Assessment and Interviewing

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Assessment and Interviewing
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(Page Stritzke, 2006)
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Matching

• Linking a client to the appropriate treatment
  option
• Screening and problem description (in which a
  decision is made about the need for further
  assessment and the presenting problems are
  identified)
• Treatment matching (in which specific information
  is collected that aids the clinical
  decision-making process).

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Measurement

• Pre, post, and follow-up assessments of a
  variable(s) to determine the amount of change
  that has occurred as a result of an intervention.

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Monitoring

• Use of periodic assessment to intervention
  outcomes to permit inferences about what has
  produced the observed change.
• Progress monitoring is aimed at determining
  deviations from the expected course of
  improvement whereas
• Outcomes monitoring focuses upon the aspects of
  the intervention process that bring about change
• Andrews Page (2006)

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Management

• Ongoing assessment and evaluation of clinical and
  administrative processes involved in the delivery
  of care.
• The role of psychological testing has expanded
  beyond client assessment and includes the
  management context.
• Total Quality Management (TQM)
• Continuous Quality Improvement (CQI)
• Health increasingly viewed as an industry
• offer effective services in an efficient manner
• demonstrate client satisfaction
• demonstrate to each patient how much they have
  changed as a result of contact with a service
• Psychologists have expertise in assessment and
  measurement

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Consumer Outcome Measures

• (Andrews et al., 1994)

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Criteria for Selection

• Applicability
• Acceptability
• Practicality
• Reliability
• Validity
• Sensitivity to change

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Theory-Based Assessment of Panic Disorder

• Page (1998). Current Opinion in Psychiatry.

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Diagnostic Interviewing

• DSM-IV ICD-10

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DSM-IV Multiaxial Assessment

• Axis I Clinical Disorders
• gt1 Axis I disorder, all reported principal
  diagnosis or reason for visit indicated by
  listing it first.
• Principal diagnosis or reason for visit assumed
  to be Axis I unless Axis II diagnosis is followed
  by "(Principal Diagnosis)" or "(Reason for
  Visit)."
• No Axis I disorder, code V71.09.
• Axis I diagnosis deferred, pending additional
  information, code 799.9.

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DSM-IV Multiaxial Assessment

• Disorders 1st Diagnosed in Infancy, Childhood, or
  Adolescence (not MR)
• Delirium, Dementia, Amnestic Other Cognitive
  Disorders
• Mental Disorders Due to a General Medical
  Condition
• Substance-Related Disorders
• Schiz. Other Psychotic Disorders
• Mood Disorders

• Anxiety Disorders
• Somatoform Disorders
• Factitious Disorders
• Dissociative Disorders
• Sexual Gender Identity Disorders
• Eating Disorders
• Sleep Disorders
• Impulse-Control Disorders NEC
• Adjustment Disorders
• Other Conditions

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DSM-IV Multiaxial Assessment

• Axis II Personality Disorders Mental
  Retardation
• Paranoid Personality Disorder
• Schizoid Personality Disorder
• Schizotypal Personality Disorder
• Antisocial Personality Disorder
• Borderline Personality Disorder
• Histrionic Personality Disorder
• Narcissistic Personality Disorder
• Avoidant Personality Disorder
• Dependent Personality Disorder
• Obsessive-Compulsive Personality Disorder
• Personality Disorder Not Otherwise Specified
• Mental Retardation

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DSM-IV Multiaxial Assessment

• Axis III Medical Conditions
• Axis IV Psychosocial and Environmental Problems
• Problems with primary support group
• Problems related to the social environment
• Educational problems
• Occupational problems
• Housing problems
• Economic problems
• Problems with access to health care
• Problems related to interaction with the legal
  system/crime
• Other PE problems
• Axis V Global Assessment of Functioning

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ICD-10

• The official coding system is the International
  Classification of Diseases, Tenth Revision,
  (ICD-10 WHO, 1992)
• Most DSM-IV-TR disorders have a numerical ICD-10
  code
• ICD-10 does not use a multiaxial system of
  diagnosis, although there is discussion of a
  triaxial system in which there are the clinical
  diagnoses on Axis I, Disabilities on Axis II, and
  contextual factors on Axis III.
• The first volume includes the clinical
  descriptions and the diagnostic guidelines

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ICD Structure

• (i) Organic, including symptomatic, mental
  disorders (e.g., dementia in Alzheimer's disease)
• (ii) Mental and behavioral disorders due to
  psychoactive substance use (e.g., harmful use of
  alcohol)
• (iii) Schizophrenia, schizotypal and delusional
  disorders
• (iv) Mood (affective) disorders
• (v) Neurotic, stress-related and somatoform
  disorders (e.g., generalized anxiety disorder)
• (vi) Behavioral syndromes associated with
  physiological disturbances and physical factors
  (e.g., eating disorders)
• (vii) Disorders of adult personality and behavior
  (e.g., transsexualism)
• (viii) Mental retardation
• (ix) Disorders of psychological development
  (e.g., childhood autism)
• (x) Behavioral and emotional disorders with onset
  usually occurring in childhood and adolescence
  (e.g., conduct disorders).

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Panic Attack

• Discrete period of intense fear or discomfort,
  gt4 developed abruptly and peaked within 10
  minutes
• (1) palpitations, pounding heart, or accelerated
  HR
• (2) sweating
• (3) trembling or shaking
• (4) sensations of shortness of breath or
  smothering
• Cont

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Panic Attack

• (5) feeling of choking
• (6) chest pain or discomfort
• (7) nausea or abdominal distress
• (8) feeling dizzy, unsteady, lightheaded, or
  faint
• (9) derealization or depersonalization
• (10) fear of losing control or going crazy
• (11) fear of dying
• (12) paresthesias
• (13) chills or hot flushes

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Agoraphobia

• A. Anxiety about being in places or situations
  from which escape difficult (or embarrassing) or
  in which help may not be available in event of
  unexpected or situationally predisposed PA or
  panic-like symptoms.
• B. Situations are avoided (e.g., travel is
  restricted) or else are endured with marked
  distress or with anxiety about having a Panic
  Attack or panic-like symptoms, or require the
  presence of a companion.
• C. Not better accounted for

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Panic Disorder Agoraphobia

• panic attacks
• avoidance of panic-related situations
• worry about future attacks

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Diagnostic Interviewing

• Since your aim will be to assist a client discuss
  what could well be sensitive, distressing,
  private, and damaging issues, it is necessary
• Good rapport is established
• Courteous
• Questioning open

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Adapted from Andrews, et al. Best practice
guideline for Panic Disorder Agoraphobia.

• An interview to diagnose panic disorder needs to
  clearly establish what it is that the individual
  is fearful of.
• The clinician needs to gather details of
  symptomatology including information to aid
  differential diagnosis.

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Theories

• Biological theories
• Familial factors
• Unique biological processes
• Focus panic-related symptoms
• Psychological theories
• Particular cognitions
• Cognitive processes
• Focus panic-related cognitions

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Symptom Groupings

• Lovibond depression, anxiety stress (worry or
  tension)
• Ormel depression, anxiety avoidance
• Page anxiety and tension
• Thus,
• Anxiety / fear
• Worry / stress / tension
• Phobic avoidance

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A Common Thread?

• Zinbarg Barlow (see also Spence) A higher
  order general factor differentiated each of the
  patient groups from the no mental disorder group.
  Several lower order factors provided the basis
  for differentiation among the patient groups (p.
  181)
• What is this common thread?

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General Neurotic Syndrome

• Andrews Common causes chief among these being a
  largely inherited tendency to arouse rapidly and
  excessively under stress (i.e., elevated trait
  anxiety or Neuroticism).

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Assessment of the Nature of Panic Disorder
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Assessing General Symptoms and Vulnerability

• General Neurotic Syndrome implies that assessment
  should evaluate both the general and specific
  structures of neurotic symptoms and the
  underlying vulnerability
• Depression Anxiety Stress Scale (DASS)
• Neuroticism subscale of Eysenck Personality
  Questionnaire

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Diagnosing Syndrome-Specific Symptoms

• Structured diagnostic interviews
• ADIS-R
• CIDI

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Assessment of Panic-Related Symptoms General
Measures

• panic frequency, severity, and duration
• panic-related phobias
• anticipatory anxiety
• impairment and general quality of life
• global problem severity

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Assessment of Panic-Related Symptoms General
Measures

• Panic and Agoraphobia Scale (PA)
• Panic-Associated Symptoms Scale (PASS)

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Assessment of Panic-Related Symptoms Specific
Aspects

• Symptoms
• Panic Attacks Symptom Questionnaire (PASQ)
• Body Sensations Questionnaire (BSQ)
• Cognitions
• Agoraphobic Cognitions Questionnaire (ACQ) and
  BSQ
• Anxiety Sensitivity Inventory (ASI)
• Anxiety Control Questionnaire (ACQ)

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Clinical Significance

• Jacobson Truax Reliable Change
• Change from pre to post-test for patient beyond
  1.96 times measurement error of instrument used
• Clinically significant patient having
  significant RC score and moving into normal range
  on instrument (halfway between normal
  pathological)

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Clinical Significance

• Michelson
• Complete BAT with min. / no anxiety
• Score of 1-2 (5-pt scale) of clinician-rated
  global functioning
• Score between 0 and 2 on 9-pt self rating of
  phobias
• Score lt 4 on 9-point self-rating scale of phobic
  anxiety avoidance

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Summary
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Directing an Interview

• Choice of direction remain with a discussion of
  the presenting problem and elicit general
  personal and historical information later
• Advantages interview continues to flow naturally
  and the client keeps relating the details of the
  presenting problem until they have said
  everything they wish to say
• Weakness clinician does not have a good picture
  of the client as a person, the social and
  historical background to the problems, a sense of
  other psychological problems, and so on.
• Clinician could signal a change of direction by
  saying perhaps, Thank you. You have given me an
  idea of the difficulties that you are having. I
  would like to pursue them in more detail, but
  before we talk about these difficulties I was
  wondering if I could get some idea about you as a
  person?

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Continuing the Interview

• Assuming that the clinician has decided to pursue
  the former line, the interview will seek to
  extend the inquiry perhaps by signally such with
  the comment, I wonder if we could discuss the
  difficulty you have been mentioning in some
  detail. When did you first notice that something
  was not right?
• This will direct the client to discuss the
  evolution of the problem acknowledging the fact
  that psychological difficulties exist in a
  dynamically evolving system. However, within the
  complexity, the clinician will be focused on
  trying to highlight the key milestones in the
  problem development.

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Continuing the Interview

• This history will lead the client towards the
  present, at which time it will be possible to get
  a clearer description of the difficulties and any
  associated behaviors
• As a mental checklist, the clinician will be
  aiming to identify
• (i) what the problem is
• (ii) when it occurs
• (iii) where it happens
• (iv) how frequently the problem takes place
• (v) with whom these difficulties arise
• (vi) how distressing
• (vii) impairing the problem is
• The interview will evolve from a historical
  discussion to consideration of the problem in its
  current form. The clinician might ask, Could
  you please tell me about a typical day or
  occurrence of the problem? and then explore some
  of the maintaining factors
• The clinician will also ask about the variability
  in the problem and factors associated with the
  fluctuations (i.e., moderating variables).

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Integrating Background Details

• After the clinician has a good sense of the
  presenting problem, its present manifestation,
  and its history, the interview can expand to
  provide a more complete picture of the person.
• You have given me a good idea of the problems
  you are struggling with, but I dont think I have
  got a good idea about you as a person. Could you
  tell me something about you, apart from these
  difficulties?
• The aim of this process is to be able to put
  yourself in the clients shoes and imagine what
  it must be like to experience the life that the
  client has had.
• may be relevant to ask about family history
  (details of parents, other significant figures,
  brothers and sisters, as well as the childhood
  environment of family, school, and peers), a
  personal history (birth date and any significant
  issues, general adjustment in childhood, lifelong
  traits or behavioral patterns and tendencies,
  significant life events), schooling (duration and
  significant events), work history and present
  duties, relationships (current status, history
  and problems), leisure activities, living
  arrangements, social relationships, prior
  significant accidents, diseases and mental health
  problems, and personality (and particularly any
  changes).

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Coping Resources

• Enquire about coping resources and any assets in
  terms of personal strengths the individual
  possesses
• Motivation for change is a critical dimension
• identify the motivations intrinsic to the person,
  but identify any extrinsic motivators that are
  present or have been successful in the past
• Identify the stage of change that the client is
  in
• Prochaska, Norcross, and DiClemente, (1995
  Prochaska Norcross, 1998) see also Miller and
  Rollnicks (2002) book.

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Finishing

• At the end of the interview, the clinician will
  need to summarize and synthesize the material
  covered.
• I will try to draw together many of the themes
  we have been discussing. If I miss something
  out, or show that I have got a point wrong,
  please let me know.
• It is also wise to ask the client if there are
  any problems or issues which you have not asked
  them about or which there has not been time to
  discuss.

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Useful Resources

• Hersen, M., Turner, S. M. (2003). Diagnostic
  interviewing (Third Edition). New York Kluwer
  Academic/Plenum.
• Sattler, D. N., Shabatay, V., Kramer, G. P.
  (1998). Abnormal psychology in context Voices
  and perspectives. New York Houghton Mifflin.
• Meyer, R. G. (2003). Case studies in abnormal
  behavior (Sixth edition). Boston Allyn Bacon.
• Oltmans, T. F., Neale, J. M., Davison, G. C.
  (2003). Case studies in abnormal psychology
  (Sixth edition). New York Wiley.
• Rogers, R. (2001). Handbook of diagnostic and
  structured interviewing. New York Guilford.
• Spitzer, R. L., Gibbon, M., Skodol, A. E.,
  Williams, J. B.W., First M. B. (2001).
  DSM-IV-TR Casebook A Learning Companion to the
  Diagnostic and Statistical Manual of Mental
  Disorders, Fourth Edition, Text Revision.
  Washington APA Press.

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Useful References

• Beck, J. S. (1995). Cognitive therapy Basics and
  beyond. New York Guilford. (Esp. chapters 3-5).
• Miller, W. R., Rollnick, S. (Eds.). (2002).
  Motivational interviewing Preparing people for
  change (2nd ed.). New York, NY Guilford Press.
• Norcross, J. C. (2002). Psychotherapy
  relationships that work Therapist contributions
  and responsiveness to patients. New York Oxford
  University press.

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Structured and Semi-structured Diagnostic
Interviews

• Structured diagnostic interviews are particularly
  helpful in
• research (where replicablity is essential), in
  training (where the structure can assist a novice
  clinician)
• practice (where use of a standardized instrument
  can increase the confidence in a diagnosis)
• Evaluate the instrument in terms of
• (i) coverage and content
• (ii) the target population
• (iii) the psychometric features of the instrument
• (iv) practical issues (e.g., duration, training)
• (v) administration requirements, and support
  (e.g., scoring algorithms, standardized manual).

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Anxiety Disorders Interview Schedule for DSM-IV
(ADIS-IV)

• The ADIS-IV (Brown, Di Nardo, Barlow, 1994) is
  a semi-structured interview that follows a
  structure similar to a clinical interview and
  relies of the clinician to ask additional
  questions to follow up issues of relevance
• Although its primary focus is the DSM-IV Anxiety
  Disorders, it also assesses Mood, Substance Use,
  and Somatoform Disorders due to their high rates
  of comorbidity with anxiety
• The whole interview assessing current and
  lifetime disorders takes 2-4 hours in clinical
  samples.
• Reliability of the instrument is acceptable and
  the limited validity data upon its predecessor
  are supportive (e.g., Rapee, Brown, Antony,
  Barlow, 1992)
• Suitable as a primary diagnostic measure when
  used by trained mental health professionals.

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Diagnostic Interview Schedule (DIS) Composite
International Diagnostic Interview (CIDI)

• The DIS-IV (Robins, Cottler, Bucholz, Compton,
  1995) is a structured diagnostic interview that
  is suitable for use by lay interviewers as well
  as mental health professionals
• The CIDI (Robins et al., 1988) is compatible with
  both DSM-IV and ICD-10
• Modular format to permit customization of the
  interview and the structured format has permitted
  computerization
• Administration time is 2-3 hours with clinical
  samples and they yield both current and lifetime
  diagnoses
• Useful in large scale epidemiological studies,
  but the level of agreement with clinical
  diagnoses is poor thus, not suitable as a primary
  diagnostic instrument in a psychiatric setting.

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Mini-International Neuropsychiatric Interview
(MINI)

• The MINI (Sheehan, Janavus, Baker,
  Harnett-Sheehan, Knapp, Sheehan, 1999) is a
  clinician-administered structured diagnostic
  interview that assesses both DSM-IV and ICD-10
  criteria
• Valid structured interview for clinical and
  research contexts, it covers a broad range of
  disorders, but does so in around 15 minutes
• Reliability and validity promising (Sheehan et
  al., 1998).

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Primary Care Evaluation of Mental Disorders
(PRIME-MD)

• PRIME-MD is a brief (10-20 min or 3 mins using
  the more recent Patient Health Questionnaire
  Spitzer, Kroenke, Williams, 1999)
  clinician-administered interview to permit
  primary care physicians to rapidly identify the
  mental disorders commonly seen in medical
  practice (Spitzer et al., 1995)
• 25-item page self-report questionnaire asking
  about general physical and mental health issues
  and a semistructured interview to follows up on
  items that the patient has endorsed, the
  instrument provides a quick assessment of DSM-IV
  mood, anxiety, somatoform, eating, and
  alcohol-related disorders
• In terms of validity, its sensitivity and
  specificity are good, although the correspondence
  with DSM-IV was only moderate.
• Fraguas et al (2006) found a kappa with SCID of
  .42 for SD and .32 for MDD, but low frequency of
  depression in sample
• Another instrument suitable for use in primary
  care is the Symptom-Driven Diagnostic System for
  Primary Care (SDDS-PC Broadhead et al., 1995).

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Schedule for Affective Disorders and
Schizophrenia (SADS)

• The SADS (Endicott Spitzer, 1978) is a
  clinician-administered semistructured interview
  developed to assess the research diagnostic
  criteria.
• assesses current (i.e., past year) and past
  symptoms, with other versions assessing symptoms
  across the whole lifetime (SADS-L Lifetime), and
  changes in symptoms (SADS-C Change), SADS-LA-IV
  (SADS Lifetime Anxiety for DSM-IV Fyer,
  Endicott, Mannuza, Klein, 1995 cited in
  Summerfeldt Antony, 2002) also assesses DSM-IV
  criteria in addition to expanded coverage of
  anxiety disorders
• SADS interview takes an hour with non-clinical
  samples, and this short duration, given to its
  breadth of coverage, is achieved by a structure
  that permits clinicians to skip sections that are
  not relevant because the respondent fails to
  endorse screening questions or they are not
  germane to the interview purpose
• Reliability excellent, when compared with the
  other structured diagnostic interviews (Rogers,
  1995) and the validity is very good (see Conoley
  Impara, 1995), particularly in the area of mood
  disorders, making it well-suited as a primary
  diagnostic screening measure.

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Structured Clinical Interview for DSM-IV Axis-I
Disorders (SCID)

• The SCID versions
• brief clinical (SCID-CV First, Spitzer, Gibbon,
  Williams, 1997)
• research (SCID-I First, Spitzer, Gibbon,
  Williams, 1996)
• Axis II Personality Disorders
• SCID-CV - brief interview that provides coverage
  of the disorders commonly seen in a mental health
  practice
• version designed for individual already
  identified as psychiatric patients (SCID-I/P) -
  extensive coverage of mental health disorders of
  all available instruments, with interviews taking
  at least an hour
• Reliability is good (Segal et al., 1994) and
  validity studies of previous versions have also
  been supportive of the instrument (Rogers, 1995
  2001).

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Schedule for Clinical Assessment in
Neuropsychiatry (SCAN)

• The SCAN (WHO, 1998) seeks to describe key
  symptoms
• semistructured clinical interview
• a glossary to rate the experiences endorsed by
  respondents
• a checklist to rate information provided by third
  parties
• a schedule to assess the respondents clinical,
  social, and developmental history
• data can be scored to generate DSM-IV and ICD-10
  diagnoses.