CLINICAL ASSESSMENT OF PATIENTS

WITH BEHAVIORAL PROBLEMS

NATIA BADRIDZE, MD
 OVERVIEW OF PSYCHOLOGICAL
TESTING-Types of tests
• Psychological tests are used to assess intelligence,
achievement, personality, and psychopathology.

• These tests are classified by functional area

evaluated.
 Individual versus group testing

• Tests administered to one individual at a time allow

careful observation and evaluation of that particular
person; a test battery looks at functioning of an individual
in a number of different functional areas.

• Tests given to a group of people simultaneously have

the advantages of efficient administration, grading, and
statistical analysis.
 INTELLIGENCE TESTS-Intelligence and
mental age
• Intelligence is defined as the ability to
understand abstract concepts; reason;
assimilate, recall, analyze, and organize
information; and meet the special needs of new
situations.
• Mental age (MA), reflects a person’s level of
intellectual functioning.
• Chronological age (CA) is the person’s actual
age in years.
 Intelligence quotient (IQ)
IQ is the ratio of MA to CA multiplied by 100: MA/CA ¥
100 = IQ. An IQ of 100 means that the person’s mental
and chronological ages are equivalent.
•IQ is determined to a large extent by genetics. However,
poor nutrition and illness during development can
negatively affect IQ.
•The results of IQ tests are influenced by a person’s
cultural background and emotional response to testing
situations.
•IQ is relatively stable throughout life. In the absence of
brain pathology, an individual’s IQ is essentially the same in
old age as in childhood.
 Normal intelligence
• Normal or average IQ is in the range of 90–109.
• Mild (IQ 50–70)
• Moderate (IQ 35–55)
• Severe (IQ 20–40)
• Profound (IQ ≥20)
• A score between 71 and 84 indicates borderline
intellectual functioning.
• A person with an IQ more than (IQ ≤130) has
superior intelligence.
 The Wechsler intelligence tests and the
Vineland Adaptive Behavior Scales
 The Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-
IV) is the most commonly used IQ test.
 The WAIS-R has four index scores: Verbal Comprehension
Index (VCI), Working Memory Index (WMI), Perceptual
Reasoning Index (PRI), and Processing Speed Index (PSI).

 The VCI and WMI together make up the verbal IQ.

 The PRI and PSI together make up the performance IQ.
 The Full Scale IQ (FSIQ) is generated by all four index scores.
 The Wechsler intelligence tests and the
Vineland Adaptive Behavior Scales cont’
 The Wechsler Intelligence Scale for Children (WISC) is used
to test intelligence in children 6–16½ years of age.

 The Wechsler Preschool and Primary Scale of Intelligence

(WPPSI) is used to test intelligence in children 4–6½ years of
age.

 The Vineland Adaptive Behavior Scales are used to evaluate

skills for daily living (e.g.,dressing, using the telephone) in
people with mental retardation and other challenges (e.g.,
those with impaired vision or hearing).
 ACHIEVEMENT TESTS

• Achievement tests evaluate how well an individual

has mastered specific subject areas, such as reading
and mathematics.

• These tests are used for evaluation and career

counseling in schools and industry.
 Specific achievement tests

• Achievement tests include the Scholastic Aptitude Test

(SAT), Medical College Admission.

• Test (MCAT), and United States Medical Licensing

Examination (USMLE).

• The Wide Range Achievement Test (WRAT), which is

often used clinically, evaluates arithmetic, reading, and
spelling skills.

• Achievement tests often used by school systems include

the California, Iowa, Stanford,and Peabody Achievement
Tests.
 PERSONALITY TESTS
• Personality tests are used to evaluate psychopathology and personality
characteristics and are categorized by whether information is
gathered objectively or projectively.

• Objective personality tests (e.g., the Minnesota Multiphasic

Personality Inventory [MMPI]and the Million Clinical Multiaxial
Inventory [MCMI]) are based on questions that are easily scored and
statistically analyzed.

• Projective personality tests (e.g., the Rorschach Test, the Thematic

Apperception Test [TAT], and the Sentence Completion Test) require
the subject to interpret the questions.

Responses are assumed to be based on the subject’s motivational state

and defense mechanisms.
 PSYCHIATRIC EVALUATION OF THE PATIENT
WITH EMOTIONAL SYMPTOMS

•The patient’s psychiatric history is taken as part of the

medical history.

•The psychiatric history includes questions about mental

illness, drug and alcohol use, sexual activity, current living
situation, and sources of stress.
 The mental status examination (MSE) and related
instruments

•The MSE is a structured interview that is used to evaluate an

individual’s current state of mental functioning.

•Objective rating scales of depression that are commonly used

include the Hamilton, Raskin, Zung, and Beck scales.

•In the Hamilton and Raskin scales, an examiner rates the

patient.

•In the Zung and Beck scales, the patient rates himself (e.g.,
measures include sadness, guilt, social withdrawal, and self
blame).
 Variables Evaluated on the Mental Status Examination
(MSE)
Variable
General Presentation
Appearance
Behavior
Attitude toward the interviewer
Level of consciousness
Cognition
Orientation, memory, attention,
concentration; cognitive, spatial,
and abstraction abilities; and speech
(volume, speed, and articulation)
Mood and Affect
Described (mood) and demonstrated
(affect) emotions
Match of emotions with current events
Patient Example
A 40-yr-old male patient looks older than
his age but is well groomed.
He seems defensive when asked about
his past experiences with drugs and
denies that he has ever used.
He has a Glasgow Coma Scale score of 15
A 55-yr-old female patient is oriented to
person, place, and time and
shows normal memory (cognitive ability),
understanding of three dimensional
space (spatial ability), and can tell you
how an apple and an orange are alike
(abstraction ability). However, she speaks
too quickly and is difficult to understand
A 35-yr-old male patient describes feeling
“low” and shows less external expression
of mood than expected (depressed with a
restricted affect)
 Variables Evaluated on the Mental Status Examination (MSE)
Variable Patient Example
Thought A 40-yr-old female patient tells you, in excessive
Form or process of thought detail (circumstantiality:
Thought content (e.g., delusion) Problem in process of thought), that the Mafia is
after her

Perception A 12-yr-old girl tells you that the clothes in her

Illusion closet look like a
Hallucination person is in there (an illusion). She then
describes hearing voices
(a hallucination)
Judgment and Insight A 38-yr-old woman tells you that she would open
a stamped letter
found on the sidewalk to see if it contained
money. She also says that she knows this would
be dishonest (normal, insightful
response)
Reliability A 55-yr-old patient correctly provides the details
of his previous
illnesses (a reliable patient)

Control of Aggressive and Sexual Impulses A 35-yr-old man tells you that he often
overreacts emotionally,
although there is little provocation (poor impulse
control)
 Glasgow Coma Scale
• The Glasgow Coma Scale (GCS) is used to
describe the general level of consciousness in
patients with traumatic brain injury (TBI) and to
define broad categories of head injury.
• [The GCS is divided into 3 categories, eye
opening (E), motor response (M), and verbal
response (V).
• The score is determined by the sum of the score
in each of the 3 categories, with a maximum
score of 15 and a minimum score of 3.
 Glasgow Coma Scale
Eye Opening Response
• Spontaneous--open with blinking at baseline 4 points
• To verbal stimuli, command, speech 3 points
• To pain only (not applied to face) 2 points
• No response 1 point

Verbal Response
• Oriented 5 points
• Confused conversation, but able to answer questions 4 points
• Inappropriate words 3 points
• Incomprehensible speech 2 points
• No response 1 point

Motor Response
• Obeys commands for movement 6 points
• Purposeful movement to painful stimulus 5 points
• Withdraws in response to pain 4 points
• Flexion in response to pain (decorticate posturing) 3 points
• Extension response in response to pain (decerebrate posturing) 2 points
• No response 1 point
 Glossary of Psychophysiological States
Psychophysiological State Symptom(s)
Mood Strong feelings of elation
Euphoric Feelings of self-importance and generosity
Expansive Easily annoyed and quick to anger
Irritable Normal mood, with no significant depression or
Euthymic elevation of mood
Dysphoric Subjectively unpleasant feeling
Anhedonic Inability to feel pleasure
Labile (mood swings) Alternates between euphoric and dysphoric
moods
Affect Decreased display of emotional responses
Restricted Greatly decreased display of emotional
Blunted responses
Flat No display of emotional responses
Labile Sudden alterations in emotional responses not
related to environmental events
Fear and Anxiety Fright caused by real danger
Fear Fright caused by imagined danger
Anxiety Fright not associated with any specific cause
Free floating anxiety
Consciousness and Attention Alert, can follow commands, normal verbal
Normal responses
Clouding of consciousness Inability to respond normally to external events
Somnolence Abnormal sleepiness
Stupor Responds only to shouting, shaking, or
Coma uncomfortable prodding
Psychological Therapies
 PSYCHOANALYSIS AND
RELATED THERAPIES
• Psychoanalysis and related therapies (e.g.,
psychoanalytically oriented psychotherapy, brief dynamic
psychotherapy) are psychotherapeutic treatments based
on Freud’s concepts of the unconscious mind, defense
mechanisms, and transference reactions.

• The central strategy of these therapies is to uncover

experiences that are repressed in the unconscious mind
and integrate them into the person’s conscious mind and
personality.
Techniques used to recover repressed
experiences include:
• Free association
• In psychoanalysis, the person lies on a couch in
a reclined position facing away from the
therapist and says whatever comes to mind (free
association).

• In therapies related to psychoanalysis, the

person sits in a chair and talks while facing the
therapist.
Techniques used to recover repressed
experiences include:
• Interpretation of dreams is used to examine
unconscious conflicts and impulses.

• Analysis of transference reactions (i.e., the

person’s unconscious responses to the
therapist) is used to examine important past
relationships
 Techniques used to recover repressed
experiences include:
• People who are appropriate for using psychoanalysis
and related therapies should have the following
characteristics:
1. Are younger than 40 years of age.
2. Are intelligent and not psychotic.
3. Have good relationships with others (e.g., no evidence of
antisocial or borderline personality disorder).
4. Have a stable life situation (e.g., not be in the midst of
divorce).
5. Have the time and money to spend on treatment.
 Techniques used to recover repressed
experiences include:

• In psychoanalysis, people receive treatment 4–5 times

weekly for 3–4 years; related therapies are briefer and
more direct (e.g., brief dynamic psychotherapy is
limited to 12–40 weekly sessions).
 BEHAVIORAL THERAPIES
• Behavioral therapies are based on learning theory, that is,
symptoms are relieved by unlearning maladaptive behavior patterns
and altering negative thinking patterns.

• In contrast to psychoanalysis and related therapies, the person’s

history and unconscious conflicts are irrelevant, and thus are not
examined in behavioral therapies.

• Characteristics of specific behavioral therapies (e.g., systematic

desensitization, aversive conditioning, flooding and implosion, token
economy, biofeedback, and cognitive/behavioral therapy)
 Behavioral Therapies: Uses and Strategies
Most Common Use
Systematic Desensitization
Management of phobias
Aversive Conditioning
Management of paraphilias
(e.g., pedophilia) or addictions
(e.g., smoking)
Strategy
In the past, through the process of classical
conditioning , the person associated an
innocuous object with a fear-provoking
stimulus until the innocuous object became
frightening
In the present, increasing doses of the fear-
provoking stimulus are paired with a
relaxing stimulus to induce a relaxation
response.
Because one cannot simultaneously be fearful
and relaxed (reciprocal inhibition), the person
shows less anxiety when exposed to the fear-
provoking stimulus in the future.
Classical conditioning is used to pair a
maladaptive but pleasurable stimulus with an
aversive or painful stimulus (e.g., a shock) so
that the two become associated
The person ultimately stops engaging in the
maladaptive behavior because it automatically
provokes an unpleasant response
 Behavioral Therapies: Uses and Strategies
Most Common Use
Flooding and Implosion
Management of phobias
Token Economy
To increase positive behavior in
a person who is severely
disorganized (e.g., psychotic),
autistic, or mentally retarded
Strategy
The person is exposed to an actual
(flooding) or imagined (implosion)
overwhelming dose of the feared
stimulus
Through the process of habituation
the person becomes accustomed
to the stimulus and is no longer afraid
Through the process of operant
conditioning , desirable behavior
(e.g., shaving, hair combing) is
reinforced by a reward or positive
reinforcement (e.g., the token)
The person increases the desirable
behavior to gain the reward
 Behavioral Therapies: Uses and Strategies
Most Common Use
Biofeedback
To manage hypertension,migraine
and tension headaches, chronic pain,
fecal incontinence, and
temporomandibular joint pain
Cognitive/Behavioral Therapy
To manage mild to moderate
depression,
somatoform disorders, eating
disorders
Strategy
Through the process of operant
conditioning, the person is given
ongoing physiologic information (e.g.,
blood pressure measurement), which
acts as reinforcement (e.g., when
blood pressure drops)
The person uses this information
along with relaxation techniques to
control visceral changes (e.g., heart
rate, blood pressure, smooth muscle
tone)
Weekly, for 15–25 wks, the person is
helped to identify distorted, negative
thoughts about him- or herself
The person replaces these negative
thoughts with positive, self-assuring
thoughts and symptoms improve
 Group therapy
Groups with therapists
• Groups of about eight people with a common problem or
negative life experience usually meet weekly for 1–2
hours; sharing the therapist reduces cost.

• Members of the group provide the opportunity to express

feelings as well as feedback, support, and friendship
to each other.

• The therapist has little input. He or she facilitates and

observes the members’ interpersonal interactions.
 Leaderless groups
• In a leaderless group, no one person is in authority.
• Members of the group provide each other with support
and practical help for a shared problem (e.g.,
alcoholism, loss of a loved one, a specific illness).

• Twelve-step groups like Narcotics Anonymous (NA)

and Overeaters Anonymous (OA) are based on the
Alcoholics Anonymous (AA) leaderless group model
 Family therapy
Family systems theory
• Family therapy is based on the family systems idea that
psychopathology in one family member (i.e., the identified patient)
reflects dysfunction of the entire family system.
• Because all members of the family cause behavioral changes in
other members, the family (not the identified patient) is really
the patient.

• Strategies of family therapy include identifying dyads (i.e.,

subsystems between two family members), triangles (i.e.,
dysfunctional alliances between two family members against a third
member), and boundaries (i.e., barriers between subsystems) that
may be too rigid or too permeable.
 Family therapy
Family systems theory
• Specific techniques are used in family therapy.
• Mutual accommodation is encouraged. This is a process in which
family members work toward meeting each other’s needs.

• Normalizing boundaries between subsystems and reducing the

likelihood of triangles is encouraged.
 Supportive and interpersonal
therapy
• Supportive therapy is aimed not at insight into problems,
but rather at helping people feel protected and supported
during life crises (e.g., serious illness of a loved one).
For people with chronic mental illnesses, supportive
therapy may be used over many years along with
medication.

• Based on the idea that psychiatric problems such as

anxiety and depression are based on difficulties in
dealing with others, interpersonal therapy aims to
develop interpersonal skills in 12–16 weekly sessions.
THANK YOU