Clinical Interviews, Behavioral Observations, and Self-Monitoring

clinical interview: overview

• clinician directed conversation to gain information relevant to

  • problem definition

  • diagnosis

  • case formulation

  • goal specification

• differs from normal conversation

  • different goals

  • focus on client

  • respectful and non-judgmental

  • confidential (to an extent)

    • safety exceptions

• central role for attending/listening skills

  • silence, clarification, paraphrasing, summarization

• 2 types of interviews

  • UNSTRUCTURED

    • no standard set of questions or structures method for integrating and summarizing obtained information

  • STRUCTURED

    • very specific format for asking questions, determining follow-up questions, integrating and summarizing obtained information

    • can be semi-structured

      • follows a script that allows for some divergence if needed to obtain more information

unstructured interview: open questions

• ask client why they have come in

• follow client’s response

  • focus on what the client presents, not necessarily psychopathological symptoms

• generally use open notebook to take notes on

structured interview: SCID

• structured clinical interview for mental disorders

  • SCID

  • First et al. (2016)

• gold standard diagnostic instrument for DSM-5 disorders

• training and supervision usually extensive

• has moderate to high interrater reliability

  • Lobbestael et al. (2010)

    • 151 patients and controls

    • Kappa 0.41-0.75= “fair”

    • Kappa >0.75= “excellent”

      

criteria for panic attack (DSM-5)

a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes

1. palpitations, pounding heart, or accelerated heart rate

2. sweating

3. trembling or shaking

4. sensations of shortness of breath or smothering

5. feeling of choking

6. chest pain or discomfort

7. nausea or abdominal distress

8. feeling dizzy, unsteady, lightheaded, or faint

9. derealization (feelings of unreality) or depersonalization (being detached from oneself)

10. fear of losing control or going crazy

11. fear of dying

12. paresthesias (numbness or tingling sensations)

13. chills or hot flushes

• recurrent unexpected panic attacks

• at leas one of the attacks has been followed by 1 month (or more) of one or both of the following-

  • persistent concern or worry about additional panic attacks or their consequences (losing control, having a heart attack, “going crazy”)

  • a significant maladaptive change in behavior related ro the attacks (behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations)

• the disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders)

• the disturbance is not better explained by another medical disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder)

interview vs. questionnaire

• diagnostic assessment via questionnaire

  • evaluate in studies examining diagnostic agreement between interview and questionnaire

  • treat interview classification of diagnosis or not as “gold standard” against which compare accuracy of questionnaire classification

  • helps determine whether questionnaire can be used in place of interviews

• prior example- AUDIT vs. structured interview

  • 

behavioral observations

• goal

  • maladaptive behavior is key aspect of many mental health problems

  • every behavior has a function/purpose/reason

  • observation used to identify behavior patterns and generate hypotheses about causal/maintaining factors (reasons for behavior)

• always observing in clinical interviews

  • observation of verbal and nonverbal behavior plays central role

  • clinician usually observes specific areas

    • appearance and behavior

    • mood and affect

    • perception

    • comprehension

    • orientation

    • insight

    • memory

    • content of communication

• mental status exam

  • commonly used system of behavioral observation in psychiatric contexts

  • 

• naturalistic behavioral observation

  • observation within normal situational contexts and under natural occurring reinforcements and consequences

  • validity and reliability and cost

  • FUNCTIONAL BEHAVIORAL ASSESSMENT

    • observe behavior

    • classify behavior into ABCs

      • 

    • 3 ideas here-

      • problematic behavior may be more likely under some conditions (antecedents)

      • problematic behavior may be reinforced by positive consequences

      • may be able to modify problematic behavior by changing antecedents and/or

        consequences

    • ex-

    • 

• structured behavioral observation

  • observation in role played scenarios in which person engages in one or more simulated social interactions

  • validity and reliability and cost

• self monitoring

  • observing and recording own behaviors, thoughts, emotions, bodily sensations, events, etc

  • provides great deal of info at low cost

    • characterize problem and presumed causal/maintaining factors

  • can be used to track treatment progress

  • can be used to highlight connections btw thoughts, behaviors, feelings, physical sensations, etc.

  • ABCs

    • 

  • contributes to objective self awareness

  • problems

    • inaccuracy and distortion, reliability and validity

role of monitoring in cognitve-behavior therapy for panic disorder

• evidence of effectiveness

  • 70-80% panic free

  • 50-70% within normal range of functioning

  • gains largely maintained over 2 year follow up

• treatment components

  • education about nature and causes of panic and anxiety, how perpetuated by feedback loops among physical / cognitive / behavioral systems

  • breathing retraining to address Sx of chronic hyperventilation that are similar to PA Sx

  • cognitive restructuring to identify, challenge, and replace distorted thoughts and beliefs

  • exposure to physical sensations of PA, to activities that provoke PA sensations, to situations avoided b/c of concern couldn’t escape / get help (agoraphobia)

evidence based symptom record

daily/weekly symptom record

education: linking sensations, thoughts, and behaviors

physiology: breathing retraining

cognitive restructuring: challenging thoughts

behavior: gradual exposure

reactivity to self monitoring

• REACTIVITY: changes in behavior being assessed due to process of self-monitoring

  • mechanisms- change in perceptions of behavior?

    • clients frequently admit not realizing how often behavior is occurring

    • clients recognize behavior somewhat predictable in ways that potentially can anticipate, control, better prepare for, etc

    • typically see improvement

    • self-monitoring considered empirically supported treatment for number of conditions

self monitoring interventions

• present rationale underlying self monitoring

• select the target response

• record the target response

• chart/graph the target response

• display the data collected

• analyze the data collected