Clinical Assessment, Interpretation and Diagnosis · PDF fileGeneral Traits Most of the conflict ... – “HTP” (House-Tree Person) ... characteristic of me LEAST characteristic

1

Clinical Assessment,Clinical Assessment,

InterpretationInterpretation

and Diagnosisand Diagnosis

Madiha Anas

Lecturer

Beaconhouse National University

Clinical AssessmentClinical 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.

2

Clinical Assessment

�� A A -- Clinical InterviewsClinical Interviews

1. Interview formats

2. Mental Status Examination

�� B B -- Clinical TestsClinical 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

• future aspirations. Personal history

includes

important events

and relationships

in the client’s life.

Family history

covers major events in the

lives of the client’s relatives

3

Interview

Information sought through interviews:

� Reasons for being in treatment

� Symptoms

� Health status

� Family background

� Life history

� Expectations from

treatment

The unstructured interview involves

a series of open-ended questions.

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

4


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 ExamMental Status Exam

Components of the mental status exam

5

XXA score of 24/30 or above is considered normalScoring

11One point if the figure has

ten corners and two

intersecting lines

Ask the client to copy a figure

of interesting pentagons

on to a piece of paper.

Drawing

11One point if the sentence has

a subject, a verb and

makes sense

Ask the client to write a

sentence.Writing

13One point for each item

correctly remembered

Ask the client to recall the

objects mentioned above.

Recall 3 objects

33One point for each item

correctly repeated

Name three objects slowly and

clearly. Ask the client to

repeat them.

Register 3 objects

55One point each for state,

country, town, building

and floor

Where are you?Place orientation

55One point each for year, day,

season, date and month.

Tell me the date?Date orientation

ScoringInstructions Task

Sample Mental Status Exam


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.

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

7


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.

8

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 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?

9


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

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

11


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).

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).

Scoring Sentence Completion Tests

Σ = 23239

93.933NNeutral

--10P3

10.411P2

3213.8162P1Positive

---6C3

3515.175C2

3615.594C1Conflict

(39/39-2) x

113 =

119

51.32OOmission

Score

Numeri

cal

Value

Percentage

(%)

Score

Frequen

cy

Numerical

Value

CodeTypes of

Respons

e

13


2d. Drawings

� 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

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 ofthe 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 air-

conditioned. 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.

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 ClassNext Class

16

� 3a. Objective Tests

� 3b. Objective Personality Tests/Self-report

inventories

– MMPI and MMPI-2

– Q-sort

– BDI

� 3c. Objective Intelligence Tests

– Nature of intellectual functioning and IQ

� 3a. Objective Tests

� 3b. Objective Personality Tests/Self-report

inventories

– MMPI and MMPI-2

– Q-sort

– BDI

� 3c. Objective Intelligence Tests

– Nature of intellectual functioning and IQ


3. Objective Tests

3a. Objective Tests

– Test stimuli are minimally ambiguous

– Roots in empirical tradition

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.

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

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

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 client-

centered therapy progresses.

21

3b. Self-report inventory

Beck Depression Inventory (BDI-II)

�The Beck Depression Inventory is a self-report measure of the presence and severity of depressive symptoms.

Trait vs. State

A personality

traitis

a durable di

sposition

to behave in

a

particular w

ay in a

variety of s

ituations

A state is a

temporary condition

that an individual is

in at a particular

point in time, and can

respond well to

psychotherapy.

22

3c. Intelligence TestingIntelligence Quotient:

A method of quantifying performance on

an intelligence test.

Originally:

I.Q.I.Q. =Mental Age

Chronological Age

Mental Age

Chronological Age

23

Intelligence Testing

=Mental Age

Chronological Age

Mental Age

Chronological Age X 100

� 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.

The distribution of IQ scores across

the population fits a normal curve.

24


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

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.”

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.”


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)

27


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 CLASSNEXT CLASS

28

DiagnosisDiagnosis

� Classification systems

� DSM IV-TR

� Issues And Possible Categories In Need Of Further Study

Classification

� What is Classification?

� Hippocrates’s classifications.

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

30

The The MultiaxialMultiaxial

ApproachApproach

Five Axis

Axis I

Clinical Disorders

Axis II

Life long

Conditions

Axis III

Medical conditions

Axis IV

Psychosocial Stressors

Axis V GAF

Multiaxial

Approach

31

Axis I: Clinical Disorders

Dissociative Disorders

Factitious disorders

Anxiety disorders

Mood disorders

Schizophrenia and other psychotic disorders

Substance related disorders

Delirium, dementia,and amnestic or other cognotive

disorders

Somatoform disorders

Disorders usually diagnosed in infancy, childhood, or

adolescence

Examples of Disorders listed on Axis I

Axis II: Developmental and

Personality Disorders

Obsessive-compulsive Personality disorder

Dependent Personality disorder

Boderline Personality disorder

Antisocial Personality disorder

Schizotypal Personality disorder

Personality disorders

Mental Retardation

Examples of Disorders Listed on Axis II

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

Problems related to interaction with the legal system and to

crime.

Problems with access to health care services

Economic Problems

Housing Problems

Occupational Problems

Educational Problems

Problems related to the social environment

Problems with primary support group

Axis IV Psychosocial and Environmental Problems to

Note

33

Axis V: Global Assessment Functioning

Persistent danger of severely hurting self or others.10

Some danger of hurting self or others or gross impairment in

communication.

20

Considerable delusions and hallucinations or serious impairment in

communication and judgment.

30

Some impairement in reality testing or communication or major

impairment in several domains.

40

Serious symptoms and difficulty in functioning.50

Moderate symptoms and difficulty in functioning.60

Some mild symptoms or difficulty in functioning.70

If symptoms are present, they are transient and expectable reactions to

psychosocial stressors; only slight impairment in functioning.

80

Absent or minimal symptoms; good functioning in all areas.90

Superior functioning in a wide range of areas100

Axis V Global Assessment of FunctioningCode

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

34

Example 2

� Tentative Diagnosis

Axis I – 296.22 – Major Depression, single episode, Moderate

severity

Axis II – V 71.09 – No diagnoses

Axis III – 558.9 – Diarrhea, unspecified

Axis IV – Problems with primary support group (health problems

in family)

Axis V – GAF: 60

MAJOR DIAGNOSTIC

CATEGORIES

35

Major Diagnostic CategoriesMajor Diagnostic Categories

Disorders of Infancy

and Childhood

Schizophrenia and related

Psychotic Disorders Mood Disorders

Substance Related

Disorders


Anxiety Disorders

Factitious Disorders

Somatoform Disorders

Dissociative Disorders

36


Sexual and

Gender Identity Disorders

Sleep Disorders

Eating Disorders

Impulse Control

Disorders

Not Elsewhere

Classified


Adjustment Disorders

Mental Retardation

Personality Disorders

37

POSSIBLE CATEGORIES IN

NEED FOR FURTHER STUDY

� Caffeine Withdrawal

� Mixed Anxiety Depressive Disorder

� Passive-Aggressive Personality Disorder

� Depressive Personality Disorder

THANK YOU

Documents

Clinical Assessment, Interpretation and Diagnosis · PDF fileGeneral Traits Most of the conflict ... – “HTP” (House-Tree Person) ... characteristic of me LEAST characteristic