552 Lec1 Assessment 2007

Assessment and Interviewing : 

Assessment and Interviewing

Slide 2: 

(Page & Stritzke, 2006)

Matching: : 

Matching: Linking a client to the appropriate treatment option Screening and problem description (in which a decision is made about the need for further assessment and the presenting problems are identified) Treatment matching (in which specific information is collected that aids the clinical decision-making process).

Measurement: : 

Measurement: Pre, post, and follow-up assessments of a variable(s) to determine the amount of change that has occurred as a result of an intervention.

Monitoring: : 

Monitoring: Use of periodic assessment to intervention outcomes to permit inferences about what has produced the observed change. Progress monitoring is aimed at determining deviations from the expected course of improvement; whereas Outcomes monitoring focuses upon the aspects of the intervention process that bring about change Andrews & Page (2006)

Management: : 

Management: Ongoing assessment and evaluation of clinical and administrative processes involved in the delivery of care. The role of psychological testing has expanded beyond client assessment and includes the management context. Total Quality Management (TQM) Continuous Quality Improvement (CQI) Health increasingly viewed as an industry offer effective services in an efficient manner demonstrate client satisfaction demonstrate to each patient how much they have changed as a result of contact with a service Psychologists have expertise in assessment and measurement

Consumer Outcome Measures : 

Consumer Outcome Measures (Andrews et al., 1994)

Criteria for Selection : 

Criteria for Selection Applicability Acceptability Practicality Reliability Validity Sensitivity to change

Theory-Based Assessment of Panic Disorder : 

Theory-Based Assessment of Panic Disorder Page (1998). Current Opinion in Psychiatry.

Diagnostic Interviewing : 

Diagnostic Interviewing DSM-IV & ICD-10

DSM-IV Multiaxial Assessment : 

DSM-IV Multiaxial Assessment Axis I: Clinical Disorders >1 Axis I disorder, all reported & principal diagnosis or reason for visit indicated by listing it first. Principal diagnosis or reason for visit assumed to be Axis I unless Axis II diagnosis is followed by "(Principal Diagnosis)" or "(Reason for Visit)." No Axis I disorder, code V71.09. Axis I diagnosis deferred, pending additional information, code 799.9.

DSM-IV Multiaxial Assessment : 

DSM-IV Multiaxial Assessment Disorders 1st Diagnosed in Infancy, Childhood, or Adolescence (not MR) Delirium, Dementia, & Amnestic & Other Cognitive Disorders Mental Disorders Due to a General Medical Condition Substance-Related Disorders Schiz. & Other Psychotic Disorders Mood Disorders Anxiety Disorders Somatoform Disorders Factitious Disorders Dissociative Disorders Sexual & Gender Identity Disorders Eating Disorders Sleep Disorders Impulse-Control Disorders NEC Adjustment Disorders Other Conditions

DSM-IV Multiaxial Assessment : 

DSM-IV Multiaxial Assessment Axis II: Personality Disorders & Mental Retardation Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder Antisocial Personality Disorder Borderline Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder Avoidant Personality Disorder Dependent Personality Disorder Obsessive-Compulsive Personality Disorder Personality Disorder Not Otherwise Specified Mental Retardation

DSM-IV Multiaxial Assessment : 

DSM-IV Multiaxial Assessment Axis III: Medical Conditions Axis IV: Psychosocial and Environmental Problems Problems with primary support group Problems related to the social environment Educational problems Occupational problems Housing problems Economic problems Problems with access to health care Problems related to interaction with the legal system/crime Other P&E problems Axis V: Global Assessment of Functioning

ICD-10 : 

ICD-10 The official coding system is the International Classification of Diseases, Tenth Revision, (ICD-10; WHO, 1992) Most DSM-IV-TR disorders have a numerical ICD-10 code ICD-10 does not use a multiaxial system of diagnosis, although there is discussion of a triaxial system in which there are the clinical diagnoses on Axis I, Disabilities on Axis II, and contextual factors on Axis III. The first volume includes the clinical descriptions and the diagnostic guidelines

ICD Structure : 

ICD Structure (i) Organic, including symptomatic, mental disorders (e.g., dementia in Alzheimer's disease) (ii) Mental and behavioral disorders due to psychoactive substance use (e.g., harmful use of alcohol) (iii) Schizophrenia, schizotypal and delusional disorders (iv) Mood (affective) disorders (v) Neurotic, stress-related and somatoform disorders (e.g., generalized anxiety disorder) (vi) Behavioral syndromes associated with physiological disturbances and physical factors (e.g., eating disorders) (vii) Disorders of adult personality and behavior (e.g., transsexualism) (viii) Mental retardation (ix) Disorders of psychological development (e.g., childhood autism) (x) Behavioral and emotional disorders with onset usually occurring in childhood and adolescence (e.g., conduct disorders).

Panic Attack : 

Panic Attack Discrete period of intense fear or discomfort, >=4 developed abruptly and peaked within 10 minutes: (1) palpitations, pounding heart, or accelerated HR (2) sweating (3) trembling or shaking (4) sensations of shortness of breath or smothering Cont…

Panic Attack : 

Panic Attack (5) feeling of choking (6) chest pain or discomfort (7) nausea or abdominal distress (8) feeling dizzy, unsteady, lightheaded, or faint (9) derealization or depersonalization (10) fear of losing control or going crazy (11) fear of dying (12) paresthesias (13) chills or hot flushes

Agoraphobia : 

Agoraphobia A. Anxiety about being in places or situations from which escape difficult (or embarrassing) or in which help may not be available in event of unexpected or situationally predisposed PA or panic-like symptoms. B. Situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion. C. Not better accounted for …

Panic Disorder & Agoraphobia : 

Panic Disorder & Agoraphobia panic attacks avoidance of panic-related situations worry about future attacks

Diagnostic Interviewing : 

Diagnostic Interviewing Since your aim will be to assist a client discuss what could well be sensitive, distressing, private, and damaging issues, it is necessary: Good rapport is established Courteous Questioning open

Adapted from Andrews, et al. Best practice guideline for Panic Disorder & Agoraphobia. : 

Adapted from Andrews, et al. Best practice guideline for Panic Disorder & Agoraphobia. An interview to diagnose panic disorder needs to clearly establish what it is that the individual is fearful of. The clinician needs to gather details of symptomatology including information to aid differential diagnosis.

Theories : 

Theories Biological theories Familial factors Unique biological processes Focus: panic-related symptoms Psychological theories Particular cognitions Cognitive processes Focus panic-related cognitions

Symptom Groupings : 

Symptom Groupings Lovibond: depression, anxiety & stress (worry or tension) Ormel: depression, anxiety & avoidance Page: anxiety and tension Thus, Anxiety / fear Worry / stress / tension Phobic avoidance

A Common Thread? : 

A Common Thread? Zinbarg & Barlow; (see also Spence) “A higher order general factor differentiated each of the patient groups from the no mental disorder group. Several lower order factors provided the basis for differentiation among the patient groups” (p. 181) What is this common thread?

General Neurotic Syndrome : 

General Neurotic Syndrome Andrews: Common causes; chief among these being a largely inherited tendency to arouse rapidly and excessively under stress (i.e., elevated trait anxiety or “Neuroticism”).

Assessment of the Nature of Panic Disorder : 

Assessment of the Nature of Panic Disorder

Assessing General Symptoms and Vulnerability : 

Assessing General Symptoms and Vulnerability General Neurotic Syndrome implies that assessment should evaluate both the general and specific structures of neurotic symptoms and the underlying vulnerability Depression Anxiety Stress Scale (DASS) Neuroticism subscale of Eysenck Personality Questionnaire

Diagnosing Syndrome-Specific Symptoms : 

Diagnosing Syndrome-Specific Symptoms Structured diagnostic interviews ADIS-R CIDI

Assessment of Panic-Related Symptoms: General Measures : 

Assessment of Panic-Related Symptoms: General Measures panic frequency, severity, and duration panic-related phobias anticipatory anxiety impairment and general quality of life global problem severity

Assessment of Panic-Related Symptoms: General Measures : 

Assessment of Panic-Related Symptoms: General Measures Panic and Agoraphobia Scale (P&A) Panic-Associated Symptoms Scale (PASS)

Assessment of Panic-Related Symptoms: Specific Aspects : 

Assessment of Panic-Related Symptoms: Specific Aspects Symptoms Panic Attacks Symptom Questionnaire (PASQ) Body Sensations Questionnaire (BSQ) Cognitions Agoraphobic Cognitions Questionnaire (ACQ) and BSQ Anxiety Sensitivity Inventory (ASI) Anxiety Control Questionnaire (ACQ)

Clinical Significance : 

Clinical Significance Jacobson & Truax: Reliable Change Change from pre to post-test for patient beyond 1.96 times measurement error of instrument used Clinically significant = patient having significant RC score and moving into normal range on instrument (halfway between normal & pathological)

Clinical Significance : 

Clinical Significance Michelson Complete BAT with min. / no anxiety Score of 1-2 (5-pt scale) of clinician-rated global functioning Score between 0 and 2 on 9-pt self rating of phobias Score < 4 on 9-point self-rating scale of phobic anxiety & avoidance

Summary : 

Summary

Directing an Interview : 

Directing an Interview Choice of direction: remain with a discussion of the presenting problem and elicit general personal and historical information later Advantages: interview continues to flow naturally and the client keeps relating the details of the presenting problem until they have said everything they wish to say Weakness: clinician does not have a good picture of the client as a person, the social and historical background to the problems, a sense of other psychological problems, and so on. Clinician could signal a change of direction by saying perhaps, “Thank you. You have given me an idea of the difficulties that you are having. I would like to pursue them in more detail, but before we talk about these difficulties I was wondering if I could get some idea about you as a person?”

Continuing the Interview : 

Continuing the Interview Assuming that the clinician has decided to pursue the former line, the interview will seek to extend the inquiry perhaps by signally such with the comment, “I wonder if we could discuss the difficulty you have been mentioning in some detail. When did you first notice that something was not right?” This will direct the client to discuss the evolution of the problem; acknowledging the fact that psychological difficulties exist in a dynamically evolving system. However, within the complexity, the clinician will be focused on trying to highlight the key milestones in the problem development.

Continuing the Interview : 

Continuing the Interview This history will lead the client towards the present, at which time it will be possible to get a clearer description of the difficulties and any associated behaviors As a mental checklist, the clinician will be aiming to identify (i) what the problem is (ii) when it occurs (iii) where it happens (iv) how frequently the problem takes place (v) with whom these difficulties arise (vi) how distressing (vii) impairing the problem is The interview will evolve from a historical discussion to consideration of the problem in its current form. The clinician might ask, “Could you please tell me about a typical day or occurrence of the problem?” and then explore some of the maintaining factors The clinician will also ask about the variability in the problem and factors associated with the fluctuations (i.e., moderating variables).

Integrating Background Details : 

Integrating Background Details After the clinician has a good sense of the presenting problem, its present manifestation, and its history, the interview can expand to provide a more complete picture of the person. “You have given me a good idea of the problems you are struggling with, but I don’t think I have got a good idea about you as a person. Could you tell me something about you, apart from these difficulties?” The aim of this process is to be able to put yourself in the client’s shoes and imagine what it must be like to experience the life that the client has had. may be relevant to ask about family history (details of parents, other significant figures, brothers and sisters, as well as the childhood environment of family, school, and peers), a personal history (birth date and any significant issues, general adjustment in childhood, lifelong traits or behavioral patterns and tendencies, significant life events), schooling (duration and significant events), work history and present duties, relationships (current status, history and problems), leisure activities, living arrangements, social relationships, prior significant accidents, diseases and mental health problems, and personality (and particularly any changes).

Coping Resources : 

Coping Resources Enquire about coping resources and any assets in terms of personal strengths the individual possesses Motivation for change is a critical dimension identify the motivations intrinsic to the person, but identify any extrinsic motivators that are present or have been successful in the past Identify the “stage of change” that the client is in Prochaska, Norcross, and DiClemente, (1995; Prochaska & Norcross, 1998) see also Miller and Rollnick’s (2002) book.

Finishing : 

Finishing At the end of the interview, the clinician will need to summarize and synthesize the material covered. “I will try to draw together many of the themes we have been discussing. If I miss something out, or show that I have got a point wrong, please let me know.” It is also wise to ask the client if there are any problems or issues which you have not asked them about or which there has not been time to discuss.

Useful Resources : 

Useful Resources Hersen, M., & Turner, S. M. (2003). Diagnostic interviewing (Third Edition). New York: Kluwer Academic/Plenum. Sattler, D. N., Shabatay, V., & Kramer, G. P. (1998). Abnormal psychology in context: Voices and perspectives. New York: Houghton Mifflin. Meyer, R. G. (2003). Case studies in abnormal behavior (Sixth edition). Boston: Allyn & Bacon. Oltmans, T. F., Neale, J. M., & Davison, G. C. (2003). Case studies in abnormal psychology (Sixth edition). New York: Wiley. Rogers, R. (2001). Handbook of diagnostic and structured interviewing. New York: Guilford. Spitzer, R. L., Gibbon, M., Skodol, A. E., Williams, J. B.W., & First M. B. (2001). DSM-IV-TR Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington: APA Press.

Useful References : 

Useful References Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford. (Esp. chapters 3-5). Miller, W. R., & Rollnick, S. (Eds.). (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York, NY: Guilford Press. Norcross, J. C. (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. New York: Oxford University press.

Structured and Semi-structured Diagnostic Interviews : 

Structured and Semi-structured Diagnostic Interviews Structured diagnostic interviews are particularly helpful in: research (where replicablity is essential), in training (where the structure can assist a novice clinician) practice (where use of a standardized instrument can increase the confidence in a diagnosis) Evaluate the instrument in terms of (i) coverage and content (ii) the target population (iii) the psychometric features of the instrument (iv) practical issues (e.g., duration, training) (v) administration requirements, and support (e.g., scoring algorithms, standardized manual).

Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) : 

Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) The ADIS-IV (Brown, Di Nardo, & Barlow, 1994) is a semi-structured interview that follows a structure similar to a clinical interview and relies of the clinician to ask additional questions to follow up issues of relevance Although its primary focus is the DSM-IV Anxiety Disorders, it also assesses Mood, Substance Use, and Somatoform Disorders due to their high rates of comorbidity with anxiety The whole interview assessing current and lifetime disorders takes 2-4 hours in clinical samples. Reliability of the instrument is acceptable and the limited validity data upon its predecessor are supportive (e.g., Rapee, Brown, Antony, & Barlow, 1992) Suitable as a primary diagnostic measure when used by trained mental health professionals.

Diagnostic Interview Schedule (DIS) & Composite International Diagnostic Interview (CIDI) : 

Diagnostic Interview Schedule (DIS) & Composite International Diagnostic Interview (CIDI) The DIS-IV (Robins, Cottler, Bucholz, & Compton, 1995) is a structured diagnostic interview that is suitable for use by lay interviewers as well as mental health professionals The CIDI (Robins et al., 1988) is compatible with both DSM-IV and ICD-10 Modular format to permit customization of the interview and the structured format has permitted computerization Administration time is 2-3 hours with clinical samples and they yield both current and lifetime diagnoses Useful in large scale epidemiological studies, but the level of agreement with clinical diagnoses is poor thus, not suitable as a primary diagnostic instrument in a psychiatric setting.

Mini-International Neuropsychiatric Interview (MINI) : 

Mini-International Neuropsychiatric Interview (MINI) The MINI (Sheehan, Janavus, Baker, Harnett-Sheehan, Knapp, & Sheehan, 1999) is a clinician-administered structured diagnostic interview that assesses both DSM-IV and ICD-10 criteria Valid structured interview for clinical and research contexts, it covers a broad range of disorders, but does so in around 15 minutes Reliability and validity promising (Sheehan et al., 1998).

Primary Care Evaluation of Mental Disorders (PRIME-MD) : 

Primary Care Evaluation of Mental Disorders (PRIME-MD) PRIME-MD is a brief (10-20 min; or 3 mins using the more recent Patient Health Questionnaire; Spitzer, Kroenke, & Williams, 1999) clinician-administered interview to permit primary care physicians to rapidly identify the mental disorders commonly seen in medical practice (Spitzer et al., 1995) 25-item page self-report questionnaire asking about general physical and mental health issues and a semistructured interview to follows up on items that the patient has endorsed, the instrument provides a quick assessment of DSM-IV mood, anxiety, somatoform, eating, and alcohol-related disorders In terms of validity, its sensitivity and specificity are good, although the correspondence with DSM-IV was only moderate. Fraguas et al (2006) found a kappa with SCID of .42 for SD and .32 for MDD, but low frequency of depression in sample Another instrument suitable for use in primary care is the Symptom-Driven Diagnostic System for Primary Care (SDDS-PC; Broadhead et al., 1995).

Schedule for Affective Disorders and Schizophrenia (SADS) : 

Schedule for Affective Disorders and Schizophrenia (SADS) The SADS (Endicott & Spitzer, 1978) is a clinician-administered semistructured interview developed to assess the research diagnostic criteria. assesses current (i.e., past year) and past symptoms, with other versions assessing symptoms across the whole lifetime (SADS-L; Lifetime), and changes in symptoms (SADS-C; Change), SADS-LA-IV (SADS Lifetime Anxiety for DSM-IV; Fyer, Endicott, Mannuza, & Klein, 1995 cited in Summerfeldt & Antony, 2002) also assesses DSM-IV criteria in addition to expanded coverage of anxiety disorders SADS interview takes an hour with non-clinical samples, and this short duration, given to its breadth of coverage, is achieved by a structure that permits clinicians to skip sections that are not relevant because the respondent fails to endorse screening questions or they are not germane to the interview purpose Reliability excellent, when compared with the other structured diagnostic interviews (Rogers, 1995) and the validity is very good (see Conoley & Impara, 1995), particularly in the area of mood disorders, making it well-suited as a primary diagnostic screening measure.

Structured Clinical Interview for DSM-IV Axis-I Disorders (SCID) : 

Structured Clinical Interview for DSM-IV Axis-I Disorders (SCID) The SCID versions: brief clinical (SCID-CV; First, Spitzer, Gibbon, & Williams, 1997) research (SCID-I; First, Spitzer, Gibbon, & Williams, 1996) Axis II Personality Disorders SCID-CV - brief interview that provides coverage of the disorders commonly seen in a mental health practice version designed for individual already identified as psychiatric patients (SCID-I/P) - extensive coverage of mental health disorders of all available instruments, with interviews taking at least an hour Reliability is good (Segal et al., 1994) and validity studies of previous versions have also been supportive of the instrument (Rogers, 1995; 2001).

Schedule for Clinical Assessment in Neuropsychiatry (SCAN) : 

Schedule for Clinical Assessment in Neuropsychiatry (SCAN) The SCAN (WHO, 1998) seeks to describe key symptoms semistructured clinical interview a glossary to rate the experiences endorsed by respondents a checklist to rate information provided by third parties a schedule to assess the respondent’s clinical, social, and developmental history data can be scored to generate DSM-IV and ICD-10 diagnoses.