?
It was Categorical, had Cultural and ethnic considerations and was Not based on deviant behaviors
when was DSM 5 published?
2013
how does DSM 5 differ from the other DSMs?
o - Published 2013
o - changes in diagnostic criteria (e.g.
o - removal of criteria e.g. bereavement is no longer an exclusion criteria for depression
what does DSM-5 list?
approximately 400 disorders
what does DSM 5 describe?
• Describes criteria for diagnoses, key clinical features, and related features that are often, but not always, present
what is required for someone to be diagnosed with a major depressive disorder?
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition.
what are the symptoms of major depressive disorder?
depressed mood, markedly diminished interest or pleasure in all, significant weight loss when not dieting or weight gain, insomnia or hypersomnia, psychomotor agitation or retardation nearly every day, fatigue or loss of energy nearly every day, feelings of worthiness or excessive or inappropriate guilt, diminished ability to think or concentrate, recurrent thoughts of death
Depressed mood in major depressive disorder
Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
Markedly diminished interest or pleasure in major depressive disorder
Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
significant wight loss when not dieting or weight gain in major depressive disorder
(e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
insomnia or hypersomnia in major depressive disorder
nearly every day
psychomotor agitation or retardation in major depressive disorder
(observable by others, not merely subjective feelings of restlessness or being slowed down).
feelings of worthiness or excessive or inappropriate guilty in major depressive disorder
which may be delusional) nearly every day (not merely self-reproach or guilt about being sick
diminished ability to think or concentrate in major depressive disorder
or indecisiveness, nearly every day (either by subjective account or as observed by others).
Recurrent thoughts of death in major depressive disorder
not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
what can the symptoms of major depressive disorder cause?
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
what is the episode of major depressive disorder not attributable to?
The episode is not attributable to the physiological effects of a substance or to another medical condition.
What is the relationship between responses of significant loss, and major depressive disorder?
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.
what is reliability?
Reliability refers to the consistency of measurements, including diagnostic decisions e.g. inter-rater reliability
what is validity?
Validity refers to whether or not accurate statements and predictions can be made from knowledge of membership class
what does a diagnosis and formulation do?
diagnosis - describes
formulation - explains
what, specifically, does formulation do?
Integrates diagnostic and non-diagnostic clinical information from history and provides a basis for a treatment plan
what is formulation based on?
a theoretical framework
how is formulation undertaken?
Identify critical events in a person’s life and link these to the presenting problems by key psychological mechanisms. Then determine a balance between comprehensive and parsimonious
what are the steps to formulation?
- Presentation: Current expression of problem
- Pattern of behaviour
- Predisposition: Pre-morbid events that have lead to the presentation
- Precipitation: Triggers for current presentation
- Perpetuation: Maintaining factors of problem/s
- Potentials: Client/family/system strengths
- Prognosis
What is an example of the CBT Formulation?
predisposing factors, precipitating factors, perpetuating factors
What are predisposing factors in CBT formulation?
o Relationship A à modelling of catastrophic cognitions
o Relationship B à modelling of avoidant behaviour
o Event A à behaviour A à -ve reinforcement of avoidant behaviour
What are precipitating factors in CBT formulation?
Trigger event à catastrophic cognitions
What are perpetuating factors in CBT formulation?
o Catastrophic cognitions and low self-efficacy à avoidant behaviour
o Avoidant behaviour à -ve reinforcement, fails to challenge catastrophic cognitions and self-efficacy
o Avoidant behaviour à relationship problems à low self-worth à low self-efficacy
what is SORCK funcitonal analyses of behavioural formulation?
S = stimuli i.e. antecedents O = organism i.e. internal factors R = response i.e. target behaviour C = consequences i.e. what happens K = Contingencies
what is involved in the stimuli of the SORCK functional analyses?
Historical, contextual or immediate
what are the consequences in the SORCK functional analyses?
Immediate and delayed
what are examples of personality inventories self-report questionnaires?
o BDI or BDI-II o HADS o CES-D o DASS o PHQ-9
what are examples of personality inventories clinician rating questionnaires?
HAM-D
what are examples of personality inventories generic case finders questionnaires?
MHI
GHQ
K10
What are the ABCs in self-monitoring of ABCs?
A (Antecendents) B (Beliefs) % believed C (Emotional Consequences)
what did Michael Lambert develop with regards to accessing process and outcome of therapy?
outcome Questionnaire (OQ45)
what did scott miller develop with regards to accessing process and outcome of therapy?
o Outcome Rating Scale (ORS)
o Session Rating Scale (SRS)
