ABPSY - CHAP 3.1-3.2

CLINICAL ASSESSMENT

CLINICAL ASSESSMENT

It is the systematic evaluation and measurement of psychological, biological, and social factors in an individual presenting with a possible psychological disorder.

DIAGNOSIS

It is the process of determining whether the particular problem afflicting the individual meets all criteria for a psychological disorder, as set forth in the DSM-5.

Reliability

– the degree to which a measurement is consistent.

Validity

– the degree to which a technique measures what it is designed to measure.

Standardization

– application of certain standards to ensure consistency across different measurements.

CLINICAL INTERVIEW

• This is the core of most clinical work and is used by psychologists, psychiatrists, and other mental health professionals.

• Professional communication with a sense of purpose, compassion & curiosity; rapid, unfeeling questions & undirected Organized and structured gathering of data.

• Gather information on current and past behavior, attitudes, and emotions, as well as a detailed history of the individual’s life in general and of the presenting problem.

• Clinicians determine when the specific problem started and identify other events (for example; life stress, trauma, or physical illness) that might have occurred about the same time.

• Gathering of some information on the patient’s current and past interpersonal and social history, including family makeup (for example, marital status, number of children, or college student currently living with parents), and the individual’s upbringing.

• Information on sexual development, religious attitudes (current and past), relevant cultural concerns (such as stress induced by discrimination), and educational history are also routinely collected conversation are avoided.

MENTAL STATUS EXAMINATION (MSE)

This involves the systematic observation of an individual’s behavior. This type of observation occurs when any one person interacts with another.

 Appearance and behavior

 Thought Process

 Mood and Affect

 Intellectual Functioning

 Sensorium

Major Components of MSE

SEMISTRUCTURED INTERVIEW

These are made up of questions that have been carefully phrased and tested to elicit useful information in a consistent manner so that clinicians can be sure they have inquired about the most important aspects of particular disorders.

BEHAVIORAL ASSESSMENT

Takes this process one step further by using direct observation to assess formally an individual’s thoughts, feelings, and behavior in specific situations or contexts.

PSYCHOLOGICAL TESTING

Includes specific tools to determine cognitive, emotional, or behavioral responses that might be associated with a specific disorder and more general tools that assess longstanding personality features, such as tendency to be suspicious.

PROJECTIVE TEST

Includes a variety of methods in which ambiguous stimuli, such as pictures of people or things, are presented to people who are asked to describe what they see.

INTELLIGENCE TEST

It is occasionally used to determine the client’s level of cognitive functioning. ________ consists of a series of tasks asking the patient to use both verbal and nonverbal skills.

Stanford-Binet Intelligence

An example is the OF INTELLIGENCE TEST which is used to assess fluid reasoning, knowledge, quantitative reasoning, visual- spatial processing and working memory.

PHYSICAL EXAMINATION

Many patients with problems first go to a family physician and are given a physical. If the patient presenting with psychological problems has not had a ______ in the past year, a clinician might recommend one, with particular attention to the medical conditions sometimes associated with the specific psychological problem.

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS

The most widely used classification system in the United States

INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS

alternative for DSM-5 produce by WHO

1952

The first edition of the Diagnostic and Statistical Manual (DSM-I) is published.

about 60 disorders

The first DSM contained about HOW MANY DISORDERS? and was based on theories of abnormal psychology and psychopathology.

1968

DSM-II is published.

eleven major diagnostics

185 total

Changes in the DSM-II included ______ diagnostic categories, with how many total diagnoses for mental disorders.

1980

 DSM-III is published.

265 diagnoses.

DSM-III provided specific diagnostic criteria for HOW MANY DIAGNOSES?

1987

DSM-III R is published.

297 diagnoses

DSM-III R provided specific diagnostic criteria for HOW MANY DIAGNOSES?

1994

DSM-IV is published.

365 diagnoses

DSM-IV provided specific diagnostic criteria for HOW MANY DIAGNOSES?

2000

DSM-IV-TR is published.

This volume is heavily researched based and includes information about the etiologies of the disorder.

2013

DSM-V is published.

312 diagnoses

DSM-V provided specific diagnostic criteria for HOW MANY DIAGNOSES?

DIAGNOSTIC CRITERIA AND DESCRIPTORS

are the guidelines for making a diagnosis. The final diagnosis is based on the clinical interview, text descriptions, criteria, and clinical judgment.

SUBTYPES AND SPECIFIERS

Since the same disorder can be manifested in different ways in different individuals, the DSM uses _________ to better characterize an individual’s disorder.

Subtypes

denotes “mutually exclusive and jointly exhaustive phenomenological subgroupings within a diagnosis.” (APA,2013)

PRINCIPAL DIAGNOSIS

is used when more than one diagnosis is given for an individual (when an individual has comorbid disorders).

- is the reason for the admission in an inpatient setting or the reason for a visit resulting in ambulatory care medical services in outpatient settings.

• is generally the main focus of treatment.

PROVISIONAL DIAGNOSIS

If not enough information is available for a mental health professional to make a definitive diagnosis, but there is a strong presumption that the full criteria will be met with additional information or time, then the _______ specifier can be used.

Neurodevelopmental Disorders

A group of conditions that arise in the developmental period and include intellectual disability, communication disorders, autism spectrum disorder, motor disorders, and ADHD.

Schizophrenia Spectrum and Other Psychotic Disorders

Disorders are characterized by one or more of the following: delusions, hallucinations, disorganized thinking and speech, disorganized motor behavior, and negative symptoms.

Bipolar and Related Disorders

Characterized by mania or hypomania and possibly depressed mood; includes Bipolar I and II, cyclothymic disorder.

Depressive Disorders

Characterized by sad, empty, or irritable mood, as well as somatic and cognitive changes that affect functioning; includes major depressive and persistent depressive disorders.

Anxiety Disorders

Characterized by excessive fear and anxiety and related behavioral disturbances; Includes phobias, separation anxiety, panic attack, and generalized anxiety disorder.

Obsessive- Compulsive and Related Disorders

Characterized by obsessions and compulsions and includes OCD, hoarding, and body dysmorphic disorders.

Trauma-and Stressor-Related Disorders

Characterized by exposure to a traumatic or stressful event; PTSD, acute stress disorder, and adjustment disorders.

Dissociative Disorders

Characterized by a disruption or disturbance in memory, identity, emotion, perception, or behavior, dissociative identity disorder, dissociative amnesia, and depersonalization/derealization disorder.

Somatic Symptom and Related Disorders

Characterized by prominent ____ symptoms to include illness anxiety disorder ____ symptom disorder, and conversion disorder.

Feeding and Eating Disorders

Characterized by a persistent disturbance of eating or eating-related behavior to include bingeing and purging.

Elimination Disorders

Characterized by the inappropriate elimination of urine or feces; usually first diagnosed in childhood or adolescence.

Sleep-Wake Disorders

Characterized by _____ complaints about the quality, timing, and amount of sleep; includes insomnia, sleep terrors, narcolepsy, and sleep apnea.

Sexual Dysfunctions

Characterized by sexual difficulties and including premature ejaculation, female orgasmic disorder, and erectile disorder.

Gender Dysphoria

Characterized by distress associated with the incongruity between one’s experienced or expressed gender and the gender assigned at birth.

Disruptive, Impulse Control, and Conduct Disorders

Characterized by problems in self-control of emotions and behavior and involve the violation of the rights of others and cause the individual to be in violation of societal norms; Includes oppositional defiant disorder, antisocial personality disorder, kleptomania, etc.

Substance-Related and Addictive Disorders

Characterized by the continued use of a substance despite significant problems related to its use.

Neurocognitive Disorders

Characterized by a decline in cognitive functioning over time and the ___ has not been present since birth or early in life.

Personality Disorders

Characterized by a pattern of stable traits which are inflexible, pervasive, and leads to distress or impairment.

Paraphilic Disorders

Characterized by recurrent and intense sexual fantasies that can cause harm to the individual or others; includes exhibitionism, voyeurism, and sexual sadism.

IDENTIFYING DATA

The first step to do before conducting the report which includes: Name, Age, Religion, Citizenship, Civil Status, Occupation, Language/Dialect Spoken, Education: Elementary, Secondary, Tertiary, Others.

ADMISSION

If the patient had prior admission under a mental institution or rehabilitation center, include the history of the admission. If there were NO admission at all, you can follow the sample below as describing the submission of your client/patient to series of interviews, tests, and observations)

CHIEF COMPLAINT AND PRESENT PROBLEM

-Specify the given dates

-any concerns coming from the client can be considered here

PREVIOUS HISTORY OF THE PRESENT PROBLEM

-This is how the chief complaint started

PERSONAL HISTORY

-Arrange the events chronologically, recent to old ones

-Identify what data we want from the client

• Extended Family, Academic, Work History, Social, Sexual Relationships

PHYSICAL EXAMINATION

Include medical check-up results if available, if none you can just include the description of height, weight, BMI, vision, hearing and medical history

BEHAVIORAL OBSERVATION

-Include the dates of the interview, arrange the _____ from recent

MENTAL STATUS EXAMINATION

a) General Appearance

b) Psychomotor behavior

c) Mood and affect

d) Speech

e) Cognition

f) Thought Patterns

g) Level of Consciousness

OVERALL IMPRESSION

Include the dominant results from the history, behavioral observation, mental status examination, psychological tests, and DSM-5 if there is/are present signs and symptoms

PROGNOSIS AND RECOMMENDATION

enumerate the area/s of concern and the suggested treatment plan

TEST ADMINISTRATION AND INTERPRETATION

Test that were given to provide prognosis
EXAMPLE:
1. Color Test September 5, 2010

comorbidity

when more than one diagnosis is given for an individual (when an individual has ______ disorders).