2. Clinical Psychology - case history, interview, abnormal behavior.ppt

CLINICAL PSYCHOLOGY 1  What we study ? I. Methodology in clinical psychology 1. Case history taking? Case history method. 2. Clinical interview – a. Types b. Factors influencing the interview 3. Clinical...

CLINICAL PSYCHOLOGY 1  What we study ? I. Methodology in clinical psychology 1. Case history taking? Case history method. 2. Clinical interview – a. Types b. Factors influencing the interview 3. Clinical observation 4. Psychological assessments (Psychological testing) a. Types b. Factors influencing the psychological assessment II. Classification of abnormal behavior 2  Methodology in Clinical Psychology Grouped into two categories - Research methods &Clinical methods I. Research methods – refers to research designs/procedures 1. Survey methods 2. Group designs 3. Single case designs 4. Experimental designs & makes use of Statistical procedures II. Clinical methods - Four important Clinical methods are- 1. Case history taking 2. Clinical interview 3. Clinical observation 4. Psychological testing/Assessments 3  CASE HISTORY METHOD This topic will be discussed in two headings - Clinical attitude & Case history - steps CLINICAL ATTITUDE 1. Should have the sound theoretical knowledge of psychopathology 2. Don’t put your values on patients or family 3. Be an assertive listener 4. Develop the skill of establishing the rapport 5. Give due respect to the client 6. Be an open minded, non committal 7. Don’t go for premature conclusion 8. Observe others taking the case history 9. Keep a clinical dairy 10. Monitor your own skill & discuss with your seniors/supervisors 4  Case history method The general steps are- I. Recording the socio- demographic data II. Estimation of reliability of the information III. Presenting complaints IV. Medical history V. Negative history VI. Personal history VII. Family history VIII. Mental status Examination IX. Summary of case history and MSE X. Diagnostic formulation & Diagnosis 5  Case history methods * I. Recording the socio- demographic data 1. Age & DOB 2. Education 3. Sex 4. Address 5. SES 6  Case history methods I. Recording the socio- demographic data 6. Occupation 7. E-mail ID 8. Contact no 9. Religion 7  Case history methods II. Estimation of reliability of the information – refers to the extent of dependability on the obtained information? Depends on the following details of informant 1. Age 2. Sex 3. Education 4. Occupation 5. Personality 8  Case history methods II. Estimation of reliability of the information – refers to the extent of dependability on the obtained information? 6. Health 7. Relation with the client 8. Duration of relationship( Acquaintance) 9. Socio Economic Status 9  Case history methods III. Presenting complaints 1. List of complaints – list out chronologically 2. Onset – a. When? - age of onset b. How ? - mode of the onset- sudden/gradual 3. Development/course – increasing the severity/decreasing/ remaining the same/addition or deletion of the symptoms 10  Case history methods III. Presenting complaints 4. Duration – since the time of the onset 5. Severity – mild/moderate/severe 6. Effect of the symptoms on the present life functioning – a. How b. Which area – education/occupation /family /personal/finance the clinical conditions/symptoms are disturbing his present life 11  Case history methods IV. Medical history – Any related illness eg. Recurrent fever/ heart problems/diabetes/headache/BP/Asthma V. Negative history- As a thumb of rule mention this. this refers to - No history of…. 12  Case history methods VI. Personal history 1. Birth order 2. Developmental history- Pre- natal, natal, post natal 3. Educational 4. Occupational 13  Case history methods VI. Personal history 5. Sexual and Marital 6. Personality 7. Health 8. Interests, hobbies/habits 14  Case history methods VII. Family history 1. Type of the family – nuclear/joint/orthodox * 2. Martial history of the parents – a. Arranged b. Separated c. Divorced d. Cordial relation e. Strained relation (marital discord) 3. Pedigree of the family 15  Case history methods VII. Family history 4. Parental history Father- age/education/occupation/health & personality Mother - age/education/occupation/health & personality 5. Sibling history – list out according to the birth order - a. Age b. Education c. Sex d. Occupation e. Health f. Personality 6. Family dynamics – communication & interaction 16 Case history methods 17  Case history methods VIII. Mental status Examination 6. Cognitive functions a. Sensation b. Memory c. Attention & concentration d. Intelligence e. Thinking & reasoning 7. Judgment – Social & personal - poor/fair/good 18 8. Insight – present/absent –  Case history methods IX. Summery a. Summery of the case history b. Mental status Examination X. Diagnostic formulation a. Inferential summery of the case history & MSE b. Diagnosis – use the standardized nomenclature c. Treatment recommendation 19  1. Definition CLINICAL INTERVIEW 2. Stages-& Types 3. Factors influencing 1. DEFINITION - a procedure through which the information about the client will be collected. 2. TYPES 1. Semi structured 2. Highly structured 3. Prolonged 4. Brief 5. Spontaneous 3. STAGES 1.Opening phase 2.Middle phase 3.Final phase 20  CLINICAL INTERVIEW Types of interviews - Based on the Purpose/Process 1. Diagnostic interview the information about the patient and family will be collected according to the case history Perform 2. Intake/ Therapeutic interview the client and family will be given orientation about the treatment/management after exploring their need, motivation and interest. 3. Social history/ case history interview The purpose is to get the information on his life, current personal and social situations. 4. Interview with informants This is for supplementing the information from relatives, teachers, friends etc. 21  CLINICAL INTERVIEW 5.Consultation interview Done by the consultant/supervisor in the teaching and training set up 6.Screening interview When the number of patients are more in the O.P.D. set up this type of brief interview needs to be carried out. 7. Discharge interview 22 This will be carried out at the time of  CLINICAL INTERVIEW Factors influencing the interview 1. Communication and language 2. Non verbal communication 3. Socio cultural background of the client 4. Orientation & background of the clinician 5. Establishing the empathetic relation with the client 6. Place or set up for the interview 7. Co-operation of the informant 8. Co-operation of the client 9. Motivation of the client 23  CLINICAL INTERVIEW Types of questions to be asked during interview – 1. Open ended questions 2. Leading questions (did you see the broken glass) 3. Directive questions (Describe your feeling) 4. Forced choice questions 24 CLINICAL OBSERVATION/OBSERVATION METHOD Basically three types- 1. Objective observation Observation of the overt behaviors like speech, language, Fluency etc. 2. Subjective observation Here the client observes his own behavior, which can’t be observed directly by others (Introspection). 3. Naturalistic observation Objectively observing the behaviors in the natural set- up. Example: Therapist observing the fluency of a person with stuttering in the classroom or in the shopping 25  PSYCHOLOGICAL ASSESSMENT/TESTING Types of psychological assessments/Psychological testing 1. Assessment of Cognitive functions- the functions are attention and concentration, perception, memory, intelligence, thinking and reasoning. 2. Assessment of personality and interpersonal relationship 3. Diagnostic assessments used for the diagnostic purpose with the help of tests like- Rorschach ink Blot Test, MPQ. 4. Neuropsychological assessments assessment of brain behavior relationship – lateralization & localization of functions & structures 5. Vocational assessments and assessments of interests and Aptitudes. 6. Behavioral assessment – behavioral diagnosis 26 FACTORS INFLUENCING PSYCHOLOGICAL ASSESSMENT 1. Age –children/adolescence/adults/old aged 2. Education 3. Occupation – type/nature of the work 4. Sex 5. Socio- cultural background 6. Interest 7. Motivation 8. Co-operation 9. Physical or sensory impediments- visual/hearing/orthopedic 10. Theoretical orientation of the clinician 27 CLASSIFICATION OF ABNORMAL BEHAVIOR 1. Few new terms 2. History 3. Need for the classification 4. Present systems- DSM and ICD 28  New terms 1. Classification: is a broad term, simply to any effort to construct groups or categories and to assign objects or people to the categories on the basis of their shared attributes or relations. 2. Taxonomy: Refers to the classification of entities like insects, rocks. 3. Nosology: Classification of psychological or medical phenomena or other clinical areas. 4. Nomenclature: The term which describes the names or labels of the disorders. 29  HISTORY Egypt and Sumeria, two conditions –Melancholia &Hysteria were identified 2600 B.C. India, psychiatric nosology was contained within the medical classification system of Ayur-Veda written about 1400 B.C. Hippocrates & Plato - classified mental disorders in Greece based on empirical observation and rational idealism respectively. European Renaissance, Carous Linneaus and Francois Boisser attempted to apply the taxonomic methods of biology to medical and psychiatric illness. Paradigms based on observation and theory continued during the 19th century Emil Krapelin - “Natural” classification in which, cause, symptomatology & course were expected, but finally the classification ended up with the inclusion of mainly symptoms. 30  HISTORY The first nosology of psychiatry - in USA by American Medico-Psychological association (1918)/ American Psychiatric Association - consisted 22 disorders In 1935, a standard classified nomenclature of disease was published. 1893- 1893-First Firstedition edition Following the World War II, WHO developed 6th revision of “Manual of International Statistical Classification of Disease, Injuries and Causes of Death -1948 1. DSM II - 1968 This was not found 2. DSM entirely III was satisfactory coordinated to American with ICD-9 -1980 Psychiatrists DSM –I 3. Revised III Edition -1987 4. DSMin - published IV 1952 - 1994 which is compatible with ICD – 10 31  APPROACHES IN THE CLASSIFICATION 1. Classical or categorical approach - assume every diagnosis has a clear underlying pathophysiology (cause) and each disorder is unique. So, diagnosis is possible if we know the cause of a disorder. - Emil Karpelin (1856-1926) Classified based on this approach. Problem: based on the biological tradition hence is possible in case of medicine Example: In Downs syndrome – 21st extra chromosome 2. Dimensional approach - variety of cognitions, moods, behavior which the patient presents quantified in a scale. Example: on a scale of 1 to 10 patient might be rated as severely anxious (10), moderately depressed (5) etc. This approach is applied in diagnosis. Problem - most theories do not agree on how 32 many dimensions are required- one or many?  APPROACHES IN THE CLASSIFICATION 3. Prototypical approach alternative approach in the classification of behavioral disorders gaining increasing support in recent years by experts all over the world. basically combines some of the essential features of first two approach. makes use of some non-essential features of clinical conditions in the classification. Example: DSM classification Note:- even today no full fledged internationally accepted classificatory system exists , which makes use of etiological factors, symptom manifestation and response to treatment. 33  Need for the classification 1. Classification is the heart of any scientific discipline. 2. For the better understanding of the abnormal behavior 3. To reduce the confusion and overlapping of symptoms 4. To communicate with the similar or other related professionals 5. To deal with any medico-legal issues 6. To avail any facilities or provisions made by law and govt. 7. Helps to decide and select the appropriate treatment procedures 8. Needs for research and documentation 34 DIAGNOSTIC AND STATISTICAL MANUAL OF DISORDERS (DSM ) This system was evolved and prevailing in USA, developed by American Psychiatric Association. It first started in the year of 1952 and subsequently underwent 5 revisions. Now we are using DSM IV. Certain features of DSM IV are- 1. Multi axial classification, I, II, III, IV & V axis 2. Provisions for the gradation of severity of clinical conditions 3. Provisions for frequently used criteria and associated features The five axis are- Axis I –All Mental Disorders except mentioned in Axis II Axis II –Personality disorder and mental retardation Axis III -Any physical disorders or general medical conditions Axis IV– Psychosocial and environmental problems Axis V - Global assessment of functioning (overall level of functioning) * * makes use of GAF Scale (Global assessment of functioning Scale) 35 International Statistical Classification of Disease and Related Health Problems ICD Aim of ICD- a. Standardized multi axial formulation b. Idiographic formulation ( clinicians/familial & combined perspective) This system was developed by W.H.O. (World Health Organization). Origin Can be traced back to Swedish biologist Carolus Linnaece’s taxonomic work in 18th Century. First international classification was done in the year 1893. Since then approximately for every 10 years it was required to be revised. Since its foundation, the WHO ( 1948 ), assumed the responsibility of preparation of this system. The 6th revision taken place in 1948. In the 10th revision which was revised in the year 1992, there are three axis Axis I – Clinical Diagnosis (Accommodates both mental and non- mental disorders) Axis II­­- Disablement – Based on WHO Disability Assessment Scale (DAS) Axis III- Contextual factors – Portray the context of illness 36  Details of AXIS – II & III AXIS – II (WHO Disability Assessment Scale) Personal care Occupational functioning Functioning with family Broad social behavior Axis –III Contextual factors (6 areas) 1. Problems in the family 2. Problems in the social environment 3. Problems in the education 4. Problems in the employment 5. Problems in the housing 6. Problems in the social environment 7. Problems in the Economic area 37