TIPPS

(Training Initiative for Psychiatry Postgraduates)

STEP- 2016
(Skills Training Exercise for Psychiatry Postgraduates)

PSYCHOLOGICAL ASSESSMENT METHODS IN CLINICAL PSYCHIATRY

JAPNEET AHLUWALIA RAO
Consultant Clinical Psychologist

contactjapneet@hotmail.com

WHAT ARE PSYCHOMETRICS?
• Basically means ‘mental measurement’ (psycho – metrics)


• includes the measurement of knowledge, abilities, attitudes, personality
traits, as well as educational measurement

• Anyone administering them should hold appropriate qualifications in their use

• In psychology we are interested in either describing the distributions of and/or
relationships among abstract concepts: e.g.

Intelligence

Neuroticism

Aggression

Key questions are:
• What are the ways by which people differ and how can we objectively measure
the differences?

• Over the last 100 years or so the discipline has become increasingly more
scientific in its approach
 DISTINCTION

Psychometric Psychological

Testing Assessment


- variety of test scores
relatively straightforward
- obtained from multiple test
process wherein a particular methods
scale/test is administered to
- considers history, referral
obtain a specific score
information, and observed
behavior

TYPES OF TESTS

II Personality Tests:

I (Human) Ability/
Objective &
III Therapy IV Psychiatric
Disability Tests Projective Assessment Assessment

• Achievement Tests • Objective • Behaviour • Assessment (scales)

• Aptitude Tests Personality Tests Assessment for psychotic
features, anxiety,

• Intelligence Tests
• Projective • Cognitive Behaviour depression, mania,

• Learning Disability substance abuse etc.
Personality/ Assessment
Tests
Psychodiagnostic
• Neuropsychological Tests
Assessment


FORMAT

Individual tests:
test administrator
gives a test to a Group tests: single
single person examiner gives a test
to a group of people

ADVANTAGES OF PSYCHOMETRIC TESTS

Providing insights not

Data represented
Objective
Demonstrable Add reliability and available through
numerically statistical validity validity observations and
interviews
VARIOUS PSYCHOLOGICAL TESTS AND BATTERIES

IQ ASSESSMENT

¨Tests of intellectual functioning are designed to measure and assess general mental
abilities (relative to peers of the same age group) and may include tests of the
following abilities: reasoning, problem solving, abstract thinking, judgment,
academic learning, and to some degree, experiential learning

¨IQ (Intelligence Quotient) = MA (Mental Age)
______________________ x 100

CA (Chronological Age)

Regularly used IQ Tests in Clinical Practice

1. Seguin Form Board Test (SFB)
2. Vineland Social Maturity Scale (VSMS)
3. Binet-Kamat Test (BKT)

4. Wechsler Adult Performance Intelligence Scale (WAPIS)

5. Bhatia’s Performance Test of Intelligence
6. Malin’s Intelligence Scale for Indian Children (MISIC)

7. Raven’s Progressive Matrices (RPM)

1. Seguin Form Board
- a screening test to select the appropriate battery of IQ tests

- measures speed and accuracy

- Used in case of speech impairment
- Age 3½ to 10 years, and upto adult level for the intellectually impaired

- Administration time - 10 minutes

- 3 trials are given to put the blocks in their appropriate shape pattern
- The quickest time is considered

- This gives the Mental Age (from a table) and then IQ is calculated

2. Vineland Social Maturity Scale (VSMS)
- originally developed by the American psychologist Edgar Arnold Doll
- The Indian version is by Dr. A.J. Malin

- Ask questions to parents / caregiver

- measures social competence, self-help skills, and adaptive behavior from infancy
to adulthood
- indicates the social deficits and social assets in a growing child
- Test items: 89, grouped into year levels, from age 0-15

Domains:
- The following illustrate the categories:
1. Self-help - general: Reaches for nearby objects

2. Self-help - eating : Discriminates edible substances

3. Self -help - dressing: Buttons coat or dress
4. Self-direction : Buys own clothing accessories
5. Locomotion : Walks about room unattended

6. Occupation : Helps a little at house

7. Communication : Makes telephones call
8. Socialization : Demands personal attention

Procedure:
- Start with item number 1, what ever may be the age of the child and go on till the item
appropriate to his/her age level

- Stop when all items in the age category score negative

Scoring:
- Raw scores are converted to an age equivalent score expressed as Social age
- The Social age is then divided by the Chronological age, multiplied by 100 yielding a
Social quotient (SQ)
- The Social Quotient can be considered a proximate intelligence quotient (IQ) (High
correlation of 0.80)

3. Binet-Kamat Test (BKT)
- Age range: 3 and above
- Items are arranged chronologically

- Domains of cognitive abilities: Language, Meaningful Memory, Non-Meaningful

Memory, Conceptual, Non-Verbal Reasoning, Verbal, Numerical, Visuo-Motor,
Social Intelligence
- Simplified Examples of items: which line is longer?, putting different shapes cut-outs
in the correct slot, which face is prettier?, what are the missing parts?, what is the
picture about?, copying a square. Copying a diamond, arranging blocks in ascending
order of weight, fitting the blocks given in the box

ICD CLASSIFICATION OF MR

IQ Range Classification

50-69 Mild

35-49 Moderate

20-34 Severe

Below 20 Profound

4. Wechsler Adult Performance Intelligence Scale (WAPIS)
• Adaptation of Wechsler Adult Intelligence Scale

• By Prabha Ramalinga Swamy

• Age range: 15-44 years

• Education norms: Literate - 5th std and above

• IQ range: 40-139
Sub-tests:

i. Picture completion
ii. Digit symbol
iii. Block Design

iv. Picture Arrangement

v. Object Assembly
i. Picture completion
- 26 cards
- point out the missing part

- measures Visual Acuity

ii. Digit symbol

- need to draw the corresponding symbol to the digits in 90 seconds

- measures Mental Speed

iii. Block Design

- Reproduce the design on the card using the blocks given

- Initially 4-block designs then 9-block designs
- measures Analytic and Synthetic Ability

iv. Picture Arrangement
- Arrange the pictures given in a particular sequence and form a logical story
- measures Social Intelligence

v. Object Assembly
- assemble the given pieces and make an object

- measures Visual Integration

WECHSLER CLASSIFICATION OF IQ

IQ Range Classification

Above 130 Very Superior

120-129 Superior

110-119 Above Average

90-109 Average
 80-89 Below Average or Dull
Normal

70-79 Borderline

Below 70 Extremely low

PERSONALITY ASSESSMENT
Regularly used Personality Tests in Clinical Practice

1. 16 Personality Factor Test (16 PF)

2. Minnesota Multiphasic Personality Inventory (MMPI)

3. Temperament Character Inventory (TCI)
4. Clinical Analysis Questionnaire (CAQ)

1. 16 PF TEST
- Lexical Hypothesis

- Extracted 18,000 personality describing words

- In 1946, Cattell with the help of a computer organized the list in to 181 clusters
- By using factor analysis generated 12 factors, and then included 4 factors
- 105 statements; 3 options each to choose from

- It measures normal range traits

- used extensively in counselling and clinical setting
- Available in more than 30 languages world wide

- Lower reading level (5th grade average)

- Updated norms

- Easy hand scoring

- Good psychometric properties (Reliability and Validity)
Primary Factors in Cattell's 16 Personality Factors
Warmth (A); Reasoning (B); Emotional Stability (C); Dominance (E); Livelness (F); Rule-
conscious (G); Social Boldness (H); Sensitivity (I); Vigilance (L); Abstractedness (M);
Privateness (N); Apprehension (O); Openness to Change (Q1); Self-Reliance (Q2);
Perfectionism (Q3) and Tension (Q4)
Second Order Factors

Extraversion; Anxiety; Tough-Mindedness; Independence and Self-Control

Administration
- Paper and Pencil/Computer format

- Check the reading ability and comfort with the language of test administration
- Ensure test takers are responding appropriately and not skipping items
- Read the instructions aloud

- Clarify their doubts if any

- Attitude toward the testing
- Physical comfort
- Psychological comfort with the testing

- Rule out any psychological condition such as severe depression or anxiety

Instructions

- Most of the questions on the test ask about your feelings, attitudes or behavior
- there are no right and wrong answers
- give the answer that comes to you first
- Try to avoid the middle (b) answer and stay with the (a) or (c) answers but if you
really can’t decide, just choose (b)

Motivational Distortion (MD)

- Denotes inaccuracy in questionnaire responses:
¤Presenting self in a favorable manner
¤Presenting self in an unfavorable way

- FG (fake good) and FB (fake bad)

2. MINNESOTA MULTIPHASIC PERSONALITY INVENTORY (MMPI)
Features
- most frequently used clinical personality test

- self-administered
- usually takes between 1 – 1.5 hours to complete
- The client simply responds T (True) or F (False) to each item on the basis of whether
the statement applies to him/her
- can be administered from a printed booklet, by audio cassette, or by computer
- translated into many languages

- sixth grade reading level

- easy and objective scoring
- ensures objective interpretations that are highly reliable over time

- Measures the test taking attitudes of the client

- provides clear, valid descriptions of people’s problems, symptoms, and
characteristics

- enable the practitioner to estimate potential future behaviors

Clinical Scales (10)

• (Scale 1) - Hypochondriasis • (Scale 6) - Paranoia

• (Scale 2) - Depression • (Scale 7) - Psychasthenia

• (Scale 3) - Hysteria • (Scale 8) - Schizophrenia

• (Scale 4) - Psychopathic Deviate • (Scale 9) - Hypomania

• (Scale 5) - Masculinity-Femininity • (Scale 10) - Social Introversion

Content Scales (15)

• Anxiety (ANX) • Antisocial Practices (ASP)

• Fears (FRS) • Type A (TPA)

• Obsessiveness (OBS) • Low Self-Esteem (LSE)

• Depression (DEP) • Social Discomfort (SOD)

• Health Concerns (HEA) • Family Problems (FAM)

• Bizarre Mentation (BIZ) • Work Interference (WRK)

• Anger (ANG) • Negative Treatment Indicators (TRT)

• Cynicism (CYN)
 PROJECTIVE TESTS
What is “projection”?
• A defense mechanism with which the ego protects itself from anxiety by
externalizing unpleasant feelings or experiential element

What are “projective techniques”?

• The use of vague, ambiguous, unstructured stimulus objects or situations open
to different interpretations in which the subject “projects” his or her
personality, attitude, opinions and self-concept to give the situation some
structure


• There are no “right” or “wrong” responses to the stimuli

• but whether the responses are normative or non-normative is of great importance

Advantages of Projective Techniques

- no reading ability required
- results are very difficult to falsify

- enable a wide variety of assumptions

- a broad and comprehensive view of the subject’s personality

Disadvantages of Projective Techniques

- relatively subjective scoring

- they are difficult to compare and retest
- the normativeness of responses is most important

- their statistical dependability is weak

Most prominent projective tests:
1. Word Association Test (WAT)

2. Sentence Completion Test (SCT)

3. Thematic Apperception Test (TAT)

4. Rorschach Inkblot Test (RIBT)

5. House-Tree-Person Drawing Test

1. Word Association Test (WAT)
- The test involves connection and production of other words in response to a given
word, done spontaneously

2. Sentence Completion Test (SCT)

- Sentence completion tests typically provide respondents with beginnings of
sentences, referred to as “stems,” and respondents then complete the
sentences in ways that are meaningful to them
- The responses are believed to provide indications of attitudes, beliefs and
motivations or other mental states.

3. Thematic Apperception Test (TAT) (IndianAdaptation)

Procedure
- Given by Henry A. Murray
- Indian adaptation by Uma Choudhary

- Presenting a series of semi-structured pictures to the patient and encouraging

him/her to tell stories about them, invented on the spur of the moment

- 10 + 1 blank card
- Gives an in depth knowledge of the patient’s personality and his/her interpersonal
relations

Instructions
“I am going to show you some pictures, one at a time, and your task is to make a story
about it. What has led up to the event (past), what is happening at the moment
(present), what the characters are thinking and feeling and what is the outcome
(future)”

Some cards and their significance:
Card I – Achievement Card
Card II – Biological/Family Card

Card V – Aggression Card

Card VI – Suicide Card

Card IX – Sex Card

Card X – Depression Card

Interpretation
! The stories are read and corroborated with the clinical history

! Who does the person relate to in the stories

! What is the main theme of the stories

! What are the predominant needs expressed (e.g. achievement, affiliation,
aggression, harm avoidance, nurturance etc.)

! What are the predominant presses expressed (lack, rejection, aggression,
illness, inferiority)

! What are the predominant defense mechanisms?

! How do the stories end?

4. Rorschach Inkblot Test (RIBT)

- Developed by Hermann Rorschach

- patients' perceptions of inkblots are recorded
- Provides in depth information about a person's personality characteristics and
emotional functioning
- detects underlying thought disorder, especially in cases where patients are reluctant
to describe their thinking processes openly
- detects psychosis even at the prodrome level

Procedure
- Bilaterally symmetrical inkblots
- 10 cards on a white background

" 5 inkblots are of black ink

" 2 are of black and red ink
" 3 are multicolored

Instructions

- Free association / response phase:

“What this might be”

(Patient sees and responds to all of the inkblots)

- Inquiry phase:
“I’ll show you all the cards again one by one. Where did you see what you originally
saw and what makes it look like that? Tell me so I can also see it like you do.”

Systems of Interpretation

- Some systems of Rorschach interpretations:

" Beck
" Klopfer
" Piotrowski
" Exner - (currently most widely used with the most objective scoring and
comprehensive interpretation)

Popular responses of the 10 cards:
• Card I - Bat / Butterfly

• Card II – Bear, Dog, Elephant or Lamb (Head or whole animal)

• Card III – Human Figure or representation thereof

• Card IV – Human or human-like figure
• Card V – Bat / Butterfly

• Card VI – Animal skin, hide, pelt or rug

• Card VII – Human head or face
• Card VIII – Whole animal figure
• Card IX – Human or human-like figures

• Card X – Spider or Crab

Interpretation

- provides data about the person’s cognition, personality variables, affectivity,

personal/interpersonal perceptions

- Some factors taken into consideration while interpreting:

! Content (e.g. humans, animal, nature, blood)

! Location (e.g. whole or part)

! Determinants (e.g. form, colour, texture)

! Popularity / Originality

! Special score (unusual / deviant / inappropriate responses)
Special Indices

Suicide Potential Index

Depression Index

Coping-Dericit Index

Hyper-vigilance Index

Obsessive-style Index

Perceptual-Thinking Index


Perceptual-Thinking Index
- Indicates the presence of psychosis

- Some contributing factors are:

" Less responses close to the norm
" More deviant responses and verbalizations
" Inappropriate combinations and contaminated responses
" Higher special score
" Higher level – 2 deviant responses and verbalizations

Organicity
- The strongest indicator of organicity in RIBT is:

- Perseveration (especially Mechanical Perseveration - patient giving the same

response for different cards like a machine)

NEUROPSYCHOLOGICAL TESTS
- Neuropsychological assessment is a clinical examination of both the working brain
and the dysfunctional brain
- The goal is to identify a deficit in functioning and not to test the limits of the top end
of performance

Approaches in Neuropsychological tests
1. Ideometric approach
• Clinical examination requiring in-depth examination of individual patients
• Emphasizes the patient’s premorbid functioning (education, occupation, social
functioning)
2. Psychometric approach
• Assessment of abilities / aptitudes using quantitative scores
• Interpretation through normative data not taking into account previous history or
functioning

! A comprehensive Neuropsychological test is a combination of both these
approaches

NIMHANS NEUROPSYHOLOGICAL BATTERY

I. Tests of Attention
II. Tests of Executive Functions
III. Tests of Speed
IV. Test of Comprehension
V. Tests of Learning and Memory

I. Tests of Attention
1. Colour Trails Test
- Measures focused attention
- Colour Trails 1: The subject is asked to point to successive numbers in ascending
order from 1 – 25
- Colour Trails 2: The subject is asked to point to numbers in alternating colours (pink
and yellow) in ascending order from 1 – 25
- The time for both is noted down

2. Digit Vigilance Test

- Measures sustained attention
- The subject is asked to scan the sheet and cancel the target numbers ‘6’ and ‘9’ (by
drawing a ‘/’ mark on them) as fast as possible without missing the targets or cancelling
wrong numbers

- The time taken and errors made are noted

3. Triads Test
- Measures divided attention
- The subject is told that the two tasks will be given simultaneously and attention should
be divided between both
- The subject is asked to call out the odd word first and then the number (written on the
palm of the non-dominant hand)
- The total number of errors made are noted

II. Tests of Executive Functions

1. Cowa Test
- Measures phonemic fluency

- The subject generates words beginning with the letters F, A, S or Ka, Pa, Ma for one
minute each

2. Animal Names Test
- Measures category fluency
- The subject generates names of animals for one minute (excluding fish, birds and
snakes)

3. N-Back Test (Verbal)

- Measures working memory
- In the 1-back test the subject responds whenever a consonant is repeated
consecutively
- In the 2-back test the subject responds whenever a consonant is repeated after an
intervening consonant

4.Tower of London Test

- Measures planning
- The subject is presented with a goal state of the arrangement of the 3 balls on one of
the boards (near the examiner)

- The arrangement of the balls in the other board is the initial state (near the subject)
- The subject has to arrive at the goal state with a minimum of 2, 3, 4 and 5 moves

- The mean time and the mean number of moves are noted

5. Wisconsin Card Sorting Test
- Measures set shifting ability
- The 4 stimulus cards are placed in front of the subject

- The deck of 128 cards is arranged according to the sequence in the test manual
- The subject is instructed to study the cards and match each successive card from the
pack to one of the 4 stimulus cards
- The subject is told only whether each response is right or wrong and is never told the
correct sorting principle

- The subject has to guess the concept based on the examiner’s feedback and continue
with the test

- The number of trials taken, errors made, perseveration is noted

6. Stroop Test
- Measures response inhibition
- The subject is asked to read the stimuli sheet (containing names of colours printed in
different colours) column-wise as soon as possible and the time is noted
- Then the subject is asked to name the colour in which the word is printed column-wise
and as soon as possible and the times is noted
- Stroop effect score = time taken to name the colour – Time taken to read the words

Other Tests
III. Tests of Speed

(Finger Tapping test, Digit Symbol Substitution Test)

IV. Test of Comprehension

(Token Test)
V. Tests of Learning and Memory
(Auditory Verbal Learning Test, Logical Memory Test, Complex Figure Test)


SUMMARY

• The psychological assessments seek to describe the ways in which people differ

• to understand how and why these arise

• there are a variety of tests and they are used widely

• founded upon an objective, scientific and empirical approach