Using the Psychologist Wisely: Understanding the Causes and Contributions to Current Problems

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

2. 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

3. Psychology • Meaning • Psyche: the mind • Logos: knowledge or study • Definition • The scientific study of behaviour and mental processes • Behavior - Overt (crying) • Processes – Covert (remembering)

4. 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

5. 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

6. Class of evidence for therapy

7. Clinical Psychology

8. Recommendation Levels

9. 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).

10. 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

11. 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

12. Cognitive Distortions • Labeling • Mind Reading • Exaggeration • Unrealistic Expectations • Belief in Entitlement • Belief in Absolute Fairness

13. 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

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

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

16. 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?

17. Neuropsychology • Acute • TBI • Brain tumors • Infection • Stroke • Deteriorating • Dementia • Static • Neurotoxicity • ADD • Learning Disorder

18. 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

19. 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 

21. 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

22. 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

23. 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

24. 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.

25. Rey 15-item Memory Test for Malingering A B C 1 2 3 a b c  I II III

26. 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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29. 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.

30. Bottom Line • Referrals • Communication • Clinical Psychology • Neuropsychology