PSYCHODIAGNOSTICS: ‘CRUTCHES FOR CLINICIANS’

1. PSYCHODIAGNOSTICS: ‘CRUTCHES FOR CLINICIANS’ CHAIRPERSON- Dr Prabhat K Chand CO- CHAIRPERSON- Dr Manoj Kumar Sharma PRESENTOR- Dr VirupakshappaIrappaBagewadi

2. Outline • INTRODUCTION • TESTS COMMONLY USED • EVIDENCE FOR SUPPORT • INDIAN PERSPECTIVE • CLINICIAN’S PERSPECTIVE • LIMITATIONS • CONCLUSION

3. Introduction

4. Introduction • 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]

5. Introduction [David Rapaport,1950]

6. Psychometry • 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]

7. Psychometric Approaches • 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]

8. Psychometry For Clinician: 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]

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

10. Psychological Tests

11. Psychological Test Clinical relevance • 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]

12. Why Are Assessments Done? • 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

13. Domains Of Tests

14. Examples Of Commonly Used Tests In A Clinical Setting

15. Cognitive Function https://encrypted-tbn2.google.com/images

16. PGI Memory Scale • Developed by DwarkaPrasad and N.N. Wig (1977) • 10 subtests • Percentile norms for 20 -45 years • Gives profiles for intervention • Indian norms available

17. Wechsler’s Memory Scale (WMS) • Developed in 1940 at Belleuvehospital,New York • Norms available for 25-50 yrs • 7 subtests • Gives a memory quotient (MQ) which is highly correlated with IQ

18. Binet-Kamat Test • 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

19. WAPIS-Wechsler Adult Performance Intelligence Scale • WAPIS Indian adaptation of WAIS [Ramalingaswamy, 1975] • Age: 15-45 • Edu : min 5th std

20. Bhatia battery of performance tests of intelligence • C.M. Bhatia-1942 -5 sub-tests • KohsBlock 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

21. Raven’s Progressive Matrices Test • 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

22. VSMS-Vineland Social Maturity Scale • 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

23. Projective Objective [downloaded from https://encrypted-tbn2.google.com/images]

24. Personality & Inter Personality • 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]

25. Rorschach Inkblot Test • 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

26. Rorschach Inkblot Test • 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.

27. Uses Of Rorschach • 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

28. Ups And Down Of Rorschach • 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

29. Thematic Apperception Test • 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

30. Sentence Completion Test • 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)

31. Object sorting test • 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

32. Minnesota Multiphasic Personality Inventory • 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

33. 16 Personality Factor Test • Cattell-trait theory of personality • Measures 16 functionally independent dimensions • Age 16 & above • Form standardized and used in India

34. Neuropsychological Assessment • Halstesd –Reitan Battery(1940) • Frontal lobe lesion • 10subtests • 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

35. Neuropsychological Assessment • 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

36. Wisconsin Card Sorting Test • David A. Grant and Esta A. Berg 1948 • Used to test “set-shifting” • “Frontal" lobe functions • Executive function • Abstract thinking

37. Rating Scales • Help in diagnosis, functioning, symptom severity and side effects

38. Evidence For Support

39. Description Of Clinical Symptomatology & DD

40. Description of Clinical Symptomatology & DD

41. Description and Prediction of Functional Behaviour • 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]

42. Mental Health Outcomes • In children Baseline self reports of negative emotionality predict behavior problems & subsequent clinical outcomes. [Mattison et al1990] • In adults, baseline testing has determined that self-reported neuroticism is a better predictor of long-term clinical outcome in depression [Hirschfeld et al1986] • In general, elevated baseline neuroticism scores predispose people to negative outcomes in individual and marital therapy [Luborsky et al1993] • Baseline assessment of hopelessness is the best predictor of subsequent suicide [Stewart, & Steer,1990]

43. Assisting In Treatment • Patients with externalizing symptoms do better in treatment that is more structured or directed by the therapist • Patients with internalizing symptoms do better in treatments where they set the pace and determine the structure [Engle & Mohr, 1993]

44. Assessment As A Treatment • 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]

45. Indian Perspective

46. Scene In India • 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]

47. Distribution Of Research Articles In India [1958-2009] [Venkatesan S. 2010]

48. Scales & Inventories Used In India [1958-2009]

49. Advances In Assessment

50. Computers In Diagnosis • 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 cross-referential diagnostic numbers to diagnostic categories, and even refer the user to a specific page number • Ashton-Tate's dBase lll+ software was utilized and it was found to be user friendly [Stout & Scheramic, 1989]