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Psychological and Neuropsychological Assessment
Overview
Psychological and neuropsychological assessments can be invaluable in cases where there is a question regarding differential diagnosis, a change in functioning from a premorbid baseline, or when a baseline is needed to assess the efficacy of planned treatments. Clinical psychologists who have doctoral and postdoctoral training in assessment perform these types of evaluations, generally working in a consultative role. Psychological evaluations focus on distinguishing between different types of psychopathology and broadly characterize cognitive and emotional functioning. Neuropsychological evaluations focus on relating an observed pattern of performances on cognitive tests to brain function and are often most helpful when there are complex differential diagnostic questions at the interface of psychiatry and neurology. Both types of evaluations involve clinical interviews, review of available records, and the administration of standardized tests that are designed to tap specific functions. Test data are interpreted using normative data for each measure that allows for comparison of an individual to the general population as well as a characterization of the individual's pattern of strengths and weaknesses. A written report is provided to the referring provider and the psychologist may also meet with the patient to review the findings and recommendations. This chapter describes both types of evaluations, using cases to illustrate the types of measures and findings.
Psychological Assessment
Psychological assessments are most commonly requested when there is a question regarding psychiatric diagnosis. For example, psychological evaluations are often requested when there are questions regarding the nature of a mood or anxiety disorder, personality features, or how an individual's overall level of cognitive functioning may interact with emotional functioning and treatment. Evaluations are performed in outpatient and inpatient settings, and are often more comprehensive in the outpatient setting. The request for psychological testing might be framed as portrayed in Case 1 .
Case 1
Please conduct a psychological assessment on Ms. B, a 28-year-old, right-handed, single attorney to help determine if her presentation represents depression with suicidality and/or atypical personality functioning.
Ms. B initially presented to the Emergency Department with complaints of extreme back pain. The physician noted mild confusion and disorientation and Ms. B was admitted to the medical service for further evaluation. By the next morning, her mental status had improved. However, she continued to complain of extreme back pain and made vague suicidal statements. A pain work-up and psychiatric consultation were both ordered.
A review of the medical chart revealed that she had graduated from a prestigious university and law school and was employed at a large legal firm. She had developed severe back pain secondary to multiple equestrian injuries that occurred while riding competitively in college. She had received various diagnoses for her pain and there had been multiple unsuccessful interventions, including medication trials, surgery, and limited progress as a patient on an inpatient pain rehabilitation unit. Ms. B's current prescribed medications included diazepam (5 mg BID), amitriptyline (100 mg QHS), and oxycodone–acetaminophen (Percocet; one tablet QHS). The pain service consultant was unsure about the diagnosis. The psychiatric consultant found her to be guarded (with regard to her mood and the level of her suicidal ideation). She reported no history of depression or suicide attempts. She got into frequent struggles with the nursing staff over the hospital's smoking rules.
Later that same day, Ms. B completed a brief, but fairly comprehensive psychological assessment. The test battery included: the Wechsler Abbreviated Scale of Intelligence (2nd edition; WASI-II); the Rorschach inkblot test; four Thematic Apperception Test (TAT) cards; and the Personality Assessment Inventory (PAI). The WASI-II was selected for its brief administration time (20 to 30 minutes) and its ability to provide an estimate of the patient's overall level of intellectual functioning, including verbal and non-verbal abilities. The Rorschach, a performance measure of personality functioning, was selected given her guardedness and unwillingness to openly discuss her emotional functioning. The PAI, a self-report measure of psychopathology was also selected because it has embedded validity indices to determine whether a respondent has completed the task with sufficient attention and willingness to disclose personal experiences. Compared with other self-report inventories, the PAI is relatively short (344 items), and contains a number of treatment-planning scales that can provide important information.
Ms. B's assessment was conducted in her semi-private room. Although this was not an ideal situation, hospital evaluations are commonly performed in this fashion. Ms. B completed all of the testing without complaint. The WASI-II data indicated that her overall level of intellectual functioning generally falls well above the average range, though there was a notable discrepancy between her verbal and non-verbal abilities with superior range Verbal Comprehension Index (Standard Score = 120; 91st percentile) and low average range Perceptual Reasoning Index (Standard Score = 87; 19th percentile).
With regard to Ms. B's implicit psychological function, the Rorschach depression index was positive and suggested either current depression or a propensity to depressive experiences. The suicide constellation was negative. Although her adaptive psychological resources were adequate, situational stress was overwhelming her ability to cope. Her affective experience was dominated by helplessness, painful internalized affect, and unmet dependency–nurturance needs. Together these findings suggested possible depression resulting from situational factors. She was not psychotic, but her thinking was over personalized and idiosyncratic. The experience of anger also decreased her reasoning and judgment. She had a self-centered and narcissistic character style. She did not process her feelings but instead tried to minimize them through intellectualization or externalization (projection).
The PAI was considered to provide a picture of her explicated psychological world. The PAI profile was valid. She reported minimal psychopathology. Her mean elevation on the 10 clinical scales was well within the range of non-patients (average T-score = 53), suggesting either that she was experiencing little overt distress or that she was reluctant to express emotional pain. Either way, she did not appear to others, including her caregivers, to be psychologically impaired. She reported mild clinical depression (T-score = 71) and excessive concern about her physical function (T-score = 85). On further clinical interview, her excessive physical complaints and concerns overshadowed her depressive symptoms. A grandiose sense of self, consistent with the pronounced signs of a narcissistic character style on the Rorschach, was also indicated by one of the PAI subscales. On the treatment consideration scales, she indicated minimal interest in psychologically oriented treatments, high levels of social stress, and minimal suicidal ideation (T-score = 54).
Impressions and Recommendations
Overall, the assessment strongly suggested the presence of a clinical depression. Depression was likely masked to some extent by both the patient's focus on her physical function (back pain) and her inability or unwillingness to express her emotional pain. As a result, her depression was likely more significant and disruptive to her functioning than she reported, particularly given her personality functioning, which is likely to include an immature, self-centered view of the world and narcissistic traits. She did not appear to be actively suicidal either on the self-report or performance tests. However, given her emotionally overwhelmed and depressed state of being and her reduced coping ability. Ms. B should be considered at an increased risk (over and above being depressed) for impulsive self-harm. Her safety should be monitored closely.
The significant discrepancy between her verbal and non-verbal abilities on intellectual testing raised several questions for further exploration, including whether there is a longstanding developmental condition (e.g., a non-verbal learning disability) or whether there has been a change in cognitive functioning (i.e., an acquired condition) secondary to medical (neurological, pain, medication effects, etc.) and/or psychiatric factors (e.g., depression). Such findings should prompt further medical evaluation, specifically a neurological exam to rule out right hemisphere dysfunction. A neuropsychological evaluation following stabilization of her emotional functioning would also be appropriate to help hone in on the factors contributing to her uneven cognitive abilities. Regardless of etiology, this profile is sometimes associated with a tendency to be detail-oriented at the expense of “seeing the big picture” and others may overestimate her level of function because of her strong verbal communication skills.
Psychotherapy will be challenging given her personality style, but is nonetheless recommended. The primary focus should be practical efforts to improve her coping skills and function. Once her functioning stabilizes, the focus of therapy might be expanded to include her interpersonal style. If her cognitive profile reflects an idiopathic developmental condition (e.g., a non-verbal learning disability), she may also have difficulties with social communication that further limit her everyday functioning and this could be targeted in individual psychotherapy.
Assessment of Intellectual Functioning
The conceptualization and assessment of intelligence have evolved over time. Current models emphasize a dimensional approach in which an estimate of current intellectual functioning is derived from performances on a number of subtests that assess different types of cognitive skills. A full discussion of the theories of intelligence is beyond the scope of this chapter, but generally speaking, IQ scores are meant to capture the patient's current ability to perform and adapt in the everyday setting.
The Wechsler intelligence tests are very commonly used to assess intellectual functioning and allow for assessment across the life span. The series includes the Wechsler Preschool and Primary Scale of Intelligence-IV (for ages 2–7 years); the Wechsler Intelligence Scale for Children-V (for ages 6–16 years); and the Wechsler Adult Intelligence Scale-IV (for ages 16–89 years). An abbreviated version of the Wechsler IQ test for ages 6–90 (Wechsler Abbreviated Scale of Intelligence, 2nd edition; WASI-II). All the Wechsler scales provide a Full Scale IQ score as well as clinical index scores that group similar cognitive abilities, including verbal and non-verbal abilities. With the exception of the WASI-II, the Wechsler scales also provide composite indices for working memory and processing speed. The Full Scale IQ and index scores have a mean of 100 and standard deviation (SD) of 15. The normative data allow the examiner to determine whether certain index scores are statistically higher than others. When there is significant variability among the index scores, the overall estimate of Full Scale IQ should be interpreted with some degree of caution, as the patient's performances may vary depending on task demands.
Tests of Personality, Psychopathology, and Psychological Function
Objective psychological tests, also called self-report tests , are designed to clarify and quantify a patient's personality function and psychopathology. Objective tests use a patient's response to a series of true/false or multiple-choice questions to broadly assess psychological function. These tests are called objective because their scoring involves standardized procedures and the application of normative data. Objective tests provide excellent insight into how patients see themselves and want others to see and treat them. Self-report tests allow the patient to communicate their psychological difficulties to their caregivers directly.
The Minnesota Multiphasic Personality Inventory–2 (MMPI-2) is a 567-item true/false, self-report test of psychological function. It was designed to provide an objective measure of abnormal behavior, basically to separate subjects into two groups (normal and abnormal) and to further categorize the abnormal group into specific classes. The MMPI-2 contains 10 clinical scales that assess major categories of psychopathology and three validity scales designed to assess test-taking attitudes. MMPI-2 validity scales are (L) lie, (F) infrequency, and (K) correction. The MMPI-2 clinical scales include (1) Hs, hypochondriasis; (2) D, depression; (3) Hy, conversion hysteria; (4) Pd, psychopathic deviate; (5) Mf, masculinity–femininity; (6) Pa, paranoia; (7) Pt, psychasthenia; (8) Sc, schizophrenia; (9) Ma, hypomania; and (10) Si, social introversion. More than 300 new or experiential scales have also been developed for the MMPI-2. The MMPI-2 is interpreted by determining the highest two or three scales, called a code type . For example, a 2–4–7 code type indicates the presence of depression (scale 2), impulsivity (scale 4), and anxiety (scale 7), along with the likelihood of a personality disorder.
The Millon Clinical Multiaxial Inventory-III (MCMI-III) is a 175-item true/false, self-report questionnaire designed to identify both symptom disorders and personality disorders. The MCMI-III is composed of 3 modifier indices (validity scales); 10 basic personality scales; 3 severe personality scales; 6 clinical syndrome scales; and 3 severe clinical syndrome scales. One of the unique features of the MCMI-III is that it attempts to assess a wide variety of psychopathology simultaneously. Given its relatively short length (175 items vs 567 for the MMPI-2), the MCMI-III has an advantage in the assessment of patients who are agitated, whose stamina is significantly impaired, or who are suboptimally motivated.
The PAI 4 is one of the newest objective psychological tests. The PAI includes 344 items and a 4-point response format (false, slightly true, mainly true, and very true) to make 22 non-overlapping scales. These 22 scales include: 4 validity scales, 11 clinical scales, 5 treatment scales, and 2 interpersonal scales. The PAI covers a wide range of psychopathology and other variables related to interpersonal function and treatment planning (including suicidal ideation, resistance to treatment, and aggression). The PAI possesses outstanding psychometric features and is an ideal test for broadly assessing multiple domains of relevant psychological function.
A patient's response style can have an impact on the accuracy of his or her self-report. Validity scales are incorporated into all major objective tests to assess the degree to which a response style may have distorted the findings. The three main response styles are careless or random responding (which may indicate that someone is not reading or cannot understand the test), attempting to “look good” by denying pathology, and attempting to “look bad” by over-reporting pathology (a cry for help or malingering).
Performance tests (formerly known as projective tests) of psychological function differ from objective tests, in that they are less structured and require more effort on the part of the patient to make sense of, and to respond to, the test stimuli. As a result, the patient has a greater degree of freedom to demonstrate his or her own unique personality characteristics. Performance tests are more like problem-solving tasks, and they provide insights into a patient's style of perceiving, organizing, and responding to external and internal stimuli. When data from objective and performance tests are combined, they can provide a fairly complete picture or description of a patient's range of psychological function.
The Rorschach inkblot test consists of 10 cards that contain inkblots (five are black and white; two are black, red, and white; and three are various pastels), and the patient is asked to say what the inkblot might be. The test is administered in two phases. First, the patient is presented with the 10 inkblots one at a time and asked, “What might this be?” The patient's responses are recorded verbatim. In the second phase, the examiner reviews the patient's responses and inquires where on the card the response was seen (known as location in Rorschach language) and what about the blot made it look that way (known as the determinants ). For example, a patient responds to Card V with “A flying bat.” The practitioner asks, “Can you show me where you saw that?” The patient answers, “Here. I used the whole card.” The practitioner asks, “What made it look like a bat?” The patient answers, “The color, the black made it look like a bat to me.”
The examining psychologist reviews these codes rather than the verbal responses to interpret the patient's performance. Rorschach “scoring” has been criticized for being subjective. However, over the last 40 years, Exner and colleagues have developed a Rorschach scoring system (called the Comprehensive System ) that has demonstrated acceptable levels of reliability. Using the scoring system, high interrater reliability coefficients can be obtained (e.g., kappa >0.80) and are required for all Rorschach variables reported in research studies. Rorschach data are particularly valuable for quantifying a patient's contact with reality and the quality of his or her thinking.
The Thematic Apperception Test (TAT) is helpful in revealing a patient's dominant motivations, emotions, and core personality conflicts. The TAT consists of a series of 20 cards in which drawings depict people in various interpersonal interactions. The cards were intentionally drawn to be ambiguous. The TAT is administered by presenting 8 to 10 of these cards, one at a time, with the following instructions: “Make up a story about this picture. Like all good stories, it should have a beginning, middle, and an ending. Tell me how the people feel and what they are thinking.” Although there is no standard scoring method for the TAT (making it more of a clinical technique than a psychological test proper), when a sufficient number of cards are presented, meaningful information can be obtained. Psychologists typically assess TAT stories for emotional themes, level of emotional and cognitive integration, interpersonal relational style, and view of the world (e.g., whether it is seen as a helpful or hurtful place). This type of data can be particularly useful in predicting a patient's response to psychotherapy. Recent research has shown that TAT narratives can be reliably scored to reveal level of personality organization, emotional regulation, identity integration and social understanding.
Psychologists sometimes use performance drawings (freehand drawings of human figures, families, houses, and trees) as a supplemental assessment procedure. These are clinical techniques rather than tests because there are no formal scoring methods. Despite their lack of psychometric grounding, drawings can sometimes be very revealing. For example, psychotic subjects may produce a human figure drawing that is transparent and shows internal organs. Still, it is important to remember that drawings are less reliable and less valid than other tests reviewed in this chapter.
Neuropsychological Assessment
Neuropsychological assessment is a specialty within clinical psychology that focuses on understanding brain–behavior relationships using standardized psychological measures. The main goal of a neuropsychological evaluation is to relate a patient's test performance to both the status of his or her central nervous system and real-world functional capacity. In addition to assessing intellectual and general psychological functioning, a complete neuropsychological assessment evaluates abilities within six major cognitive domains: attention, executive functions, language (expressive and receptive), memory (immediate and delayed recall in verbal and visual modalities), and visual–spatial functions. Higher-order motor functions may also be assessed. While the domains focused on in this evaluation are similar to those within a mental status examination used by neurologists, it provides a deeper, more comprehensive, and better-quantified assessment. The application of a battery of tests covering these major cognitive areas allows for a broad assessment of the patient's strengths and areas of weakness or impairment and provides some indication as to how these may impact real-world adaptation. The request for neuropsychological testing might be framed as portrayed in Case 2 .
Case 2
Mr. A is a 20-year-old, right-handed male with a childhood history of attention-deficit hyperactivity disorder (ADHD) and a seizure disorder. He developed psychotic symptoms approximately 4 years ago and these prompted a recent psychiatric hospitalization for stabilization. A neuropsychological evaluation was requested to assess his current cognitive function, establish a baseline to monitor his future course, aid in differential diagnosis, and guide treatment. Assistance in determining the degree to which his presentation may reflect focal neurologic dysfunction was requested.
Mr. A was recently discharged from a psychiatric unit, where he was being treated for symptoms of schizophrenia that included hallucinations (in multiple perceptual systems) and dysregulated behavior. Despite a long history of emotional and behavioral concerns (including a diagnosis of ADHD at the age of 9, seizures that were clinically diagnosed at age 12, and visual hallucinations that first developed at the age of 16), there was no history of significant developmental delays or learning difficulties. He has completed some college courses. Since his diagnosis with a seizure disorder, he has been treated with antiepileptic medication, and a variety of antidepressants and anti-anxiety agents were attempted in his mid to late teens. Antipsychotics were started in the past year. He denied use of substances within the past 4 months, but has a past history of regular marijuana use and had taken hallucinogenic mushrooms, and used inhalants.
Mr. A's evaluation included a review of medical records, an interview with him and his mother, and a discussion with his outpatient treaters. The following tests were administered: Test of Premorbid Functioning (TOPF); Wechsler Adult Intelligence Scale (4th edition; WAIS-IV); Wechsler Memory Scale-IV (WMS-IV) Logical Memory, WMS-IV Visual Reproduction, Trail Making Test; Stroop Color Word Test; Controlled Oral Word Association Test (COWA); Conners' Continuous Performance Test (CPT), 3rd edition; Boston Naming Test; Hooper Visual Organization Test; Rey-Osterrieth Complex Figure; Grooved Pegboard Test; and PAI. Mr. A cooperated fully with the evaluation. Overall, his performance was believed to be a valid reflection of his current behavior and level of function. Performances on embedded measures of performance and symptom validity were within normal limits (i.e., all the psychological tests were valid and interpretively useful).
Intellectual Functioning
Based on his performance on a test of word reading, premorbid intellectual functioning is estimated to fall in the average range for age (TOPF, 40th percentile). Consistent with this estimate, his performance on the WAIS-IV indicated that his current level of intellectual functioning falls in the average range for age (Full Scale IQ Standard Score = 91, 27th percentile). However, his performance on measures of verbal abilities (Verbal Comprehension Index, Standard Score = 98, 45th percentile) was significantly higher than on measures of non-verbal abilities (Perceptual Reasoning Index, Standard Score = 90, 25th percentile). Working memory (Working Memory Index, Standard Score = 86, 18th percentile), and processing speed (Processing Speed Index, Standard Score = 89, 23rd percentile) fell in the low average range for age. The magnitude of the discrepancy between his verbal and non-verbal abilities was statistically significant, raising the possibility of relative right hemisphere inefficiency.
Memory
Performances on measures of verbal memory were also stronger than on measures of visual memory, again pointing to possible greater right-hemisphere dysfunction. Immediate recall of narrative passages (WMS-IV Logical Memory) was average (37th percentile). After a delay period, free recall fell to the low average range (16th percentile). Qualitatively, Mr. A's recall of the two stories was disjointed, and some facts were misrepresented which raises some concerns about his functional verbal memory. However, delayed recognition of the material was grossly accurate, indicating that he is able to retain information that he learns. In contrast to verbal memory, immediate visual memory (ability to recall designs) fell in the borderline to low average range (9th percentile). After a delay, free recall fell in the low average range (16th percentile) and delayed recognition was intact. Thus, there was no evidence of loss of visual information over time.
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