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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
Psycho diagnosis
Framework of
physiology
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 TO C LINIMETRY
TRADITIONAL
PSYCHOMETRY
CLINIMETRICS
 Less sensitive to symptom
 Sensitive
change
 Less clinically coherent
–assess sx
based on their prevalence
 Clinically coherent
 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
longitudinal course of
illness
[Venkatesan S. 2010]
P SYCHOLOGICAL T ESTS
P SYCHOLOGICAL T EST
C LINICAL 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]
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
Norm referenced tests of
memory, intelligence,
perceptual-motor functions,
Neuropsychological tests,
etc.
Tests of Personality
Projective tests and self
report inventories
Tests for Diagnostic
Clarification
Tests of concept formation
(thought deviance and
psychosis), projective tests,
inventories and rating scales
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-16PF,MMPI
Diagnostic
Neuropsychological
assessment
• RIBT ,MPQ, OST,TAT
• Halstead –Reitan
• Luria
• Indian Batteries – PGI BBD,NIMHANS
C OGNITIVE F UNCTION
https://encrypted-tbn2.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 20th percentile
Psychotics Below 40th 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 5th std
B HATIA BATTERY OF PERFORMANCE
TESTS 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-tbn2.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 Choudary10 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

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
SORTING TEST
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 FACTOR 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)




Luria’s neuropsychological investigation




Frontal lobe lesion
10subtests
Criticized being not theoretical
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
Screening brain
neuropsychological 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 ESCRIPTION OF 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 ESCRIPTION AND 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 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]
A SSISTING I N T REATMENT

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]
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 N 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 N 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 N 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 dBase lll+ software was utilized and it was
found to be user friendly
[Stout & Scheramic, 1989]
Q UICK P SYCHO D IAGNOSTICS
PANEL [QPD PANEL ]

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 PsychoDiagnostics
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 VALIDITY FOR
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 VALIDITY 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 TILITY OF QPD

Sensitivity to Change

Patient Satisfaction

Physician Acceptance
Items
% Strongly agree
QPD R EPORT -S CREENING
[Shedler Quick PsychoDiagnostics
Panel]
QPD R EPORT -M ONITORING
[Shedler Quick PsychoDiagnostics
Panel]
R ECOMMENDATION TO C LINICIANS
E VALUATING A P SYCHOLOGICAL
T EST

Theoretical Orientation

Practical Considerations

Standardisation

Reliability

Validity
R ECOMMENDATIONS TO
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.
[Garb1998]
R ECOMMENDATIONS TO
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 the
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
[Garb1998]
C LINICAL VS 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 4th edition Gary Groth ]
C LINICAL VS 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 4th 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 YOU
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 OMMONLY USED
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
Design fluency test
Working memory
N Back (verbal& visual)
Attention
Executive functions
C OMMONLY USED
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

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