Chapter 6. Psychological and Neuropsychological Assessment

Psychological evaluation in the psychiatric context generally refers to measurements from psychological testing (in addition to the utilization of information from the history and traditional mental status examination), made for the purpose of helping delineate and clarify a patient's psychopathology. Psychological testing is frequently requested to address specific clinical issues such as the patient's need for hospitalization, personality factors complicating Axis I symptoms, the possible presence of malingering, identification of major therapeutic issues, the patient's potential for suicide, his or her primary defense mechanisms and coping style, and the most appropriate discharge options. The child psychiatrist may need to rule out neurodevelopmental disorders such as mental retardation with cognitive testing. Questions a psychiatrist may ask in a neuropsychological referral are typically related to the role of possible central nervous system dysfunction in a patient's pathology and its impact on daily functioning. For example, does a patient have dementia or pseudodementia, is a patient's behavioral or emotional dyscontrol the result of personality factors or impaired central nervous system mechanisms that modulate such reactions, and what is the extent of organic damage and associated cognitive impairment? In addition to clarifying the diagnosis and assisting in treatment planning, psychological testing can play an important role in outcome assessment by helping to document the effectiveness of the treatment provided to a given patient.

The psychiatrist's ability to call upon and utilize psychological consultation on complex clinical cases in the course of practice leads to many diagnostic advantages over relying upon interview and observations alone, particularly in today's health care environment that emphasizes documentation. Further, having an understanding of a patient's personality structure, amenability to treatment, and verbal skills, for example, are extremely useful in deciding whether psychosocial treatments or pharmacological treatment alone would be the preferred treatment modality. The demonstration of treatment effectiveness by measurably positive changes on symptom report scales is important documentation for insurance companies, managed care corporations, and patient consumers. The measurement of a patient's tendency to deliberately exaggerate or to experience somatoform symptoms is often critical in the medicolegal context. Similarly, the measurement of cognitive skills and deficits adds a dimension to the psychiatrist's understanding of the patient's abilities, whether it be the identification of precocity in a preschooler or dementia in an aged professional who is reluctant to retire despite complaints from clients and business partners.

Measurement Concerns

The selection of tests to address given referral questions is determined according to whether they satisfactorily meet key psychometric standards. Psychological tests are typically norm-referenced, that is, the score of an individual patient is compared to the average of the standardization sample, the group of persons to whom the test was initially administered, and who were carefully chosen as being representative of the population of interest (e.g., patients with a diagnosis of bipolar I disorder). The test procedures themselves are also standardized. While informal bedside testing can be adapted to one's personal style and has the flexibility of incorporating items specific to the referral questions, standardized testing implies uniformity of test administration, scoring, and interpretation.

Standardization contributes to the test's reliability, that is, it must be internally consistent and produce the same or similar results if given to the same individual at different times. For example, if a medical school applicant scores in the 98th percentile on the Medical College Admissions test (MCAT) on Saturday and in the 60th percentile on Monday using the same test version or an equivalent form, the measure is said to be unreliable because little confidence can be put in either score. The useful psychological test must ultimately also have validity, the most important criterion for a test: the degree to which the test actually measures what it claims to be measuring. The validity of a test can be assessed in a number of different ways. It can be measured against an external, well-accepted criterion (criterion validity). For example, with regard to its criterion validity, does the MCAT score actually predict medical student performance as measured by relevant external criteria, such as grades, faculty evaluations, and successful completion of training? Does a test for obsessive–compulsive disorder (OCD) correctly identify most patients who have been diagnosed as meeting OCD criteria by multiple raters? Criterion validity is assessed by calculating the test's sensitivity (its ability to correctly classify a patient as having the condition of interest), and its specificity (its success in correctly classifying patients without the condition). Another type of validity, content validity, involves a systematic analysis of the individual items comprising the test in order to determine how well the items sample the behavior domain under study. For example, a measure of depression should consist of items that sample all major aspects (e.g., cognitive, physiologic, and behavioral) of the construct with respect to their relative importance. A test must also have ecological validity, the degree to which the test genuinely reflects cogent, real-world realities and behavior. For example, an elderly patient may perform very poorly on a test of mental arithmetic skills, but the score may bear little relationship to her ability to balance a checkbook if she can compensate for her concentration problems by using the aid of pencil and paper. The utility of a test is another key characteristic, referring to its unique usefulness in answering the relevant referral questions and contributing to the desired outcome. The tests described in this chapter are among those that have withstood scrutiny over time and demonstrated their utility in psychiatric practice.

Interest in personality assessment predates the scientific advances in psychological testing. Throughout the ages, people have evaluated their own conduct and the actions of others for the purpose of understanding and predicting behavior. Scientific personality testing has its origins in the study of individual differences through psychological measurement.

Contemporary personality and behavior measures are typically described as being either objective or projective in type. The use of the term “objective” implies that responses are objectively scored and interpreted according to normative data. Examples of the former include comprehensive objective personality tests, behavioral rating scales, and actuarial assessment techniques. We have selected examples of these types of objective personality and behavioral instruments for discussion, as they are the ones the psychiatrist is most likely to encounter in clinical practice. That is, when referring patients for personality testing, there will be a greater likelihood that many of the following will be administered and discussed in the psychologist's report. There will also be a parallel discussion of projective tests.

Comprehensive Objective Personality Tests

Comprehensive personality tests are structured paper-and-pencil self-report instruments whose items are answered in a standard format (e.g., true–false). Usually the patient is the respondent, though some tests utilize the input of significant others. They are scored in a quantitative manner, and resulting numerical scores are subjected to statistical analyses. Typically, a profile is generated that contrasts the patient's scores with those of the normative sample. Normative data are provided in the test manual, as are reliability and validity information.

Minnesota Multiphasic Personality Inventory-2

The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) is the most frequently used personality inventory in clinical practice. In the 1930s, psychiatrists and psychologists had to rely almost exclusively on interview procedures to assist them in making clinical decisions. Starke Hathaway and Charley McKinley, a psychologist–psychiatrist collaborative team at the University of Minnesota, published the original MMPI in 1943. It was developed entirely from an empirical perspective, with response items chosen solely on the basis of their ability to distinguish among cohorts of psychiatric patients with given disorders. This 566-item true-false test was designed to yield 10 clinical subscales: Hypochondriasis, Depression, Hysteria, Psychopathic Deviate, Masculinity–Femininity, Paranoia, Psychasthenia, Schizophrenia, Hypomania, and Social Introversion. For ease of communication, each scale was given an associated number. For example, Hypochondriasis = 1, Depression = 2, and so forth. Psychologists typically refer to these numbers when discussing an MMPI profile among themselves, as many scale names are clinically outdated (e.g., Psychasthenia). In addition, there are multiple validity scales available which measure the respondent's test-taking attitude (e.g., defensiveness, exaggeration of symptoms). Sets of items selected for inclusion in the test's final version differentiated a specific clinical sample (e.g., depressed patients on the Depression subscale) from the normal subjects who comprised the standardization group.

The MMPI was revised in 1989 as the MMPI-2, which consists of 567 self-descriptive statements. In the revision, several original items were reworded or deleted, and statements focusing on suicide, substance abuse, and related matters were added. The revised version also includes a standardization sample that is more representative of the U.S. population (based on census data). In 2003, an extensive project was completed that restructured the clinical scales of the MMPI-2 and anchored them in an empirically derived factor structure. Another extensive revision of the MMPI-2 is reportedly soon to be published, reducing its length and revising the primary clinical scales. These changes guarantee that the MMPI-2 and its successors will continue to play an important role in the assessment of psychopathology, though its evolution as an instrument raises many questions about validity and utility that will need to be addressed by careful research.

Interpretation of the MMPI-2 is based primarily on a profile analysis consisting of two or three highest scale elevations. Scales with T scores of 65 or above are considered clinically significant. Abnormally low scores are interpretable. Numerous books are available to help the clinician interpret specific code types. The basic profile form of a hand-scored MMPI-2 is shown in Figure 6–1. The patient's profile suggests a depressive disorder with possible cognitive changes or even psychotic involvement (elevated Depression and Schizophrenia scales) in an individual who is overly dependent, self-centered, and naïve about their own feelings and motivations (elevated Hysteria scale).

Personality Assessment Inventory

The Personality Assessment Inventory (PAI) was constructed in 1991 by Leslie Morey, then a professor of psychology at Vanderbilt University, with the goal of closely corresponding to contemporary psychiatric concepts and diagnostic nomenclature, such as found in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The test consists of 344 items answered on a four-point Likert-type format: totally false, slightly true, mainly true, and very true. In addition to the 11 clinical scales (diagnosis), there are 5 treatment consideration scales (prognosis), 2 interpersonal scales (social support), and 4 validity scales. The clinical scales are Somatic Complaints, Anxiety, Anxiety-Related Disorders, Depression, Mania, Paranoia, Schizophrenia, Borderline Features, Antisocial Features, Alcohol Features, and Drug Features. An important feature of the PAI scales is that they are further divided into subscales that reflect specific components or subtypes of a given disorder. For example, a patient's specific manifestation of anxiety may be as excessive worry and concern (i.e., cognitive) rather than trembling hands (e.g., physiologic). The treatment scales (Suicidal Ideation, Treatment Rejection, Nonsupport, Stress, Aggression) also provide the clinician with pertinent information for treatment planning, an especially useful feature of this test.

Applications and Limitations of Comprehensive Personality Tests

The MMPI-2 and PAI are two important objective personality inventories for diagnostic classification and treatment planning. The empirically developed MMPI-2 is used primarily for spotlighting acute psychiatric (Axis I) issues and for identifying patients’ psychopathological patterns that may not be explicitly apparent to either the patient or the clinician. The PAI is a more “face-valid” test; that is, the scales correspond, often very explicitly, with current psychiatric (DSM) conceptions of Axis I disorders and Axis II personality disorder criteria. Though designed to be an improved MMPI-2, most clinicians who have used both have found each to contribute uniquely useful information to the assessment process, as reflected by the immense popularity of both instruments.

There are several advantages to using comprehensive personality measures. They are relatively simple to administer. The arduous task of data entry, scoring, and calculating scales may be accomplished by computer. Test manuals provide standardization and psychometric information (e.g., validity and reliability data) for the user, as well as guidance in clinical interpretation. Comprehensive personality instruments also have limitations. They are primarily behavioral in content and may provide inadequate information about the respondent's underlying motives or psychodynamics. For example, two patients may produce identical profiles indicating that they feel depressed and anxious. In one case the symptoms may be the result of acute situational stress (e.g., financial reversals), whereas in the other case, the symptoms may be long-standing and connected to historical issues, such as unresolved childhood trauma. Further, the prescribed objective response method (e.g., true-false or four-point scale) prevents patients from elaborating or qualifying their responses.

Behavior Rating Scales

Behavioral rating scales are objective scales that may be self-administered or, especially when used with children or severely impaired individuals, rely on the reports of knowledgeable informants. These scales usually focus upon a single disease construct (e.g., depressive symptoms, obsessive–compulsive symptoms, PTSD symptoms) or upon a set of specific behaviors of interest in a given population, such as ratings of childhood behavioral problems. The scale's scores are then typically compared to normative data in the form of averages or cutoff points identified by research as optimal in predicting a given criterion. Behavior rating scales tend to be more focused on a given set of behaviors or symptoms, or are developed on a given subpopulation (e.g., children, PTSD victims) than comprehensive personality tests. As such, they may be more limited in scope, but may assist the clinician in specifically elucidating a patient's clinical presentation in a more complete fashion.

The chapters in this volume on child assessment reference some of the most widely used comprehensive child behavior rating scales (e.g., Child Behavior Checklist). Adaptive behavior rating scales for children and adults, such as the Vineland Adaptive Behavior Scale, provide standardized procedures for assessing functional abilities, key to the assessment of mental retardation, and other developmental disorders. These tests, and ones like them, are in reality collections of multiple behavior rating scales that are conormed on a single population and designed to tap several domains of behavior.

Beck Depression Inventory

One of the most widely used rating scales is the Beck Depression Inventory, now in its second version. Though often used to aid in diagnosing depression, its major utility is in measuring the severity of self-reported depressive symptoms, and in describing the particular manifestation of depression in a given patient. It contains self-rating items of all the DSM criteria of depression, as well as other changes commonly experienced in depressive patients. A simple glance at the rating form yields a wealth of information, such as the overall severity of the symptoms, and whether the patient's symptoms are more physiological, cognitive, or mood-oriented in nature.

Applications and Limitations of Behavior Rating Scales

Many advantages of behavioral rating scales have already been mentioned. They represent powerful tools in assessing the severity of psychiatric disorders and in illuminating the nature and characteristics of many behavioral syndromes. The sheer wealth of scales is almost bewildering: for nearly any given disorder, the clinician or researcher will have an array of well-researched instruments from which to choose. Their utility is in great demand whenever objective, repeatable, quantifiable data are required to assess patients’ progress in treatment, the efficacy of new research treatments, or the measurement of quality outcomes.

Their very specificity unfortunately contributes to some of their disadvantages. By focusing only on a given syndrome or symptom cluster, the use of a targeted rating scale may serve to mask initial diagnostic errors because symptoms from other syndromes may not be assessed. Perhaps their greatest weaknesses are apparent in the forensic assessment context. In most cases, the scales are so transparent (“face-valid”) that it is easily apparent to the respondent exactly what disorder or set of behaviors is being assessed by the scale. Few of the measures have acceptable validity indexes to identify the impact of potentially defensive responding or malingering. Even unintentional false reporting, such as by a frustrated parent who is at wit's end over a child's disruptive behavior, or a parent who is determined to cast their child's conduct problems in an acceptable light by over-endorsing depressive symptoms, can muddy the conclusions. In sum, the utility of these scales is quite limited in the forensic realm, and are best used in the context of a comprehensive, multimodal assessment.

Actuarial Assessment Techniques

Actuarial measures are assessment methods based purely on given patient characteristics, demographic information, and historical data that are mathematically combined to make probabilistic classifications of patients (e.g., risk of violence or likelihood of responding favorably to a given type of treatment). However, for many clinicians, the thought of basing treatment or placement decisions on actuarial descriptors or cut scores may seem foreign, if not repellent. Yet there are psychiatric evaluation contexts that sometimes require the input of such techniques. For example, the psychiatrist who assesses a patient's suicide risk by asking about history of prior attempts, current plans, intentions, means, age, level of stress, and religiosity is in fact using an informal analogue of an actuarial process to make a critical determination. Attempts to more rigorously codify systems for assessing suicidal risk have met with some success (e.g., Suicide Potential Scale).

Actuarial techniques are most often appropriate in clinical situations in which a decision must be made in one direction or the other, regardless of the quality of the data, because of the gravity of the potential outcomes. In addition to suicide risk, the most common situations requiring an estimate of risk usually revolve around violent behavior. Multiple actuarial rating systems have been researched and developed in this area, including aids to the evaluator involved in assessing risk of sexual reoffending (e.g., STATIC-99), risk of suicide (e.g., Suicide Potential Scale), and risk of violent reoffending in individuals with a known history of violence (e.g., Violence Risk Assessment Guide, or VRAG).

Violence Risk Assessment Guide

The latter technique, the VRAG, is the product of an extensive research program on violent offenders in a maximum-security institution in Ontario. The VRAG represents a typical actuarial procedure. The patient is rated on several static dimensions, such as the nature of their offense, the presence of a psychotic disorder, age, presence of childhood conduct disorder, and several other variables. The patient is also subjected to an interview with the Hare Psychopathy Checklist, a semistructured interview technique designed to identify the degree of a patient's psychopathy, or tendency to demonstrate personality characteristics shown to be related to serious acts of violence (see Table 6–1).

The patient's overall score is then compared to a sample of offenders with a known recidivism rate, and a probability value of future reoffending is assigned. While marked by a large error rate, this method is considerably superior to nonquantitative clinical judgments of violence risk made by psychologists and psychiatrists. This and similar methods are now commonly used in forensic consultation, and have been accepted for use by the courts in multiple court decisions.

Applications and Limitations of Actuarial Methods

The advantages to the psychiatrist in utilizing these actuarial methods, when available, are considerable. In addition to providing a check on personal biases and minimizing the inherent inaccuracy of general impressions based on a global impression of the patient, professional risk issues are minimized. By definition, these techniques represent the standards generally accepted by the mental health community, and thus would presumably serve as a powerful protective measure in the unhappy event of liability litigation following a patient committing a violent act. Disadvantages include the fact that the error rates of these methods, though superior to clinical judgment, remain very high. Presumably, many more predictive factors or combinations thereof need to be identified in order to reduce the error rate. Such methods also do not usually take into account dynamic factors such as availability of treatment, compliance with treatment, intrapersonal changes due to the consequences of past acts of violence, or the impact of supervision and scrutiny, to name a few. Consequently, actuarial analysis is best employed as an adjunct to, not a replacement for, comprehensive psychological or psychiatric assessment.

Projective Personality Tests

As opposed to objective personality testing, in projective personality testing, the individual is provided unstructured test stimuli (e.g., inkblots, incomplete sentences, pictures of human figures) and required to give meaning to them. The theoretical assumption is that the patient's responses reflect primarily a “projection” of the individual's inner needs, motivations, defenses, and drives. That is, tests are intended to elicit a projection of unconscious material from the subject's inner life. In theory, the manner in which the patient organizes and perceives the ambiguous test stimuli reveals something about his or her distinctive personality. There are objective scoring systems for some projective tests, such as the Exner Comprehensive Scoring System, one of the most sophisticated and widely used for the Rorschach. However, some clinicians prefer to make psychodynamic interpretations from the thematic content of the patient's Rorschach responses, arguing that they are achieving a much richer understanding of the patient than that provided through more sterile numerical analysis of the person. Proponents of objective personality inventories often criticize their counterparts who favor projective testing for not meeting higher standards of validity, reliability, and standardization. Many clinicians, however, utilize a test battery of both objective and projective tests when performing a psychological workup on a patient. Such a strategy will likely result in a more comprehensive evaluation of a patient and provide more confidence in replicated findings from different types of test stimuli. Three of the projective tests that have stood the proverbial “test of time” are the Rorschach Inkblot Test, the Thematic Apperception test (TAT), and the Sentence Completion test (SCT).

Rorschach Inkblot Test

The Rorschach Inkblot Test was the creative effort of a Swiss psychiatrist, Hermann Rorschach, who first published the test in 1921. Out of several hundred inkblot configurations, he selected 10 cards because of the variety of responses they elicited. Five of the bilaterally symmetrical inkblots are achromatic, two have additional spots of red, and three combine several colors (Figure 6–2).

During the test administration, the examiner asks the patient what each card looks like (i.e., “What might this be?”). The examiner then records the patient's responses verbatim, the time it takes to generate responses, and any nonverbal reactions. After the responses are compiled, the examiner asks the patient to go through the cards again. This is referred to as the inquiry phase. In the latter phase, the examiner is attempting to identify the factors influencing the response—what parts of the blot are used and what features made the blot look a certain way (e.g., color, movement, texture, shading, and form). All of these factors are interpretable. For example, perception of movement (e.g., the percept of a bird in flight) is considered to relate to the richness of an individual's fantasy life. The form determinant (e.g., how closely the response corresponds with the selected area of the inkblot) is believed to indicate an individual's reasoning powers and reality testing. Persons with good psychological functioning tend to have refined and differentiated perceptions, whereas the perceptions of psychologically impaired persons generally fit poorly with the form of the blot associated with their response. Color responses are believed to reflect the emotional life of the respondent. For example, pure color responses (i.e., the blot color itself stimulates the respondent's associative process) are considered to reflect an individual with poorly integrated emotional reactions. Location choice (e.g., the area of the blot where the respondent associates his or her response) is also considered to reflect something about one's personality. For example, an emphasis on very small details is considered to reflect an individual who has a very critical attitude or is overly concerned with trivialities.

Responses are analyzed in terms of the number that fall into various categories (e.g., movement, form, location), the normative frequency of these categories for different clinical groups, and the relationships among determinants (i.e., ratios such as percentage of conventional form). Psychodynamically oriented examiners also interpret the content of responses in terms of symbolic meaning (e.g., perception of an island may reflect a sense of isolation). When interpreted within the respondent's specific experiences, the latter analyses are believed to reveal a great deal about an individual's unique personality style.

A number of Rorschach scoring and interpreting systems have been developed since its inception. Irving Weiner and John Exner have attempted to put contemporary Rorschach assessment on a psychometrically sound basis. For instance, the Exner Comprehensive Scoring System emphasizes structural rather than thematic content of responses. This complex scoring system involves categorizing responses in an objective manner by converting them into ratios, percentages, and other indices. Interpretations are primarily data based rather than theoretically based. The Exner system has been well received by the current generation of Rorschach testers whose graduate training has emphasized the importance of psychometric standards in assessment.

Thematic Apperception Test

The TAT was developed in 1943 by Harvard psychologist Henry Murray. The test consists of 29 pictures and one blank card. The cards have recognizable human figures (Figure 6–3), and the patient is asked to generate a story of what is happening in the scene. The subject is asked to tell what led up to the situation, what the people are thinking and feeling, and how the situation will end. There is significant variability in the scoring of TAT responses. Some examiners prefer a more intuitive approach to understanding the psychodynamic implications of a story; others favor a more complex scoring system (e.g., Murray's drive system analysis). In the former case, the psychologist attempts to identify significant emotions and attitudes projected onto the cards. Each card is intended to elicit information about a specific type of relationship (e.g., child–mother, child–father) or an important psychological area (e.g., sexuality). Themes that recur with unusual frequency are judged to reflect prominent psychological needs. As on the Rorschach, the examiner records the verbatim responses of the examinee for later analysis. Because of their real-life content, TAT stimuli are less ambiguous than are Rorschach cards.

Sentence Completion Tests

Like the Rorschach and the TAT, SCTs are used frequently in personality assessment. They generally consist of a number of incomplete sentences (e.g., I feel guilty when….) that are completed by the patient. They are intended to provide information about the respondent's interpersonal attitudes and relationships, personality style, and other issues that are important to the examiner. The referral questions will help determine which one of several different published SCT versions is used in a given case. Many psychologists would agree that the SCT is more likely a semiprojective test because the items are more transparent than are the Rorschach inkblots and the TAT cards. As psychologists who have reviewed these instruments have pointed out, incomplete sentences are among the least researched of projective methods. They appear to persist because, like a slot machine, there is an intermittent payoff in their usage. It may be that some patients are more comfortable communicating information to the clinician in a written form than they are in the face-to-face conversational context.

Application of Projective Personality Tests

Psychodynamically oriented psychologists use the Rorschach as part of a test battery for evaluating clinical issues such as the degree of a patient's cognitive–perceptual pathology. For example, to evaluate whether a patient has a low-grade thought disorder, the psychologist may examine the Rorschach protocol in terms of idiosyncratic responses with a distorted form level. Further, persons with a thought disorder often emit three types of pathologic responses: (1) confabulated whole responses (using a single detail as a basis for an entire response, for example, “This looks like a whisker, so the rest of the card is a cat's face.”); (2) fabulized combinations (making one incongruous concept out of two percepts in close physical proximity, for example, “This looks like a bridge and this looks like legs, so this area is a bridge with legs.”); and (3) contaminated responses (seeing two different things at the same blot area and then fusing them together, for example, “This is a dog. It's a bug. No, it's a dog-bug.”). In these responses, the patient is demonstrating inadequate conceptual boundaries, as well as confusion in thought, perception, and reasoning. The Rorschach is also useful for generating hypotheses about the individual's personality style; however, psychologists often look for collateral support for their inferences about personality style in the patient's objective personality data, interview statements, and case history. The TAT and the SCT are used primarily to generate hypotheses about an individual's family and social relationships, areas of conflict, and related Axis II issues.

Advantages and Limitations of Projective Personality Tests

Some controversy surrounds the use of projective personality tests. Many clinicians find the instruments described here as highly useful for diagnostic purposes and for evaluating personality functioning. However, results of studies examining the psychometric properties of these tests at best have yielded equivocal results, perhaps with the exception of elements of the Exner Comprehensive Scoring System for the Rorschach Inkblot Test. Nonetheless, a sizable number of clinicians continue to argue that projective personality tests should not be subject to standard psychometric evaluation and that such attempts are damaging to the potential richness of these methods for understanding an individual's distinctive personality. It is highly unlikely that these differences will be resolved anytime soon.

Clinical Decision Making in Personality Assessment

Following the gathering of test data, the psychologist analyzes the materials for purposes of clinical decision making and prediction, and endeavors to address the specific referral questions. If testing included both objective and projective measures, then the examiner performs two functions—one being that of the psychometrist or actuary who minimizes subjective interpretation, and the other that of the clinician who relies heavily on clinical interpretation and behavioral observations. The objective of such a dual role is to use separate data points as a means of cross-validating the ultimate conclusions. For example, if a patient scores several standard deviations above the mean on the MMPI Schizophrenia scale, the clinician anticipates bizarre responses (e.g., contaminated responses) on the Rorschach, and would expect behavioral observations to support the presence of disordered thought and behavior. If these assumptions are correct, then there is increasing support for the presence of a psychotic adjustment. If not, then an alternative explanation is sought.

After analyzing the data, the psychologist communicates the findings, resulting clinical impressions, and any treatment recommendations to the referring psychiatrist in the form of a psychological test report. The report is crafted to communicate a meaningful picture of the patient in a format most useful for the referring physician. For example, a psychodynamically oriented psychiatrist generally prefers a report that helps him or her better understand the patient from that perspective. A psychiatrist whose practice is primarily medication focused may prefer a report that focuses on specific symptoms, suggested by objective testing, that the psychiatrist can address pharmacologically. The psychiatrist may also ask that a patient be retested after treatment to assess quantitatively the effectiveness of his or her intervention. With the psychiatrist's approval, the psychologist will review test findings with the patient. However, psychotherapy-oriented psychiatrists often prefer to have their patients discover insights for themselves, rather than from reading the psychological report.

An example of a psychological test report follows. A pretest interview was conducted with the patient, as with all testing cases. The goals of the interview are to establish rapport, gain clinically useful information, and address any concerns that the patient may have about the evaluation.

Psychological Test Report

The patient is the 19-year-old son of a hard-driving and successful attorney living in a medium-sized southeastern city. The patient's father was very concerned about his son's suspension from an Ivy League college for academic reasons. According to the father, the patient appeared depressed, withdrawn, and somewhat uncommunicative since his return home. He sought only minimal contact with long-time friends attending a local college. The patient's inability to hold down a job as a salesman in a small store owned by a family friend was embarrassing to the patient's parents. His father consulted with a physician friend who recommended that the patient be referred to a psychiatrist for a formal evaluation. The psychiatrist requested a testing consult from a clinical psychologist.

Tests Administered

MMPI, Wechsler Adult Intelligence Scale-Revised (WAIS-R), PAI, TAT, Suicide Probability Scale (SPS), SCT, Rorschach Inkblot Test

Background

The patient, a 19-year-old single male, was referred by his psychiatrist for psychological evaluation. The focus of this assessment was to explore whether the patient's recent emotional, academic, occupational, and social dysfunction are related to individual or family dynamic issues or are a manifestation of some other more malignant underlying pathology.

Interview

The patient reported that he was suspended by his university for academic failure after one semester but hoped to reenroll this coming fall. He noted that, despite experiencing no academic difficulties in high school, “a lot of stuff happened at [college].” He specified that motivational difficulties (inability to get out of bed) and increasing alcohol abuse contributed to his academic troubles. He denied the use of other illicit substances. He added that he initially was comfortable with the move away from home and family to a new city and college dorm life. However, he then became progressively more isolated, socially disconnected, and lonely. The patient claimed, “Even in a room full of people I would feel left out.” He further qualified that such a situation did not always distress him, as he sometimes preferred to remain aloof, withdrawn, and to “wallow in my misery.” He claimed that his pattern of isolation was long-standing, but not as frequent or severe as it became in college. He admitted to periods of depressed mood of varying severity, during which his preference for isolation was enhanced. The patient endorsed passive thoughts of suicide in the past but denied urges to act on impulses for self-harm or elaboration of a plan to do so.

The patient revealed a number of idiosyncrasies centering around social interaction. For example, he admitted to often pretending that one of his friends or acquaintances is riding in the car with him, or sitting in his bedroom with him, and he will rehearse how he would act if the person were really present. He acknowledged that such fantasy is much less threatening than social reality, as it “gives me an idea of what I’d be like in front of others and helps me boost my self-image.”

He mentioned that his deflated self-image and low self-esteem have troubled him throughout his life. He claimed that he continually worries “if I’m good enough” and that he will “mess up.” The patient stated that his parents, especially his father, often reacted to his mistakes with “a lot of yelling and shouting, and making me feel guilty.” He described his relationship with his parents and only sister to be much like his social experiences, characterized by a lack of connectedness and belongingness. In reference to his father, the patient said, “I have no real connection, I guess; I don't identify with him and don't even really talk to him.” However, the patient added that his father had “smoothed out” after having a heart attack a few years earlier, resulting in him being more talkative than volatile. Still, the patient denied the growth of a close emotional bond with his father.

The patient was employed by a local sporting goods store after being dismissed from college, but he was fired because of “disagreements with the boss.” He stated that he is not presently in a romantic relationship but has been in the past. Interestingly, he described past sexual experiences as “emotionally confusing,” adding, “I want more than just a squeeze toy, I want someone I can talk to.”

Test Findings

Intelligence

The patient achieved an estimated Full Scale intelligence quotient (IQ) score of 105 on selected subtests of the WAIS-R, which places him in the average range of intellectual functioning. His Verbal scale IQ score of 107 and Performance scale IQ score of 102 are also within the average range. Although the patient's Verbal–Performance IQ score discrepancy (5 points) is not diagnostically significant, his inter- and intratest scatter suggests the likelihood of a disruption in cognitive functioning. This is further indicated by the pattern of WAIS-R subtests on which he performs best (Vocabulary, Information) and worst (Comprehension, Similarities, and Digit Symbol). Based on these findings, one would anticipate that academically he performed best on courses depending on long-term memory (e.g., history) and poorest on those requiring complex abstraction and new learning. His social judgment is also likely poor. Finally, it appears that his cognitive inconsistency has resulted in lower-than-expected IQ scores.

Personality

On objective testing (MMPI, PAI), the patient's profiles consistently suggest someone emphasizing his problems, perhaps making a “plea for help” in the midst of intense psychological turmoil. His MMPI profile is invalid because of excessive endorsement of pathologic items. That is, he overstated his symptoms to an unusual degree. His PAI profile is remarkable for symptoms of depression, anxiety, and assent to disturbed thought processes. Individuals with similar profiles often experience feelings of hopelessness, worthlessness, and personal failure. Their affective distress is often accompanied by a backdrop characterized by social isolation and detachment. They typically have few interpersonal relationships that could be described as deep, close, and supportive. These individuals experience great ambivalence between urges to fulfill unmet needs for affiliation and belongingness and the threatening anxiety they feel related to intimate involvement.

The patient's scores on both the SPS and PAI Suicidal Ideation Scale indicate that he is experiencing intense and recurrent thoughts related to suicide. He should be considered at serious risk for self-harm.

Projective test results also suggest that the patient is experiencing substantial psychological turmoil at this time. Numerous responses on the Rorschach reflect inner disharmony, intense anger, and a possibly burgeoning paranoid cognitive process. A review of his Rorschach protocol reveals descriptors such as “frightening” and “menacing” to card 3 (see Figure 6–2) and “mad,” “angry,” “being attacked,” “decaying,” and “about to collapse” to other cards. These projections lead to speculation that the patient is externalizing the emotions and sense of deterioration that he is experiencing internally. The lack of human content perceived on the Rorschach suggests that the patient has likely established a wall between himself and others and is experiencing significant social isolation.

The patient's TAT scenarios provide rich themes of disruptive relations with each parent figure. The patient described a card depicting a father–son interaction as “two ships passing in the night as the father has no awareness or insight into the son's emotional needs.” To the family card, he referred to the figures as immersed in their own activities while the son is left to feel “lonely, depressed, and unneeded.” He responded to the mother–son card with a scenario in which the child is confused as to what he needs to do to gain his parents’ approval or positive attention. Of concern, the patient responded with an upbeat theme of contentment to a TAT card that often generates depressive and sometimes suicidal scenarios.

On the SCT, the patient also provided prominent themes of detachment from parental figures, loneliness, rumination, and social isolation. Most alarming is “Sometimes… I think about my own funeral.” After the four SCT stems “I am,” the patient responds: “lost,” “worried,” “alone,” and “exhausted.”

Clinical Impressions

Although the patient denied suicidal ideation or impulses on interview, test results (SPS, PAI, TAT, SCT) consistently suggest that he may be experiencing severe and recurrent thoughts related to self-harm at this time. Close monitoring of the patient in this regard is indicated, with consideration of future hospitalization if warranted. His tendency for isolation and excessive rumination, his apparent perplexity and apprehension about his own functioning, his lack of perceived support, and his age all combine to make him a worrisome patient.

The patient's overall personality test data (including Rorschach perceptions of “decay” and things “collapsing”) likely reflect on the patient's own subjective experience of decline. The patient appears preoccupied with his symptoms and failures to the extent that he has lost all interest in others. So apprehensive is this morbid self-concern that the patient appears to be exhibiting profound passivity and social lethargy and, for all practical purposes, appears to be approaching virtual immobility. The patient reported spending much of his day in his room, withdrawn from peer or substantial familial interaction. We would also anticipate that he is moving in the direction of the bottom of the mood cycle with recurring self-annihilative thought content.

On the SPS he responded that he feels he cannot be happy no matter where he is and that the world is not worth continuing to live in. His morbidly depressed feeling tone may reflect grieving over loss of functioning or a component of a possible schizoaffective disorder. We suspect that the patient was able to function academically in a highly structured high school environment but was also perceived as “odd” by teachers and peers. However, the transition to a less-structured college situation may have highlighted how poor his adjustment actually was. Further complicating the situation are his family dynamics, which leave him feeling even further disconnected and unsupported. A major concern in this case is that the patient may be developing a chronic pattern of apathy, dysfunction, severe social disruption, and peculiarity. That is, an evolving schizophrenic or schizoaffective disorder cannot be ruled out.

In addition to pharmacologic management of his cognitive and affective disturbances, some important practical issues will need to be addressed. The patient reported that he anticipates returning to college in the fall. It is difficult at this point to envision that being anything other than another failure experience. He will likely have significant difficulty in attention, persistent concentration, and processing of complex intellectual tasks. If his condition is stabilized by medication, a less severe transition might be considered. For instance, living at home and taking a significantly reduced college course load at a less academically stressful local institution might be worth a try. However, even that might prove a stretch.

An alternative would be referral to a vocational rehabilitation service that could evaluate and direct the patient to an appropriate training or work situation that would be low pressure and highly structured. The patient would likely confront serious difficulties if he tried on his own to enter a competitive work environment. However, with his family background, if he chose the latter option, a job such as a clerk in a hospital medical records’ division might be a consideration. Perhaps this option would be more attractive to him and his high-achieving family than would blue-collar work. Further, it would entail relatively limited public contact.

Traditionally, psychologists have been relied upon to measure cognitive constructs such as intelligence, academic skills, and language abilities. The development of intellectual assessment methods in the early part of the twentieth century, with the subsequent development of standardized assessment methods for a whole range of cognitive functions, added immeasurably to clinical psychiatry's and psychology's understanding of mental retardation and other neurodevelopmental disorders.

Intellectual and academic skills testing is most often sought during childhood development, though at times intellectual functions are also examined in adults. Some common referral questions include:

1. Is this child mentally retarded?

2. Does the patient meet the criteria for an academic skills disorder?

3. Is this child's learning problems due to overall cognitive deficiency, or to attentional and behavioral problems?

4. Is the patient likely to succeed in college?

5. What is the patient's preferred learning style?

6. Does this person have the capacity to parent a child without assistance?

A wide range of psychological tests exists to examine intelligence, academic skills, and other cognitive abilities. The most widely used intellectual tests are the Wechsler series of comprehensive intelligence tests. The Wechsler tests, produced by Harcourt Assessments, are available in different versions for testing throughout the lifespan: preschool (Wechsler Preschool and Primary Scale of Intelligence, 3 years to 7 years 3 months), childhood (Wechsler Intelligence Scale for Children-IV, ages 6 (through 16), and adulthood (Wechsler Adult Intelligence Scale-III, ages 16 through 84). This test in its various forms also often serves as a major portion of most neuropsychological assessments (see below). Another popular comprehensive intelligence test with a venerable history is the Stanford Binet series of intelligence tests, now in its fifth version.

These and other intelligence tests generally provide a composite standard score, known as the intelligence quotient (IQ) that represents the patient's overall performance on the test as compared to others of the same age group. IQ scores are typically expressed as a standard score in which 100 is the mean, with a standard deviation of 15. Thus, a Wechsler Full-Scale IQ score of 115 would correspond to a percentile of 84. A Wechsler Full-Scale IQ of 70 (2nd percentile) represents the traditional margin between individuals considered to be mentally retarded and those not so classified. Of course, scores between one and two standard deviations below the mean reflect a degree of subaverage function, and scores in this range raise the possibility of the DSM classification of “Borderline Intellectual Function.”

In addition to a composite score, intelligence tests yield component summary scores reflecting specific areas of function, such as verbal abilities. In the case of the WISC-IV, for example, the Verbal Factor score is a summation of the patient's scores on the subtests tapping general knowledge and verbal expression (Information, Similarities, and Comprehension). Other summary scores, depending on the test used and the theory of its author, include “Performance IQ,” or visual-perceptual-motor skills, processing speed, memory, quantitative skills, and sequential versus simultaneous processing.

The Wechsler tests each contain similar subtests that make up the overall tests. It is of course not legally permissible or wise to publish exact intelligence test items. Figure 6–4 provides a set of sample items that are very similar to items found on the Wechsler series of tests, and should convey to the reader a sense of the tasks offered to the patient. General fund of knowledge is assessed on the Information subtest, whereas expressive word knowledge is tapped by the Vocabulary subtest. The Arithmetic subtest measures the patient's ability to compute numerical problems mentally. Digit Span assesses the patient's ability to complete number repetitions forward and backward, thus tapping simple auditory focusing. The patient's social judgment and reasoning are evaluated on the Comprehension subtest, on which interpretation of proverbs is also required. On the Similarities subtest, the patient is asked to explain how opposite or unrelated objects (e.g., an orange and a peach) are alike in some obvious or abstract way (e.g., both fruits). The Picture Completion subtest is a visual analysis task in which the patient indicates the essential missing parts of pictures (e.g., a handle on a car door). The Picture Arrangement subtest requires the patient to create a logical sequence for cartoon-like cards that tell a story. On the Block Design subtest, a nonverbal test of abstraction, the patient must use colored blocks to replicate in three dimensions a two-dimensional construction shown on a card. The Object Assembly subtest requires the patient to place jigsaw puzzle pieces together to form familiar objects. The Digit Symbol subtest requires the patient to match numbers to symbols, measuring speed of visual processing. Other subtests found on the WAIS-III include Matrix Reasoning (an untimed test of visual analysis and nonverbal reasoning), Letter–Number Sequencing (a test of working memory and mental control), and Symbol Search (a test involving visual scanning speed and accuracy).

Examination of a patient's performance on summary scores, as well as on individual subtests, can yield a wealth of data about cognitive strengths and weaknesses, learning style, and areas of clinical deficit. For example, a relatively low score on verbally mediated tasks may raise the likelihood of a verbal academic skills disorder, a paucity of educational or cultural learning experiences, or even an aphasic syndrome.

Academic skills disorders are defined by DSM as a learning impairment that is associated with significantly worse performance on an academic skill than would be expected based on a patient's intelligence. Thus, psychological testing is a necessity for the accurate assessment of such cases. For example, the expected reading level of a young man with an average IQ of 105 would likewise be 105. If his reading score departed significantly from this figure, such as falling in the 70’s, the possibility of a reading skills disorder should be entertained. Child psychologists have at their disposal an array of academic skills tests, usually termed “achievement tests,” to assess such academic skills as reading, writing, spelling, and mathematical skills. Many of these tests are very sophisticated and comprehensive, allowing for precise diagnosis not only of the overarching academic skills disorder, but also its particular expression in a given child or adult. For example, it is often possible not only to diagnose a reading disorder, but also to determine whether the reading problem is primarily due to failure to identify the word or to comprehend and retain the words’ contents.

Neuropsychological assessment refers to the application of standardized measurement techniques to determine the relationship between brain impairment and its cognitive and behavioral concomitants. Interest in cases that focus on the interface between psychiatry and neurology provided the impetus for the modern clinical development of neuropsychology as an important subspecialty within clinical psychology. The clinical neuropsychologist is typically a clinical psychologist who is also trained in the neurosciences and clinical neurology. The application of standardized cognitive measurement techniques to brain-behavior relationships has proved a useful and often determinative source of information in individuals with neurodevelopmental disorders and acquired brain dysfunction. The American Academy of Neurology (1996) has produced official guidelines affirming the value of neuropsychological assessment in the practice of neurology.

Neuropsychological assessment in the psychiatric setting is often indicated when questions about cognition or brain-behavior relationships are raised during the course of the psychiatric evaluation that are not explicable by history, mental status observations, radiological techniques, or laboratory techniques alone. The neuropsychologist is typically called upon when a complex set of symptoms and behaviors dictates indepth measurement and observation of an individual's neurocognitive function and/or neurobehavioral characteristics.

Once used primarily to help identify focal brain lesions, the role of neuropsychology in diagnosis has diminished somewhat with the advent of advanced neuroradiological techniques. However, neuroimaging may provide equivocal results in many instances of diffusely based disorders (e.g., hypoxic–anoxic dementia, neurotoxic exposure, early dementia). Magnetic resonance imaging (MRI) techniques may detect gross structural damage but not changes at the molecular or cellular level. Under such circumstances, neuropsychological testing may provide a more sensitive measure of brain function. For example, neuropsychological testing is useful in distinguishing between early dementia and those symptoms of depression that mimic cognitive impairment. Because these conditions may be present simultaneously, sorting out the relative contribution of each can help indicate appropriate treatment. Depressed elderly patients perform differently on neuropsychological tests than do patients with irreversible cognitive deficits, although the deficits may be indistinguishable on mental status examination. Indepth neuropsychological testing can lead to a better perspective of the patient's effort and level of energy, frequency of giving up on more difficult items, attempts to minimize deficiencies, and patterns of strengths and weaknesses.

Psychiatrists and psychologists are often called upon to estimate whether a brain-injured individual has returned to a prior level of function, such as when confronted with the question of whether the patient can return to work. This is also an issue of great interest in many medicolegal situations, such as the estimation of compensable impairment in workers’ compensation injuries, or damage liability in personal injury cases. For example, after receiving a left frontal contusion, a law student may expect to encounter difficulty in classes that tap verbal reasoning, whereas a skilled machinist might be just as debilitated from a comparable right-hemisphere lesion. Examination of these referrals often hinges upon comparison of current test results with premorbid abilities. Premorbid function can be assessed informally by taking a careful history including prior educational achievement, occupations, daily activities, hobbies, and personal achievements. Both actuarial and assessment techniques also exist that allow for estimation of prior function. Prior intelligence can be predicted within a degree of error by mathematical regression techniques, utilizing demographic information such as educational level, occupational history, age, and region of the country. Reading ability is highly resistant to most acquired cognitive disorders, with the exception of course of alexia. Thus, reading skill is a good marker of prior function. Other cognitive skills that can be assessed with the neuropsychological evaluation tend to remain constant, even with significant cortical insults. The most powerful techniques are those which mathematically combine both psychometric data with demographic estimation techniques (e.g., Wechsler Test of Adult Reading, Oklahoma Premorbid Intelligence Assessment).

Referral for assessment of patients in the acute recovery process from stroke or traumatic brain injury can assist with treatment planning regardless of whether diagnosis is an issue. However, within the first few days or weeks of recovery from acute compromise in ability, as occurs with head injury or stroke, a comprehensive evaluation may not be appropriate for two reasons. First, data may not be reliable because of disruption of attentional mechanisms and, therefore, may not reflect the patient's true capacities at the time of testing. Second, until the patient has stabilized and begun to reach a plateau of recovery, limited predictive value can be gathered from testing. For example, the prognostic value of testing a patient at 3 weeks after cessation of drinking will more accurately predict long-term recovery than will similar testing done at 3 days. In degenerative illnesses (e.g., dementia), repeated longitudinal evaluations are essential for accurate diagnosis and tracking of symptom progression. Differential diagnosis is sometimes not possible without follow-up testing, in which case the first evaluation serves as a baseline.

In variable or ongoing illness, such as multiple sclerosis or epilepsy, timing is also essential in that the referring psychiatrist must have an idea of whether a recent exacerbation has occurred. Also, fatigue, anxiety, and performance inconsistencies due to recent seizures, motivational problems, and lack of tolerance in brain-compromised patients must be considered in the referral process. These issues are critical because results will have varying prognostic value depending on the point at which the patient is evaluated.

Another important set of referral questions addresses the patient's level of residual functional capacity after recovery. Normal resumption of activities of daily living, socialization, and performance in work-like settings may not be possible depending on age, course of illness, severity of injury, and the presence of concomitant psychiatric illness. These are functional questions that may be best answered by a combination of assessment techniques, including administering formalized tests (see next section), observing the patient in demanding environments, interviewing the family, and taking a complete history of illness.

Neuropsychological Assessment Instruments

The most recent version of a popular handbook for neuropsychologists reviews more than 160 tests that have found their way into common use among neuropsychologists (Strauss et al., 2006), and these are only a small subset of the tests available commercially or in the research literature. Instead of attempting to present specific tests to the reader, categories and representative examples of neuropsychological tests will be described here, in order to convey a sense of the range and utility of neuropsychological testing.

Intelligence Tests in Neuropsychological Assessment

As noted above, a comprehensive intelligence test, usually the Wechsler test appropriate to the age of the patient, often serves as the backbone of most neuropsychological evaluations. Comprehensive intelligence tests have the advantage of carefully developed norms and the fact that they tap many key neurocognitive abilities (e.g., verbal expression, processing speed, visual analytic skills). Due to the development of the standardization samples on these tests, it is also possible to account for the expected effects of such variables as educational level and ethnicity, if desired. A disadvantage is the fact that comprehensive IQ scores and summary index scores tend to be resistant to changes caused by neurocognitive disorders. Partially, this is due to the fact that neurocognitive disorders rarely cause generalized dysfunction except in more severe cases. Also, intelligence tests are not weighted heavily with executive function and memory tests, the tests shown to be most sensitive to cortical dysfunction. Indeed, it is not unusual for an early- to mid-stage Alzheimer's patient to be relatively debilitated due to memory loss, but score near normal limits on most sections of the WAIS, or for a Pick's Disease patient to exhibit grossly inappropriate behavior but have an average or better IQ.

Folstein Mini-Mental State Examination

The Folstein Mini-Mental State Examination (MMSE) is a universally recognized neuropsychological test that is widely used by psychiatrists, psychologists, neurologists, and geriatric practitioners. This test taps several cognitive functions including orientation, word memory, naming, verbal comprehension, writing, and drawing. Benefits of the MMSE are the instant recognizability of the test and the fact that so many clinicians across differing disciplines can readily interpret its scores. Unfortunately, it is short on items tapping executive function, and its memory section, as generally administered, is crude. The MMSE is often supplanted with tests that have additional memory and executive items to allow for greater sensitivity to senile dementia and a broader range of assessed functions (e.g., Modified MMSE; Dementia Rating scale).

Halstead-Reitan Neuropsychological Test Battery

The Halstead-Reitan Neuropsychological Test Battery (HRNTB) contains many of the most commonly used neuropsychological tests. It originated from the work of Ward Halstead, who in 1947 at the University of Chicago, published his observations of several hundred case studies of patients who had frontal lobe damage. By using 10 scores, Halstead blindly distinguished patients with confirmed brain lesions from control subjects. Ralph Reitan, a student of Halstead’s, modified the battery in 1955 to identify lateralizing features of patient performances such as motor deficits expected in subtle stroke, the effect of temporal lobe epilepsy on memory, and the loss of abstraction ability associated with frontal damage. Reitan also modified the original battery to include tests that would accurately measure aphasia and variations of normal aging. The battery often had limited utility other than in merely determining the presence of organicity before other techniques (e.g., neuroimaging) were available to do so. From continued use of the battery over the decades, three of the original ten scores were dropped because of questionable validity.

Currently, the Halstead Impairment Index is the most widely accepted global measure of brain dysfunction in neuropsychology. Most normal subjects are able to pass 60–100% of the tests included in the Index. Patients who have moderate impairments may be within the normal range on only 30–60% of the tests, and those with severe dysfunction on less than 30%. The Index includes seven scores within the following five subtests:

Category Test

The Category Test is an abstract reasoning task consisting of 180 items. The patient is required to use mental flexibility and problem solving to form concepts, utilizing feedback from the examiner about the accuracy of their attempts.

Tactual Performance Test

The Tactual Performance Test is a test requiring the integration of multiple cognitive skills: spatial skills, spatial memory, dexterity, processing speed, and planning ability. The patient is blindfolded and placed before a board with cutouts into which blocks can be inserted. The patient is then asked to place the blocks in the cutouts, first using the dominant hand, then the nondominant hand, then both. Then the patient is asked to draw a representation of the board from memory. Since more than 40% of the brain's processing power is devoted to visual processing, removal of vision presumably cripples the efficiency with which the patient can approach the task. For the brain-injured patient, excessive time is often required to complete this task. The lateralized nature of the test allows for some comparison of relative hemispheric efficiency.

Finger Tapping Test

Finger tapping is a test of fine motor speed. Five consecutive 10-second trials are obtained with the dominant and nondominant index fingers, and then compared to norms. Injury to either region of motor cortex, as well as injuries affecting overall cortical efficiency, can result in degraded scores on this task.

Rhythm Test

The Rhythm test originated from the Seashore Measures of Musical Talent test, in which the patient is asked to differentiate between 30 pairs of rhythmic patterns. These pairs are presented in rapid succession on a tape recorder, and the patient must distinguish whether they are the same or different.

Speech Sounds Perception Test

The Speech Sounds Perception Test involves 60 spoken nonsense words that are administered by audiotape. The patient is required to underline the corresponding printed response on an answer sheet, measuring verbal discrimination and sustained attention.

General Neuropsychological Deficit Scale

In addition to the seven scores provided by five Index subtests, other subtests from the HRNTB are used to represent patients’ performances on the General Neuropsychological Deficit scale (GNDS). Subtests used to contribute to this scale, in addition to those in the Index, include the Lateral Dominance examination, Grip Strength, the Sensory–Perceptual examination, Tactile Form Recognition, the Trail-Making Test Parts A and B, and the Aphasia Screening test. The GNDS, much like the Impairment Index, provides a global impairment rating but takes into account 42 variables, thus increasing reliability. Clinical judgment also allows the clinician to take into account variables in the interpretation of data related to level and pattern of performance, pathognomonic signs and laterality.”

Functions Measured in Neuropsychological Assessments

Sensorimotor Functions

Many neuropsychologists administer a partial neurological examination as part of their overall assessment. Depending on the referral questions, the sensorimotor assessment may include informal testing of olfactory function, visual fields, auditory perception, stereognosis (tactile appreciation of objects), and cerebellar function (e.g., heel-to-shin testing, alternating hand movements). As mentioned above, standardized testing of strength, motor speed (hand and foot tapping), and fine motor control are generally a component of the examination.

Attention and Concentration

After assuring an adequate level of consciousness, assessment of attention provides fundamental information as to whether evaluation of other cognitive domains, such as intelligence, memory, or language, will be valid. Further, because the ability to focus and maintain attention is highly sensitive to many acute and ongoing conditions (e.g., alcohol withdrawal, intoxication, delirium), a stable, chronic process may be affected less than will a recent or changing one. At the most basic level, this domain measures the patient's ability to attend to incoming information without being distracted. Examples of simple attentional tasks include digit repetition or visual tapping span, requiring forward or backward sequencing of auditory or visual stimuli.

Sustained attention, known as vigilance or continuous performance, is another type of attention. Attention Deficit Hyperactivity Disorder (ADHD) is a disruptive behavior disorder in which individuals have a great deal of difficulty avoiding distractions and maintaining appropriate, goal-directed behavior. A newer area of cognitive assessment that shows great promise for practitioners who work with ADHD children and adults is continuous performance testing for sustained attention (e.g., Conners Continuous Performance Test, Test of Variables of Attention). Continuous performance tests are most often computer-administered, and generally exist in either visual or auditory formats. In the visual modality, the child (or adult) is asked to sit before a computer screen and to respond to one type of stimulus, while suppressing responses to another. The tests go on for several minutes, and the boring nature of the task tends to elicit omissions and variable response times from individuals with attentional deficits. While only limited success has been achieved with these tests as diagnostic instruments for ADHD, they are quite successful in measuring the effectiveness of psychostimulant medication on individuals known to have ADHD. As such, an assessment using these tests can allow the psychiatrist to avoid the use of costly and potentially risky psychostimulant medications among patients who are unresponsive to its effects. These tests are also widely used by neuropsychologists to assess the attentional abilities of brain-injured patients.

Figure 6–5 represents the attempt of a right parietal stroke patient to complete a sustained visual attention task, the Mesulam Visual Cancellation Task, revealing neglect in the left visual field. This patient resumed driving after her stroke, but she likely contributed to an accident when she pulled into traffic and was struck by a car she did not see on the left side. Similar lateralized inattention may occur in other modalities (e.g., tactile) when patients have focal lesions.

Learning and Memory

Compromise of memory is the most common patient complaint and referral question for neuropsychological testing. Milder memory problems, or problems with visual memory may not be readily apparent on screening tasks such as the MMSE. Because memory is not a static or unitary process, careful assessment can help to characterize variations in performance, which can have diagnostic value. Patients who have anterograde amnesia, or faulty learning of new material or events after the onset of their disorder, have more difficulty consolidating their learning experiences into longer storage. Retrograde amnesia, or the inability to retrieve remote memories, is less prominent in organic memory loss, especially if the onset is sudden, as in head injury. However, certain chronic conditions and disease processes, such as Korsakoff's syndrome and Alzheimer's disease, may produce a more dense retrograde amnesia. Memory is often evaluated in the mental status examination by assessing orientation, current events, and recall of words or objects. Although screening is sometimes adequate to determine the presence of a gross dementia, full neuropsychological evaluation can detect whether the difficulty is with encoding, storage, or retrieval mechanisms, and whether the impairment is associated more with one modality than another (e.g., verbal or visual).

The most widely used global memory test is the Wechsler Memory Scale (WMS), now undergoing its most recent revision, which will result in the WMS-IV. These tests yield memory quotients similar to IQ scores (expected mean is 100; standard deviation is 15). It provides for evaluation of immediate memory, delayed memory, and working memory skills, in both visual and verbal modalities.

Language

Testing for aphasia is a necessary part of diagnosis and treatment planning in some developmental and learning disabilities, progressive disorders (e.g., dementia, tumor), or recovery from an acute injury such as stroke or head injury. Impairment of language on a gross level is often more noticeable because of the frequent need for clear communication. However, subtle language deficits can go undetected in informal conversation and occasionally in more formal assessment. At the very least, language screening should include tasks to measure quality of spontaneous speech, naming, comprehension, repetition, reading, writing, calculation, and left–right orientation. Naming, the most sensitive element of most underlying language disturbances, is often measured through confrontational naming tasks such as the Boston Naming Test, a 60-item test of picture identification. Well-studied aphasia screening batteries include the Boston Diagnostic Aphasia examination and the Western Aphasia Battery. If the neuropsychological assessment confirms the presence of aphasia, a speech language pathology evaluation may be required to plan detailed treatment.

Executive Functions

Executive functions refer to cognition and personality skills that are integrative in nature, allowing the person to attend to salient stimuli while disregarding others, maintain situational awareness, plan, reason hypothetically, solve problems, self-monitor demands and emotional reactions; in short, executive function is composed of all metacognitive and emotional processes that serve to help the person adapt to the environment or reach an overarching goal. Though many of these functions are partly if not primarily subserved by the frontal lobes, their complex nature generally requires the entire brain working in concert for maximal success, thus the descriptive term “integrative functions” is also often used. Neuropsychological functioning under the rubric of executive tasks includes abstraction, problem solving, set generation and sequencing, ability to maintain or terminate behaviors, and ability to plan and organize. These functions are mediated by the frontal lobes. Personality characteristics having to do with judgment, social appropriateness, inhibition versus impulsivity, and motivation are also at least partially related to frontal activity. The most famous example of an organically driven personality change is that of Phineas Gage, a railroad worker in the 1880s, who sustained a traumatic injury to the frontal lobes when a tamping iron was blown through his head. This formerly docile, responsible worker became irascible, foul-mouthed, and disinhibited. As his reckless and menacing behavior continued, his coworkers described him as “no longer Gage.”

Specific tasks that are frequently used to study the integrity of the frontal systems include the Wisconsin Card Sorting Test. This procedure provides an index of how well the examinee can formulate hypotheses and solve problems. Cards are matched by principles that are not stated directly, and the patient must shift cognitive sets as the rules for sorting change without forewarning. Other good measures of executive functioning include Controlled Oral Word Fluency, which requires verbal set generation (e.g., words beginning with certain letters), the Category test (concept formation), and the Trail-Making Test (measuring visual shifting and sequencing).

Visuospatial Functioning

Visuospatial functioning measures both the patient's ability to function within his or her environment with regard to recognition of objects and his or her construction and perception of spatial relations. Such abilities are important in daily activities that require the patient to recognize faces and remember geographic location and spatial orientation and in procedural learning tasks such as driving a car. Because patients with progressive neurologic disorders such as Alzheimer's disease or right hemisphere strokes are particularly susceptible to deficits in this area, careful testing will be able to determine whether the patient is likely to encounter problems in getting lost or living independently. Figure copying, clock drawing, visual organization of parts to whole, facial recognition, and map orientation are samples of tasks used to assess this domain.

Clinical Decision Making in Neuropsychological Assessment

Before the psychiatrist or neurologist can be assured of the diagnosis of dementia or other acquired cognitive disorders, most often a host of alternative diagnoses must be ruled out. For depression, delirium caused by physical illness or medication effects, a recent but recovering brain insult (e.g., closed head injury), recent seizures, and malingering are only a few possible explanations for apparently impaired function or transiently deficient test scores. In cases of documented brain compromise from treatable conditions, the psychiatrist may wish to begin appropriate therapy (e.g., treatment of depression in pseudodementia). If cognitive recovery is less than expected, follow-up neuropsychological examination or referral for further neurodiagnostic procedures may be warranted.

In some cases, neuropsychological evaluation may provide the only means for detecting alteration or recovery in brain function in more subtle disorders. Additionally, an estimate of the patient's capacity to return to normal work and social activities will be addressed most effectively in an open dialogue with the referring psychiatrist. The following case example illustrates the need for such close communication.

Neuropsychological Evaluation Report

A 23-year-old single female was seen in psychotherapy for depression, which was thought to be a reaction secondary to an unwanted pregnancy. Although distinct neurovegetative signs were absent, the patient's family noticed that she was socially withdrawn and had lost interest in usual activities. She had difficulty initiating behavior and spent most of her day appearing “bored,” according to her concerned family. She spent most of her time sitting motionless in front of the television. Although she did not exhibit improvement from psychotherapy, sessions were continued. The patient's development of severe headaches was thought to be related to depression. When she developed a slight right facial droop, language abnormalities, and a right hemiparesis, she was referred for organic workup, including neuropsychological testing. Examination revealed an expressive aphasia, slowness in initiating activity, poor planning ability, decreased judgment, and a marked visual neglect on the right visual field. This finding coincided with her clock drawing (Figure 6–6A), which showed obvious right-sided neglect due to the frontal mass shown on MRI (Figure 6–6B). On surgical removal, the mass was found to be a rare meningioma.

The possible presence of faked or exaggerated symptoms for personal gain is a vital threat to the validity of any examination, mental or medical. Numerous studies have shown that malingering is common among psychiatric and neurological patients who are referred for psychological or neuropsychological evaluation and also engaged in litigation, workers’ compensation actions, or disability insurance findings. Most studies suggest a 30–50% proportion of malingering patients among such referrals. Even young children have been shown in research studies to be able to successfully mislead skilled clinicians. The prospect that one out of every two or three medicolegal patients is feigning or exaggerating is a sobering one, and one whose implications are arresting for the average clinician who prefers to take care of patients rather than systematically investigate the validity of the patient's complaints. The situation is seen to be even more complex when one considers that in the course of everyday practice, the potential agenda of some patients may not be apparent for weeks until a letter arrives from an insurer or the local disability determination office.

Patients often malinger physical disorders, pain, psychosis, posttraumatic stress disorder, severe depression, panic disorder, seizures, and memory deficits, to name a few feigned presentations. Disorders that are episodically manifested, such as panic attacks or seizures, represent a unique challenge to the clinician because of the relative lack of power of the mental status examination. In our experience, memory deficits are often feigned, presumably because it seems to many patients that loss of memory would be easy to both describe and feign on examination, though these expectations are in fact inaccurate.

The most powerful tool the clinician has in identifying malingered disorders is thorough knowledge of, and experience with, the disorder in question. It is a challenge for most patients to learn what symptoms to report to feign a given disorder, and an even greater challenge to convincingly produce facsimiles of symptoms upon mental status examination. For this reason, referrals to rule out malingering should preferably be sent to clinicians who are very experienced with the disorder in question. The patient suspected of feigning schizophrenia should be referred to a specialist in psychotic disorders, and the apparently head-injured patient to a clinician with extensive experience with patients who have experienced mild, moderate, and severe head injuries.

Another powerful tool to detect malingering is psychological assessment. Many standardized psychological assessment techniques are now available for assessing many malingered disorders. Referral to a psychologist, or neuropsychologist in the case of suspected malingered dementia, presents several advantages to the psychiatrist or neurologist. The quantitative nature of the results yields an ability to report more precisely and convincingly the impression of malingering. It is much better, in our experience, to be able to report that “Test X indicated a 95% probability of malingering,” than to have to base such a grave determination on clinical observations and judgment alone. Deferring the question to a referral source allows the clinician to maintain some professional distance from the situation, perhaps allowing a therapeutic relationship with the patient to be maintained, even if the conclusion is adverse. And finally, malingering tests are much more successful at detecting exaggeration or malingering when the patient is very clever, has been coached, or is claiming subtle deficits or symptoms.

Detection of Malingered Psychiatric Symptoms

The MMPI-2 and the PAI, discussed previously, both contain scales designed to detect the exaggerating or the overly defensive patient. Much more research has been done with the MMPI-2 in this area, making it the better choice if only one test can be administered. Scales have been developed for the MMPI-2 to assess wholesale endorsement of unusual symptoms (F scale, F [B] scale); endorsement of unusual symptoms rarely endorsed even by an inpatient psychiatric population (F [p] scale), and to identify patients who are feigning physical debility (Fake Bad scale), just to name a few. The MMPI-2 also has a scale that identifies persons who are presenting themselves as unusually virtuous (Lie scale), and several scales of defensiveness, or tendency to deny negative or unhealthy characteristics.

Another test used to identify individuals feigning psychiatric problems is a structured interview technique, the Structured Interview of Reported Symptoms (SIRS). Developed by Rogers (1991), the SIRS provides for systematic assessment of common patterns of responses and behaviors in malingering patients, such as assent to absurd symptoms, improbable combinations of symptoms, and differences between item endorsement and observable behaviors. The SIRS was designed to minimize false positives, that is, to avoid identifying individuals as malingering who are not feigning mental illness. As such, it fails to identify a proportion of malingerers, but is very successful in given forensic populations where patients often grossly overendorse symptoms while faking psychosis or other debilitating syndromes.

Detection of Malingered Cognitive Deficits

Many patients present with malingered memory or reasoning deficits. Intellectual, neuropsychological, and other cognitive tests can be easily compromised by poor effort, and often such lack of effort is intentional. Without formal testing for malingering, low test scores or apparent dementia on mental status examination may inaccurately result in classifications of patients as demented or mentally retarded. Even children have been shown to be able to successfully feign cognitive deficits.

Cognitive malingering tests utilize several different strategies to detect feigned cognitive problems, and fortunately knowledge of these strategies does not always subvert the tests, even in clever and well-informed patients. One set of tests utilizes floor effect tests, that is, tests that appear to be difficult but in fact are nearly always successfully performed even by individuals with moderate cognitive impairment. The malingering patient often scores well below the expected level as compared to genuinely impaired patients, thus allowing a probabilistic determination of malingering to be made.

Forced choice tests are another strategy, often combined with the strategy above. These tests utilize the fact that forcing the patient to guess between two dichotomous responses, one correct and the other incorrect, results in a known expected value if the patient has no ability in that area at all: 50%. If a patient scores significantly worse than he or she would by flipping a coin, then strong evidence of malingering is produced. In that circumstance, the only credible explanation is that the patient must have known the right answer, since the wrong one was so often chosen. When failed, these tests provide the strongest evidence of malingering. The technique is also adaptable to a wide variety of possibly malingered conditions, e.g., blindness, tactual imperception, deafness. Unfortunately, very few malingers fail forced choice tests, presumably recognizing that a higher level of performance would be the norm even for a severely impaired individual.

An example of a widely used test that combines both forced-choice and floor effect features is the Test of Memory Malingering (TOMM). This test is composed of fifty pictures, which are shown to the patient in repeated trials. The patient is tested by being given a dichotomous choice between each correct picture and a foil. The patient's score yields a classification of likelihood of malingering. If the patient scores below chance levels, a precise probability rating can be assigned demonstrating the certainty level of malingering beyond any reasonable question.

Other cognitive malingering tests utilize known principles of learning or test taking to identify unusual patterns of test performance. For example, even individuals with severe memory impairment tend to respond with significantly more correct answers when they are given recognition choices. Another principle is that, on average, the patient should score better on easier items than on more difficult ones, and that once a patient's level of ability has been exceeded, further answers should have no greater accuracy than chance. The Validity Indicator Profile is a successful test utilizing this principle. Figure 6–7 shows two VIP profiles in which the patients’ accuracy of responses is charted. The first profile represents an honest, effortful profile on the verbal portion of the VIP. The patient successfully gets most of the easier items correct, then a point is reached at which mistakes are made. Eventually the patient is able to perform no better than chance. On the Nonverbal subtest, however, the patient is malingering. The patient fails many items, even though the profile shows that he can pass more difficult items successfully. These results are consistent with a patient feigning reasoning problems, but presenting with intact language function, a common combination among sophisticated malingerers feigning disability.

This chapter has attempted to provide the reader with an introduction to psychological evaluation techniques that are relevant to psychiatry. Psychological testing often provides clinicians with greater diagnostic confidence than interview data alone. It is uniquely useful for comprehensively describing personality styles, diagnosing syndromes dependent upon psychometric data (e.g., mental retardation, academic skills disorders), comprehensively describing a patient's neurocognitive functions, and identifying malingering patients.

Psychological testing referrals from medical specialties other than psychiatry are becoming much more commonplace. Internists and orthopedists typically refer for psychological testing patients with pain complaints for which no organic basis can be detected, or for which the complaints are far in excess of what one would anticipate from physical findings. Transplant surgeons want information about an individual's cognitive ability to follow a complex medical regimen and how personality factors may affect treatment compliance. Neurologists and neurosurgeons utilize neuropsychological evaluation in differentiating the relative contributions of neurologic and psychological factors in a patient's behavioral symptoms. Contemporary personality and neuropsychological techniques are linked closely to advances in statistical methodology. The increasing partnership between quantitative psychology and psychological assessment holds promise for improving our understanding and measurement of complex human behavior.