CHAIRPERSON Dr Prabhat K Chand CO CHAIRPERSON Dr

CHAIRPERSON- Dr Prabhat K Chand CO- CHAIRPERSON- Dr Manoj Kumar Sharma PRESENTOR- Dr Virupakshappa Irappa Bagewadi PSYCHODIAGNOSTICS: ‘CRUTCHES FOR CLINICIANS’

O UTLINE INTRODUCTION TESTS COMMONLY USED EVIDENCE FOR SUPPORT INDIAN PERSPECTIVE CLINICIAN’S PERSPECTIVE LIMITATIONS CONCLUSION

I NTRODUCTION

I NTRODUCTION Like other branches of medicine, PSYCHIATRIC practice, needs diagnostic tests to supplement anamnesis and clinical examination. In clinical psychiatry, even more than elsewhere in medicine, differential diagnosis is safer, if several tests are available than if only one test is at our disposal. Attempts at developing and clinically exploring psycho diagnostic procedures can be a potent tool in exploring organization and disorder of the personality. [David Rapaport, 1950]

I NTRODUCTION Medical diagnosis Framework of physiology Psycho diagnosis Framework of psychology. [David Rapaport, 1950]

P SYCHOMETRY Psychometry has now evolved as study on theory & technique of psychological measurements. Includes measurement of knowledge, skills , abilities, aptitudes, attitudes, intelligence, memory, creativity, adjustment & personality. Field uses – questionnaires, schedules, rating scales, inventories & tests [Venkatesan S. 2010]

P SYCHOMETRIC A PPROACHES Relies on Normative approaches to psychological assessments. Comparisons with a norm group enabled statistically based diagnostic decisions. In criterion referenced testing the scores relate directly to individual competencies. Behavioral assessments look into contemporary behaviors in individuals and are directly linked to planning / implementing for there remediation. In recent times idiometric approaches to assessments is gaining momentum based on search for underline common denominators for overt behavioral deficits. [Venkatesan S. 2010]

P SYCHOMETRY F OR C LINICIAN: CLINIMETRICS Introduced by Alvan R. Feinstein in 1982. The purpose is to provide an intellectual home for a number of distinct clinical phenomenon. It includes Types , severity and sequence of symptoms; Rate of progression of illness , Severity of comorbidity ; Problems of functional capacity ; reasons for medical decisions and many other aspects of daily life , such as well being and distress Example : Apgar’s score [Venkatesan S. 2010]

P SYCHOMETRY T O C LINIMETRY TRADITIONAL PSYCHOMETRY CLINIMETRICS Less sensitive to symptom Sensitive change Less clinically coherent Clinically coherent –assess sx based on their prevalence Homogeneity of Assess More subjective More Cross sectional Consider components were given importance to symptom change sx based on importance of those sx to define severity (weighting of sx) objective illness longitudinal course of [Venkatesan S. 2010]

P SYCHOLOGICAL T ESTS

P SYCHOLOGICAL T EST C LINICALRELEVANCE It elicits, in a scientifically standardized manner, responses which reveal psychological characteristics in the patient being tested with a high degree of statistical reliability and validity. It includes obtaining samples of behaviour, relevant to cognitive or affective functioning, and for scoring and evaluation. [Essentials of behavioral science]

W HY A RE A SSESSMENTS D ONE? Screening & diagnosing Treatment Planning Functional Impairment/Severity Subjective Distress Social Support and Attachment Style Reactant/Resistance Tendencies Coping Style Monitoring of Treatment Progress Prognostic Indicators

D OMAINS O F T ESTS Tests of Cognitive Functions Tests for Diagnostic Clarification Norm referenced tests of memory, intelligence, perceptual-motor functions, Neuropsychological tests, etc. Tests of concept formation (thought deviance and psychosis), projective tests, inventories and rating scales Tests of Personality Projective tests and self report inventories Other Tests Developmental tests, Aptitude tests, Psychoeducational tests and Behavioral procedures

E XAMPLES O F C OMMONLY U SED T ESTS I N A C LINICAL S ETTING Cognitive Functions • Memory-PGIMS, WMS • Intelligence-BKT , WAPIS, Bhatia, SPM, VSMS Personality & Inter personality • Projective –Rorschach IBT, draw a man test, SCT, TAT • Objective-16 PF, MMPI Diagnostic Neuropsychological assessment • RIBT , MPQ, OST, TAT • Halstead –Reitan • Luria • Indian Batteries – PGI BBD, NIMHANS

C OGNITIVE F UNCTION https: //encrypted-tbn 2. google. com/images

PGI M EMORY S CALE Developed by Dwarka Prasad and N. N. Wig (1977) 10 subtests Percentile norms for 20 -45 years Gives profiles for intervention Indian norms available In at least 5 subsets Organics Below 20 th percentile Psychotics Below 40 th percentile Controls Between 40 - 60 percentile

W ECHSLER’S M EMORY S CALE (WMS) Developed in 1940 at Belleuve hospital, New York Norms available for 25 -50 yrs 7 subtests Gives a memory quotient (MQ) which is highly correlated with IQ

B INET- K AMAT T EST Includes both verbal and performance tests 3 -22 yrs, age level Pattern analysis Language Reasoning Conceptual thinking Memory Social Intelligence Visuo-motor……. etc. Verbally loaded , difficult to assess if verbal function is impaired

WAPIS-W ECHSLER A DULT P ERFORMANCE I NTELLIGENCE S CALE WAPIS Indian adaptation of WAIS [Ramalingaswamy, 1975] Age: 15 -45 Edu : min 5 th std

B HATIA BATTERYOF PERFORMANCETESTS OF INTELLIGENCE C. M. Bhatia-1942 -5 sub-tests ⌾ ⌾ Kohs Block Design- discrimination of patterns Alexander’s Pass along test- discrimination of movement of concrete material ⌾ Pattern drawing test- analysis in terms of lines ⌾ Immediate memory- verbal memory ⌾ Picture construction- discrimination of picture parts Norms- 11 to 16 yrs, literate and illiterate PQ (performance quotient) IQ (intelligence quotient) Can not be used to assess MR

R AVEN’S P ROGRESSIVE M ATRICES T EST Has three versions Advanced, Standard , Coloured. Standard Progressive Matrices (SPM), 60 problems divided into five sets of A, B, C, D and E. Each 12 items in the order of progressive difficulty. It does not give IQ It can be used in everyone irrespective of culture, nationality, age, education, physical condition

VSMS-V INELAND S OCIAL M ATURITY S CALE DR. Edgar A. Doll- 1935 Assesses 8 areas of development Self-help general , Eating , Dressing , Direction Occupation, Communication , Locomotion , Socialization. 0 -25 yrs age level items Done with the informants

Projective Objective [downloaded from https: //encrypted-tbn 2. google. com/images]

P ERSONALITY& I NTER P ERSONALITY Projective Techniques Purpose is to gain insight into the individual personality as a system Rely to some degree on ambiguous stimuli and opaque directions as catalysts for creating data. The projective hypothesis Ambiguous stimulus will reveal important aspects of his or her personality [Frank, 1939]

R ORSCHACH I NKBLOT T EST Hermann Rorschach- 1910. The test consists of ten ambiguous, symmetrical inkblots, card appears as if a blot of ink was poured onto a piece of paper and folded over—hence, the symmetrical appearance. These 6½ × 9½–inch inkblot cards are the standard stimuli Are referred by Roman numerals I to X. Scoring Location , Determinants , Content , Popular, Form level

R ORSCHACH I NKBLOT T EST Scoring Systems Beck (1937) , Klopfer (1937), Pitrowski , Hertz , Rapapport, Exner (1969) Pathognomic Signs Colour shock, Shading shock, Perseveration. Contamination, Confabulation, Number responses Behavioral responses like rejection , perplexity, automatic phrasing etc.

U SES O F R ORSCHACH Main use differential diagnosis and detecting early schizophrenics Other uses – Detecting organicity : Pitrowsky’s signs Measuring hostility : Elizur’s hostility scores Screening psychopathology Studying personality patterns Evaluating treatment outcomes Prognosis indication

U PS A ND D OWN O F R ORSCHACH At one time it was most commonly used test for various conditions including child dispute, divorce etc Validity of the result has been questioned Critically reviewed by psychologists Number of psychology school have stopped using the test

T HEMATIC A PPERCEPTION T EST Developed by Morgan and Murray 1935 A narrative projective device 21 Black & White cards of individuals in classic human situation Indian Adaptation by Uma Choudary 10 cards & a blank card Murray’s scoring (need aggression, affiliation, affection) Bellack’s Scoring

S ENTENCE C OMPLETION T EST Semi projective technique by Sacks and Levy-1950 60 item test that assesses adjustment through 4 subscales family, sex, interpersonal relationships and self concept My father seldom……. (family) When I see a man and woman together…. . (sex area)

O BJECT SORTINGTEST Kurt Goldstein , Martin Scheerer -1941 Consists of 30 objects like ribbon, bottle , needle, cloth etc 2 phases- active and passive phase, Responses -Common, Impoverished, Peculiar Measures thought deviance

M INNESOTA M ULTIPHASIC P ERSONALITY I NVENTORY Hathaway& Mckinley -1942 566 items, T /F, Cannot Say 10 Clinical scales Hypochondriasis, Depression, Hysteria, Psychopathic deviation, Paranoia. . etc 4 Validity Scales (? , L, F, K) Additional Scales – Ego Strength, Alcohol Scale

16 P ERSONALITY F ACTOR T EST Cattell-trait theory of personality Measures 16 functionally independent dimensions Age 16 & above Form standardized and used in India

N EUROPSYCHOLOGICAL A SSESSMENT Halstesd –Reitan Battery(1940) Frontal lobe lesion 10 subtests Criticized being not theoretical Luria’s neuropsychological investigation More comprehensive Based on theoretical principles 11 major cortical functions Luria-Nebraska Neuropsychological Battery Standardized luria’s test by Golden

N EUROPSYCHOLOGICAL A SSESSMENT INDIAN TEST BATTTERIES PGI Battery of Brain Dysfunction(PGI BBD)- 5 subtests PGI memory scale WAIS Verbal scale Bhatia’s short revised scale Bender –Gestalt scale Nehor & Benson scale Gives a profile of 19 variables NIMHANS Neuropsychological Battery 19 tests

W ISCONSIN C ARD S ORTING T EST David A. Grant and Esta A. Berg 1948 Used to test “set-shifting” “Frontal" lobe functions Executive function Abstract thinking

R ATING S CALES Help in diagnosis, functioning, symptom severity and side effects Domain Scales Functional status/ impairment GAF, IDEAS MOSSF 36 Side effect AIMS, SAS Psychiatric diagnosis SCID, MINI, CIDI Psychotic disorder PANSS, BPRS Mood disorders HDRS, YMRS Anxiety disorders BAI

E VIDENCE F OR S UPPORT

D ESCRIPTION O F C LINICAL S YMPTOMATOLOGY& DD Test Domain Evidence Neuropsychological test Differentiating Dementia R-0. 68 Brief neuropsychological Screening brain tests dysfunction WAIS Predicting a range of criterion measures R-0. 57 MMPI Descriptor of personality R--0. 42 MMPI & MCMI -2 Depression Good positive & negative predictive power. Good negative predictive power Schizophrenia

D ESCRIPTIONOF C LINICAL S YMPTOMATOLOGY& DD Test Domain Evidence Rorschach Description of symptomatology R-0. 37 Ego deficits Impairment in social and occupational functioning Rorschach Schizophrenia Index Diagnosing psychotic disorders Excellent Positive predictive power Rorschach & TAT Problematic interpersonal relationships Strong association with clinical ratings Interviews or informal observation Low accuracy

D ESCRIPTIONAND P REDICTION OF F UNCTIONAL B EHAVIOUR Psychological assessments will predict functional behaviours which have an effect on diagnosis, treatment and prognosis. [Moras, 1997] Tests of Cognitive Ability Highly predictive of proficiency on the job and success in job training Strong utility as descriptors and predictors of academic achievement [Gottfredson, 1997] Self-Report Personality Measures Multi method assessment batteries better than single method approaches to assessment. [Robertson & Kinder, 1993]

M ENTAL H EALTH O UTCOMES In children Baseline self reports of negative emotionality predict behavior problems & subsequent clinical outcomes. [Mattison et al 1990] In adults, baseline testing has determined that self-reported neuroticism is a better predictor of long-term clinical outcome in depression [Hirschfeld et al 1986] In general, elevated baseline neuroticism scores predispose people to negative outcomes in individual and marital therapy [Luborsky et al 1993] Baseline assessment of hopelessness is the best predictor of subsequent suicide [Stewart, & Steer, 1990]

A SSISTING I N T REATMENT Patients with externalizing symptoms do better in treatment that is more structured or directed by therapist Patients with internalizing symptoms do better in treatments where they set the pace and determine the structure [Engle & Mohr, 1993]

A SSESSMENT A S A T REATMENT Patients receiving a 2 -hour MMPI-2 assessment with feedback reported symptomatic improvement compared who did not. [Finn and Tonsager 1992] Personality testing can assist the formation of a "therapeutic community" among men in inpatient treatment for severe substance dependence. [Moffett et al. 1996] Personality testing also help to analyze and resolve interpersonal difficulties that arise between difficult patients and their therapists or treatment teams [Berg 1988]

I NDIAN P ERSPECTIVE

S CENE I NDIA Clinimetrics is of a recent origin in the country. It is still in the process of establishing Economical, cultural, educational, language & gender differences contribute to the scenario of poor understanding or acceptance of psychometry. Despite these limitations and challenges , the field of clinimetrics has witnessed a periodic although unsteady or patchy growth in mental health practice in the country. [Venkatesan S. 2010]

D ISTRIBUTION O F R ESEARCH A RTICLES I NDIA [ 1958 -2009] Year Total Personality Cognitive/organic Diagnostic General Total <1970 339 6 1 1 2 10 1971 -80 521 14 2 10 3 30 1981 -90 705 2 2 16 2 22 1991 -00 546 1 2 5 21 29 2001> 471 1 5 3 5 14 Total 2582 24 13 35 33 105 [Venkatesan S. 2010]

S CALES & I NVENTORIES U SED I NDIA [1958 -2009] PERSONALITY COGNITIVE DIAGNOSTIC RIBT Luria nebraska NPA Middlesex hospital Q Family interaction patterns scale Draw a person Wisconsin card s PGI health Q SES Scale Eysenck PI BGT Beck depression I Parental handling Maudsley PQ PGI Memory General health Q Sex knowledge and attitude scale MMPI Cattell’s infant IS Hamilton depression Brief addiction scale rating scale Bortner rating scale for type A peronality Suicidal intent Q 16 PF Q SANS BPRS. . SOCIAL Burden assessment schedule. . .

A DVANCES I N A SSESSMENT

C OMPUTERS I N D IAGNOSIS Computer soft wares are also utilized in a variety of ways. To aid mental health professional in arriving at a psycho diagnostic classification To define psychiatric symptomatology terms, employ crossreferential diagnostic numbers to diagnostic categories, and even refer the user to a specific page number Ashton-Tate's d. Base lll+ software was utilized and it was found to be user friendly [Stout & Scheramic, 1989]

Q UICK P SYCHO D IAGNOSTICS P ANEL [ QPD P ANEL] Designed for primary care physicians. It integrates easily into busy medical clinics and provides valid diagnostic information in a user-friendly format. Fully automated. Self-administered in 6. 2 minutes using portable, hand-held computer tablets. The test screens for nine common psychiatric disorders. Physicians immediately receive a computer-generated “lab report” [Shedler Quick Psycho. Diagnostics Panel]

E VIDENCE F OR QPD Criterion validity tested with Structured Clinical Interview for DSM-IV In 203 patients , not on treatment , 59 core questions, with more than 200 questions Diagnosis Sensitivity Specificity Kappa QPD (PRE) SCID (PRE) Major D 0. 81 0. 96 0. 79 30 34. 2 Gad 0. 79 0. 90 0. 67 26. 4 23. 9 Panic 0. 71 0. 97 0. 72 12. 4 13. 4 OCD 0. 69 0. 97 0. 64 8. 3 7. 6 [Shedler et al 2000]

C ONVERGENT V ALIDITYFOR QPD Sample ranging from 113 to 215 The QPD Panel depression scale correlated highly with Beck Depression Inventory (BDI, r=. 80) Hamilton Depression Inventory (r=. 87) Center for Epidemiological Studies Depression (CESD) Scale(r=. 79) Zung Self-Rating Depression Scale (r=. 78) [Shedler et al 2000]

C ONVERGENT V ALIDITY F OR QPD The QPD Panel anxiety scale correlated highly with Spielberger State-Trait Anxiety Inventory (r=. 67) Anxiety subscale of the Symptom Checklist-90 (SCL-90) (r=. 76). The QPD Panel somatization scale correlated highly with somatization subscale of the Symptom Checklist 28 (SCL 28), r=. 59. All correlations are statistically significant (Ps <. 001) [Shedler et al 2000]

U TILITYOF QPD Sensitivity to Change Patient Satisfaction Physician Acceptance Items % Strongly agree

QPD R EPORT- S CREENING [Shedler Quick Psycho. Diagnostics Panel]

QPD R EPORT- M ONITORING [Shedler Quick Psycho. Diagnostics Panel]

R ECOMMENDATION T O C LINICIANS

E VALUATING A P SYCHOLOGICAL T EST Theoretical Orientation Practical Considerations Standardisation Reliability Validity

R ECOMMENDATIONS T O C LINICIANS Should use comprehensive, structured or at least semi structured approaches to interviewing. Should not only consider the data that supports their hypotheses, but also carefully consider or even least evidence that does not support their hypotheses. This will likely reduce the possibility of hindsight and confirmatory bias. Diagnoses should be criteria based to minimise gender & ethnicity bias Should avoid relying on memory and refer to careful notes as much as possible. [Garb 1998]

R ECOMMENDATIONS T O C LINICIANS In making predictions, clinicians should attend to base rates as much as possible. Should seek feedback when possible regarding the accuracy and usefulness of their judgments. Should learn as much as possible regarding theoretical and empirical material relevant to the person or group they are assessing Familiarity with the literature on clinical judgment should be used to continually update practitioners on past and emerging trends [Garb 1998]

C LINICALVS A CTUARIAL P REDICTION The clinical approach used clinicians’ judgment, Actuarial approach used empirically derived formulas, such as single/multiple cut offs and regression equations, to come to decisions regarding a client Statistical decisions consistently outperformed clinical judgments When the focus changes from institutional to individual decision making, the relevance of statistical rules becomes less practical Controlled studies generally favour a statistical approach over a clinical one but, at the same time, that truth is seldom useful to the practitioner involved in the changing and unique world of practice [Hand book of psychological assessments 4 th edition Gary Groth ]

C LINICALVS A CTUARIAL P REDICTION Ideally, clinicians need to be aware of and to use, whenever available, actuarial approaches such as multiple cut offs and regression equations. Future computer-assisted analysis of assessment results can increasingly provide actuarial predictions especially from multiple sources Clinicians must recognize possible increases and decreases in test interpretation and clinical judgment resulting from the incremental validity of their instruments Because more information does not necessarily increase the accuracy of clinically based predictions [Hand book of psychological assessments 4 th edition Gary Groth ]

L IMITATIONS

L IMITATIONS Although many studies have recommended these assessments, the validity & reliability are low. The test norms needs to be periodically revised. Most of assessments are developed in western countries which has to adapted for INDAN setting. Non availability of well trained & experienced professional limits the use of test. Cost & time spent on testing may not be feasible for Indian setting

C ONCLUSIONS Tests can be used for screening, diagnosing, treatment planning, monitoring & as prognostic indicators Considerable empirical support exists for the validity of psychological assessments Psychological assessments may be viewed as analogues to lab reports of other medical conditions. While it is unlikely that actuarial prediction rules will replace clinical judgment Formal prediction rules can and should be used more extensively as a resource to improve the accuracy of clinical decision making

T HANK Y OU 22 -08 -2012

C ASE V IGNETTE Mr P, 38 year old, married male, MBA, HSES, Mumbai (Settled in US for past 16 yrs) Pre morbidly sensitive & quick to temper with low frustration tolerance, Personal h/o ongoing marital discord, Family h/o difficulties in relationship b/w pt & parents, Past h/o thalassemia minor, C/O difficulty in establishing emotional connections with people, frequent change in jobs since the past 10 yrs, with h/o intermittent bouts of irritability & withdrawn behavior since the past 8 months in the back ground of severe marital discord. While in US the pt has consulted 3 psychiatrists, at the insistence of his wife, who had variously diagnosed him as adjustment disorder, paranoid schizophrenia & PPD. The pt had come to NIMHANS

W HAT WOULD YOU LIKE TO DO? How would you like to proceed this case? Would you refer this case for psychometry? What areas would you assess? What are the tests you would chose?

C OMMONLYUSED NEUROPSYCHOLOGICAL TESTS Domain Function Test Speed Motor speed Finger tapping Mental speed Digital Symbol Substitution Focussed Colour trails Sustained attention Digit vigilance Divided attention Triads test Verbal fluency Controlled oral word Category fluency Animal names Design fluency test Working memory N Back (verbal& visual) Attention Executive functions

C OMMONLYUSED NEUROPSYCHOLOGICAL TESTS Domain Function Test Executive functions Planning Tower of london Set shifting Wisconsin card sorting Response inhibition Stroop Comprehension Verblal Token Learning & memory Verbal Auditory verbal learning Passages test Visuo-spatial construction Learning &memory Complex figure Visual Complex figure Design learning test