Using the Psychologist Wisely Janet Leathem School of

Using the Psychologist Wisely Janet Leathem School of Psychology Massey University - Wellington

Impossible l No specific question l l Specify relative contributions of various causes to current condition/s l l Please see and treat 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 l Meaning l l l Psyche: the mind Logos: knowledge or study Definition l The scientific study of behaviour and mental processes l l Behavior - Overt (crying) Processes – Covert (remembering)

Clinical Psychology l l 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 l l Assessment (describing, understanding, predicting) Treatment

Assessment: Standardized Instruments l Psychopathology l l l l 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 l Wechsler Scales

Class of evidence for therapy Class I. High quality randomized controlled trials (RCTs) Class II. Prospective matched group cohort studies or RCTs lacking adequate randomization concealment or blinding, or potentially liable to attrition or outcome ascertainment bias Class III. Other studies such as natural history studies Class IV. Uncontrolled studies, case series, or expert opinion

Clinical Psychology

Recommendation Levels Level Established as effective, ineffective or harmful, or as A useful/predictive or not useful/predictive Level Probably effective, ineffective or harmful, or as B useful/predictive or not useful/predictive Level Possibly effective, ineffective or harmful, or as C useful/predictive or not useful/predictive Level Data inadequate or conflicting; Treatment, test, or U predictor unproven

Depression l DSM-IV Criteria for Diagnosis l 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). l l l

Talking treatments l Cognitive behavioural therapy (CBT) l l l 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) l focuses on relationships and on problems such as difficulties in communication, or coping with bereavement. More research is needed

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 l l l Labeling Mind Reading Exaggeration Unrealistic Expectations Belief in Entitlement Belief in Absolute Fairness

Fighting Dysfunctional Thoughts l l l l 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. l l l l 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.

Neuropsychology l A neuropsychological assessment is a comprehensive assessment of cognitive and behavioural functions using a set standardised tests and procedures.

Neuropsychology l l l l Academic skills Intelligence Perceptual & motor abilities Attention, learning & memory Language Planning and organization Problem solving & conceptualization Emotions, behavior, and personality

Neuropsychology l l l l 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?

Neuropsychology l Acute l l l Deteriorating l l TBI Brain tumors Infection Stroke Dementia Static l l l Neurotoxicity ADD Learning Disorder

Common Outcomes of Neuropathology l Cognition l l l attention memory slowed thinking higher executive function Interpersonal l l speaks without thinking abrupt troubled by noise self centred l Emotion l l l depression/anxiety short fuse/irritability lethargy lack of insight Activities of Daily Living l l motor function other physical driving, dressing communication

Cautions l l l 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 l l 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 Malingering l l 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 Malingering l l 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 l 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 Malingering A B C 1 2 3 a b c I II III

Forced Choice l l l 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) l l l 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 l l Referrals Communication Clinical Psychology Neuropsychology