Psychological Assessment – Lecture 3 / 4, interim exam 2 summary [UNIVERSITY OF AMSTERDAM].

Clinical neuropsychology studies the relations between the brain and behaviour. It makes use of modern diagnostic tools such as interviews (1), personality questionnaires (2), complaint lists (3), neuropsychological tests (4) and neuroimaging research (5). The most important tool is knowledge of different cognitive and emotional domains.

Localization refers to the theory that focuses on the specific behavioural effects of selective disorders on specific parts of the brain (i.e. a specific disorder is localized in a specific area in the brain). Holism focuses on the general behavioural effect of the brain as a whole.

There are several requirements for the intake interview:

1. Environment
   The environment must not distract (1), must be neutral but pleasant (2) and must be comfortable (3).
2. Interviewer’s knowledge
   The interviewer must have extensive knowledge of his subject area (1), must be up-to-date on the current classification systems (e.g. DSM-5) (2) and must have appropriate knowledge of epidemiology (3).
3. Interviewer’s skills
   The interviewer must be empathetic (1), needs to provide unconditional positive acceptance (2) and needs to be authentic (3).

The organization’s attitude towards the client must be respectful. The interviewer must dress appropriately. The interviewer must keep an appropriate emotional and physical distance from the client. Age influences the topics that are discussed during the intake interview.

Advantages of structured interviews are better and higher reliability (1), a fairer estimation of the severity of complaints (2), a greater comprehensiveness (3) and a reduction in both information variance and criterion variance (4). Disadvantages of structured interviews are that they are time-consuming (1), the interviewers need to be regularly trained (2) and the interviewer may conduct the interview too routinely (3). There are several structured interview instruments:

1. Structured Clinical Interview for DSM disorders (SCID-S and SCID-P)
   This is a semi-structured interview for the classification of mental disorders according to the DSM. It has satisfactory interrater reliability.
2. Mini-International Neuropsychiatric Interview (MINI)
   This is a structured interview for both DSM-5 and ICD-10 classifications. The administration time is relatively short and the psychometric properties are sufficient.
3. Diagnostic Interview Schedule (DIS)
   This is a structured interview to assess most common mental disorders. It is very time consuming but requires less specialized knowledge of psychopathology.
4. Composite International Diagnostic Interview (CIDI)
   This is a highly structured interview to establish classifications according to the ICD and the DSM.

There are several potential obstacles during the interview:

1. Interviewer obstacles
   The interviewer may avoid topics he is not comfortable with. This can be solved by being self-aware.
2. Client obstacles
   The obstacles that originate with the client are often the result of psychopathology.
3. Interaction obstacles
   There may be obstacles in the interaction between the client and the psychologist (e.g. client does not accept psychologist’s authority).

The referrer question is not always the same as the general practitioner question. The diagnostic cycle within clinical neuropsychology takes several steps:

1. Observation
   This step includes the registration and the referral question. It is imperative that the client has appropriate expectations and understands the referral questions.
2. Induction
   This step includes reflection of the diagnostician and generating hypothesis.
3. Deduction
   This step includes instrument selection and formulating testable predictions based on the hypotheses.
4. Testing
   This step includes testing the hypotheses and processing the findings.
5. Evaluation
   This step includes reporting the results and providing feedback to the client.

The basic questions of the diagnostic process are recognition (1), explanation (2), prediction (3), indication (4) and evaluation (5). There are three categories of questions in clinical neuropsychology:

1. Identifying strengths and weaknesses (i.e. cognitive profile of the client).
2. Identifying neuropsychological consequences of a particular diagnosis (i.e. behavioural consequences of brain injury).
3. Identifying indications for brain dysfunction when there is no diagnosis (i.e. cause of behavioural changes).

It is important to know what the relevance for the patient is of these questions. The test-retest reliability is important in neuropsychological tests because sometimes tests need to be made in a short span of each other to indicate improvement after treatment or surgery.

There are several groups of neuropsychological tests:

1. Level tests and screening tests
   The level tests can be used to indicate general level of cognitive functioning (e.g. intelligence test). Screening tests are presumed to indicate a potential deficit and these tests should have a low cut-off score (i.e. very sensitive).
2. Cognitive tests
   This is a test regarding one or more of the following; attention (1), information processing speed (2), perception (3), memory and learning (4), language (5), spatial functions (6), social cognition (7) and targeted action (8).
3. Emotional functioning, personality and attitude tests
   This is a test regarding emotional functioning, personality and attitude tests. However, interviews and observation are often used for this.
4. Clinimetric methods
   These methods focus on instruments that measure the effects of illness and abnormalities.

The behaviour and behavioural limitations in daily life can be explained on the basis of a cognitive profile. Information processing speed may impact the test profile without it saying anything about the underlying specific functional domains. Therefore, it is necessary to assess this. Intelligence tests should not be used as a screener for possible disorders in cognitive disorders.

There are several problems with interpretation of neuropsychological tests:

1. Test conditions
   The testability of a patient may skew interpretation (e.g. a person with brain injury might not be able to partake in neuropsychological test batteries).
2. Premorbid functioning
   The premorbid functioning of a patient needs to be assessed when trying to draw conclusions about acquired brain damage. This can be done by forming a purely qualitative idea (i.e. usually stereotyped views) (1), assume that the client functioned normally before (2) and use the NLV (3).
3. Multiconditionality
   The neuropsychological test scores are influenced by a lot of factors (e.g. brain damage, education, age) and not all factors can be taken into account. The interpretation can be skewed because other factors than brain damage explain the test scores.
4. Sensitivity and specificity
   The sensitivity and the specificity can skew the interpretations of the results (i.e. false positives and false negatives).

File study refers to reviewing the file for the history of the patient. There are several benefits to this:

• The opportunity to ask focused questions during the anamnesis.
• It improves efficiency during testing.
• It helps pinpoint risk factors for neuropsychological dysfunctions
• It provides information about the medical record.

Medical records may be essential to establish differential diagnosis. When studying a file, it is important to know what any unknown terms mean (1), whether medication use is associated with specific cognitive complaints (2) and whether relevant research has been conducted previously.

The anamnesis is the medical history of the patient told by the patient himself. This patient is never objective and prone to be influenced by external factors (e.g. personality). The structure of an anamnesis consists of:

• Introduction, including informed consent.
• Receiving information regarding complaints, cognitions and emotions.
• Receiving information regarding origin and course of complaints.
• Receiving information on daily functioning.
• Receiving information regarding previous treatments.
• Receiving information about background (e.g. education, hobbies).
• Receiving information about medical history and related information.

During the anamnesis, there is a chance to observe the patient. There are several reasons for the importance of observation:

• To get a general idea of how the patient is functioning.
• To test hypotheses and adjust these hypotheses.
• To determine the validity of the test results.

There are several things that are included in the observation:

• Physical appearance and presentation.
• Contact.
• Situation understanding, orientation and socialization.
• Emotional reactions.
• Work attitude and executive action.
• Sensory functions.
• Gross and fine motor skills.
• Attention and concentration.
• Memory.
• Speech and language.
• Other details.

The neuropsychological exam is the operationalization of testing the hypotheses. Anamnesis alone is not enough to test a hypothesis. One test is also not sufficient because tests only measure parts of a function (1), it measures multiple cognitive processes at the same time (i.e. they do not measure one thing) (2), multiple tests are needed for falsification and verification of the results (3) and tests are needed for alternative explanations of the observed behaviour.

The test selection depends on the referral question (1), the hypotheses (2), the information from previous research (3), the professional literature (4), reliability of a test (5), validity of a test (6), availability of a test (7), the available time (8) and specific handicaps of the client (9).

Test results need to be corrected for age (1), education (2), premorbid IQ (3) and sex (4). Pattern analysis refers to checking whether the pattern of findings fit a specific disorder. This consists of several steps:

1. Estimation of the premorbid level.
2. Organize tasks according to what they have in common (i.e. check for discrepancies).
3. Focus on the difference between the tests (i.e. check for discrepancies).
4. Place performance in the context of observation, premorbid level and other information (i.e. check for discrepancies).

The combination of different strengths and weaknesses is essential for many diagnoses. Deviating scores may indicate pathology. Observation can be used to see if other factors may explain the score (e.g. not paying attention). It is also important to look for a consistency or pattern in findings. A combination of quantitative and qualitative interpretation is necessary for diagnostics. The interpretation should be placed in the context of the question and the information from the anamnesis.

It is also important to take possible interference factors into account as this could influence the validity of the results (e.g. psychiatric problems; emotional factors; cultural background; peripheral disorder; use of medication; fatigue; pain).

Potential pitfalls of interpretation are considering a symptom as evidence of the cause (1), thinking that a particular test has a fixed meaning (2), thinking that subjective data provides a reliable impression of function disorders (3) and forgetting that dissociations also emerge in healthy individuals (4).

The psychological report is the end product of the diagnostic cycle. It must be clearly formulated (1), tailored to the reader (2), answer the asked questions (3), has a clear focus and no unnecessary information (4) and it is characteristic of the client (i.e. particularly about the client) (5).

A neuropsychological report consists of the client data (1), information on the psychologist (2), information on the initiator and the initiator’s questions (3), anamneses (4), observation (5), the test results sorted by cognitive domain (6), a conclusion (7), advice (8) and the period of validity for the report and test data (9).

The certainty of the interpretation depends on the validity of the method. There are several common mistakes in a diagnostic report:

• The question is not answered.
• The report gives an excess of uncontrolled information.
• The report is formulated too general.
• The report is formulated too ambiguous.
• The formulation is not adapted to the reader.

The client is entitled to feedback. Furthermore, the feedback can have a therapeutic effect. The feedback must include information about the diagnosis (1), must fit the diagnostic cycle (2) and there must be an agreement on recommendation (3).

There are some general points for the oral report:

• The patient must be comforted.
• The referral question must be discussed.
• The most important points must be discussed and not all details.
• The language needs to be adjusted to the client level.
• The results need to be verified with the client.
• The difficult things need to be discussed as well.
• The emotions of the client need to be taken into account.

There are several steps of a bad news interview:

1. Preparation
2. Communicating bad news
   This includes assessing what the patient already knows and wants to know and then communicate step by step in clear language.
3. Discussion
   This includes leaving room for emotions. It is important to not move to the next stage too soon.
4. Elaboration
   This includes an elaboration, explanation or argumentation for the bad news message.
5. Future views
   This includes the view of the future and the search for solutions. This is not always incorporated in the first bad news interview if the client is not ready for this.

It is important to check whether the client understands the message. This can be checked by asking the client to repeat the message. The caregiver may dread bad news interviews because it elicits strong emotions which confronts the caregiver with his own powerlessness (1), the well-being of seriously ill clients is contingent on how bad news is delivered (2), the caregiver may not agree with the message (3) and the caregiver may be confronted with complaints of the client (4).

There are several ethical guidelines:

• Responsibility
  This includes being responsible for the professional conduct and not abusing this responsibility (i.e. knowing what is suitable and what is not).
• Integrity
  This includes honesty towards client and openness towards clients and treatments.
• Respect
  This includes having respect for the client and the client’s contacts.
• Expertise
  This includes being wary of own limitations of knowledge and skill.
• Confidentiality
  This includes that all information is confidential unless there is an immediate threat because of the information the client provided. Written consent of the client is necessary to share notes with other psychologists.
• Voluntary participation
  The neuropsychological examinations are always voluntary. Informed consent is necessary for participation.

The patient has several rights that are relevant to the psychological report:

• The patient has the right to see the report before it gets sent to the referrer.
• The patient has the right to block the report getting sent.
• The patient has the right to correct, add or delete information in the report, except for the conclusion.
• The patient has the right to a copy of the report.
• The patient has the right to look into his file.

Non-external initiators do not have direct contact with the client in a personal manner. There are three ways in which a report can be structured:

1. Around the diagnostic methods that have been used
   The results of the psychological examination are explained consecutively for each of the methods that have been used. The advantage is that all available information is in the report. The disadvantage is that information that is included can be contradictory and is not always relevant.
2. Around the hypotheses that have been examined
   This is a goal-oriented method of reporting in which the results for each hypothesis are discussed. It is shorter than other reports but it does not include all information.
3. Around the client
   The report is based around the overall picture of the client. This is often strongly based on one theory.

A comprehensive psychological examination consists of client data (1), information on the psychologist and other persons involved (2), initiator and initiator request (3), client consultation (4), definitive hypotheses (5), diagnostic methods used (6), interview details (7), observational data (8), explanation of the test results (9), summary of main results (10), conclusions of hypotheses (11) and the period of validity for the report and the test data (12).