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Chapter 13 : 

Chapter 13 Clinical Assessment

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Clinical assessments are used in counseling to: diagnose mental disorders guide treatment decisions monitor treatment progress provide final outcomes measures Clinical Assessment

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The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision is commonly used by mental health workers in numerous fields to categorize mental disorders in clients. DSM-IV-TR

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The DSM-IV-TR has 17 categories and over 300 different disorders. Each disorder has a list of specific diagnostic criteria that are used to evaluate the presence of the disorder. Each disorder is coded for easy reference.

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The DSM-IV-TR uses a multiaxial diagnostic system. Axis I: Clinical Disorders Axis II: Personality Disorders or Mental Retardation Axis III: General Medical Condition Axis IV: Psychosocial or Environmental Problems Axis V: Global Assessment of Functioning (GAF)

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Interviews are commonly used in conjunction with other forms of assessment. Interviews may be structured, semi-structured or unstructured. Interviews in Clinical Assessment

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Structured interviews have increased in use since the development of the DSM-IV-TR. Common structured interviews include: Anxiety Disorders Interview Schedule for the DSM-IV (ADIS-IV) The Child Assessment Schedule (CAS) Composite International Diagnostic Interview (CIDI) Diagnostic Interview Schedule (DIS) Diagnostic Interview Schedule for Children (DISC-IV) Substance Use Disorders Diagnostic Schedule (SUDDS-IV) Structured Interviews

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Semi-structured interviews provide greater flexibility than structured interviews, but provide greater reliability than unstructured interviews. Some semi-structured interviews include: Diagnostic Interview for Children and Adolescents (DICA-IV) Schedule for Affective Disorders and Schizophrenia (SADS) Semistructured Clinical Interview for Children and Adolescents (SCICA) Structured Clinical Interview for DSM-IV Axis-I Disorders, Clinical Version (SCID-CV) (see Figure 4.1) Structured Clinical Interview for DSM-IV Axis-II Disorders (SCID-II) Semi-Structured Interviews

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Despite the increasing use of structured interviews, unstructured interviews are the most common style of interviews used in clinical settings. Unstructured interviews often focus on core domains relating to the client issue and general functioning. Unstructured Interviews

Unstructured Interviews : 

Unstructured Interviews Includes assessing client’s presenting problem in three main areas: Onset/Course: When did the problems begin? Was there a time when the client felt worse or better? Was there any particular pattern? Severity: Do the problems interfere with the client’s life and/or lead to suffering or distress? Stressor: Does the client believe that some external event brought on the problems? Are any stressful life events associated with the problem?

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The MSE is a structured assessment modeled after physician medial exams. Focuses on core areas of psychiatric functioning. Commonly used in medical and psychiatric settings. Mental Status Exam (MSE)

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Orientation Memory Concentration and Attention Intelligence Judgment and Insight Reliability Appearance Behavior/Psychomotor Activity Attitude toward Examiner Affect and Mood Speech Perceptual Disturbances Thought Common MSE Categories

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Often focus on pathology May have a broad or narrow scope. Tests with a broad scope include: Brief Symptom Inventory Minnesota Multiphasic Personality Inventory Millon Multiaxial Inventory Symptom Checklist 90-Revised Tests with a narrow scope include: Beck Depression Inventory Eating Disorder Inventory Posttraumatic Stress Diagnostic Scale Substance Abuse Screen Inventory Instruments Used in Clinical Assessment

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The SCL-90-R measures nine scales of psychological symptoms and provides three global scales. The SCL-90-R uses T scores to measure outcomes. Symptom Checklist 90-Revised

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Somatization (SOM) Obsessive-Compulsive (O-C) Interpersonal Sensitivity (I-S) Depression (DEP) Anxiety (ANX) Hostility (HOS) Phobic Anxiety (PHOB) Paranoid Ideation (PAR) Psychoticism (PSY) SCL-90-R Psychological Symptoms

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Global Severity Index (GSI): overall psychological distress level. Positive Symptom Distress Index (PSDI): the average level of distress or intensity of symptoms. Positive Symptom Total (PST): the number of self-reported symptoms. SCL-90-R Global Indices

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Most commonly used measure of depression 21-items Each item is scored on a scale from 0 to 3 Normed for adults 17 to 80 years in age Higher scores indicate greater levels of depression. Beck Depression Inventory (BDI-II)

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0-13 minimal depression 14-19 mild depression 20-28 moderate depression 29-63 severe depression Beck Depression Inventory Scoring

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Self-report assessment 91 items on 12 scales Provides six composites: Eating disorder risk Ineffectiveness Interpersonal problems Affective problems Overcontrol General psychological maladjustment Eating Disorder Inventory (EDI-3)

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Used to detect PTSD 17 items rather on from 0 to 3 Provides multiple outcomes including: PTSD Diagnosis (yes or no) Symptom Severity Score and Rating (Mild = 1-10, Moderate = 11-20, Moderate to Severe = 21-35, and Severe ≥ 36) Number of Symptoms Endorsed Level of Impairment of Functioning Posttraumatic Stress Diagnostic Scale

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Self-report assessment Assesses for high probabilities of substance dependence disorder Measures ten scales or dimensions of substance dependence Substance Abuse Screen Inventory (SASSI-3)

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Assessing suicidality involves evaluating client risk factors and warning sites. Risk factors are ongoing client characteristics that increase suicide risk Warning signs are client behaviors that warn of imminent suicide risk Suicide Risk Assessment

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Social isolation/rejection by others Physical illness (life-threatening/chronic/debilitating) Unemployed/retired Family history of affective disorder, alcoholism, or suicide Bereavement/loss Childhood bereavement Social classes at the extremes Family destabilization Recent trauma (physical/psychological) Specific suicide plan formulated intense negative emotions Preoccupation with earlier abuse Male Single Widowed Divorced/separated Elderly Psychiatric illness Psychosis Hopelessness/helplessness Previous suicide attempt(s)/self-harm Risk Factors

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Giving away prized possessions* Putting personal affairs in order Radical changes in characteristic behaviors or moods Warning Signs

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Unstructured interviews are the most common method for assessing suicide. Many standardized assessments for assessing suicidality are also available. Core indicators of suicidality are also embedded in many inventories (such as the BDI-II)

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Observation can be used for many purposes in clinical settings: to help determine a diagnosis to target specific patterns of behavior to provide behavioral baseline data to identify effective treatment approaches Observation and Clinical Assessment

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Formal/Informal Direct/Indirect Intrusive/Unobtrusive Informal, director observation is often the initial type of observation used in clinical settings. Types of Observations

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Neuropsychological assessment involves assessing : attention concentration learning and memory sensory-perceptual abilities speech and language abilities visuospatial skills overall intelligence executive functions Neuropsychological Assessment

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Halstead-Reitan Neuropsychological Test Battery Luria-Nebraska Neuropsychological Battery (LNNB) Bender Visual-Motor Gestalt Test, Second Edition (Bender-Gestalt II) Neuropsychological Tests

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Assesses brain and nervous system functioning Designed for adults 15 or older Requires 6-8 hours of testing, including use of the Wechsler Intelligence tests Halstead-Reitan Neuropsychological Test Battery

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Assesses brain and nervous system functioning Designed for adults 15 or older Requires 1.5- 2 hours of testing Includes 11 clinical scales, two optional scales, three summary scales, and 11 factor scales Luria-Nebraska Neuropsychological Battery (LNNB)

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Motor functions Rhythm Tactile functions Vision functions Receptive speech Expressive speech Writing Reading Arithmetic Memory Intellectual processes Clinical Scales

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Assesses neuropsychological impairment for children and adults Uses nine stimulus cards to assess visual perception and visual-motor ability Test taker’s drawing ability is matched against the images on the cards Bender Visual-Motor Gestalt Test, Second Edition (Bender-Gestalt II)

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The Bender-Gestalt can be used to assess emotional problems with children. Emotional problems are detected through specific types of trends in drawing images.

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Assessors should be sensitive to cultural differences when performing clinical assessments. Actively exploring and being open to differences is essential to working with all clients. Counselors should take care not to confuse cultural differences for psychopathology. Cultural Considerations in Clinical Assessment

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