UNIT- II

CLINICAL PSYCHOLOGY

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

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

CASE HISTORY METHODThis 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 patient or family

3. Be an assertive listener

4. Develop the skill of establishing the rapport

6. Give due respect to the client

7. Be an open minded

8. Don’t go for premature conclusion

9. Observe others taking the case history

10. Keep a clinical dairy

11. Monitor your own skill & discuss with your seniors/supervisors

Case history methodsThe general steps are-

I. Recording the socio- demographic data

II. Estimation of reliability of the information

III. Presenting/Chief complaints

IV. History of present illness

V. Negative history

VI. Past Psychiatric/Medical history

VII. Personal history

VIII. Family history

IX. Mental status Examination

X. Summary of case history and MSE

XI. Diagnostic formulation & Diagnosis

Case history methods

Recording the socio- demographic data

1. Age & DOB

2. Sex

3. Education

4. Religion

5. Language Spoken

Case history methods

Recording the socio- demographic data

7. Occupation

8. Marital Status

9. SES (Income)

10. Domicile (Address with E-mail id & Contact no)

Case history methods

II. Estimation of reliability of the information – refers to the extent of dependability on the obtained information?

Depends on 5 C’s

1. Continuity2. Contact3. Closeness4. Consistency5. Corroboration

Case history methods

II. Estimation of reliability of the information – refers to the extent of dependability on the obtained information?

(Age, Sex, Education, Occupation, Personality, Health, Relation with the client, Socio Economic Status, Socio-cultural background)

Case history methods

III. Presenting/ Chief complaints

1. List of complaints – list out chronologically with duration

2. Onset – a. When? - age of onset b. How ? - mode of the onset-

Abrupt/ Acute/insidious or gradual.

Course – Continuous, episodic

Progress: increasing the severity/decreasing/ Static/ Fluctuating

IV. History of Present Illness: – Chronological account of the development of the

symptoms should be presented including the precipitating factor.

– 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.

V. Negative history-

As a thumb of rule mention this. this refers to - No history of….

VI. Medical history – Any related illness eg. Recurrent fever/ heart problems/diabetes/headache/BP/Asthma

VII. Personal history

1. Birth and Developmental history- Pre-natal, natal, post natal; early childhood traits

2. Educational: Early childhood, Middle childhood, late childhood and adolescence

3. Occupational history

4. Sexual and Marital history

5. Premorbid Personality/ Temperament– Attitude to others – Attitude towards self – Moral and religious beliefs– Predominant mood– Leisure activity and interest– Reaction pattern to stress

CLINICAL INTERVIEW

1. DEFINITION

Interview is a face to face situation between

the interviewer and the respondent, which

intends to elicit some desired information

from the latter. Thus, interview is a social

process involving at least two persons, the

interviewer and the respondents.

1. Definition2. Stages & Types3. Factors influencing

The success of the interview depend upon

three conditions:

1. Accessibility

2. Cognition

3. Motivation

2. TYPES

Formal Interview

1. Can be defined as one in which already prepared questions are asked in a set order by the interviewer and answers are recorded in a standardized form.

2. Conducted in a uniform way

3. Structured/ Patterned interview

• Relatively less trained interviewer can also

conduct the interview.

• Expensive and time consuming

Informal Interview

One where there are no predetermined questions

nor is there any preset order of the questions and

is left to the interviewer to ask some questions in

a way he likes regarding the no. of key points

around which the interview is to be built up.

• Unstructured interview

• Flexible method of collecting data

• Can “Dig deeper” and therefore get deeper

understanding of the respondents behaviour.

• Can have personal influence of the interviewer

• Requires greater skill on the part of the

interviewer.

Other Types Of Interview

• Semi structured• Prolonged • Brief • Spontaneous

CLINICAL INTERVIEW

1. Diagnostic interview

The information about the patient and family will be collected according to the case history Proforma

2. Intake/ Therapeutic interview

The client and family will be given orientation about the treatment/management after exploring their need, motivation and interest.

Types of interviews - Based on the Purpose/Process

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.

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

• This will be carried out at the time of termination

/discharge of in- patient

3. STAGES

1. Opening phase

2. Middle phase

3. Final phase

CLINICAL INTERVIEWFactors 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

CLINICAL INTERVIEW

Types of questions to be asked during interview –

1. Open ended questions

2. Leading questions

3. Directive questions

4. Forced choice questions

Observation

• Useful when the investigator wants to see the

behaviour in natural situation and study the

situation-based feature of conduct, such

situations questionnaires, interview are of

limited use.

Definition

Observation, as a fundamental technique of

data collection, refers to watching and

listening to the behaviour of other persons

over time without manipulating and

controlling it and record findings in ways

that allow some degree of analytical

interpretation and discussion.

• There is natural social context in which

persons behaviour is studied.

• It captures those significant events or

occurrences that affect the relations among

persons being studied.

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

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Types contd….

• Systematic observation: one which is done

according to some explicit procedures as well as

in accordance with the logic of scientific

inference.

• Unsystematic observation: Inference made by

investigator without specifying any explicit and

objective inference.

Based on the role of the investigator:

• Participant Observation: Investigator actively participates in the activities of the group to be observed.

• May be the member of the group/ organization.

• Procedure of the investigator is unstructured and the usually the identity of the investigator is not known to the other members of the group.

• Observer is flexible to decide what to observe and how to record it.

• More meaningful and convincing conclusions.

• Broader aspect of the human behaviour is assessed.

• Time consuming.

• Influenced by the subjectivity of the observer.

• Non-participant observation: Observes the natural setting without becoming the member of the group to be observed.

• Usually structured.

• Observer preplans the likely nature of the natural setting, representatives of the data, problems associated with the presence of the investigator etc.

• because the observation is structured, results are more reliable.

• Not influenced by the subjectivity of the observer.

• Observer misses the important aspect of the group.

• Participants become conscious that they are being observed.

Definition of Psychological Testing

• "An objective and standardized measure of a

sample of behaviour" (Anastasi, 1990).

• Psychological assessment is defined as the

process of ‘systematic collection, organization

and interpretation of information about a person

and his situation’. (Sunderberg and Taylor,1962)

–Psychological tests are written, visual, or verbal

evaluations administered to assess the cognitive

and emotional functioning of children and adults.

–Psychological tests are used to assess a variety of

mental abilities and attributes, including

achievement and ability, personality etc.

• Psychological tests are formalized measures of

mental functioning. Also known as inventories,

measurements, questionnaires, and scales,

psychological tests are administered in a variety of

settings, including preschools, primary and

secondary schools, colleges and universities,

hospitals, outpatient healthcare settings, social

agencies, prisons, and employment or human

resource offices.

PSYCHOLOGICAL ASSESSMENT/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 (Extrovert, introvert, ambivert, shy, tense, extravagant, outgoing etc.) 16 PF, California Psychological inventory.

3. Diagnostic assessments: Used for the diagnostic

purpose with the help of tests like- MPQ, Childhood

Autism Rating scale, Adolescent Psychopathology

Scale, Beck’s depression rating scale.

4. Neuropsychological assessments: Assessment of

brain behavior relationship – lateralization &

localization of functions & structures

5. Vocational assessments and assessments of

interests and Aptitudes. (Differential

aptitude test, Wide Range achievement test.)

6. Behavioral assessment – behavioral diagnosis

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/ Motivation/ Co-operation

7. Physical or sensory impediments- visual/hearing/orthopedic

8. Theoretical orientation of the clinician

New terms

1. Classification: is a broad term, the action or process of classifying.

2. Taxonomy: (Chiefly Biology) the branch of science concerned with classification. Refers to the classification of entities like insects, rocks.

3. Nosology: the branch of medical sciences concerned with the classification of diseases.

4. Nomenclature: The term which describes the names or labels of the disorders.

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.

• 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.

HISTORY

• First modern attempt at classification was International list of causes of Death (1893).

• 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.

• Following the World War II, WHO developed 6th

revision of “Manual of International Statistical

Classification of Disease, Injuries and Causes of Death -

1948 included psychiatric disorders for the first time.

• ICD 8 (1972) glossary

• ICD 9 (1978) glossary

• ICD 10 (1992) International Statistical classification of

diseases & related health problems

• Dissatisfied with ICD 6 The American

Psychiatric Association published

DSM 1 1952

DSM II 1968

DSM III 1980

DSM IIIR 1987

DSM IV 1994

DSM IVTR 2000

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

many dimensions are required- one or many?

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

Need for the classification1. 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

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-TR.

Certain features of DSM IV-TR 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

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)

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

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

Books of reference• Korchin, S.J. ( 1976). Modern Clinical Psychology, New York: Basic Books, Inc.,

Publishers.

• Gelder,M., Gath,D. & Mayou,R. (1983). Oxford Text book of Psychiatry. Oxford: Oxford University press.

• Sadock, B.J., & Sadock, V.A. (2000). Comprehensive text book of Psychiatry. New York: Lippinccott Williams & Wilkins.

• Franks, C.M. 9 1969). ( Ed.) Behavior therapy. New York: Mc Graw- Hill Book Ccompany

• Donna m. Gelfand & Donald P. Hartmann (1989) Child Behavior Analysis & Therapy – II Ed.