The Importance of Behavioral Observations

National Association of Psychometrists

Autumn 2015

Goal

• To make explicit what we’re already doing

• To systematize our thinking

• To think about our thinking

Goal

• Safety

• “Containment” of the other

• Progressing through testing

• Timing and prioritizing

Purpose

• An attempt to interpret psychological and neurological phenomena from observable behaviors

• Because patient report and testing alone are insufficient

• Allows corroboration and differential diagnosis with formal testing, neurobehavioral examination, and reporting

Caveat Observor

• With understanding that there is still error with their report, testing, and our interpretation– This is their behavior at this time, under these

conditions– We cannot achieve objective perfection

• What can affect behavior?– Motivation, rapport, social, political, sleep, burrito?– Research looking at African-Americans and testing

with Caucasian evaluators• I.e., Stereotype Threat

Why are behavioral observations important?

• In neuropsychology is there value added?– Down side to technicians is the psychologist not

seeing the behavior ourselves• NY doesn’t allow technicians

– Upside can be two sets of expert eyes across time• Context– Legal/forensic– Mood vs cognition

• Interpretation

Interpretation

• Do we accept our patients report at face value?• Diagnosis– Someone has read about Bipolar online?– ADHD symptom reporting?– Any attempt at motivated symptom reporting

Breadth

• What goes into behavioral observations reporting?

• What behaviors can we observe?• Domains:– Physical– Emotional– Cognitive– Socioeconomic

Physical

• Ambulation- independent, chair, cane, walker, assisted• Gait and balance-slow, shuffling, unsteady, antalgic• Motor

• Fading of parkinsons medications

• Posture• Psychomotor-agitated, slowed, fidgety, hyperactive• Tremor, paresis, dyskinesia• Energy, fatigue• Pen grasp

Physical

• Sensorium-glasses, hearing aids, need for…• Pulse, sweating, posture, fidgeting, gaze• Sex, gender• Dress–misbuttoned, bizarre, disheveled • Hygiene/ grooming• Height• Weight• Fitness• Identifying marks

Emotional• Demeanor –open, friendly, honest, guarded, quiet, talkative, expansive,

irritable, hopeless, elated, apathetic, indifferent• Eye contact• Interpersonal skills –immature, inappropriate, disinhibited, humorous,

can appreciate humor, interpretation of nonverbal cues• How you feel around them• How they feel around you• How they react to specific subjects• Special preoccupations and experiences• A/VHs, Delusions, obsessions, distortions, HI/SI, paranoia, dissociation,

fugue, unreality• Ability to relax, self sooth• Rapport

Mood vs. Affect

• Mood-an emotional state– Prevailing emotional tone– Unfocused, diffuse• Vs. emotion which has a more focal cause

– Usually a positive or negative valence– Think of “Mood Disorders”• Depressed, manic

• Also consider – Euthymic, irritable, positive, jocular

Mood vs. Affect

• Affect– Range and appropriateness of emotional response• Flat, restricted, blunted, labile• Congruent, inhibited, disinhibited

Cognitive

• Level of consciousness-alert, somnolent, obtunded, lethargic

• Orientation• Intellect• Thought process– Confusion, associations, logic, clarity, coherence,

rate, blocking, confabulation, circumstantial• Attention

Where are they at?

• Insight– Do they appreciate there is a problem?– Do they appreciate their contribution?

• Understanding – Do they see the full extent of the problem?– Do they comprehend the consequences?

What can interfere?

• Insight – Rapport– Anxiety– Fatigue– Addiction– Dementia– Somatoform– Personality Disorder

• Understanding– Intellect– Other cognitive abilities (e.g. post-stroke)– Resistance

Speech

• Paraphasic errors• Tangentiality• Perseveration• Empty speech• Circumlocutions• Word-finding• Intonation

• Prosody• Rate• Garrulousness• Articulation• Phrasing• Ease• Anomia

Understanding Effort

• Positive impression management• Optimal effort• Passively cooperative• Suboptimal effort• Negative impression management• Malingering

Effort

• Engagement– Looking away during testing– Quitting quickly/easily, “don’t know”

• Fluctuations and fatigue

Multicultural

• Sex• Gender • Apparent age• Ethnicity• Dress• Style of clothing, hair, accoutrement • Language

Cultural Differences

• Display Rules– How, when, where, to whom to display– Strength of display

• Ritualized Displays– Indian “tongue bite” to display embarrassment

• Eye contact

Which emotions are these?

6 Basic Emotions

• Happy, sad, anger, fear, surprise, disgust

Cultural emotions and attitudes?

• Schadenfreude • Greetings-men hugging or kissing, holding

hands

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Difficulty expressing emotion

• Conflict avoidance• Fear of rejection• Passive aggressive • Hopelessness• Low Self-esteem• Belief that others should just know• Cultural, training• Parkinson’s

Difficulty feeling emotion

• Alexithymia• Anxiety• Psychopathy• Frontal lobotomy• Inebriation

Difficulty reading emotion

• Autism• Psychopathy• Neurological?

Location, location, location

• Different settings– Work– School– Home– Office

Biases

• Attribution– The act of assigning meaning to a behavior

• Attribution theory– 1st try to assess whether an internal or external cause

• Fundamental attribution error – Judging another’s behavior as internal, or own as

external• Self-serving bias– Our success due to internal, failure is external

Behavior Checklists

• Classroom

• ABA?

• Summer ADHD Baseball

• Task specific– Some are observable to the clinician:– Purposeful approach on TMT vs. quick vs.

impulsive

• Some are not observable:• Block design and recording broken

configurations• Get sample page

• Errors on WRAT• Timing marks on timed tests-Coding, COWAT• Rationale

Language• Aphasia

– Fluency, naming, repetition, comprehension

• Regionalisms/ multicultural

• Paraphasias– Neologisms, semantic, phonemic

• Dyslexia

• Dementias– Empty, loss of meaning

Attention

• Sustained

• Perseveration, impulsivity, tangentiality

• Stimulus bound

Vision

• Acuity

• Hemispatial Neglect

• Anopsia

Vision

• Block construction– Boston Process Approach

• Agnosia

• Visuospatial confusion

Test Behaviors

• Behavioral observations during performance of the WAIS Block Design Test related to abnormalities of regional cerebral blood flow in organic dementia.

Memory

• Only reporting new items on CVLT

• Appearing overwhelmed

• Disorganized LM

• Rey-O approach

Research

• How might behavioral observations be important in research?

Kinds of Observational Studies

• Case-control– Comparison of two groups differing in outcome

• Cross-sectional – Observations of a population at one point in time

• Longitudinal– Repeated observations of same variables over time

• Cohort– Same individuals followed over time

• Observational– At least one variable studied at the group level

What Might Impair These Studies?

• Selection bias– Don’t have a random selection

• Information bias– Wrong or inexact recording of variables

• Measurement error– Faulty or imprecise measurement

• Confounding– A red herring– smoking, coffee, heart disease

Case Studies

#1

• Pressed speech• Rapid movements• Difficulty sitting still• Rapid change in topics• Not following through

#2

• Flat affect• Little facial expression• Slowed movements• Difficulty initiating behavior• Little speech

#3

• Avoids shaking your hand• Guarded • Withdrawn

How to Improve Behavioral Observations

1. Examine everything with healthy skepticism. Stop and question your own thoughts. By filtering your thoughts, they can't sneakily influence your behavior outside your awareness.

2. Work to overcome your biases, developed-over-a-lifetime. With practice, we can overcome the automatic wiring of our brains to become more objective in our thinking.

3. Observe all first impressions closely. Something superfluous often influences our judgments.

4. Be inclusive. Get all the insight possible, using all of your senses.

5. Be more engaged. Studies have shown that those who are motivated by their personal engagement in a situation are more likely to make the effort to counteract their autopilot-like initial judgments.

6. Step back. Imaginative thinking is enhanced when we walk away from a problem. The further away from our own perspective, the wider the picture we can see.

7. Continue educating yourself. Take cases that are a challenge in order to keep learning.

8. Keep a diary. Overconfidence—believing you already know the cause of some problem—can keep you from observing mindfully. Write everything down and then look for patterns, without jumping to conclusions.