Descriptive Psychopathology: The Signs and Symptoms of ...

119 Chapter 5: Examination style, structure, and techniqueof the phenomena covered in this text. Some specific scales are briefly discussedin the end notes. 10Structured examination instruments such as the Schedule for Affective Disordersand Schizophrenia (SADS) permit the collection of large amounts ofinformation for research purposes by relatively unskilled interviewers. The instruments,however, are unwieldy for clinical use and cover limited psychopathology.Their structured approach is interpersonally robotic, and ignores most of theexamination principles covered in this text. 11Because symptom rating scales are used clinically to assess severity and symptomchange during treatment, all trainees should be experienced with the contentand use of the commonly employed scales to help shape their skills in thesystematic and objective assessment of their patients. Clinician-generated scalesare also helpful, the clinician listing and rating the features identified in the initialexamination, and then periodically re-assessing the patient using that list.Whether applied to clinical assessment or in research, a rating scale’s designedpurpose should determine its use. For example, the Beck Depression Inventory isa psychotherapy assessment instrument that does not have adequate specificitywhen used in the care or study of hospitalized patients with depressive illness. TheHamilton Depression Rating Scale is a better scale for use in patients with severedepression, but it is a severity scale, not a diagnostic scale, and should not beused to distinguish subgroups of depressed patients. The Montgomery–AsbergDepression Rating Scale was specifically designed to assess behavioral change intreatment trials. But like most scales used to measure symptom change duringtreatment, it offers only a limited measure of outcome. 12Self-rating scales are intended to provide evaluations with the minimal use ofprofessional time, and thereby expense. They do not replace skilled examination.They are of little use when the patient is severely ill, a child, or cognitivelyimpaired.SummaryThe behavioral examination of the brain remains an art. But art is based onprinciples and crafted skills. It is neither haphazard, nor casual. An effectivebehavioral examination that elicits valid diagnosis has a structure and employsspecific techniques. The interpersonal skills of the examiner can ameliorate theanxieties of the patient and family, and a semi-structured conversational manneris an effective model. However, the examination is not therapy. Although aneffective examination instills confidence in the examiner and encourages compliance,its purpose is to establish the diagnosis and the gathering of other informationneeded for effective treatment.