Using the psychologist wisely
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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

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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


Class of evidence for therapy

Class of evidence for therapy


Clinical psychology1

Clinical Psychology


Recommendation levels

Recommendation Levels


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).


Using the psychologist wisely

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Using the psychologist wisely

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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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