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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

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using the psychologist wisely

Using the Psychologist Wisely

Janet Leathem

School of Psychology

Massey University - Wellington

impossible
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
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
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
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
depression
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
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
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
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.

Fighting Dysfunctional Thoughts
neuropsychology
Neuropsychology
  • A neuropsychological assessment is a comprehensive assessment of cognitive and behavioural functions using a set standardised tests and procedures.
neuropsychology1
Neuropsychology
  • Academic skills
  • Intelligence
  • Perceptual & motor abilities
  • Attention, learning & memory
  • Language
  • Planning and organization
  • Problem solving & conceptualization
  • Emotions, behavior, and personality
neuropsychology2
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?
neuropsychology3
Neuropsychology
  • Acute
    • TBI
    • Brain tumors
    • Infection
    • Stroke
  • Deteriorating
    • Dementia
  • Static
    • Neurotoxicity
    • ADD
    • Learning Disorder
common outcomes of neuropathology
Common Outcomes of Neuropathology
  • Cognition
    • attention
    • memory
    • slowed thinking
    • higher executive function
  • Emotion
    • depression/anxiety
    • short fuse/irritability
    • lethargy
    • lack of insight
  • Interpersonal
    • speaks without thinking
    • abrupt
    • troubled by noise
    • self centred
  • Activities of Daily Living
    • motor function
    • other physical
    • driving, dressing
    • communication
cautions
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
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 malingering1
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 malingering2
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
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 malingering1
Rey 15-item Memory Test for Malingering

A B C

1 2 3

a b c



I II III

forced choice
Forced Choice
  • Forced-Choice Procedure, (Hiscock & Hiscock, 1989)
  • Portland Digit Recognition Test, (Binder & Willis, 1991)
  • Test of Memory Malingering, (Tombaugh, 1997).
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test of memory malingering tomm
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
Bottom Line
  • Referrals
  • Communication
  • Clinical Psychology
  • Neuropsychology
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