Clinical Psychology - Essay Example

 Abstract: A comprehensive test battery where the respective strengths and weaknesses of the different testing approaches are balanced within the test package, has been developed. The patient is a taxi-driver who has suffered four whiplash injuries in automobile rear-end collisions, in the last three months. He has made four claims for whiplash injuries suffered. The clinical assessment package has been prepared to assess K. Kar’s condition, as required by the Insurance Corporation of British Columbia (ICBC). A selection of tests to comprehensively evaluate the Subject, has been formulated. INTRODUCTION: In this assignment the case of taxi-driver K. Kar (age 53 years), who has made four claims for whiplash injury following rear-end collisions in the last three years, is studied. In the vignette on this Subject, the details are given. In order to assess his injury claim for the fourth time which is under civil trial, a comprehensive battery of clinical assessment tests is to be formulated. The first more serious accident had been fully settled. The emergency physician who attended on Kar after the fourth accident, had raised the suspicion of mild brain trauma in her report. The current methodology and content of psychiatric diagnosis, the level of treatment planning in regard to both medication and psychosocial interventions, and the nature of the healthcare delivery system are all significant factors in determining the psychological tests and rating scales to be used (Hales; Yudofsky (Eds), 2003: p.189) . Two major forces have influenced treatment planning in the recent past: 1) the use of a diagnostic system since 1980 which has been strong on reliability and relatively weak and uneven on validity and 2) the impact of changes in the priorities and structures of the healthcare delivery system with its emphasis on cost-saving and delivery of services deemed “medically necessary”. Psychological assessment has evolved and diversified, and its new features are: 1.The use of instruments to provide data on patients in a managed care system, and 2.The assessment of systems of care as a whole. DISCUSSION: Whiplash Injury: According to Otte, et al (1997: p.368), the “whiplash brain” is an often seen and therefore an important post-traumatic condition which has been ignored by modern imaging diagnostics for years. The whiplash injury is defined as distortion of the cervical spine which results from acceleration forces. Besides cervical symptoms, cerebral symptoms may appear. Patients often complain of headache, vertigo, auditory disturbances, tinnitus, disturbances in concentration and memory, difficulties in swallowing, impaired vision and temporomandibular dysfunction. These symptoms may become debilitating for the patient if they persist. About 5% of whiplash patients remain incapacitated after one year. Brain contusion may be diagnosed with the help of advanced computed tomography tests. Neuropsychological disturbances after whiplash injury are mostly borderline, hence the complaint of patients with whiplash injury may often have been ignored (p.369). Financial compensation for whiplash injury: The subjective nature of whiplash injury symptoms and their high prevalence have led to controversy over the determination of their cause and appropriate financial compensation (Cassidy, et al, 2000:p.1179). An insurance system in which financial compensation is determined by the continued presence of pain and suffering, provides barriers to recovery. In this respect, such an insurance system may promote illness and disability. In places such as Saskatchewan, Canada, where the tort system for compensation was changed to a no-fault system, payments for pain and suffering, and therefore: most court actions were eliminated; and medical and income-replacement benefits were increased. Tort action was still possible under the no-fault system if the medical costs exceeded $500,000, or if the annual income-replacement claim exceeded $50,000. The study conducted by Cassidy, et al (2000:p.1184) in Canada confirmed that providing compensation for pain and suffering after whiplash injury increased the frequency of claims for compensation and delayed the closure of claims and recovery; as seen under the Tort system in the United States. Regarding prognosis, the authors state that it depends on the patients’ age, sex and initial intensity of pain. It is also seen that minimal intervention in the acute period aids recovery. METHODS OF CLINICAL ASSESSMENT According to Anastasi (1988:p.23) as quoted in Tovian (Ed.) (1991:p.292), a psychological test is essentially a standardized measure of a sample of behavior. Hales; Yudofsky (Eds) (2003: p.189) state that the three types of psychological assessment instruments currently used are: psychological tests, rating scales, and semi-structured interviews. Careful standardization of the test stimuli, the method of presenting these stimuli and the method of scoring the responses help to make the psychological tests valid and reliable, as methods of sampling behaviors. Other important approaches include: behavioral observations and physiological recordings. The clinical psychologist further attempts to understand the individual within the broad context of his social and cultural environment, family system, psycholgical and medical history, educational and vocational attainment (Tovian (Ed):1991: p.292) . Comprehensive Test Battery: Standard interview and case note taking: According to Tovian (Ed) (1991: p.174), the patient’s interview should be conducted in a private setting, without any disturbance. Surveys have shown that 76% of patients were seen on the same day as the consultation request. This percentage was even higher for consultations related to depression or suicide risk: 87% were seen on the same day. This prompt response for consultation request is perceived very positively, as shown in a survey of physicians. The initial steps of the psychiatric interview include recording background data about the patient, details about the case, and the expectations of the treatment and outcome. Besides the patient’s particulars, other significant details about background information are: presenting complaints, treatment history, concurrent medical conditions, what patient hopes to gain, and determination of urgency (Hales; Yudofsky (Eds) 2003: p.158). The expectations related to time for assessment, cost of evaluation, purpose of assessment, psychiatrist’s availability for treatment are significant factors. Note-taking is an essential part of the psychiatric interview, so that the psychiatrist has accurate information for preparing the report of the interview. If a recording device is used, it should be in clear view of the patient, and an explanation is to be given to the patient about its use. The patient should be assured that the tapes will be erased after they are reviewed. In case of written notes, prompt recording of data and information while still fresh in the psychiatrist’s mind maximises the accuracy of the information and minimises distortions and gaps in the database, which may occur with delay. This task should be accomplished at the conclusion of the interview, for which the psychiatrist should set aside the time (p.158). The main weakness of this testing approach is that the patient should give honest answers to the crucial questions that will help the psychiatrist to treat him appropriately. Sharing of truthful information alone can be beneficial for the outcome to be positive. The reliability of this test depends on the validity of the data given by the patient. Intelligence Quotient (IQ) test: The scales designed by Binet and Simon were the first intelligent tests that became widely accepted at the beginning of the 20th century. In recent years, the Wechsler scales are the most widely used instruments in the field of psychology for measuring intelligence. The designer of these tests, Wechsler, published his first scale in the 1930s. He used material from the Binet Alpha and Beta tests to make his test. An important feature of his test was, that when calculating the IQ, this test took age into account. In other words, in the computation of the IQ, an age-correction takes place. Because of this feature, the IQ stays constant over the life span1. This test for measuring the intelligence quotient is reliable, and has stood the test of time in the validity of its results. Rorschach Inkblot Test: Introduced in 1921 by the Swiss psychiatrist Hermann Rorschach, this test has been considered a vital tool in personality assessment, and in identifying mental disorders. A person is shown ten inkblots and asked to tell what each resembles. When scored and interpreted by an expert, people's responses to the blots are said to provide a full and penetrating portrait of their personalities (Lilienfeld, Wood, Nezworski, Garb, 2000: p.1). The scientific evidence for the Rorschach has always been feeble. By 1965, research psychologists had concluded that the test was useless for most purposes for which it was used. The most popular modern version of the Rorschach, developed by psychologist John Exner, has been promoted as scientifically superior to earlier forms of the test. In 1997 the Board of Professional Affairs of the American Psychological Association bestowed an award on Exner for his "scientific contributions”. Such bloated claims to the contrary, however, research has shown that Exner's approach is beset by the same problems that have always plagued the test. The Rorschach--including Exner's version, tends to mislabel most normal people as abnormal. In addition, the test cannot detect most psychological disorders (with the exception of schizophrenia and related conditions marked by thinking disturbances), nor does it do an adequate job of detecting most personality traits (Lilienfeld 1999; Lilienfeld, Wood, Nezworski, and Garb 2000 p.2). The Rorschach Inkblot test cannot be considered as a very reliable tool for testing personality disorders, as the answers to the test can be very subjective, and hence not completely valid. Comprehensive neuropsychological examination: According to Vanderploeg (2000:p.419), the field of clinical neuropsychology has enjoyed great success not only in contributing to scientific knowledge about brain behavior relationships, but also in applying such knowledge through the provision of humane and effective assessment, treatment and advocacy services with persons with central nervous system (CNS) impairment. A great number of testing instruments have emerged over the past few decades for assessing the behavioral and cognitive effects of brain disease. These instruments known as neuropsychological tests, represent formal observation-measurement systems, in which behavior is measured under certain specified conditions and evaluated against normative or individual comparison standards (Lezak 1995) as quoted in Vanderploeg (2000:p.419). There is a wide range of opinion about the stability or accuracy of neuropsychological measures, and about the relative importance of criterion-oriented versus construct validity considerations in test development. Because of this diversity, there is no consensually agreed-on acid tests, or even empirical criteria other than basic standards of reliability and validity, for including or excluding particular neuropsychological tests. The selection of particular neuropsychological tests thus remains an individual professional decision. Most modern neuropsychological test procedures derive either from the psychometric tradition within clinical psychology, or from the information-processing tradition in cognitive psychology, and experimental neuopsychology (p.420). This test is very diverse, and a reliability depends on the selection of the right combination of neuropsychological tests for valid results. The Halstead-Reitan Battery: Vanderploeg (2000:p.484) states that the battery has grown by accretion and revision and continues to be modified by many of its users. This means that the battery has been gradually improved over the years. The Halstead-Reitan battery transformed into an instrument that could measure various functions, locate impairments, diagnose various neurological conditions, and separate neurological from affective conditions. Recent computer scoring programs which are available with the HRB, in addition to providing an efficient method of scoring have also introduced new methodological procedures into neuropsychology norming. The coordinated set of tests with age, education and gender corrections are among the new innovations. Norms have been incorporated into the computer programs in order to make the rather extensive calculations involved in these tests more efficient and accurate. One of the weaknesses of this test is the extensive calculations that are involved. However, the incorporation of norms into the computer make the tests more efficient and accurate. In this regard, the cognitivemetric approach to neuropsychology is particularly adapted to the use of computers (Vanderploeg, 2000:p.484). This is a highly reliable tool, and gives valid results. Magnetic Resonance Imaging or any other high-tech brain scan: Brain injury as a result of whiplash injury: Morphological imaging methods such as computed tomography (CT) and magnetic resonance imaging (MRI) have been unable to delineate traumatic brain lesions in patients with whiplash injury. By contrast, results from functional brain perfusion imaging single photon emission computed tomography (SPECT) and F-18-fluoro-deoxyglucose (FDG) PET disclosed a pattern of biparieto-occipital hypo-perfusion in most patients. Brain contusion may also be present in some areas. Neuropsychological testing include a test battery of twenty-seven tests on attention, concentration, memory and higher cognitive functions (Otte, et al 1997: p.369). This study shows that neuropsychological disturbances after whiplash injury are mostly borderline, hence the complaints of patients with whiplash injury may not be taken seriously. PET and SPECT although more costly techniques may lend more objectivity to controversial medico-legal discussion on patients with late onset whiplash syndrome and associated disorders. Further studies on this topic are being conducted (p.372). These methods are reliable, giving accurate results. Minnesota Multiphasic Personality Inventory (MMPI): The Humm-Wadsworth Temperament Scale was the first personality questionnaire to actually use the responses of psychiatric patients to determine the direction in which items should be scored and their suitability for scale development. This contained 318 items and provided scores for seven scales: Normal, hysteroid, manic, depressive, autistic, paranoid, and epileptoid. The item assignments for each scale were based on the difference between the item’s frequency of endorsement among a group of patients judged high on the trait, and a comparison group of normals (Nichols, 2001: p.3). The above method of contrasted groups provided the inventor of the MMPI, Hathaway a practical means of avoiding theory and side-stepping rational or intuitive guidance in the selection of the items for the MMPI clinical scales. Another advantage was that the method of contrasted groups required items to surmount a validity hurdle from the beginning. The 504 items were divided into twenty-five content areas. These included items related to general medical and neurological symptoms, political and social attitudes, affective and cognitive symptoms, and fears and obsessions; items implicating family, educational and occupational experience, and a set of items to reveal an overly virtuous self-presentation on the inventory. An additional 55 items thought to be related to masculinity, femininity were later added, and 9 items were subsequently deleted to achieve the final pool of 550 items (p.6). The item format chosen was the first person declarative sentence, written with simplified wording with brevity and clarity, based on contemporary word-frequency tables. Common English slang and idioms were used, but esoteric or specialized language was avoided. Responses were limited to True, False and Cannot Say. Further improvements to the MMPI scales were regularly introduced, and it went on to become a widely used instrument (Nichols, 2001:p.6). The chief chronic inadequacy of the MMPI stemmed from the fact that the original sample of 724 normals who had served as the primary non-pathological reference group for the development of the eight basic clinical scales of the MMPI and MMPI-2, were required to be compared under other conditions also. Another factor was the tendency of later test administrators to discourage the use of Cannot say response category, in order to avoid ambiguity in the test data. The reliability of this method depends on the common set of control group that is used. In the case of studies with completely different criteria to that of the original, the results may not be highly valid. Peer Assessment: In peer assessment, the patient’s friends, siblings, and other people who know him/ her well are asked to give their assessment of any changes or new traits in the patient. A questionnaire with a well-formulated structure, will be able to draw out all the required information from the individuals who know the Subject closely. The only weakness in this method would be that the patient may prepare them earlier to give only those answers which he wanted the researchers to know, hiding crucial facts from coming into the light. Peer assessment by means of interview or questionnaire can be a very reliable tool. The test should be given without prior warning, to ensure factual information. Medical Record Check/ Chart Reading: The medical record is a significant tool, which has to be updated regularly, to be of use. All important details should be entered in the medical record. The patient’s chart, on the other hand, is for marking with important information, so that other health care workers who may attend on the patient, will be updated about the patient’s case, and will know the next step in the procedure. This method is extremely reliable, and are a vital tool in health care. Behavioral Assessment in Office (Overt): During the diagnostic interview, the psychologist asks questions, and converses with the patient. At the same time, he/ she keeps an alert eye on the patient, noting from the body language and method of speaking, various details about the patient. The behavioral assessment done at the time of the diagnostic interview, is recorded for further use, in evaluating and treating the patient. This is also a reliable method, as the intuitive decisions taken by the physician by careful observation of the patient, give valid information. Evaluation of the battery of tests in the assessment package: Each of the tests described above have their own strengths and weaknesses. If the entire battery of tests is applied, the strengths and weaknesses will be balanced, each standing in where another may have a shortfall. For example, in the standard interview and case note taking done by the physician, the patient’s answers may not be completely true to facts. This deficiency is overcome by the Overt Behavioral Assessment done by the physician at the time of the diagnostic interview. His observation of the patient’s demeanor and body language can direct him as to whether the patient is trying to hide something, or is giving the true information. Similarly, any shortfall in the Intelligence Quotient test which may show a higher or lower reading than the actual one, can be balanced out by the peer assessment instrument which can include questions about the peers’ perception about how intelligent the Subject is, and related questions. The personality and identification of abnormality that is purported to be done by the Rorschach test, if cannot be relied upon completely, the Minnesota Multiphasic Personality Inventory can prove to be a strong supplement for it. The only drawback in the MMPI test is that the 724 normals who had served as the primary non-pathological reference group for the development of the eight basic clinical scales of the MMPI and MMPI-2, were required to be compared in all studies, though the facts of the case or the background may be different. Recent studies have shown that magnetic resonance imaging or computed tomography are not feasible for detecting several types of brain injuries. More advanced methods of computed tomography: single photon emission computed tomography (SPECT) and F-18-fluoro-deoxyglucose (FDG) PET are being used today, for studying the brain and to identify any brain injury that may be present. The neuropscychological tests in the Halstead-Reitan Battery, are quite comprehensive, and contribute to a structured approach in the tests which are administered to the whiplash injury patient K.Kar. Reducing the Assessment Package to a Real World Package: The comprehensive test battery is reduced to a smaller assessment package at a total cost of $ 1200/ per assessment /patient, as follows: Structured Interview for Irritability or Anxiety: $ 400/- Physiological Assessment of Stress Response: $ 200/- Medical Record Check/ Chart Reading: $ 300/- Behavioral Assessment in Office (Overt): $ 300/- The reduced assessment package consists of tests which can reliably reveal the changes that have come about in the Subject as a result of the automobile accidents, in which he has suffered from whiplash injury. To start treating the patient, it is essential to ascertain the exact nature of the injuries, the extent to which he has been affected, and the degree of pain and discomfort he may still be suffering from. By physiological assessment of stress response, whether the patient displays pain reaction and how long the discomfort lasts, will reveal any injury in the cervical spine area. Further, whether the patient speaks clearly and coherently will show whether any area of the brain has received injury. The behavior assessment in office will reveal to the physician several details which the patient may not verbally communicate to him. Since the Subject is an immigrant, with limited knowledge of English, a translator may be arranged during the structured interview for irritability or anxiety. Some of the tests were deleted, in order to form the economy package of assessment tests. Though all the tests are valuable in their own way, their prohibitive costs made it imperative that they should be removed from the clinical assessment battery of tests. The intelligence quotient test would be truly valuable only in case an earlier reading taken several months ago, before the first accident took place, was available for comparison with the present reading. So, the I.Q. test has been deleted. Since a structured interview for irritability can be conducted, the larger standard interview and case note taking have been removed. In any case, notes and data will be recorded in the medical records and in the patient’s chart. These recorded data are crucial for the treatment and evaluation of the patient. Peer assessment has been excluded because of possibility of bias or lack of required information in the Subject’s friends or family members. The MMPI would be too large for this assessment, and hence has been deleted. A high tech brain scan of the latest computed tomography development, would be ideal to identify any brain disorder due to brain injury. But this test alone would be very expensive, and hence had to be excluded. The same reason holds for the neuropsychological test by the Halstead-Reitan battery, which would be very beneficial in revealing the patient’s condition, but had to be substituted by the less expensive tests. The Rorschach Inkblot test, has been recognized as low in reliability because of its subjective nature, and hence has not been included in the economy package of assessment tests. The selected tests administered together, would give reliable data on the patient’s condition. Information required by the Insurance Corporation of British Columbia (ICBC) regarding the Subject K.Kar: 1) Whether K.Kar is still able to earn a living driving a taxi? Answer: It appears that after four accidents, with rear-end collisions, K.Kar will not be able to continue driving the taxi. His health problems of whiplash injury in the neck with possible brain injury as indicated by the emergency physician who attended on him, is causing him difficulty in leading a normal life. 2) Whether K.Kar is exaggerating his claim of disabling pain? Answer: It is unlikely that he is exaggerating the discomfort caused by his condition. But it is possible that in order to claim insurance on the fourth accident, he continues to show suffering from pain and disability, in case he loses the insurance amount. 3) Whether K.Kar has brain injury? Answer: It is possible that he has brain injury, because the whiplash injury directly affected the cervical spine area of the neck. This is just below the brain, and the impact of the rear-ender may have affected the brain also, especially since he has been previously involved in three similar accidents, the first being very serious. 4) To what degree his condition can be related back to the first, more serious accident which had been fully settled? Answer: K. Kar’s condition can be related to the first accident which was more serious because repeated whiplash injuries on the same area of the spine and neck, can prove to cause progressive damage to the same part. Thus, the fourth accident which did not cause much discomfort to his passengers, or damage to his taxi, has aggravated his earlier whiplash injuries to the neck. ----------------------------------------------------- REFERENCES Cassidy, J. David; Carroll, Linda J; Cote, Pierre; Lemstra, Mark; Berglund, Anita; Nygren, Ake. (2000). Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury. New England Journal of Medicine, Vol.342(16), pp.1179-1187. Hales, Robert E; Yudofsky, Stuart C.(Eds) (2003). The American Psychiatric Publishing Textbook of Clinical Psychiatry. American Psychiatric Publishers, Inc. Lilienfeld, Scott O; Wood, James M; Nezworski, M Teresa; Garb, Howard N. (2003). What’s Wrong With The Rorschach? Science Confronts the Controversial Inkblot. California: John Wiley and Sons, Inc. Nichols, David S. (2001). Essentials of MMPI-2 Assessment. Canada: John Wiley and sons. Otte, E; Ettlin, T.M; Nitzsche, E.U; Hoegerle, S; Simon, G.H; Fierz, L; Moser, E; Mueller-Brand, J. (1997). PET and SPECT in whiplash syndrome: a new approach to a forgotten brain? Journal of Neurology, Neurosurgery, and Psychiatry, Vol.63, pp.368-372. Tovian, Steven M (Ed); Sweet, Jerry J; Rozensky, Ronald H. (1991). Handbook of Clinical Psychology in Medical Settings. Springer. Vanderploeg, Rodney D. (2000) Clinician’s Guide to Neuropsychological Assessment. New Jersey: Lawrence Erlbaum Associates. Yudofsky, Stuart C. (2003). Essentials of Clinical Psychiatry. Virginia: American Psychiatric Publications. Read More