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Psychological testing in inpatient psychiatry

Authors:
  • Mount Sinai Beth Israel
In: New Psychological Tests and Testing Research ISBN: 978-1-60021-570-4
Editor: L. S. Boyar, pp. - © 2007 Nova Science Publishers, Inc.
Chapter 1
PSYCHOLOGICAL TESTING
IN INPATIENT PSYCHIATRY
Lisa J. Cohen
Associate Professor of Clinical Psychiatry; Beth Israel Medical Center;
1st Ave and 16th St. NY, NY 10003; Ph: 212-420-2316; Lcohen@chpnet.org
ABSTRACT
A fundamental challenge in inpatient psychiatry involves accurate diagnosis. This
chapter addresses the role of psychological testing on an inpatient service and its
contribution to differential diagnosis and treatment planning. Relevant tests include tests
of intellectual functioning (with emphasis on the WAIS-III), projective tests (the
Rorschach, TAT) and targeted tests of specific disorders and syndromes (e.g., Yale Brown
Obsessive Compulsive Scale (YBOCS); Positive and Negative Symptoms Scale
(PANSS)). Literature on the relationship between cognitive and projective testing and
other measures of psychopathology will reviewed. An overarching conceptual framework
within which to approach differential diagnosis will also be proposed, specifically a
hierarchical systems model of mental phenomena. Guidelines for interpreting test results
will then be discussed with an emphasis on a step-wise approach to test interpretation.
The first step focuses on potential confounds of test results (e.g., perceptual problems,
excessive sedation). The second step involves assessment of cognitive function.
Cognitive assessment is used to establish the client's level of information processing, to
identify mental retardation, and to delineate specific cognitive impairments. The third
step involves assessment of axis I pathology such as psychosis, depression, and mania.
Information on relevant mental status parameters, such as organization of thought and
regulation of affect, is gleaned from both cognitive and projective testing as well as
patient history and behavioral observation. Additionally, specific axis I disorders can be
assessed with targeted instruments. As the presence of significant mental status changes
can confound assessment of character pathology, assessment of axis I pathology must
precede assessment of axis II pathology. The fourth step involves evaluation of axis II or
character pathology. Projective testing, including the Rorschach and the TAT, can
illuminate patterns of self and other representation. Structured clinical interviews and self
report questionnaires can also identify specific DSM IV axis II diagnoses and relevant
personality traits. Finally, case material will be included to illustrate key points.
Lisa J. Cohen
INTRODUCTION
Psychological testing can be a highly valuable component of inpatient psychological
treatment. Due to the severity and acuity of patients’ conditions, accurate diagnosis is
critically important. When the diagnostic picture is not readily determined by psychiatric
interview, psychological testing can be an extremely useful addition to the treatment plan.
The most common diagnoses seen on inpatient psychiatric units include
schizophrenia/schizoaffective disorders, mania, depression and severe personality disorders.
Also frequent are organic mental syndromes, substance induced mood or psychotic disorders
and mental retardation. For example on a single day on a 30-bed unit in a large, metropolitan
hospital,1 the following diagnoses were present. (Because of comorbid disorders the number
of diagnoses exceeds thirty.)
12 patients were diagnosed with schizophrenia or schizoaffective disorder,
4 patients with bipolar mania,
7 with major depressive disorder (3 with psychotic features),
3 patients with severe axis II pathology (3 borderline, 1 Cluster A, and 2 antisocial),
3 with substance induced mood or psychotic disorder,
2 with mental retardation,
1 with mood disorder due to a general medical condition,
3 with dementia, and
1 with psychosis NOS.
For most patients, a thorough clinical interview along with solid collateral information is
sufficient to establish the diagnosis. For other patients, however, this is insufficient and the
picture remains murky. In these cases, psychological testing can shed light on critical aspects
of mental status not readily apparent on clinical interview. In fact, psychological testing on an
inpatient unit differs from that in many other settings. For one there is an enormous amount of
clinical information already available. The testing clinician can read the chart, speak with the
treating clinicians and other members of the interdisciplinary team, and observe the patient
over a period of time. If the testing clinician works on the unit, he or she may already know
the patient and thus be able to contextualize the test results to a greater extent than in most
other settings.
In the following chapter we will discuss psychological testing on the inpatient setting.
Specific emphasis will be placed on the importance of differential diagnosis, the relationship
between axis I and axis II pathology, and the utility of tests with less reliance on self report,
such as cognitive and projective tests. The chapter will be organized into a stepwise approach
to psychological testing with Step 1 involving potential confounds to test data, Step 2 the
assessment of cognitive function, Step 3 the assessment of axis I pathology, and Step 4 the
assessment of axis II pathology. We will also present an overarching conceptual framework
within which to approach differential diagnosis. Finally, three case examples will be
presented to illustrate the concepts discussed.
1 October 6, 2006 at Beth Israel Medical Center in New York, NY
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Psychological Testing in Inpatient Psychiatry
HIERARCHICAL SYSTEMS MODEL
As a conceptual framework with which to approach inpatient psychological testing, we
will use a hierarchical systems model of mental functioning. Such a systems model proposes
the mind to be an organic, coherent whole comprised of interacting but distinct parts working
in concert (Cohen et al, 1997; von Bertalanffy, 1968). The hierarchical model is similar to that
used in studies of neuropsychological function (Siegel, 1999; Goldberg, 2001; Stuss et al,
2001). In this view, those mental functions that a) are most simple, b) form the basis of more
complex mental functions, and c) are mediated by evolutionarily older, lower and deeper parts
of the brain are considered lower level functions. Higher level functions are likewise a) more
complex, b) built upon simpler, lower level functions, and c) mediated by evolutionarily
newer, higher, and more anterior parts of the brain. For example, simple arousal and alertness
is widely considered a lower level function and is mediated by the reticular activating system,
located in the brain stem (Goldberg, 2001; Stuss et al, 2001). In contrast, abstract thinking,
widely considered a high level mental function, is a complex function mediated by the
prefrontal cortex (Goldberg, 2001; Stuss et al, 2001). Borrowing from the systems model of
Sabelli and Carlson-Sabelli (1989), lower level functions can be considered fundamental, in
that all higher level functions depend upon them. Likewise, higher level functions are
considered to have priority in that they have greater power to direct the system as a whole
(i.e., executive power).
Conceptualizing diverse mental functions as belonging to a single, integrated, and
hierarchically organized system has significant implications for differential diagnosis and
therefore for psychological testing. In general, the level at which the primary
psychopathology occurs determines the diagnosis. Moreover, the pathologies located at lower
levels need to be ruled out before considering higher level pathology. For example, a patient
may present with demanding and presumptuous interpersonal behavior but also with flight of
ideas and expansive affect. In this case, the primary impairment in cognition and affect
suggests a more fundamental level of psychopathology than the interpersonal disruptions
alone might indicate. Thus a diagnosis of mania must be considered before assuming a
diagnosis of narcissistic personality pathology. Likewise, the relationship of lower level
pathology to that of higher levels is always a concern with differential diagnosis. This concept
is particularly important for psychologists, as their expertise in higher-level psychological
functions may tend to bias them towards presumptions of higher-level psychopathology.
Figure 1 gives a schematic overview of the hierarchy of mental functions relevant to
psychological testing on an inpatient psychiatric setting. This conceptual schema is meant to
be used as a general guideline and not as an exact mapping of psychobiological systems.
Moreover, it is recognized that not all psychological functions or brain regions can be seen as
falling on a single dimension. Nonetheless, there is general agreement that a broadly
hierarchical approach is a useful heuristic tool when considering the relationship among
diverse psychological functions (Sabelli and Carlson-Sabelli, 1989, Cohen et al, 1997;
Schwartz, 1981).
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Lisa J. Cohen
Figure 1. Schematic Overview of Hierarchical Structure of Psychological Functions As Pertinent to
Differential Diagnosis.
As depicted in figure 1, the domain focused upon in inpatient testing is toward the top of
the figure. In other words, psychological testing addresses fairly high level, complex
psychological functions which are nonetheless built upon lower level, simpler functions. Note
also that axis I pathology is identified with mood, affect, cognition and behavior and is
located below axis II character pathology. It is a central tenet of this chapter that character
pathology, diagnosed on axis II (e.g., narcissistic and borderline pathology), reflects
impairment in higher level interpersonal representations, whereas the major axis I disorders
(e.g., schizophrenia, bipolar disorder) reflect primary impairment in more fundamental, lower
level psychological processes (e.g, mood, affect, cognition). Differentiating between these
two classes of pathology, therefore, involves locating the appropriate level of primary
pathology.
STEP 1: POSSIBLE CONFOUNDS TO TEST DATA
Step 1 is less about psychological testing per se than ruling out possible confounds to
interpretation of the results. Many of these confounds come from levels below or above the
level of psychology. Sub-psychological confounds can include sedation or perceptual
problems. Supra-psychological confounds can include cultural or societal factors. For
example, the patient must first be observed and the records reviewed in order to ensure that
there are no significant sensory or perceptual difficulties, such as visual or auditory problems,
that would preclude valid test results. Sedation is another factor that should be considered,
especially on an inpatient unit where patients may be heavily medicated. If perceptual/sensory
impairments can be corrected with glasses or hearing aids, testing can proceed. Otherwise
tests which do not rely on the compromised sense modality should be used.
Language can also be a confound when patients are tested in a language other than their
native language. While non-native speakers of English can be tested in English, interpretation
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Psychological Testing in Inpatient Psychiatry
of results must take language fluency into account. Further, tests with minimal reliance on
verbal skills and culturally mediated learning should be included. It is of course preferable if
standardized translations are available in the patient’s native language, as well as a tester who
speaks the patient’s native language. This may be more likely in areas where the patient’s
native language is widely spoken, as with Spanish speakers in the United States. Additionally,
features of the testing environment should be considered. While ideal testing situations are
generally rare on inpatient settings, distractions such as outside noise should be minimized as
much as possible and taken into account when interpreting test results.
Finally, there are numerous possible confounds resulting from differences in cultural
background and educational level. To the extent possible, the patient should be considered
relative to their cultural and educational norms. Separate norms for subjects with different
educational levels are available for some tests (e.g., Boston Naming Test, Trailmaking Test,
Stroop) (Mitrushina et al, 2005). Other tests are obviously more dependent on educational
exposure than others, for example the Information subtest on the WAIS-III, which includes
questions such as “Who wrote Faust?” Simple visual-spatial tests should be less sensitive to
educational and cultural background. Although there remains considerable debate about this
issue (Lezak et al, 2004), arguably it is virtually impossible to remove the role of cultural bias
from psychological testing. Nonetheless, it is incumbent upon the tester to be mindful of these
issues.
STEP 2: ASSESSING COGNITION
Because cognition is so central to higher level affective and interpersonal functions and to
regulation of complex behavior, it is extremely helpful to thoroughly assess cognition prior to
assessing other mental functions. Additionally, numerous cognitive disorders, such as mental
retardation, dementia, or learning disability, are frequently found in inpatient psychiatry. Such
disorders can either lead to or complicate the emotional and behavioral disturbances that
precipitate inpatient admission. Primary cognitive disorders can also produce symptoms that
mimic other disorders. For example, it may be difficult at times to distinguish delusional
ideation from magical thinking, a failure of logic which is associated with cognitive
immaturity (Subbotsky, 2004) and neuropsychological dysfunction (te Wildt and Schultz-
Venrath, 2004). Finally, many axis I disorders have considerable cognitive sequelae.
Depression results in decreased attention and concentration (Lockwood et al, 2002; Taylor et
al, 2006; APA, 1994), psychosis affects executive functions and abstraction (Brickman et al,
2004; Joyce et al, 2005), and autism is characterized by increased focus of interests and
impaired social cognition (APA, 1994).
The WAIS-III
The Wechsler Adult Intelligence Scale-3rd edition (WAIS-III; Wechsler, 1997, 2002) is
one of the most widely used cognitive tests available, with extensive data supporting multiple
aspects of reliability and validity. Due to both its excellent psychometric properties and the
comprehensive profile it provides, it is a highly valuable tool on an inpatient setting. The
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Lisa J. Cohen
WAIS-III is comprised of 14 subtests, 4 Index Scores (Verbal Conceptual Index (VCI),
Perceptual Organizational Index (POI), Working Memory Index (WMI), and Processing
Speed Index (PSI)) and 3 overall intelligent quotients (Full Scale IQ, Verbal IQ and
Performance IQ). All indices are standardized with a mean of 100 and a standard deviation of
15. For all subtests, the mean is 10 and the standard deviation 3. The WAIS-III was normed
on a sample of 2,450 American adults, stratified according to age, gender, race/ethnicity,
educational level and geographical region to match the United States census. Criterion
validity was obtained by correlating the four indices and three IQ scores with the Stanford-
Binet Intelligence Scale and the Standard Progressive Matrices. Convergent and divergent
validity was obtained by correlating the seven composite measures with 17 external measures,
grouped according to general cognitive ability, attention, memory, language, spatial
processing, executive functions and fine motor speed and dexterity. Although these last data
support the discriminative validity of the WAIS-III, the sample sizes involved were often very
small, ranging from 103 down to 16.
When interpreting the WAIS it is helpful to move from the general to the particular. The
Full Scale, Verbal and Performance IQ’s (FSIQ, VIQ, and PIQ) give an overall sense of the
patient’s cognitive ability. The Index Scores should next be considered to gain a more finely
grained understanding of cognitive function. The differences between WAIS scores are also
important and the test manual provides normative data on discrepancies between them. It is
important next to consider the individual test scores. Particularly on an inpatient setting, the
subtests within each index might vary considerably from each other. Thus the amount of inter-
test scatter offers critical information. Significant scatter may indicate the intrusion of
psychiatric illness into cognitive performance or the presence of a specific
neuropsychological deficit. In contrast, individuals with mild and moderate mental retardation
tend to show low, flat profiles with little variation across indices (Wechsler, 1997). Intra-test
scatter also warrants attention. If a patient answers more difficult questions correctly but
misses easier ones, he or she may be functioning below capacity, possibly due to
psychopathology. Finally, peaks and troughs of subtest scores should be noted. All of these
features can have diagnostic implications, as will be discussed in more detail under Step 3:
Assessment of Axis I Pathology.
It is also important to consider the time course of cognitive impairment. While the WAIS-
III gives only a cross-sectional assessment, the pattern of scores can give clues as to whether
the impairment is acute or longstanding or reflective of a higher level of premorbid
functioning. The distinction between crystallized and fluid intelligence is helpful in this
regard (Cattell, 1987; Horn and Catell, 1966). Crystallized intelligence refers to learned
information or skills that are relatively resilient to age and psychopathology. WAIS tests
associated with verbal conceptual abilities, such as Vocabulary and Information, may be seen
as reflective of crystallized abilities. Similarly, word knowledge or reading ability is
frequently used to measure premorbid IQ and has been found to remain relatively intact in
patients with neuro-cognitive and psychiatric disorders (Crawford et al, 1992; Joyce et al,
2005).
Fluid intelligence refers to the ability to reason and solve problems effectively and relates
to functions such as attention, learning, memory, and processing speed (Douchemane and
Fontaine, 2003: Engle et al, 1999). These skills tend to deteriorate with age and are
compromised in many psychiatric illnesses (Lockwood et al, 2002; Taylor et al, 2006; Nebes
et al, 2000; Brickman et al, 2004; Joyce et al, 2005). WAIS tests that might be associated with
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Psychological Testing in Inpatient Psychiatry
fluid skills include Digit Symbol, Digit Span, and Letter-Number Sequencing. Some tests,
such as Arithmetic, may tap both crystallized and fluid processing skills. Reduced fluid skills
juxtaposed against higher crystallized knowledge may suggest deterioration from a higher
level of functioning. Likewise, lowered crystallized and fluid abilities may suggest
longstanding and even lifelong cognitive impairment.
Additional Cognitive Tests
While the WAIS-III gives an excellent overview of overall cognitive function, there are
times when more targeted cognitive assessments are indicated. For this a wealth of additional
cognitive tests are available. The Mini Mental Status Exam (MMSE) (Folstein, Folstein, and
McHugh, 1978) is a widely used screen for dementia while the Dementia Rating Scale
(Mattis, 1988) offers a more thorough dementia evaluation. The Wechsler Memory Scale-3rd
Edition (WMS-III) (Wechsler, 1997, 2002) provides a comprehensive and well standardized
assessment of memory; the Boston Naming Test assesses language (Kaplan et al, 1983); and
the Halstead Reitan Battery (Reitan and Wolfson, 1993) and the Luria-Nebraska
Neuropsychological Battery (Golden and Freshwater, 2001) offer more comprehensive
assessments of neuropsychological function. There are also a number of test manufacturers,
such as Psychological Assessment Resources (1-800-331-8378), Pro-Ed (1-800-897-3202),
and Harcourt Assessment (formerly the Psychological Corporation) (1-800-211-8378), that
publish cognitive tests. Additionally, there are two classic compendia of cognitive tests by
Lezak and colleagues (Lezak, Howieson, and Loring, 2004) and by Spreen and Strauss
(1998). Finally The Handbook of Normative Data by Mitrushina et al (2005) lists norms for a
number of tests lacking norms from the test manufacturers.
STEP 3: ASSESSMENT OF AXIS I PATHOLOGY
The assessment of axis I pathology is often the primary goal of inpatient testing.
Consistent with the hierarchical model of mental processes mentioned earlier, axis I disorders
are conceptualized to reflect disruption at the level of thought, emotion and behavior. Such
pathology might involve affective lability or flattening; impaired initiative or impulse control;
or significant disorganization of thought.
Because of the wealth of clinical information available on the inpatient unit, we will first
focus on tests that address questions not easily answered in the clinical interview. Specifically
we will focus upon the WAIS-III and the Rorschach Inkblot Test, both of which provide a rich
overview of mental processes. As such, they are particularly useful for either generating
clinical hypotheses or confirming provisional diagnoses. Moreover, as these tests measure
actual test taking behavior as opposed to self description they are less vulnerable to self-report
biases than many questionnaires or interviews. Following this discussion, we will address
more targeted tests of specific axis I diagnoses.
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Lisa J. Cohen
Diagnostic Indications of the WAIS-III
While there is little literature that specifically compares WAIS performance across
psychiatric diagnoses, there is a large cognitive literature about different psychiatric disorders.
Given the excellent validity of the WAIS, it is reasonable to hypothesize that robust
neurocognitive findings about various psychiatric diagnoses will be reflected in WAIS
performance. Of course, these suggestions must be seen as preliminary and awaiting
empirical validation. Nonetheless, examination of WAIS profiles can reveal valuable
information to help the clinician form diagnostic hypotheses during the testing process.
Depression
Neurocognitive studies of depression have shown decrements in working memory,
processing speed, attention/concentration and psychomotor speed (Lockwood et al, 2002;
Taylor et al, 2006; Nebes et al, 2000) and reduced concentration is a diagnostic criterion for
major depression in DSM-IV (APA,1994). Thus we would anticipate lower Performance IQ
than Verbal IQ in depression along with select decreases in Working Memory and Processing
Speed Indices. Among Perceptual Organization Index tests, we would anticipate worse
performance on timed (e.g., Block Design) vs. untimed tests (e.g., Matrix Reasoning). Verbal
Conceptual scales, such as Vocabulary, Information and Comprehension2, should be relatively
intact.
Psychosis
There is a large literature documenting neurocognitive pathology in schizophrenia and
related psychotic disorders. Schizophrenics, and to a lesser extent patients with schizotypal
personality disorder and first degree relatives of schizophrenics, demonstrate marked deficits
in working memory, executive functions, and attention (Brickman et al, 2004; Joyce et al,
2005).
Further, patients with schizophrenia demonstrate evident deterioration from premorbid IQ
(Joyce et al, 2005; Crawford et al, 1992). Thus, as with depressed patients, we would expect
lowered performance on the Working Memory Index and Psychomotor Speed Index. In fact,
as reported in the WAIS-III manual, a sample of schizophrenics scored best on the VCI (93.3
+ 16.4) followed by the POI (89.6 + 13.9), the WMI (85.0 + 15.1) and the PSI (83.4 + 11.8).
Whereas such deficits in depressed patients may be related to reduced effort and processing
speed (Lockwood et al, 2002; Nebes et al, 2000), problems organizing and synthesizing
information may be more prominent with schizophrenics. For example, difficulties
synthesizing complex details into a whole may lead to lowered Block Design or Object
Assembly. Additionally, difficulties maintaining a coherent mode of processing may result in
notable intra-test scatter. Further, schizophrenics show a select difficulty with abstraction,
such that tests of abstraction abilities, e.g., proverbs, are often used in mental status exams
(Sadock and Sadock, 2003). Thus lowered Similarities relative to other VCI scales may be a
useful marker of a schizophrenic process.
As language functions in schizophrenics have been shown to be less impaired than
memory, attention, executive, motor or visual-spatial functions (Bilder et al, 2000; Brickman
et al, 2004) Verbal Conceptual tests, such as Vocabulary and Information, may be relatively
2 Although Comprehension is not included in the VCI, it does load on the Verbal Conceptual factor (Wechsler,
1997).
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Psychological Testing in Inpatient Psychiatry
intact. In the case of significant thought disorder, however, the abstract thought necessary for
defining words may be compromised, reducing the Vocabulary score. The duration of illness
should also be taken into consideration. While there is robust evidence of significant
cognitive impairment even at illness onset (Bilder et al, 2000; Joyce et al, 2005; Brickman et
al, 2004), greater duration of illness can result in greater cognitive decline (Bilder et al, 2000).
Negative Symptoms
As the literature has shown a strong relationship between negative symptoms and
neurocognitive impairment in schizophrenia (Milev et al, 2005), globally reduced cognitive
function in the absence of florid psychotic process may be indicative of prominent negative
symptoms. Reduced processing speed, working memory, attention, visuo-spatial skills,
problem-solving, and language skills have all been correlated with negative symptoms (Milev
et al, 2005). In contrast, strikingly disorganized thought process may be more reflective of
positive symptoms and may be thus more responsive to medication (Andreasen, 1985;
Buchanan et al, 1998).
Mania
Studies of neurocognition in mania have been mixed and surprisingly sparse compared to
similar literature on schizophrenia. Bipolar patients offer a number of difficulties with regard
to characterization of their cognitive functioning. There is considerable variety among
patients with bipolar disorder, as such patients vary according to level of baseline functioning,
degree of depressive, manic or mixed symptomatology, and degree of psychotic process. As
all of these factors have a strong impact on cognitive functioning, we can expect significant
heterogeneity in cognitive function among bipolar patients, which has been supported by the
literature (Dickerson et al, 2004). Overall, bipolar patients have been shown to have general
decrements in fluid processing skills, which are less severe than those of schizophrenics
(Hobart et al, 1999). In a study comparing demographically matched pairs of bipolar and
schizophrenic patients, bipolar patients scored better than schizophrenics in most tests of a
large neuropsychological battery. The largest effect sizes were observed with general
intellectual functioning (WAIS III full scale IQ), WAIS Vocabulary test, memory and complex
attention (Hobart et al, 1999). The same study demonstrated a smaller decline in general
intellectual functioning from estimated premorbid IQ in bipolar patients relative to
schizophrenics. In addition, although this must be seen as entirely speculative, it is worth
considering whether hypomanic patients, particularly those without notable thought disorder,
may have elevated attention and psychomotor speed and thus might show elevations on tests
within the Psychomotor Speed and Working Memory Indices.
Autism/PDD
Although there is still considerable debate about the assessment of autism spectrum
disorders (ASD’s), studies have suggested several consistent neurocognitive findings. Deficits
in social functioning are characteristic of autism and related disorders and form part of the
criteria for diagnosis. Therefore, we should expect relative deficits in scales sensitive to social
competence, such as Comprehension and Picture Arrangement. Studies on visual spatial
functioning have been inconsistent, suggesting that some patients demonstrate reduced visual-
spatial function, while others may show enhanced visual-spatial processing (Caron et al,
2006; Williams et al, 2005). A number of studies have documented elevated Block Design
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Lisa J. Cohen
scores in autistic subjects (Caron et al, 2006; Motron, 2004). Thus patients with ASD’s may
demonstrate either decreased or elevated Perceptual Organizational Index Tests, especially
Block Design.
Although patients in the autistic spectrum have demonstrated memory deficits in several
studies (Salmond et al, 2005; Minshew and Goldstein, 2001), there is also evidence for
superior memory in at least a subgroup of ASD’s. Such strengths appear to be restricted to
particular types of memory, including memory for factual information (O’Shea et al, 2000), or
"rote" memory (Toichi and Kamio, 2002). This is consistent with the diagnostic criteria for
autism and Asperger’s Syndrome, which include highly focused interests and preoccupations
(APA, 1994). This is also consistent with the clinical presentation of ASD’s, and especially
autistic savants, who can store and process vast amounts of factual information about very
specific topics, such as train schedules or calendars (Bodaert et al, 2005). If we extrapolate
such findings to the WAIS, we could hypothesize that some individuals falling on the autistic
spectrum would have relative strengths on Information and Digit Span (Digits Forward more
than Backward), as these tests are sensitive to rote or factual memory.
Learning Disorders
If there is a consistent relative deficit across a particular cognitive domain (e.g., verbal or
spatial skills), a learning disorder should be considered. Learning disabilities can have direct
implications for school or occupational functioning and may also result in associated
problems with frustration tolerance, perseverance, and achievement behavior (Charlton,
1985). As such, test taking behavior can also support diagnosis of an undiagnosed learning
disorder. Comments such as “I’ve never been good at this” or a pattern of giving up easily on
tests in which the subject does poorly while persevering on tests of intact skills may also
reflect adaptation to long standing but specific cognitive deficits.
The Rorschach Inkblot Test
The Rorschach Inkblot Test is uniquely sensitive to psychotic processes that may not be
discernible on clinical interview. Because of the debate surrounding its merits, we will discuss
its history and psychometric properties in some detail. First developed by Hermann
Rorschach in 1922, the Rorschach Inkblot test has had a long and somewhat controversial
history. Rorschach, a psychiatrist with an interest in psychoanalysis, was intrigued by the
evocative power of his inkblots. Selecting 10 blots from an initially larger collection, he
created the standard stimuli for the Rorschach test, which would later become a cornerstone
of psychoanalytic assessment. Of interest, given our focus on the inpatient setting, his work
was originally based on comparisons between healthy adults and schizophrenics
(Rorschach,1922). Although quite a few scoring systems were developed, spanning from
comprehensive assessments (Klopfer et al, 1954; Hertz, 1942; Rapoport et al, 1946; Shafer,
1954; Beck, 1944) to measurements of more specific psychological traits (Blatt and Lerner,
1983; Blatt et al, 1976; Mayman, 1967; Urist, 1977), the extensive claims of Rorschach
interpretive power were inadequately grounded in conventional psychometric data. Largely
because of this, outside of psychoanalytic circles the Rorschach was vigorously discredited
(Meyer, 2003; Meyer and Archer, 2001; Exner, 1993). This problem was greatly minimized in
1974 when John Exner published the Comprehensive Scoring System for the Rorschach.
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Psychological Testing in Inpatient Psychiatry
Basing his scoring system on previous comprehensive approaches, Exner finally provided
extensive psychometric data to bring the Rorschach up to contemporary standards of
psychological test construction. Although distrust of the Rorschach still continues, the Society
for Personality Assessment has recently produced a white paper supporting the psychometric
properties of the Rorschach (SPA, 2005). Meanwhile, the Comprehensive System has been
revised and updated several times (Exner, 1993; Exner 1997).
There is at present a fairly large empirical literature on the Rorschach, the vast majority
of studies using Exners system. Meyer and Archer (2001) applied meta-analytic techniques
to compare the reliability and validity of the Rorschach to that of other well known
instruments. With regard to general concurrent validity, i.e., the relationship between any
subscale and any outcome measure, the Rorschach, MMPI, and the WAIS “obtained generally
similar estimates of global validity, falling in the range between .25 and .35.” (p. 490). These
effect sizes lie in the moderate range and are similar to those found in many other
psychological studies. A similar meta-analysis was performed looking at specific subscales
(e.g., the Rorschach SCZI, DEPI, and oral dependency scale) and outcome variables, (e.g.,
thought disturbance, depressive diagnosis, and dependent behavior, respectively). Again
concurrent validity of Rorschach scales was comparable to that found in MMPI and IQ scales.
As the authors point out, however, while there is adequate data supporting the overall
reliability and validity of Rorschach scales, there is inadequate data evaluating the specific
Rorschach scales and summary indices. In fact, in the second meta-analysis, the Rorschach
schizophrenia index (SCZI) produced a considerably higher effect size (.44) than did the
depression index (DEPI) (.14). This discrepancy may reflect variation in face validity across
Exner’s scores. For example, measures of disorganized thought process on the Rorschach
have clear similarities with disorganized thought process in other contexts. On the other hand,
it is a much greater inferential leap to determine depression from scores of reflections or three
dimensional vistas, which are included in the DEPI.
The issue of face validity has relevance for clinicians. As discussed by Meyer and Archer
(2001), scores that have less intuitively obvious relation to the constructs attributed to them
may have weaker evidence of construct validity than scores that bear more obvious relation to
their associated constructs.
It should also be noted that there has been criticism of the generalizability of the norms
provided by Exner, suggesting they may lead to overestimation of pathology in non-patient
adults (Wood et al, 2001). Whereas norms for many tests are drawn from samples
representative of the US population, Exner derived his norms from non-patient adults, thereby
producing an atypically healthy sample (Meyer and Archer, 2001). Thus there may be
difficulties using such data to gauge precise levels of psychopathology. It is therefore
recommended that the clinician use the norms as guidelines for test interpretation, rather than
as definitive diagnostic criteria.
Despite these caveats, Exner’s extensive normative data is a pivotal contribution to the
Rorschach literature and provides the best comparative data of individual scores across
different clinical groups. In the 1993 edition of the 1st volume of his series on the
Comprehensive System (Exner, 1993), Exner presents norms for 700 healthy adults along
with those of children of various ages, inpatient schizophrenics, inpatient depressives and
several other groups. Although he does not present statistical analyses of these data, he does
provide sufficient information (means, standard deviations and n’s) to calculate t-tests, such
that different patient groups can be compared with the sample of healthy adults. Table 1 lists
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Lisa J. Cohen
the means and standard deviations from his samples of normal adults, 10 year old children,
inpatient schizophrenics and inpatient depressives, along with the statistical significance of
each group’s comparisons with the index group of normal adults. Additionally, t-tests were
performed to compare inpatient schizophrenics with inpatient depressives. Variables were
selected for their significance for the inpatient setting. Data on ten year old children were also
included to illustrate response patterns typical of immature minds, which may show parallels
with emotionally immature adults as well as individuals with developmental delays or mental
retardation. Due to the large sample sizes involved, relatively small differences reach high
levels of statistical significance.
Table 1. Comparison of Rorschach Scores Based on Exner’s Normative Data
Rorschach Measure Normal
Adults
n=700
10 y.o.
Children
N=120#
Inpatient
Schizophrenics
N=320
Inpatient
Depressives
N=315
Intellectual Complexity
R 22.67 + 4.2 20.97 + 1.9 c 23.44 + 8.7 22.70 + 8.5
W 8.55 + 1.9 9.52 + 0.9 c 8.79 + 5.1 8.48 + 4.1
Dd 1.23 + 1.7 1.35 + 0.4 4.86 + 5.0 c 4.28 + 5.3 c
S 1.47 + 1.2 1.48 + 0.7 2.77 + 2.5 c 2.51 + 2.3 c
Thought Organization
FQxo 16.99 + 3.3 15.80 + 2.0 c 8.92 + 3.4 c,f 11.76 + 4.3 c
FQxu 3.25 + 1.8 2.95 + 0.8b4.89 + 3.2 c 5.20 + 3.2 c
FQx- 1.44 + 1.0 1.58 + 1.0 c 8.95 + 5.3 c,f 4.70 + 3.4 c
X-% 0.07 + 0.1 0.08 + 0.1 0.37 + 0.1 c,f 0.20 + 0.1 c
Xu% 0.14 + 0.1 0.15 + 0.1 0.20 + 0.1 c,e 0.22 + 0.1 c
WSum6 3.28 + 2.9 10.22 + 3.8 c 44.69 + 35.4 c,f 18.20 + 13.7
Color (Affective Processing)
FC 4.09 + 1.9 2.55 + 1.0 c 1.54 + 1.6 c 1.58 + 2.0 c
CF 2.36 + 1.3 3.68 + 1.3 c 1.24 + 1.4 c,e 1.58 + 1.4 c
C 0.08 + 0.3 0.13 + 0.3 0.42 + 0.7 c,f 0.72 + 1.0 c
SumColor 6.54 + 2.3 6.37 + 1.5 3.25 + 2.6 c,e 3.91 + 2.5 c
WSumC 4.52 + 1.8 5.16 + 1.3 c 2.63 + 2.2 c,f 3.45 + 2.2 c
Shading (Dysphoric Affect)
SumC’ 1.53 + 1.3 0.79 + 0.9 c 1.50 + 1.6f2.16 + 1.8 c
SumV 0.26 + 0.6 0.02 + 0.13 c 0.60 + 1.2 c,f 1.09 + 1.23 c
SumY 0.57 + 1.0 0.43 + 0.7 2.12 + 2.6 c 1.81 + 1.4 c
Sum Shading 3.39 + 2.2 1.83 + 1.3 c 4.68 + 4.5 c,f 5.92 + 3.7 c
Movement Responses
M 4.31 + 1.9 3.65 + 1.6 c 6.00 + 4.3 c,f 3.57 + 2.2 c
FM 3.70 + 1.2 5.53 + 1.5 c 2.41 + 2.4 c,f 3.12 + 2.8 c
MQ- 0.03 + 0.2 0.17 + 0.4 c 2.42 + 2.5 c,f 0.58 + 0.8 c
a 6.48 + 2.1 7.15 + 1.4 c 5.51 + 3.9 c,d 4.79 + 3.2 c
p 2.69 + 1.5 3.27 + 0.7 c 4.25 + 3.3 c,d 3.66 + 2.5 c
Content
H 3.40 + 1.8 2.47 + 1.1 c 3.17 + 2.4f2.05 + 1.5 c
A 8.18 + 2.0 8.92 + 1.2 c 8.21 + 3.5d7.57 + 3.3b
# n=90 for some Rorschach variables.
a p<.05, bp<.01, c p<.001 compared to Normal Adults.
d p<.05, ep<.01, f p<.001 for schizophrenics vs. depressives.
The first section in table 1 includes measures considered reflective of intellectual effort
and ideational complexity. R refers to the number of responses generated. W, Dd, and S refer
to the areas of the blots incorporated into the subject’s response. W is scored when the subject
incorporates the whole blot into the concept, Dd when the subject utilizes an infrequently
12
Psychological Testing in Inpatient Psychiatry
used area of the blot, and S when the subject incorporates the white space into the response.
In comparison with normal adults, 10 year old children have significantly fewer R responses
and significantly more W responses, while no such differences are found with the two adult
patient groups. This suggests reduced complexity in children’s responses, consistent with
their developmental level. In contrast, both inpatient groups showed significantly more Dd
and S responses than the normal adults, reflecting unconventional modes of attending to
features of the blot.
The second section refers to the organization of thought. Because the accuracy of the
subject’s percepts cannot be objectively determined, Exner estimates accuracy of perception
by measuring the frequency of each response within a normative population. Responses listed
by at least 2% of the normative sample are coded as having ordinary form quality (Fo). Those
that are less commonly perceived but still maintain some visual link to the contours of the
blot (as determined either by scoring guidelines or subjectively by the tester) are coded
unusual (Fu) and those that are both uncommon and have no visual connection to the blot are
coded as having poor form quality (F-). The first five variables listed in this section all refer
to form quality. While all groups demonstrate lower form quality than the normal adults, the
differences are most dramatic among the schizophrenics, followed by the inpatient
depressives and then the children. Thus, schizophrenics demonstrate the most difficulty
perceiving ambiguous information in conventional ways. The last variable, WSum6, refers to
the number of special scores, which indicate responses with illogical and bizarre reasoning.
Thus while form quality may be seen as a measure of reality testing, special scores may be
seen as a measure of thought disorder. As is evident in table 1, schizophrenics far exceed the
other groups on this measure as well. Of note, schizophrenics score significantly worse than
inpatient depressives on most of these measures.
The processing of color is considered reflective of the processing of emotion. FC
responses incorporate both form and color into the percept but predominantly rely on form.
This suggests an integration of affect and cognition, in which cognition strongly mediates the
experience and expression of emotion. FC responses thus reflect healthy and mature
emotional functioning. Likewise, in table 1, FC responses are more common in the index
group of healthy adults than in all other groups. CF responses also incorporate both color and
form but are predominantly dependent on color, suggesting that affect dominates the exercise
of cognition. In support of this notion, healthy adults produce more FC responses and fewer
CF responses than do 10 year old children. Pure C responses involve color with no form,
suggestive of affect wholly unmediated by cognition. These are relatively rare but are
nonetheless least common in the index group of healthy adults. Further, the relative paucity of
color based responses in both the schizophrenic and depressed patients is consistent with the
constricted or blunted affect characteristic of both diagnostic groups.
Responses based on shading or variations in black and white tonality are considered
indicative of dysphoric emotion, and thus should be elevated in depressed patients. As
presented above, both depressed and schizophrenic inpatients show significantly more
shading responses than do normal adults, with depressives also providing more shading
scores than schizophrenics. Children, on the other hand, provide significantly fewer shading
responses than the index group, probably reflecting their tendency towards simpler and less
nuanced responses.
Human movement (M) and animal movement (FM) responses may be reflective of
several traits, such as ideational complexity, interpersonal relatedness, and level of mental
13
Lisa J. Cohen
activation. Children are expected to see more animal movement responses relative to human
movement responses than do adults, which is supported by the data above. Similarly, relative
to adults, children have less human content (H) and more animal content (A) responses.
While schizophrenics show more M responses than either normal adults or depressives, the
form quality of these responses (MQ-) is much lower than the other groups. Finally both
patient groups show fewer active movement responses (a) and more passive movement
responses (p) than do normal adults.
Exner (1986) also compared 84 borderline personality disorder patients to 80
schizophrenic and 76 schizotypal patients (using DSM III diagnoses) on a broad range of
scores from the Comprehensive System. Borderlines clearly differed from both schizophrenic
and schizotypal patients on color (WSumC, D), achromatic color (sum shading, es), and
special scores (Sum6, WSum6), such that borderlines showed increased expression of
emotion, including dysphoric emotion, and better organization of thought than either of the
other groups. Additionally borderlines had a much higher percentage of extratensive subjects
(WSumC - M > 1.5) than either group and 35% of borderlines had CF + C – FC >1. These
findings suggest a propensity towards emotion-dominated thought in borderline patients,
consistent with their characteristic affective lability and impulsivity. Of note, schizophrenics,
but not schizotypals, also showed a high rate of color dominated color responses (CF + C
FC >1). Thus while both borderlines and schizophrenics can demonstrate signs of poorly
mediated affect, borderlines demonstrate greater affectivity overall and significantly less
thought disorder than do schizophrenics.
In summary, use of the Rorschach can illuminate aspects of patients’ mental functioning,
such as mood, emotional regulation, mental maturity, and the complexity and organization of
thought processes, which might not be accessible through either self report or behavioral
observation. Thus, as part of a broad-based, comprehensive assessment, the Rorschach can be
highly useful tool in the service of differential diagnosis.
Additional Tests
The value of the WAIS and the Rorschach is in their breadth of focus and hypothesis-
generating capacity. Once specific diagnoses are identified, however, more targeted measures
of specific axis I disorders may be indicated.
The Structured Clinical Interview for DSM-IV (SCID I) (First et al, 1997)
This is a semi-structured interview that assesses whether the subject meets criteria for a
range of DSM-IV axis I disorders. There is an extensive overview section followed by six
modules, Mood Episodes, Psychotic and Associated Symptoms, Differential Diagnosis of
Psychotic Disorders, Mood Disorders, Alcohol and Other Substance Use Disorders, and
Anxiety and Other Disorders. The clinician version (SCID-CV) has been streamlined from
the original research versions to focus on the most common diagnoses. While administration
of the entire SCID-I is fairly time intensive, separate modules can be selected to evaluate
specific diagnoses.
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Psychological Testing in Inpatient Psychiatry
The Positive and Negative Symptoms Scale (PANSS) (Kay et al, 1994)
The PANSS is also a semi-structured interview and assesses schizophrenic
symptomatology in considerable detail. Ratings are made only after the completion of the
interview. The PANSS consists of three scales totaling 30 items, Positive Symptoms (7 items),
Negative Symptoms (7 items) and General Psychopathology, which includes somatic, mood
and anxiety symptoms among others (16 items). As ratings depend on clinical judgment, the
PANSS is most effective with raters with some clinical and interviewing experience.
The Young Mania Scale (Young et al, 1978)
This is a clinician administered checklist that measures the severity of manic symptoms.
There are eleven items ranked on either a 4 point or 8 point scale. While reliability for total
scores is strong, there is more variability in reliability for individual items (APA, 2000).
Ratings incorporate clinician observations of patients’ behavior and thus, while less reliant on
self report, ratings are more dependent on inter-rater reliability. Nonetheless, this is a
relatively short and easily administered instrument.
The Hamilton Depression Rating Scale (HRSD) (Hamilton, 1980)
The HRSD is a clinician administered questionnaire which rates the severity of
depressive symptomatology. The original 17-item version has the strongest psychometric
support but a 21 item version is also available. This is a widely used instrument to measure
depression and is fairly quick and easy to administer. As with the PANSS and YMS, however,
the ratings do depend on some degree of clinical judgment; thus clinical training and
experience can influence the outcome.
Yale Brown Obsessive Compulsive Scale (YBOCS) (Goodman et al, 1989)
The YBOCS is a clinician-administered questionnaire that addresses the severity of
obsessions, compulsions and related symptoms. The YBOCS symptom checklist assesses for
the presence (current or past) of 64 OCD symptoms. The original 10 item scale is comprised
of a 5-item scale measuring severity of obsessions, a 5 item scale for severity of compulsions
and a 10-item total score. An additional 9 items have been added which assess indecisiveness,
pathological doubting, avoidance and other symptoms associated with OCD. The YBOCS is
considered the gold standard of OCD research and, like the HRSD and the YMS, it is fairly
quick and easy to administer.
The South Oaks Gambling Scale (SOGS) (LeSeur and Blume, 1987)
The SOGS is also a clinician administered questionnaire. The rater asks 26 questions
which incorporate 35 items but only 20 items are actually scored. Questions address severity
of gambling and gambling related activities (e.g., Have you ever borrowed from someone and
not paid them back as a result of your gambling?). As the general clinician may not be as
familiar with the details of pathological gambling as with the symptoms of other disorders,
this instrument is a useful and informative measure that is relatively easily administered.
For more information, The Handbook of Psychiatric Outcomes and Measures (APA,
2000) is an excellent compendium of clinically relevant psychiatric measures.
15
Lisa J. Cohen
STEP 4: ASSESSING AXIS II PATHOLOGY
The distinction between axis I and axis II is a controversial and complex topic and merits
discussion in some detail. There is even question of the utility of this distinction. Likewise,
some authors have conceptualized borderline personality disorder to be a variant of mood
disorders (Gunderson et al, 2006). From the perspective of inpatient testing, however, the
distinction between the major axis I disorders and the axis II personality disorders is
extremely useful. For example, this distinction has implications for the degree of volitional
control the patient has over problematic behavior, the utility of behavioral reinforcement
contingencies, the effectiveness of medication, and the type of follow up treatment needed. To
illustrate, if combative and threatening behavior is deemed to be secondary to mania, the
patient will be aggressively medicated, expected to improve rapidly, and outpatient follow up
will focus upon adequate monitoring of medication. If the behavior is deemed secondary to
personality pathology, verbal and behavioral interventions will be the primary line of
treatment, pharmacological treatment will be deemed secondary if even indicated, and
outpatient follow up will focus upon psychotherapy or a more intensive behavioral treatment
such as Dialectical Behavioral Therapy (DBT) (Linahan, 1993).
To address the assessment of personality pathology on an inpatient setting, it is necessary
to first provide a definition. Cloninger (Cloninger et al, 1993; Cloninger, 1994) defined
personality to be comprised of both temperament and character. Temperament refers to in-
born, mostly hereditary, information processing biases that are largely impervious to learning,
memory and environmental influences. Relevant personality traits include shyness, sensation
seeking, introversion, extraversion, and to some extent impulsivity (Cloninger et al, 1993;
Cloninger, 1994, 1996; Cohen et al, 2005). In this light, many axis I disorders, such as
ADHD, hypomania, or autism spectrum disorders, might be conceptualized as grossly
abnormal temperaments. Similarly the emotionality associated with borderline personality
disorder could be partly attributable to temperament. Thus in keeping with the hierarchical
systems model employed in this chapter, temperament would fall on a level similar to that of
axis I pathology.
In contrast, character may be considered a higher-order structure than either
temperament or the fundamental processes underlying axis I pathology. In Cloninger’s
definition, character refers to a system of learned concepts. Prototypes of interpersonal
relationships are derived from salient experiences in childhood. These create a set of
expectations which in turn guide thought, affect and behavior in interpersonal contexts. Thus
character is comprised of a system of interpersonal representations.
While it is beyond the scope of this chapter to determine to what extent axis II diagnoses
can be attributed to either temperament or character, it is a central tenet of this chapter that
character pathology has a critical if not predominant role in axis II personality diagnoses.
Thus the evaluation of character pathology has a meaningful, albeit not necessarily
isomorphic, relationship with the diagnosis of axis II personality disorders. Moreover, as will
be evident below, the diagnostic measures of axis II personality disorders expressly address
aspects of interpersonal representations.
The concept of character presented here has a rich history, originating in psychoanalytic
literature. The notion of interpersonal representations as a kind of blue-print for psychological
functioning was explored and developed in multiple psychoanalytic schools, including Object
16
Psychological Testing in Inpatient Psychiatry
Relations, Interpersonal Psychology, Relational Psychoanalysis, and Self Psychology
(Mitchell, 1988; Kernberg, 1975; Kohut, 1968). The construct was later adopted and refined
by empirical psychologists, including attachment theorists, who spoke of internal working
models (Main, Kaplan, Cassidy, 1985; Bretherton, 1993) and cognitive therapists, who spoke
of schemas and core beliefs (Beck et al, 1990; Young, 1990). While the concepts of character
from these different traditions are not identical, we can summarize a number of central,
overlapping features.
1. Character is based on a system of interpersonal representations, out of which are
abstracted representations of self and other.
2. Fundamental interpersonal representations are laid down in childhood but continue to
be elaborated throughout life.
3. Interpersonal representations are conceptual systems derived from memory: a kind of
prototypical memory of a routine, comprised of a set of expectations or rules about how
events transpire. (e.g., Mother acts like this, I act like this. If I want X, I have to do Y.)
4. Interpersonal representations are higher order mental structures that serve to guide
thought, affect and behavior. Thus character influences psychological functions from
the top down.
5. While fairly fixed and conservative, they are nonetheless open to modification. Depth
psychotherapy works by restructuring core interpersonal representations.
To illustrate, a child with a loving mother will develop a sense of self as worthy,
competent, and able to make an impact on others. S/he will develop a representation of others
as benign and emotionally responsive. The child will then interact with the world in an
optimistic, confident way and consequently tend to elicit consonant responses. Alternatively, a
child with a rejecting and critical mother will develop a sense of self as inadequate and
unworthy along with a sense of others as cold, rejecting, and unreachable. With concomitant
feelings of isolation and anger, the child will tend to see the world and interpret ambiguous
situations concordantly, thereby eliciting hostile, critical or distant reactions. Of course, these
scenarios should be seen as highly simplified, omitting consideration of extra-familial and
post-childhood influences.
Character pathology can be defined as any deficit in the content and form of interpersonal
representations that impedes flexible adaptation to the environment. Maladaptive content may
include malevolent, distant, critical, or coercive views of others or overly dependent,
appeasing, or helpless views of self. Such representations are rigid, fixed and unresponsive to
new information.
Problems in form refer to the organizational quality of interpersonal representations.
Theories of cognitive development stipulate that mental representations develop from a state
of relative simplicity to relative complexity (Werner and Kaplan, 1963). These developmental
processes include the coordinated processes of integration and differentiation (Piaget, 1954).
Psychoanalytic theorists adapted these concepts to the study of character pathology, such that
pathology was considered a failure of development (Blatt and Lerner, 1983; Blatt et al, 1976;
Fast, 1985, 1996). Maladaptive representations remain overly global, totalistic, and lacking
nuance. There is inadequate integration of disparate elements of self and other, and
inadequate differentiation of self from other. For example the classic splitting of a borderline
involves a totalistic and global representation of the other as “all bad,” a failure to integrate
17
Lisa J. Cohen
previous, more benign experiences of the other with the current denigrated form, and a failure
to differentiate the evaluation of the other from the person’s own affective state.
Developmentally, this is akin to the psychological processes of a very young child.
We can now consider how this conceptualization of character pathology can be applied to
psychological testing on an inpatient unit. As above it is necessary to first delineate the degree
to which pathology derives from a more fundamental level of organization, as in the case of
mood disorder, psychosis, or low IQ. After this is established, the content and form of
interpersonal representations can be evaluated. Of note, this is not meant to imply that axis I
and character pathology are mutually exclusive. Patients can certainly have character
pathology along with axis I illness. Nonetheless, in the case of a clear axis I disorder,
clinicians must be very cautious in interpreting character pathology, especially if the
symptomatic behavior is consistent with the axis I disorder, as in the case of negativistic and
dependent traits in a patient with major depression. However, if the traits in question are not
consistent with the axis I diagnosis, there may well be comorbid axis II pathology. For
example if someone with bipolar II disorder has a history of self mutilation, intense
dependency, unstable and overly involved relationships and childhood sexual abuse,
comorbid borderline pathology is strongly indicated.
Scales for assessing maladaptive form and content of interpersonal representations have
been developed for use with the Rorschach (Blatt and Lerner, 1983; Blatt et al, 1976;
Mayman, 1967; Urist, 1977). In Exner’s system, the quality of interpersonal representations is
reflected in the content of scores. The number of human movement responses (M) and
associated cooperative (COP) vs. aggressive (AGG) or morbid (MOR) descriptors are
informative in this regard as are specific content scores, such as explosions, blood, and sex.
The Thematic Apperception Test (TAT) (Murray, 1943)
The TAT is particularly well suited for eliciting both the content and form of interpersonal
representations. Developed by Henry Murray in 1938, the TAT consists of 20 cards with
evocative and ambiguous images generally involving one or more people. Typically, only 10
cards are administered at a time. Subjects are instructed to tell a story about what is
happening in the picture, what led up to the picture, and what will happen afterwards.
Subjects are also asked what the characters are thinking and feeling. The ambiguity of the
images allows for personalized responses that reflect the subject’s characteristic modes of
processing interpersonal stimuli. This is the traditional aim of a projective test. The
naturalistic depictions, however, constrain variability, making it easier to identify atypical
responses.
Although there have been numerous scales developed to measure the TAT, most of these
scales measure targeted personality traits. Such measures include the Self Integration and
Self-Other Differentiation Scales (Fast et al, 1996), the Defense Mechanism Manual (DMM)
(Cramer 1988), The Social Cognition and Object Relations Scale (SCORS) (Westen et al,
1990) and the Personal Problem Solving Scale (PPSS) (Ronan et al, 1993). A review of meta-
analytic studies comparing the last three scales with other psychological measures suggested
comparable reliability and validity (Meyer, 2003). To date, however, there is no
comprehensive scoring system similar to Exners that provides normative data of
18
Psychological Testing in Inpatient Psychiatry
characteristic responses to each card. Consequently, the TAT is frequently used as a
qualitative measure.
Originally, Murray developed a quantifiable scoring system for the TAT (Murray, 1943;
Groth-Marnat, 1984). Clearly influenced by Freudian drive theory, Murray proposed
personality and behavior to result from the interplay of Needs and Presses. “Needs" refer to
motivational forces, such as affiliation, achievement, and aggression. “Presses” refer to the
actual or perceived environmental contingencies that impact on the expression of needs, e.g.,
nurturance, rejection, lack or loss. In Murray’s system, subjects’ responses to each card were
scored on 5-point scales according to the intensity of specific Needs and Presses along with
the outcomes of the story and the overall story themes. Unfortunately, adequate reliability and
validity were never established. Consequently the scoring system fell out of favor. Thus the
field awaits a comprehensive revision of Murray’s system which would a) be compatible with
contemporary models of personality and b) provide acceptable psychometric properties.
Nonetheless qualitative analysis of the TAT still affords significant information on the
content of basic interpersonal schemas despite the inherent limitations in quality control. This
is particularly true with psychiatric inpatients, whose TAT stories are often quite dramatic. It
must be noted, however, that such qualitative analysis should only be used in conjunction
with a much broader test battery and substantial background information about the patient.
While the TAT can serve as a useful addition to a test battery, it cannot stand alone.
Themes such as the perceived malevolence, trustworthiness, invasiveness or concern of
others or the perceived competence, isolation, dependency or self-reliance of the self can be
identified in subjects’ stories. In addition, coping and problem solving techniques may also be
evident, such as the presence or absence of delayed gratification, long-term planning, and
impulse control. Of particular relevance to inpatient psychiatry, themes of violence,
hopelessness and suicidality can also appear in TAT protocols. Likewise, Murray’s initial
descriptions of the cards and the typical themes they elicit can provide guidance for such a
qualitative analysis. Table 2 presents this information for select cards as presented in Murray
(1943) and Groth-Marnat (1984). Additional commentary is also provided, based upon the
author’s clinical experience with approximately 150 TAT protocols on inpatient and outpatient
psychiatric patients.
The formal properties of interpersonal representations can also be evaluated with the
TAT. Are the characters presented as uni-dimensional (an evil person) or as multi-faceted and
nuanced? Do they have distinct motivations or are they defined solely in response to each
other (e.g., she wants him to stay with her and he just wants to hurt her)? Is the story
appropriate to the image or does the subject inject unrelated material? Of course severe
incoherence in story structure may indicate psychosis.
Table 2. Murray’s Descriptions and Typical Themes for Select TAT Cards
Card
Number
Description Themes
19
Lisa J. Cohen
1 A young boy is contemplating a
violin which rests on a table in front
of him.
Typical stories emerging from this card revolve around a
rebellious boy being forced by his parents, or some other
significant authority figure, to play the violin, or around a
self-motivated boy who is daydreaming about becoming
an outstanding violinist. (Issues of aspiration, self-
discipline, and authority are common)
2 Country Scene: in the foreground is
a young woman with books in her
hand: in the background a man is
working in the fields and an older
woman is looking on.
Frequently encountered stories for this card involve a
young girl who is leaving the farm to increase her
education or to seek opportunities which her present
home environment cannot provide. Usually the family is
seen as working hard to gain a living from the soil, with
an overall emphasis on maintaining the status quo.
3BM On the floor against a couch is the
huddled form of a boy with his head
bowed on his right arm. Beside him
on the floor is a revolver.
The stories usually revolve around an individual who has
been emotionally involved with another person or who is
feeling guilty over some past behavior he has committed.
(Suicidal depression is also a frequent theme.)
4 A woman is clutching the shoulders
of a man whose face and body are
averted as if he were trying to pull
away from her.
Often the woman is seen as the advice giving moral agent
who is struggling with the more impulsive and irrational
man. In approximately half the stories, the vague picture
of a woman in the background is brought into the plot.
(Frequently, the woman is trying to dissuade the man
from abandoning her.)
5 A middle aged woman is standing
on the threshold of a half-opened
door looking into a room.
The most frequent plot is of a mother who either has
caught her child misbehaving or is surprised by an
intruder entering her house.
6BM A short elderly woman stands with
her back turned to a tall young man.
The latter is looking downward with
a perplexed expression.
The picture typically elicits stories of a son who is either
presenting sad news to his mother or attempting to
prepare her for his departure to some distant location. (A
mother and son concerned about his father or her
husband are also common)
7GF An older woman is sitting on a sofa
close beside a girl, speaking or
reading to her. The girl, who holds
a doll in her lap, is looking away.
The picture is usually perceived as a mother and her
daughter, with the mother advising, consoling, scolding,
or instructing the child. Less frequently, there are themes
where the mother is reading to the child for pleasure or
entertainment.
8BM An adolescent boy looks straight out
of the picture. The barrel of a rifle
is visible at one side, and in the
background is the dim scene of a
surgical operation, like a reverie-
image.
Stories revolve around either ambition, in that the young
man may have aspirations towards becoming a doctor, or
aggression. Frequently the aggressive stories related to
fears of becoming harmed or mutilated while in a passive
state. Another somewhat less frequent theme centers on
a scene in which someone was shot and is now being
operated on.
9BM Four men in overalls are lying on
the grass taking it easy.
Stories typically provide some sort of explanation of why
the men are there and frequently describe them either as
hoboes or as working men who are taking a much-needed
rest.
13MF A young man is standing with
downcast head buried in his arm.
Behind him is the figure of a
woman lying in bed.
The most frequent plot centers on guilt induced by illicit
sexual activity. Themes involving the death of the
woman on the bed and the resulting grief of the man,
who is often depicted as her husband, are somewhat less
frequent.
Table 2. (Continued).
Card
Number
Description Themes
18GF A woman has her hands squeezed Aggressive mother-daughter interactions or sibling
20
Psychological Testing in Inpatient Psychiatry
around the throat of another woman
whom she appears to be pushing
backwards across the banister of a
stairway.
relationships are often disclosed in response to this
picture.
Descriptions are obtained from Murray (1943) and themes from Groth-Marnat (1983). Italics are
drawn from the author’s clinical experience with approximately 150 inpatient and outpatient
protocols.
Additional Personality Tests
Evaluation of the content and formal qualities of interpersonal representations can give
general data about the presence and severity of character pathology. This can be critical when
attempting to discern whether target behavior is secondary to an axis I disorder or to character
pathology. As mentioned above, however, such information may not directly translate into
DSM-IV axis II diagnoses. For this purpose, there are many questionnaires and interviews
with well established psychometric properties. While the psychometric data increases
confidence in test results, the self-report nature of most of the axis II measures can be a
limitation, however. This is especially pertinent for psychiatric inpatients whose insight and
reliability as informants are often sub-optimal.
Structured Clinical Interview for DSM-IV Axis II (SCID-II) (First et al,1997)
The SCID II is a widely used semi-structured interview that assesses for the presence of
all of the axis II diagnoses in DSM IV as well as two of the diagnoses from Appendix B of the
DSM IV (passive aggressive and depressive personality disorder). There is a 119 item
questionnaire that can be given as a screening instrument. All items which the subject
endorses can be followed up in greater detail in the interview. While the screening
questionnaire has no validity scales to check for response bias, it does permit a much less
time-intensive evaluation.
Personality Disorder Interview-IV (PDI-IV) (Widiger et al, 1995)
Similar to the SCID-II, the PDI-IV is a semi-structured interview that assesses for the
presence of all DSM-IV axis II personality disorders plus passive aggressive (negativistic)
and depressive personality disorders from Appendix B. There are two versions of the PDI,
one in which the questions are arranged by topic (e.g., Attitudes towards self, Attitudes
towards others) and another in which the questions are arranged by diagnosis. There is no
screening questionnaire with the PDI-IV.
The Structured Interview for DSM-IV Personality (SIDP-IV) (Pfohl et al, 1997)
The SIDP-IV is also a semi-structured interview which assesses for all DSM-IV axis II
personality disorders. The SIDP-IV also includes passive aggressive, depressive and self-
defeating personality disorder as well as the criteria for sadistic personality disorder. Similar
to the PDI-IV, there are two versions, a thematic version that is arranged into 10 topics (e.g.,
Interests and Activities, Work Style, Close Relationships, Self-Perception) and a modular
version arranged by personality disorder. As with the PDI-IV, there is no screening
questionnaire.
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Lisa J. Cohen
The Personality Questionnaire-4 (PDQ-4) (Hyler, 1994)
The PDQ-4 is a self-administered questionnaire that assesses for all of the DSM-IV axis
II diagnoses. There are 85 items with two validity scales to measure response bias. The
presence or absence of each disorder is calculated along with the two personality disorders in
Appendix B. A total score is also calculated, measuring the overall degree of personality
disturbance. The Clinical Significance Scale provides a brief interview through which the
clinician can probe personality disorders that have been positively identified. Computerized
versions are also available.
Millon Clinical Multiaxial Inventory (MCMI-III) (Millon et al, 1997)
This 175-item, true-false, self administered questionnaire assesses for 14 DSM-IV axis II
diagnoses. The MCMI III also assesses 10 clinical syndromes, such as dysthymic, anxiety or
thought disorder. There are also 4 Correction scales (3 Modifying and 1 Validity scale) and 4
scoring methods, including hand scoring, computerized scoring, optical scanning or a mail-in
scoring service.
For more information on personality tests, the Handbook of Psychiatric Measures (APA,
2000) and the Comprehensive Handbook of Psychological Assessment, Volume 2, Personality
Assessment (Hilsenroth et al, 2003) are valuable resources.
CASE EXAMPLES
Three case examples will now be presented to illustrate the concepts discussed in this
chapter. The first example involves a fairly straightforward case of mild mental retardation.
The second case concerns comorbid diagnoses of schizophrenia and a nonverbal learning
disability. The third case addresses the complex interplay between major depression,
psychotic thought process, severe character pathology and organic brain disease.
Case 1
Case I involves a 27 year old male who had originally been admitted to medicine with
excessively high blood sugar levels. His apparent lack of concern about his poorly regulated
diabetes was attributed to a major depressive disorder. However, his presentation on the
psychiatric unit, along with his concrete thought process, suggested an additional diagnosis of
mental retardation. In order to obtain the appropriate outpatient services for him, an IQ test
was requested. The WAIS III scores are presented below.
WAIS III
22
Psychological Testing in Inpatient Psychiatry
FSIQ 56 (0.2%) VCI 61 (0.5%)
VIQ 57 (0.2%) POI 64 (1.0%)
PIQ 63 (1.0%) WMI 51 (0.1%)
PSI 66 (1.0%)
Verbal Subtests Score %tile Performance Subtests Score %tile
Vocabulary 3 1 Picture Completion 4 2
Similarities 3 1 Digit Symbol 4 2
Arithmetic 1 <1 Block Design 4 2
Digit Span 3 1 Matrix Reasoning 3 1
Information 3 1 Picture Arrangement 5 5
Comprehension 2 <1 Symbol Search 2 <1
Letter-Number Seq. 2 <1 Object Assembly 5 5
This WAIS III profile is consistent with mild retardation. While there is slight variation
across index scores and subtests, the patient performed at or below the 5 th percentile for all
tests. Further, none of the subtests significantly differ from the mean subtest score. That the
Working Memory Index significantly differs from the other three index scores is consistent
with his history of depression.
Case 2
Case 2 involves a 31 year old male who was admitted after escalated arguments with his
parents. He had an approximately 10 year psychiatric history, although his diagnosis was
unclear. Differential diagnoses included bipolar disorder, major depressive disorder with
psychotic features, and borderline personality disorder. The WAIS profile is listed below.
WAIS III
FSIQ 93 (32%) VCI 105 (63%)
VIQ 106 (66%) POI 76 (5%)
PIQ 77 (6%) WMI 99 (47%)
PSI 76 (5%)
Verbal Subtests Score %tile Performance Subtests Score %tile
Vocabulary 12 75 Picture Completion 9 37
Similarities 8 25 Digit Symbol-Coding 6 9
Arithmetic 12 75 Block Design 7 16
Digit Span 10 50 Matrix Reasoning 7 16
Information 14 91 Picture Arrangement 5 5
Comprehension 13 84 Symbol Search 4 3
Letter-Number
Sequencing
9 37
Of immediate interest is the significant discrepancy between VIQ and PIQ, which is
borne out by the similar contrast between the VCI and WMI vs. the POI and PSI. This
dramatic and consistent discrepancy points to a non-verbal learning disorder which
presumably predates his 10 year psychiatric history. Nonetheless, among the verbal tests, his
relative deficit in Similarities and Letter-Number Sequencing suggests some decrement in
23
Lisa J. Cohen
fluid intelligence, indicating possible deterioration from a higher level of baseline
functioning. His score of 8 on Similarities is in stark contrast to his other VCI scores
(Vocabulary = 12, Information = 14, Comprehension = 13) and points to deterioration in the
capacity for abstract thinking. This raises the question of a schizophrenic process.
His Rorschach profile is also illuminating. His R (number of responses) of 12 is well
below the mean and in fact too low to be considered a valid profile. At least 14 responses are
required to yield fully reliable quantitative data. Nonetheless, 8 out of his 12 responses (67%)
were pure form responses, 11 out of 12 (92%) had poor form quality, and there were 5 special
scores, three of which were quite serious (WSum6=14). Thus his reality testing was
extremely poor and there was evidence of thought disorder. Of note, his responses appeared
highly perseverative, which lead them to depart from the formal properties of the stimulus
blot. His use of color was also interesting. While the predominance of pure form is consistent
with affective constriction, color occurred only in color-dominated responses (2 CF-‘s), with
one form dominated shading response (FC’-). Thus when affect is expressed, it is poorly
mediated by cognition and consequently may be explosive. Overall this protocol is consistent
with a schizophrenic spectrum disorder. In response to this testing, the diagnosis was changed
accordingly, the anti-psychotic medication increased and the patient’s affect and relatedness
improved noticeably.
It must also be noted that his poor performance on the Rorschach may have been
confounded by his difficulty processing visual-spatial stimuli. This is a significant
consideration and may have also affected his effort, in that he was less likely to put full effort
into cognitive tasks that have traditionally been difficult for him. Nonetheless, taken together,
his grossly impaired Rorschach record, his history of poor occupational and social
functioning, his long psychiatric history, and his low Similarities score supported the
interpretation of psychosis above and beyond the influence of visual-spatial processing
deficits. The subsequent improvement of his mental status with increased antipsychotic
medication further supported this conclusion.
Case 3
Case 3 is more complex than the previous two cases. This involves a 58 year old woman
with a 40 year history of anorexia nervosa. For most of her adulthood she had a fairly high
level of functioning, having worked as a grade school teacher and lived in her own apartment.
More recently, however, she spent her entire inheritance in the space of two years, lost her
apartment, and ended up in a homeless shelter. On admission she was profoundly labile,
dysphoric and tearful. In an initial interview she admitted to a childhood history of sexual
abuse by a close female relative. Provisional diagnoses included major depressive disorder
with psychotic features, anorexia nervosa, and Cluster A personality disorder. The patient also
reported a history of seizure disorder and a fall during a seizure 5 years previously that caused
a skull fracture. As her abrupt decline in functioning suggested possible organic pathology, an
MRI was ordered. An old encephalomalocia in her left inferior temporal lobe cortex and an
ischemic lesion in the white matter of the left posterior frontal lobe were identified on MRI.
The encephalomalocia was attributed to contusion and therefore may have caused by her fall.
For the psychological evaluation, the WAIS III, Rorschach, TAT, several neuropsychological
tests, and the MCMI-II were administered. The WAIS results are presented below.
24
Psychological Testing in Inpatient Psychiatry
WAIS-III
FSIQ 112 (79%) VCI 124 (95%)
VIQ 122 (93%) POI 111 (77%)
PIQ 99 (47%) WMI 115 (84%)
PSI 73 (4%)
Verbal Subtests Score %tile Performance Subtests Score %tile
Vocabulary 14 91 Picture Arrangement 10 50
Similarities 16 98 Picture Completion 12 75
Information 13 84 Block Design 9 37
Comprehension 11 63 Matrix Reasoning 15 95
Arithmetic 12 75 Digit Symbol 4 3
Digit Span 15 95 Symbol Search 6 9
Letter-Number Seq. 11 63 Object Assembly 9 37
Her WAIS is remarkable for the degree of inter-test scatter. Her subtests range from the
98th percentile (Similarities) to the 3rd percentile (Digit Symbol). Her extremely strong VCI
speaks to a very high cognitive baseline. Most of the lowered test scores can be attributed to
psychomotor slowing. Likewise, her processing speed index is grossly impaired (PSI = 73,
4%). Moreover, her performance on Matrix Reasoning (15, 95%), which is untimed, was two
standard deviations higher than her performance on Block Design (9, 37%), which is time-
sensitive. The two tests measure fairly similar visual-spatial functions. There is also evidence
of a relative deficit on Letter-Number Sequencing, a test of working memory, although it still
falls in the average range (11, 63%). Additionally, her Comprehension score is surprisingly
lower than the VCI scores, suggesting a relative deficit in social processing, possibly of
longstanding.
The Rorschach is also striking. There were 16 responses, sufficient for a valid protocol.
Most notable were the number of special scores (Sum6=8). There were three Deviant
Responses, reflective of extraneous commentary, suggesting a difficulty restricting her
verbalizations to the task at hand.
“Maybe it’s a bear or a tiger skin, a hide hanging on the wall as a trophy. I hate hunting.
That was taken from a living creature while it still needed it. It’s a trophy to the
inhumanity of many humans.”
Additionally there were five special scores indicative of more serious thought disorder
(WSum6=21). There was an unusual amount of movement scores, with elephants dancing,
fish swimming and a volcano exploding. The large number of movement responses
(M+m+FM=13) is puzzling. It could reflect some degree of mania or a habitual focus upon
elaborated fantasy, consistent with her suggested Cluster A traits. There was also a
considerable number of art, anthropology, geography, and science content scores, which
reflect both a high level of education and a tendency to intellectualization (2AB + Art +
Ay:R=25%). Also of note was the unusual references to pure human emotion, scored as
human experience (Hx=4).
25
Lisa J. Cohen
“Something sinister and foreboding. Something to guard against…. It’s two projections
here and it is black and dark…. They are out to get somebody. They are sharp. There is
no friendly intention.”
In sum, the complexity of her Rorschach responses (Zsum=45, Blends:R= 35%) is
consistent with a high level of premorbid intelligence. The elevated number of special scores
points to a loosening of thought process. The predominant use of color, shading and human
experience responses suggests high affective reactivity and extremely poor emotional
regulation.
In this case, the TAT was particularly revealing. While the Rorschach did not disturb her,
she evidenced significant distress at several of the TAT cards. Her themes were predominantly
dysphoric with questions of suicidality occurring frequently. A focus on the historical and
cultural details of the images was consistent with her Rorschach protocol. Profound
difficulties with mother-child relationships were also evident as is illustrated in the responses
below.
Card 6BM
She’s the mother, he is the son. And he’s trying to communicate something important to
her but she’s looking out the window as an escape from the reality of what she knows her
son’s pain is. He walks away—he gives up. He has no one to talk to, no friends. Although he
is a man, he wanted a mother. It’s not that she can’t be a mother, it’s that she won’t – she’s
very selfish. (What caused the man’s pain?) He lost his job because of the emotional damage
done to him by this mother. He knows he is basically all alone. I think he’s going to kill
himself. (Long pause) She’ll find a way to escape that, too. And then she’ll draw attention to
herself, none to her son.
Card 7GF
The woman is the mother and the girl is the daughter. She’s not in the least bit interested
in the doll she’s holding. The mother is really trying—sincerely trying to be a good mother. I
think she’s holding a book – I’m not sure –but she’s reading to the daughter. She bought the
child pretty clothes, pretty barrettes for her hair, nice shoes and socks, but the girl …here it is
the mother who is the victim. Here is a girl who is emotionally disturbed and unable to
respond to the mother. The mother has a lot of love for her daughter but she doesn’t know
how to reach her. (How does it end?) The daughter is institutionalized and the mother is
broken-hearted. That doesn’t happen for a number of years, though. I think it’s in the 1940’s,
again because of the clothing, and the help the daughter needed was not available at that time.
Had she gotten the help she needed then, it wouldn’t be that way.
Her severely personalized and disorganized response to Card 5 is also notable, suggestive
of a dissociative response to experiences perceived as traumatic concurrent with an escapist
focus on intellectual pursuits.
Card 5
I like everything in this picture except the woman. Her face is one of shock and dismay. I
like the interior of the room – there are flowers, the lamp. I want to shut the door on her. The
books on the bookshelf are all my favorite books and I want to read them. I don’t want to help
26
Psychological Testing in Inpatient Psychiatry
her, I just want to shut her out. No compassion, and I do shut her out. There aren’t any happy
pictures? Only depressed ones?
Along with the obvious disturbances in content, the formal quality of the interpersonal
representations is also significant. Portrayals of the relationships and the individuals within
them are global, unidimensional, and entirely lacking in nuance. Relationships are depriving,
frustrating, and hurtful. Characters are either self-involved and withholding or victimized and
abandoned. There are no mixed emotions or motivational conflicts; nor is there any
complexity in mental states. Moreover, characters’ behaviors are solely determined by the
relationship to the other (“He lost his job due to the emotional damage done to him by his
mother.”) Thus the form and content of this patient’s interpersonal representations are
indicative of significant character pathology.
In order to test for neuropsychological impairment, several tests were administered. The
Controlled Oral Word Association (COWA) (Benton 1969, Ruff 1996), a test of verbal
fluency associated with left prefrontal function, showed no impairment. The Trailmaking test
(Lezak et al, 2004) was also administered. This measures set switching, an executive function
mediated by the prefrontal cortex. While her work was neat and accurate, her extreme
psychomotor slowing significantly impaired her performance. Thus it is unclear whether
slowed performance or executive dysfunction is implicated. On the Bender-Gestalt, a test of
visual-spatial function and planning (Brannigan and Decker, 2003), her designs were largely
accurate and well placed. When two of the last and most complex designs proved too difficult
for her, however, she responded with fairly disorganized scribbles across the right side of the
page. Thus when taxed, her problem solving abilities appear to break down.
Finally, the MCMI-II revealed elevations in schizoid, avoidant, and obsessive-compulsive
personality disorder scales.
To summarize, this protocol is consistent with significant affective reactivity and lability,
profound dysphoric affect, uneven but pronounced cognitive impairment in someone with
high premorbid intelligence, and moderate disorganization of thought. There appears to be
notable premorbid character pathology with particular disturbance of representations of
mother-child relationships. She also has evidence of dissociative and post-traumatic
responses. In conclusion, it appears that her current diagnosis involves a major depressive
disorder with psychotic features that is complicated by fronto-temporal lesions. Likewise her
premorbid character pathology is likely disinhibited by these lesions, rendering her grossly
unable to modulate her affect and exercise adequate judgment.
CONCLUSION
In conclusion, psychological testing on an inpatient unit offers unique challenges and
opportunities. The dramatic and often quite complex psychopathology of psychiatric
inpatients is well captured on test protocols and test findings can provide valuable input to aid
in differential diagnosis and treatment planning. In this chapter a hierarchical systems model
of mental processes was proposed as a conceptual framework within which to address the
27
Lisa J. Cohen
critical question of differential diagnosis. A stepwise approach to inpatient psychological
testing was then reviewed, starting with an assessment of possible confounds, then moving to
the assessment of cognitive function, axis I pathology and axis II pathology. Finally, case
examples were provided to illustrate the concepts discussed above.
REFERENCES
Andreasen, N. C. (1985). Positive and negative symptoms in schizophrenia: A critical
evaluation. Schizophrenia Bulletin, 11, 380-389.
Beck A.T., Freeman A., and Associates. (1990). Cognitive Therapy of Personality Disorders.
New York: Guilford Press.
Beck, S.J.(1944). Rorschach’s Test I: Basic Processes. New York: Grune and Stratton.
Benton, A. (1969) Differential behavioral effects in frontal lobe disease. Oral version of word
fluency test. Neuropsychologia, 6, 53-60.
Beversdorf, D.Q., Smith, B.W., Crucian, G.P., Anderson, J.M., Keillor, J.M., Barrett, A.M.,
Hughes, J.D., Felopulos, G.J., Bauman, M.L., Nadeau, S.E., Heilman, K.M. (2000)
Increased discrimination of “false memories” in autism spectrum disorder. Proceedings
of the National Academy of Sciences of the United States of America, 97, 8734-7.
Bilder, R.M., Goldman, R.S., Volavka, J., Czobor, P., Hoptman, M., Sheitman, B.,
Lindenmayer, J.P., Caron, M.J., Mottron, L., Berthiaume, C., Dawson, M. (2006).
Cognitive mechanisms, specificity and neuroal underpinnings of visuospatial peaks in
autism. Brain. 129(7),1789-1802.
Blatt, S.J., Brennis, B., Schimek, J.G., Glick, M. (1976). Normal development and
psychopathological impairment of the concept of the object on the Rorschach. Journal of
Abnormal Psychology, 85, 364-373.
Blatt, S.J. and Lerner, H. (1983). The psychological assessment of object representations.
Journal of Personality Assessment, 47,7-28.
Boddaert, N., Barthelemy, C., Poline, J.B., Samson, Y., Brunelle, F., Zilbovicius, M. (2005).
British Jouranl of Psychiatry, 187, 83-86.
Brannigan, G.G., Decker, S.L. (2003). Bender Visual-Motor Gestalt (Bender-Gestalt II).
Itasca, IL: Riverside Publishing.
Bretherton, I. (1993). From dialogue to internal working models: The co-construction of self
in relationships. In C. A. Nelson (Ed.) Minnesota Symposia on Child Psychology: Vol.
26. Memory and Affect in Development (pp.237-264.) Hillsdale, NJ: Erlbaum.
Buchanan, R.W., Breier, A., Kirkpatrick, B., Ball, P., Carpenter, W.T. (1998). Positive and
negative symptom response to clozapine in schizophrenic patients with and without the
deficit syndrome. American Journal of Psychiatry, 155,751-760.
Cattell, R. B. (1987). Intelligence: Its Structure, Growth, and Action. New York: Elsevier
Science Pub. Co.
Charlton, T. (1985). Locus of control as a therapeutic strategy for helping children with
behaviour and learning problems. Maladjustment and Therapeutic Education, 3(1), 26-
32.
28
Psychological Testing in Inpatient Psychiatry
Citrome, L., McEvoy, J., Kunz, M., Chakos, M., Cooper, T.B., Horowitz, T.L., Lieberman,
J.A. (2002). Neuropsychology of first-episode schizophrenia: Initial characterization and
clinical correlates. American Journal of Psychiatry, 157, (4): 549-559.
Cloninger, C.R. (1996). Assessment of the impulsive-compulsive spectrum of behavior by the
seven-factor model of temperament and character. In J.M. Oldham, E. Hollander, and
A.E. Skodol (Eds.) Impulsivity and Compulsivity, (pp. 59-95) Washington, DC: American
Psychiatric Press.
Cloninger, R.C., Svrakic, D.M., Prsybeck, T.R. (1993). A psychobiological model of
temperament and character. Archives of General Psychiatry, 50,975-990.
Cloninger, R.C. (1994). Temperament and personality. Current Opinion in Neurobiology,
25,189-96.
Cohen, L.J.(2005). The Neurobiology of Antisociality. In C. Stough (Ed.). Neurobiology of
Exceptionality (pp.107-124). New York: Kluwer Academic/Plenum.
Cohen, L.J., Stein, D., Galynker, I., and Hollander, E. (1997) Towards an integration of
psychological and biological models of OCD: Phylogenetic considerations. CNS
Spectrums: International Journal of NeuroPsychiatric Medicine, 2, 26-44.
Cramer, P. (1988). Threat to gender representations: identity and identification. Journal of
Personality 66, 335-357.
Crawford, J.R., Besson, J.A., Bremner, M. et al (1992). Estimation of premorbid intelligence
in schizophrenia. British Journal of Psychiatry, 161, 69-74.
Dickerson, F.B., Boronow, J.J., Stallings, C.R., Origoni, A.E., Cole, S., Yolken, R.H. (2004).
Associations between cognitive functioning and employment status of persons with
bipolar disorder. Psychiatric Services, 55,(2):54-58.
Douchemaine, D., Fontaine, R. (2003). Can fluid intelligence decline with aging be explained
by complexity? Vieillissement et Developpement Adulte: Cognition, Rhymicite et
Adaption. Tours, France: Universite Francois Rabelais (pp.1-4) http://www.univtours.
fr/ed/ edsst/comm2003/douchemane.pdf.
Engle, R.W., Tuholski, S.W., Laughlin, J.E., Conway, A.R. (1999). Working memory, short-
term memory, and general fluid intelligence: a latent-variable approach. Journal of
Experimental Psychology General, 128, (3):309-31.
Exner, J.E. (1986). Some Rorschach data comparing schizophrenics with borderline and
schizotypal personality disorders. Journal of Personality Assessment, 50, (3),455-471.
Exner, J.E. (1997). The Rorschach: A Comprehensive System. Vol. 1, Basic Foundations and
Principles of Interpretation. (4th edition). Hoboken, NJ: John Wiley and Sons.
Fast, I. (1985). Event Theory: A Piaget-Freud Integration. Hillsdale, NJ, Erlbaum, N.J.
Fast, I., Marsden, G., Cohen, L., Heard, H., and Kruse, S.. (1996). The self as subject: A
formulation and an assessment strategy. Psychiatry,59, 34-47.
First, M., Gibbon, M., Spitzer, R.L., Williams, J.B.W. (1997). Structured Clinical Interview
for DSM-IV Axis II Personality Disorders (SCID II.) Washington, D.C.: American
Psychiatric Press.
First, M.B., Spitzer, R.L., Williams, J.B.W. et al. (1997). Structured Clinical Interview for
DSM-IV – Clinician Version (SCID-CV) (User’s Guide and Interview). Washington D.C.:
American Psychiatric Press.
Folstein, M.F., Folstein, S.E., McHugh, P.R. (1975). “Mini-Mental State”: A practical method
for grading the cognitive state of patients for the clinician. Journal of Psychiatric
Research, 12, 189-198.
29
Lisa J. Cohen
Goldberg, E. (2001). The Executive Brain: Frontal Lobes and the Civilized Mind. New York:
Oxford.
Golden, C. J., Freshwater, S. M. (2001). Luria-Nebraska Neuropsychological Battery, In W. I.
Dorfman and M. Hersen (Eds.).Understanding Psychological Assessment: Perspectives
on Individual Differences. New York: Kluwer Academic/Plenum Publishers.
Goodman, W.K., Price, L.H., Rasmussen, S.A., Mazure, C., Fleischmann, R.L., Hill, C.L.,
Heninger, G.R., Charney, D.S. (1989). The Yale Brown Obsessive Compulsive Scale, I:
Development, use, and reliability. Arch Gen Psychiatry, 746,1006-1011.
Groth-Marnat, G. (1984). Handbook of Psychological Assessment. New York: Van Neustrand
Reinhold.
Gunderson, J.G., Weinberg, I., Daversa, M.T., Kueppenbender, K.D., Zanarini, M.C., Shea,
M.T., Skodol, A.E., Sanislow, C.A., Yen, S., Morey, L.C., Grilo, C.M., McGlashan, T.H.,
Stout, R.L., Dyck I. (2006) Descriptive and longitudinal observations on the relationship
of borderline personality disorder and bipolar disorder. American Journal of Psychiatry,
163,(7):1173-8.
Hamilton, A. (1980). Rating depressive patients. J Clin Psychiatry, 41,(12):21-24.
M.Hersen, M. J. Hilsenroth, D.L. Segal (Eds.) (2003). Comprehensive Handbook of
Psychological Assessment, Volume 2, Personality Assessment. Hoboken, NJ: John Wiley
and Sons.
Hertz, M.R. (1942). Frequency Tables for Scoring Rorschach Responses. Cleveland: Western
Reserve University Press.
Horn, J.L. and Cattell, R.B. (1966) Refinement and test of the theory of fluid and crystallized
general intelligence Journal of Educational Psychology, 57,253-270.
Hyler, E. (1994). Personality Diagnostic Questionnaire—4. New York: New York State
Psychiatric Institute.
Joyce, E.M., Hutton, S.M., Mutsatsa, S.H., Barnes, T.R.E. (2005). Cognitive heterogeneity in
first-episode schizophrenia. The British Journal of Psychiatry, 187(6), 516-522.
Kaplan, E., Goodglass, H., Weintraub, S. (1983).The Boston Naming Test. Philadelphia: Lea
and Febiger.
Kay, S.R., Opler, L.A., Fiszbein, A. (1994). Positive and Negative Symptoms Scale Manual.
North Tonawanda, NY: Multi Health Systems.
Kernberg, O. (1975) Borderline Conditions and Pathological Narcissism. Dunmore, PA:
Jason Aronson.
Klopfer, B., Ainsworth, M.D., Klopfer, W.G., and Holt, R.R. (1954). Developments in the
Rorschach Technique. I. Technique and Theory. Yonkers-on-Hudson, NY: World Book.
Kohut, H. (1968). The psychoanalytic treatment of narcissistic personality disorders: Outline
of a systematic approach. The Psychoanalytic Study of the Child. 23, 86-113.
LeSeur, H.R., Blume, S.B. (1987). The South Oaks Gambling Screen (SOGS): A new
instrument for the identification of pathological gamblers. American Journal of
Psychiatry, 144,1184-1188.
Lezak, M.D., Howieson, D.B., Loring, D.W. (2004). Neuropsychological Assessment 4th
Edition. New York: Oxford University Press.
Linahan, M.M. (1993). Skills Training Manual for Treating Borderline Personality Disorder.
New York: The Guilford Press.
Main, M., Kaplan, N., and Cassidy, J. (1985), Security in infancy, childhood and adulthood: A
move to the level of representation. In I. Bretherton and E. Waters (Eds.) Growing points
30
Psychological Testing in Inpatient Psychiatry
of attachment theory and research. Monographs of the Society of Research in Child
Development, 50(2-3, Serial No. 209), 66-104.
Marmor, J. (1983). Systems thinking in psychiatry: some theoretical and clinical implications.
American Journal of Psychiatry,140, 833-838.
Mattis, S. (1988). Dementia Rating Scale: Professional Manual. Odessa, FL: Psychological
Assessment Resources.
Mayman, M. (1967), Object representations and object relationships in Rorschach responses.
Journal of Projective Techniques and Personality Assessment, 32, 303-316.
Meyer, G.J. (2003). The reliability and validity of the Rorschach and Thematic Apperception
Test (TAT) compared to other psychological and medical procedures: An analysis of
systematically gathered evidence. In M.J. Hilsenroth, D.L. Segal, M. Hersen (Eds.),
Comprehensive Handbook of Psychological Assessment, Volume 2, Personality
Assessment. Hoboken, NJ: John Wiley and Sons.
Meyer, G..J, Archer, R.P. (2001). The hard science of Rorschach research: What do we know
and where do we go? Psychological Assessment, 13, (4) 486-502.
Millon, T., Davis, R., Millon, C. (1997). MCMI-III Manual, 2nd edition. Minneapolis, MN:
National Computer Systems.
Minshew, N., Goldstein, G. (2001). The pattern of intact and impacted memory functions in
autism. Journal of Child Psychology and Psychiatry, 42,(8) 1095-1101.
Mitchell, S.A. (1988). Relational Concepts in Psychoanalysis: An Integration. Cambridge,
Mass: Harvard University Press.
Mitrushina, M., Boone, K.B., Razani, J., D'Elia, L.F. (2005). Handbook of Normative Data
for Neuropsychological Assessment, 2nd Ed. New York: Oxford University Press, Inc.
Mottron, L. (2004). Matching strategies in cognitive research with individuals with high-
functioning autism: Current practices, instrument biases and recommendations. Journal
of Autism and Developmental Disorders, 34,(1):19-27.
Murray, H.A. (1943). Thematic Apperception Test Manual. Cambridge, MA: Harvard
University Press.
Pfohl, B., Blum, N., Zimmerman, M. (1997). Structured Interview for DSM-IV Personality.
Washington, D.C.: American Psychiatric Press.
Piaget, J. (1986/1954) The Construction of Reality in the Child. New York, Basic Books.
Rapoport, D., Gill, M., and Schafer, R. (1946). Diagnostic Psychological Testing. Volumes 1
and 2. Chicago: Yearbook Publishers.
Reitan, R.M., Wolfson, D. (1993). The Halstead Reitan Neuropsychological Test Battery:
Theory and Clinical Applications (2nd Ed.) Tucson, Az: Neuropsychology Press.
Ronan, G.F., Colavito, V.A., Hamontree, S.R. (1993). Personal Problem-Solving System for
scoring TAT responses: Preliminary validity and reliability data. Journal of Personality
Assessment, 61, 28-40.
Ruff, R.M., Light, R.H., Parker, S.B. (1996) Benton Controlled Oral Word Association Test:
Reliability and updated norms. Archives of Clinical Neuropsychology,11,329-338.
Sabelli, H.C., Carlson-Sabellim L. (1989). Biological priority and psychological supremacy: a
new integrative paradigm derived from process theory. American Journal of Psychiatry,
146, 1541-1551
Sadock, B.J., Sadock, V.A. (2004). Kaplan and Sadock’S Synopsis of Psychiatry: Behavioral
Sciences/Clinical Psychiatry, 9th Edition. Philadelphia, PA: Lippincott Williams and
Wilkins.
31
Lisa J. Cohen
Salmond, C.H., Ashburner, J., Connelly, A., Friston, K.J., Gadian, D.G., Vargha-Khadem, F.
(2005). The role of the medial temporal lobe in autistic spectrum disorders. European
Journal of Neuroscience, 22(3):764-72.
Schafer, R. (1954). Psychoanalytic Interpretation in Rorschach Testing. New York: Grune and
Stratton.
Schwartz, G.E. (1981) A systems analysis of psychobiology and behavior therapy:
Implications for behavioral medicine. Psychotherapy and Psychosomatics, 36,159-184.
Siegel, D.J. (1999). The Developing Mind: How Relationship and the Brain Interact to Shape
Who We Are. New York: The Guilford Press.
Society for Personality Assessment. (2005). The status of the Rorschach in clinical and
forensic practice: An official statement by the Board of Trustees of the Society for
Personality Assessment. Journal of Personality Assessment, 85, (2): 219-237.
Spreen, O. and Strauss, E. (1998). A Compendium of Neuropsychological Tests (2 nd Ed.). New
York: Oxford University Press.
Stuss, D.T., Picton, T.W., Alexander, M.P. (2001). Consciousness, self-awareness, and the
frontal lobes. In S.P. Salloway, P.F. Malloy, J.D. Duffy (Eds.) The Frontal Lobes and
Neuropsychiatric Illness. Washington, D.C.: American Psychiatric Publishing, Inc.
Subbotsky, E. (2004). Magical thinking in judgments of causation: Can anomalous
phenomena affect ontological causal beliefs in children and adults? British Journal of
Developmental Psychology, 22,(1):123-152.
Task Force for the Handbook of Psychiatric Measures (Eds.). (2000). Handbook of
Psychiatric Measures. Washington, DC: American Psychiatric Association.
Taylor, B.P., Bruder, G.E., Stewart, J.W., McGrath, P.J., Halperin, J., Ehrlichman, H., Quitkin,
F.M. (2006). Psychomotor slowing as a predictor of fluoxetine nonresponse in depressed
outpatients. American Journal of Psychiatry, 163, (1), 73-78.
Toichi, M., Kamio, Y. (2002). Long-term memory and levels-of-processing in autism.
Neuropsychologia, 40,(7):964-9.
Te Wildt, B.T., Schultz-Venrath, U. (2004). Magical ideation—Defense mechanism or
neuropathology? A study with multiple sclerosis patients. Psychopathology, 37,141-144.
Urist, J. (1977). The Rorschach test and the assessment of object relations. Journal of
Personality Assessment, 41, 3-9.
von Bertolanffy, L. (1968) General Systems Theory. New York, Braziller.
Wechsler, D. (2002). WAIS-III, WMS-III Technical Manual—Updated. San Antonio, TX:
Psychological Corporation.
Werner, H., Kaplan, B.(1984/1963). Symbol Formation. Hillsdale, NJ: Erlbaum.
Westen, D., Lohr, N., Silk, K.R., Gold, L., Kerber, K. (1990). Object relations and social
cognition in borderlines, major depressives, and normals: A Thematic Apperception Test
analysis. Psychological Assessment, 2, 355-364.
Widiger, T.A., Mangine, S., Corbitt, E.M., Ellis, C.G., Thomas, G.V (1995). Personality
Disorder Interview-IV: A Semi-Structured Interview for the Assessment of Personality
Disorders. Odessa, Fla: Psychological Assessment Resources.
Williams, D.L., Goldstein, G., Carpenter, P.A., Minshew, N.J.(2005) Verbal and spatial
memory in autism. Journal of Autism and Developmental Disorders,35, (6):747-756.
Wood, J.M., Paso, M.T., Garb, H.N., Lilienfeld, S.O. (2001) The misperceptions of
psychopathology: Problems with the norms of the comprehensive system for the
Rorschach. Clinical Psychology: Science and Practice, 8,(3) 350-373.
32
Psychological Testing in Inpatient Psychiatry
Young, J.E. (1990). Cognitive Therapy For Personality Disorders: A Schema-Focused
Approach. Sarasota, FL: Professional Resource Exchange.
Young, R.C., Biggs, J.T., Ziegler, V.E., Meyer, D.A. (1978). A rating scale for mania:
Reliability, validity, and sensitivity. British Journal of Psychiatry, 133,429-435.
33
... When early childhood relationships have been harmful to psychological development, for example through lack of validation (Linehan, 1993), inadequate parental attunement (Fonagy et al., 2010), or outright maltreatment (Cohen et al., 2013), the resultant interpersonal schemas can become inflexible, crudely organized, lacking in nuance, and negative in tone (Caligor and Clarkin, 2010;Cohen, 2007;Fonagy et al., 2010). In turn, these maladaptive schemas provide the foundation of personality pathology in adulthood (Caligor and Clarkin, 2010;Cohen, 2007;Fonagy et al., 2010). ...
... When early childhood relationships have been harmful to psychological development, for example through lack of validation (Linehan, 1993), inadequate parental attunement (Fonagy et al., 2010), or outright maltreatment (Cohen et al., 2013), the resultant interpersonal schemas can become inflexible, crudely organized, lacking in nuance, and negative in tone (Caligor and Clarkin, 2010;Cohen, 2007;Fonagy et al., 2010). In turn, these maladaptive schemas provide the foundation of personality pathology in adulthood (Caligor and Clarkin, 2010;Cohen, 2007;Fonagy et al., 2010). ...
... As described above, a schema model of BPD provides an explanatory framework of the underlying reason why these two classes of disorders differ (Caligor and Clarkin, 2010;Cohen, 2007;Fonagy et al., 2010;Nigg et al., 1992;Westen et al., 1990). The present study supports a critical aspect of the schema model of BPD, namely that maladaptive schemas play a privileged role in BPD but not mood disorders. ...
Article
Background: Despite a robust literature documenting the relationship between childhood maltreatment and personality pathology in adulthood, there is far less clarity about the mechanism underlying this relationship. One promising candidate for such a linking mechanism is disturbance in the sense of self. This paper tests the hypothesis that disturbances in the sense of self mediate the relationship between childhood maltreatment and adult personality pathology. Specifically, we assess the self-related traits of stable self-image, self-reflective functioning, self-respect and feeling recognized. Methods: The sample included 113 non-psychotic psychiatric inpatients. Participants completed the Child Trauma Questionnaire (CTQ), the Personality Diagnostic Questionnaire-4 (PDQ-4+), and the self-reflexive functioning, stable self image, self-respect, and feeling recognized scales from the Severity Indices of Personality Problems (SIPP-118). A series of linear regressions was then performed to assess the direct and indirect effects of childhood trauma on personality disorder traits (PDQ-4+ total score), as mediated by self concept (SIPP-118 scales). Aroian tests assessed the statistical significance of each mediating effect. Results: There was a significant mediating effect for all SIPP self concept variables, with a full mediating effect for the SIPP composite score and for SIPP feeling recognized and self-reflexive functioning, such that the direct effect of childhood trauma on personality did not retain significance after accounting for the effect of these variables. There was a partial mediating effect for SIPP stable self image and self-respect, such that the direct effect of the CTQ retained significance after accounting for these variables. SIPP feeling recognized had the strongest mediating effect. Conclusions: Multiple facets of self concept, particularly the degree to which an individual feels understood by other people, may mediate the relationship between childhood maltreatment and adult personality pathology. This underscores the importance of attending to disturbances in the sense of self in patients with personality pathology and a history of childhood maltreatment. These findings also support the centrality of disturbed self concept to the general construct of personality pathology.
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