using the psychologist wisely janet leathem school of psychology massey university - wellington
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Using the Psychologist Wisely
Janet Leathem
School of Psychology
Massey University - Wellington
Impossible
No specific question Please see and treat
Specify relative contributions of various causes to current condition/s Please advise what proportions, prior sexual
abuse, head injury, substance abuse, maternal deprivation and the fact that his parents were close relatives contribute to current problems
Is this person malingering
Psychology
Meaning Psyche: the mind Logos: knowledge or study
Definition The scientific study of behaviour and mental
processes Behavior - Overt (crying) Processes – Covert (remembering)
Clinical Psychology
Scientist-Practitioner Model Inferences from base rates, law of large numbers
and descriptive data, versus generalising from small samples and anecdotes
Empirical data with reason & logic over intuition, experience & speculation
Currently utilises all in roles of Assessment (describing, understanding, predicting) Treatment
Assessment: Standardized Instruments
Psychopathology Symptom Checklist 90-R Patient Health Questionnaire (PHQ) Million Behavioral Health Inventory (MBHI) Minnesota Multiphasic Personality Inventory(MMPI-2) Beck Depression Inventory Zung Depression Inventory (ZDI) Pain Patient Profile (P-3)
Cognition Wechsler Scales
Class of evidence for therapy Class I. High quality randomized controlled trials
(RCTs)
Class II. Prospective matched group cohort studies or RCTs lacking adequate randomization concealment or blinding, or potentially liable to attrition or outcome ascertainment bias
Class III.
Other studies such as natural history studies
Class IV.
Uncontrolled studies, case series, or expert opinion
Clinical Psychology
Recommendation Levels
Level A
Established as effective, ineffective or harmful, or as useful/predictive or not useful/predictive
Level B
Probably effective, ineffective or harmful, or as useful/predictive or not useful/predictive
Level C
Possibly effective, ineffective or harmful, or as useful/predictive or not useful/predictive
Level U
Data inadequate or conflicting; Treatment, test, or predictor unproven
Depression
DSM-IV Criteria for Diagnosis Occurring over a two week period Helplessness/hopelessness Anhedonia Poor concentration Sleep disturbance (initiating and/or maintaining
sleep) Suicidal ideations Appetite disturbance (typically weight loss, but in a
small subgroup, weight gain).
Talking treatments
Cognitive behavioural therapy (CBT) based on the fact that the way we feel is partly
dependent on the way we think about events. stresses the importance of behaving in ways
which challenge negative thoughts – e.g., challenge feelings of hopelessness.
Interpersonal therapy (IPT) focuses on relationships and on problems such as
difficulties in communication, or coping with bereavement. More research is needed
CBT: The process
Assessment • Assess patient's self management beliefs, attitudes & knowledge • Identify personal barriers and supports • Collaborate in setting goals • Develop individually tailored strategies and problem solving
Goal setting and personal action plan • List goals in behavioural terms • Identify barriers to implementation • Make plans that address barriers to progress • Provide a follow up plan • Share the plan with all members of the healthcare team
Active follow up to monitor progress and support
Cognitive Distortions
Labeling Mind Reading Exaggeration Unrealistic Expectations Belief in Entitlement Belief in Absolute Fairness
Fighting Dysfunctional Thoughts
Hot Thoughts He is always mean to
me. I did a lousy job. I deserve better. It’s not fair. That bastard! They’re driving me
nuts.
Cool Thoughts Maybe he had a bad
day. It’ll be better next time But people are people Life is not fair. It’s his problem! I’m letting them drive
me nuts.
Neuropsychology
A neuropsychological assessment is a comprehensive assessment of cognitive and behavioural functions using a set standardised tests and procedures.
Neuropsychology
Academic skills Intelligence Perceptual & motor abilities Attention, learning & memory Language Planning and organization Problem solving & conceptualization Emotions, behavior, and personality
Neuropsychology
Differential diagnosis Prognosis Rehabilitation potential Ability to return to work or school or
playing field Ability to function independently Need for specialised school services Forensic issues--is the patient legally
competent?
Neuropsychology Acute
TBI Brain tumors Infection Stroke
Deteriorating Dementia
Static Neurotoxicity ADD Learning Disorder
Common Outcomes of Neuropathology CognitionCognition
attention memory slowed thinking higher executive function
EmotionEmotion depression/anxiety short fuse/irritability lethargy lack of insight
InterpersonalInterpersonal speaks without thinking abrupt troubled by noise self centred
Activities of Daily LivingActivities of Daily Living motor function other physical driving, dressing communication
Cautions
Assessment should consider information from collateral sources
Defective performance does not mean brain injury & intact performance does not rule it out.
Head injury is the same as brain injury Flexible in the use and intepretation of tests Neuropsychological tests are subject to other
factors which affect validity and reliablity
Features of Test Performance that raise question of Malingering
a degree of deficit that is disproportionate to the severity of injury
bizarre errors not typically seen in patients with genuine deficits
patterns of test performance that do not make sense, e.g., doing as badly on easy items as hard items
not showing expected patterns (e.g., scoring low on recognition; failing to show any learning at all on auditory learning; discrepancies between scores on tests measuring similar processes
Features of Test Performance that raise question of Malingering
inconsistencies between test performance and real life behaviour (e.g., unable to repeat strings of digits or short sentences, but in general conversation able to respond to multi-stage instructions; extreme slowness in responding to test questions, but able to converse and provide history normally
inexplicable claims of remote memory loss even for important life events
Features of Test Performance that raise question of Malingering
low performance on these that look hard but are in fact easy, e.g., Rey 15 item
absence of severe depression or anxiety that might cause performance to deteriorate
absence of improvement or deterioration of function over time
below chance responding on forced choice tests
Rey 15-item Memory Test for Malingering
Subject shown card for 10 seconds. Study carefully in order to try to remember as many of the items as they can. Cut off of 9 items gives specificity of 73% (sensitivity 12%). Cut off of 8 gives specificity of 94%. Recent metaanalysis (Reznak, 2005), suggests cut-off of 7, giving specificity of 95% sensitivity of 10%, i.e., some malingerers missed, but all of those identified likely to be true positives.
Rey 15-item Memory Test for Malingering
A B C
1 2 3
a b c
I II III
Forced Choice Forced-Choice Procedure, (Hiscock &
Hiscock, 1989) Portland Digit Recognition Test, (Binder &
Willis, 1991) Test of Memory Malingering, (Tombaugh,
1997).
52984
71395
52984
Test of Memory Malingering (TOMM)
50 line drawings, for 3 seconds each 50 two choice recognition items Examiner gives feedback each time Two learning trials One retention trial (no re-administration of
target items Scores lower that chance/scores lower that
45 on Trial 2 or Retention indicates possibility of malingering.
Bottom Line
Referrals Communication Clinical Psychology Neuropsychology