Psychological Testing: Use Do-It-Yourself Tools Or Refer? Quick Checklists Are Handy but Not Always Sufficient

Current p SYCHIATRY

Psychological testing: Use do-it-yourself tools or refer? Quick checklists are handy but not always sufficient

C. Don Morgan, PhD Associate professor

John F. Bober, MD Assistant professor Residency program director

Department of psychiatry and behavioral sciences University of Kansas School of Medicine, Wichita

r. A, age 38, presents with severe anxiety Informed use of psychological testing can help M symptoms that suggest generalized anxi- you plan treatment by clarifying the causes, ety disorder (GAD). You wish to confirm the diag- diagnosis, and prognosis of patients’ symptoms. nosis before starting medication, measure treatment With hundreds of instruments available, we response, and provide documentation to Mr. A’s offer an overview to help you quickly choose managed care company. appropriate in-office tools or refer for more- Miss B, age 73, complains of memory and intensive testing. organization problems. Her history of transient ischemic attacks suggests vascular dementia, but QUICK BUT IMPERFECT the gradual symptom onset suggests Alzheimer’s Checklists and rating scales can quickly gauge a dementia. You need to clarify the diagnosis. personality trait such as impulsivity or target

56 Current VOL. 4, NO. 6 / JUNE 2005 p SYCHIATRY Current p SYCHIATRY

symptom such as anxiety, using a numerical Table 1 list of words or statements: Pros and cons of checklists/rating scales • A checklist’s response format is dichotomous (typically yes/no). Pros • Rating scales offer greater options, • May be rapidly given (≤15 minutes) and scored such as a 4-point scale for measuring by staff symptoms as 0 (not present), 1 • Usually inexpensive (mild), 2 (moderate), 3 (severe). • May be used repeatedly to document change • Provide symptom frequency and severity Many rapid-assessment instruments are data (rating scales) self-report, and some require an observer (such as a parent or teacher) to respond. Cons Rating scales may take more time to complete • May have questionable validity/reliability than checklists but provide useful symptom • May be long and difficult to score • May provide inadequate symptom frequency and severity data. data (checklists) Some checklists/rating scales can assess • Susceptible to response distortion (patients may more than one disorder or target symptom. exaggerate or minimize symptoms) These wide-band instruments—often called inventories or schedules—tend to be lengthy (1 to 2 hours), often require an interview, and generally Objective tests’ ability to assess a wide band require specialized training to administer.1-4 of psychopathology can help you evaluate Pros. Two attributes make checklist/rating scales patients with complex differential diagnoses.6 popular in clinical practice: their convenience, Projective tests are unstructured instruments and managed care’s quest for documentation of developed to detect covert psychosis and pathologic service need, quality of care, cost-effectiveness, conflicts/impulses. Patients respond to ambiguous and symptom reduction.5 Brief, accurate, efficient stimuli (inkblots, pictures, incomplete sentences) checklists/rating scales can help you give managed that are assumed to function as a screen onto which care firms the documentation they require to a person projects his or her conflicts and issues.3 authorize continued treatment—whether psy- Useful projective tests include the Rorschach chotherapy or medication monitoring. ink blot test, Thematic Apperception Test (TAT) Cons. Many checklists/rating scales are psychome- of interpersonal relationships, and several sen- trically weak, with low reliability and unproven tence-completion tests. The Rorschach can take 1 validity. Some are lengthy or have other traits that to 2 hours to administer and score and requires diminish their clinical value (Table 1). years to master. The Rotter Incomplete Sentences Blank (2nd ed) (RISB) is well-constructed; avail- LONGER AND MORE DETAILED able in high school, college, and adult forms; and Objective tests typically contain true/false ques- can help clarify major conflicts.3 tions for which responses are reported as percentiles Projective tests’ psychometric properties have or standard scores. Examples are the Minnesota been questioned, but the Rorschach is considered Multiphasic Personality Inventory (MMPI-2), useful in detecting subtle psychoses.6 used to clarify axis I diagnoses, and Millon Neuropsychological tests can identify and localize Clinical Multiaxial Inventory (MCMI-III), brain injury. Board-certified neuropsychologists chiefly used to assess personality disorders. (with 2 years’ postdoctoral training) use them to

VOL. 4, NO. 6 / JUNE 2005 57 Psychological testing

Table 2 Commonly used checklists/rating scales for adult assessment

Disorder/target symptom Commonly used scales

Anger Anger, Irritability and Assault Questionnaire (AIAQ)

Anxiety Phobias Fear Questionnaire (FQ) GAD Beck Anxiety Inventory (BAI) OCD Yale-Brown Obsessive Compulsive Scale (Y-BOCS) PTSD Posttraumatic Stress Diagnostic Scale (PDS)

Bipolar disorder Young Mania Rating Scale (YMRS)

Depression Beck Depression Inventory (BDI) Zung Self-rating Depression Scale (SDS)

Eating disorders Eating Disorders Inventory-2

Family issues Family Assessment Device (FAD)

Impulse control Barratt Impulsiveness Scale, Version II (BIS-II)

Pain McGill Pain Questionnaire (MPQ)

Personality disorders Millon Clinical Multiaxial Inventory (MCMI-III)

Psychosis Brief Psychiatric Rating Scale (BPRS) Manchester Scale

Sexuality Sexual Interaction Inventory (SII)

Sleep Sleep Disorder Questionnaire (SDQ)

Suicide risk Beck Scale for Suicide Ideation (BSS)

GAD: Generalized anxiety disorder OCD: Obsessive-compulsive disorder PTSD: Posttraumatic stress disorder

assess traumatic brain injury, evaluate post- motor integration, imperception, and motor stroke syndromes or early dementia, and differ- dexterity. Others may select specific instruments entiate dementia and depression.7 These tests to answer a referring psychiatrist’s question. also have litigation and forensic applications, such as assessing competence or malingering. CHOOSING AN INSTRUMENT Some neuropsychologists use a comprehen- Medical reference librarians can help research sive instrument such as the Halstead-Reitan specific instruments and choose useful testing Neuropsychological Test Battery, which evaluates tools. We also recommend Corcoran and memory, abstract thought, language, sensory- Fischer’s Measures for Clinical Practice,8 which

58 Current VOL. 4, NO. 6 / JUNE 2005 p SYCHIATRY Current p SYCHIATRY

Table 3 Common checklists/rating scales for geriatric assessment

Disorder/target symptom Commonly used scales

Cognitive status Mini-Mental State Examination (MMSE) Neurobehavioral Cognitive Status Examination (Cognistat) Dementia Rating Scale Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)

Caregiver stress Caregiver’s Burden Scale (CBS)

Death concerns Concern About Death-Dying (CADD) and Coping (C) checklist

Depression Geriatric Depression Scale (GDS)

provides practical information on administra- Results can be readily used for feedback to patients tion, advantages, and disadvantages of instru- or third-party payers. ments that: Mr. A’s score of 19 is consistent with GAD and • are used in clinical practice justifies a medication trial. The BAI provides infor- • provide data on psychometric properties mation about his experience of anxiety (subjective • take <15 minutes to complete vs. somatic) that can guide psychotherapy. You plan • are rapidly scored to repeat the BAI over time to monitor treatment. • provide information on symptom severity Miss B would benefit from referral to a neuropsy- • can be used to document change. chologist, as screening tools do not reliably differen- Other useful references are available,1,2,4,9 but tiate among the dementias. The neuropsychologist most include research tools or wide-band, multi- will likely use all or part of the Halstead-Reitan Neuro- scale instruments—such as the MMPI-2—that psychological Test Battery to localize any ischemic- require specialized training. Tables 2-4 list com- related brain injury and clarify the diagnosis. This test mon instruments to test patients of all ages. also can provide data to stage her dementia and help you and her family with care decisions. IN-OFFICE TESTING VS REFERRAL You could use in-office testing to diagnose Mr. A’s PSYCHOLOGIST REFERRAL anxiety symptoms and provide documentation to When referring patients for psychological testing, his managed care company. For Miss B’s memory we recommend that you tell the psychologist what problems, we recommend referral for psycho- information you need and let him or her select the logical testing. tests. Relying on their expertise can save time and Mr. A completes the 21-item Beck Anxiety Inven- yield a report that targets the referral question. tory (BAI) in your office. You select the BAI because Three cases follow that illustrate types of it is psychometrically sound, brief (about 10 minutes referral questions doctoral-level psychologists can to complete and score), and easily understood. help answer with appropriately chosen tests: continued

VOL. 4, NO. 6 / JUNE 2005 59 Psychological testing

Table 4 Common checklists/rating scales for child and adolescent assessment

Disorder/target symptom Commonly used scales

Anxiety Multidimensional Anxiety Scale for Children (MASC)

Assertiveness Assertiveness Scale for Adolescents (ASA)

Conduct Child Behavior Checklist (CBCL)

Depression Children’s Depression Self Rating Scale (CDRS)

Drug/alcohol risk CAGE Questionnaire Michigan Alcohol Screening Test (MAST)

Impulsivity Impulsivity Scale (IS)

PTSD Child Report of Posttraumatic Symptoms (CROPS)

Reaction to divorce Children’s Belief About Parental Divorce Scale (CBAPS)

Self-esteem Rosenberg Self-Esteem Scale (RSE)

Suicide risk Multi-Attitude Suicide Tendency Scale (MAST)

Test anxiety Children’s Cognitive Assessment Questionnaire (CCAQ)

PTSD: Posttraumatic stress disorder

WHAT EXPLAINS TREATMENT RESISTANCE? The MCMI-III was developed to assess axis II Mr. C, age 43, presents with mixed anxiety and diagnoses and has scales to assess each personality depression. He complains of insomnia, fatigue, disorder. These tests provide information about tightness in the chest, and trembling hands. You psychological-mindedness, treatment resistance, give him the Beck Depression Inventory (BDI) and and characteristics that can guide psychotherapy. Beck Anxiety Inventory (BAI), which show mild depression/anxiety. You prescribe fluoxetine, 20 DRUGS, PSYCHOSIS, OR BIPOLAR DISORDER? mg/d, and 8 weeks later his symptoms are Mr. D’s parents report that their 20-year-old is iso- unchanged. The patient is demanding, critical, and lating himself in his room, is not sleeping, and has has a pattern of interpersonal difficulty. You suspect grandiose beliefs of special powers and knowledge. a personality disorder is complicating treatment. He has no psychiatric history. Because these symptoms could suggest numerous psychopathologies, In this case, the MMPI-2 and MCMI-III would be you would like help with the differential diagnosis. useful to clarify diagnosis. The MMPI-2 gauges anxiety (state anxiety, phobias, social anxiety and Mr. D’s symptoms could suggest drug abuse, posttraumatic stress disorder), and depression. schizophrenia, psychotic depression, or bipolar continued on page 66

60 Current VOL. 4, NO. 6 / JUNE 2005 p SYCHIATRY neuropsychological, or wide- or neuropsychological, doctoral-level psychologists more-complex differential diagnosesto to managedcare.Refer patients with response, andprovidedocumentation psychiatric disorde rapidly diagnosemanyuncomplicated I 66 fortheAssessmentofNeuropsychological Battery Status Examination(Cognistat)orRepeatable with antoolsuchastheNeurobehavioralCognitive can becompletedin15to20minutes. Depression Scaleispsychometricallysoundand priate forMr. E. The30-item,self-rated Geriatric An in-officedepressionchecklistwouldbeappro- also wishtodocumentchangeovertime. inhibitor, antidepressant,orothermedication.You diagnosis todecidewhetherstartacholinesterase dementia anddepression.You wishtoconfirm the are unremarkable,andyoususpectearlyAlzheimer’s appetite, andanhedonia.Physicalexamlabtests finding deficitsandcomplainsoffatigue,loss Mr. E,age78,presentswithmildmemoryandword- IS THISEARLY ALZHEIMER’SDISEASE? months togaugetreatmentresponse. process. TheMMPI-2couldberepeatedinafew scale wouldpointtobipolardisorder. is likely, whereasanelevationchieflyonthemania depression arebothelevated,psychotic be clinicallyuseful;ifscalesgaugingpsychosisand chosis. Therelativeelevationofeachscalecould abuse,depression,mania, andpsy- to assessdrug disorder. ThepsychologistmightusetheMMPI-2 continued frompage60 n-office assessmenttools Referral isrecommendedfordementiascreening The Rorschachtestcouldassesspsychotic Current Psychological testing p SYCHIATRY VOL. 4,NO. 6/JUNE2005 rs, monitortreatment Bottom can helpyou band testing. for projective,

Line References repeat asneededtodocumentchange. than theMMSEtoearlydementia. the patient’seducationlevelandaremoresensitive decline. CognistatorRBANSarelessinfluencedby cognitive deficitsbutlackssensitivitytodetectmild ination (MMSE)isusedforin-officescreeningof Status (RBANS).TheMini-MentalStateExam- .Adams RL,CulbertsonJL.Personality assessment:adultsandchildren. 6. .RushAJ,PincusHJ,First MB,etal(eds). 4. .CorcoranK,Fischer J. 8. SwandaRM,HaalandKY, LaRueA.Clinicalneuropsychology 7. BelarCD.Psychological assessmentincapitatedcare. In: Butcher 5. AikenLR. 3. 2. Sajatovic M, Ramirez LF. SajatovicM,Ramirez 2. ME(ed). Maruish 1. .BlackerD.Psychiatric ratingscales.In:SadockBJ,VA (eds). 9. DRUG BRANDNAMES are mentionedinthisarticleorwithmanufacturersofcompetingproducts. The authorsreportnofinancialrelationshipwithanycompanywhoseproducts DISCLOSURE Fluoxetine • Lippincott Williams &Wilkins; 2000:755-83. Comprehensive textbookofpsychiatry, vol.1(7thed) New York: Free Press; 2000. Measures Baltimore: LippincottWilliams &Wilkins; 2000:689-701. (eds). and intellectualassessmentofadults.In: SadockBJ,VA (7th 1 ed vol. Sadock BJ,VA In: (eds). in treatmentplanning JN (ed). OH: Lexi-Comp;2003. Associates; 1999. ning andoutcomesassessment All three instruments arebriefenoughto All threeinstruments New York: Free Press; 2000. faq-findtests.html. about psychologicaltests.http://www.apa.org/science/ American Psychological Association.FAQ/Finding information measures Rush AJ,PincusHJ,First MB,etal.(eds). Associates; 1999. planning andoutcomesassessment ME(ed). Maruish Corcoran K,Fischer J. Related resources Comprehensive textbookofpsychiatry, vol.1(7thed) . Washington, DC:AmericanPsychiatric Association;2000. Personality assessmentinmanagedcare:UsingtheMMPI-2 Prozac . Washington, DC:AmericanPsychiatric Association;2000. Assessment ofadultpersonality ). Baltimore:LippincottWilliams &Wilkins; 2000:702-21. The useofpsychologicaltestingfortreatmentplan- The useofpsychologicaltestingfortreatment . NewYork: OxfordPress; 1997:13-80. Measures forclinicalpractice,vols1and 2 Measures forclinicalpractice,vols.1and2 Rating scalesinmentalhealth . Mahwah,NJ:LawrenceErlbaum Comprehensive textbookofpsychiatry, . Mahwah,NJ:LawrenceErlbaum . NewYork: Springer;1997. Handbook ofPsychiatric Handbook ofpsychiatric . Baltimore: . Hudson, . . .