Chapter 10: Psychological Assessment of Patients with Behavioral Symptoms

Intro

Introduction

The evaluation of patients who show abnormal behavior typically occurs in the context of the clinical interview (see Chapter 24). The psychiatric history and structured instruments, such as the mental status examination (MSE) and Beck Depression Inventory (BDI), are also used in the evaluation of such patients.

Evaluation instruments can be administered to an individual or to a group of individuals at one time. Individually administered tests allow careful observation and evaluation of that person. Tests given to a group of people simultaneously have the advantages of efficient administration, grading, and statistical analysis. Tests commonly used in the psychological evaluation of patients fall into three main categories: intelligence, achievement, and personality/psychopathology (Table 10-1).

Table 10.1 Commonly Used Intelligence, Achievement, Attention and Concentration, and Personality/Psychopathology Tests

Type of Test Specific Test
Intelligence Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV)
Wechsler Intelligence Scale for Children (WISC)
Wechsler Preschool and Primary Scale of Intelligence (WPPSI)
Stanford-Binet Intelligence Scale
Achievement Scholastic Aptitude Test (SAT)
Medical College Admissions Test (MCAT)
United States Medical Licensing Examination (USMLE)
Wide-Range Achievement Test (WRAT)
California, Iowa, Stanford, and Peabody Achievement Tests
Woodcock-Johnson Psychological and Educational Battery
Attention and concentration Wisconsin card sort
Digit span (component of the WAIS and Mini-Mental State Exams)
Personality and psychopathology Minnesota Multiphasic Personality Inventory (MMPI)
Rorschach Test
Sentence Completion Test (SCT)
Thematic Apperception Test (TAT)
Mental Status Examination (MSE)
Beck Depression Inventory-II (BDI-II)
Zung Self-Rating Depression Scale
Hamilton Rating Scale for Depression (HAM-D)
Raskin Depression Scale

Psychiatric Evaluation

The psychiatric history

A patient’s psychiatric history is taken as part of the medical history. Although both histories focus on gathering factual information to define the chief complaint and determine the background of the current illness, the psychiatric history also investigates the patient’s personality characteristics, relationships with others, and sources of stress. Aspects of the psychiatric history are summarized in Table 10-2.

Table 10.2 Areas Addressed in the Psychiatric History

Early Childhood (0–3 Years) Childhood (3–11 Years) Adolescence (11–20 Years) and Adulthood (>20 Years)
Background
 

  • Normal pregnancy and delivery?
  • Wanted child?
  • Feeding, sleep, and toilet training?
  • Timely development of motor and social skills?
  • Caretakers other than mother?
 

  • School history and skill development?
  • Learning disabilities?
  • Punishment methods used in the home?
  • Response to first separation from mother?
 

  • Employment history?
  • Legal history?
  • Psychiatric history of family members?
  • Military service?
  • Level of education achieved?
  • Religious activities?
  • Current living situation?
Personal characteristics
 

  • Parental and sibling relationships?
  • Personality (e.g., shy or outgoing, active or passive)?
  • Temperament (e.g., easy, difficult, slow to warm up)?
 

  • Peer relationships (e.g., follower, leader, popular)?
  • Personality (e.g., assertive, anxious)?
  • Presence of unrealistic fears?
  • Cruelty to animals, bed wetting?
 

  • Emotional problems?
  • Drug and alcohol use?
  • Role models?
  • Social relationships?
  • Sexuality?

The MSE and related instruments

The MSE is a comprehensive survey used to evaluate an individual’s current state of mental functioning. The MSE assesses a variety of characteristics, including general presentation (appearance, behavior, attitude toward the examiner, and level of consciousness); cognition (orientation, memory, attention and concentration, cognitive ability, and speech); emotional state (mood and affect); thought (form or process, content); perception; judgment and insight; and reliability and impulse control (Table 10-3). Terms used to describe psychophysiologic symptoms and mood in patients with psychiatric illness are listed in Table 10-4.

Table 10.3 The Mental Status Examination

Category Characteristic Example Indicating Need for Further Evaluation
Presentation
Appearance Posture
Grooming
Appearance for age
Clothing
Has a hunched-over posture while standing
Is unshaven
Appears older than his chronological age
Is wearing a heavy coat on a hot day
Behavior Mannerisms
Psychomotor behavior
Tics
Shows unusual facial expressions or hand movements
Seems physically speeded up (agitated) or slowed down (retarded)
Uses repetitive, nonproductive movements
Attitude toward the examiner Cooperative
Seductive
Hostile
Defensive
Is not helpful
Behaves in a sexually provocative fashion
Seems angry
Seems to take remarks personally
Level of consciousness Consciousness
Lethargy
Sleepiness
Has a Glasgow Coma Scale of 10 (see Chapter 6)
Seems mentally slowed down
Dozes off repeatedly
Cognition
Orientation Person
Place
Time
Does not know her name or with whom she lives
Does not know where she is
Does not know the year, day, or time
Memory Immediate
Recent
Remote
Cannot remember three words when questioned after 5 minutes
Cannot remember her activities during the last 12 hours
(verify information to rule out confabulation, that is, filling in memory gaps with false information)
Cannot remember where she was born
Attention and concentration Attention
Concentration
Cannot pay attention to you without being distracted by other stimuli
Cannot repeat a string of three to six numbers forward and backward (digit span) or spell the word “world” backward
Cognitive ability Verbal ability
Spatial ability
Abstraction ability
Cannot read a simple paragraph of text; cannot tell you how many states make up the United States
Cannot copy a simple drawing
Cannot describe how a pear and an apple are alike
Cannot explain the meaning of the proverb, “People who live in glass houses should not throw stones”
Speech Timbre
Speed
Articulation
Deficiencies in language
Speaks too softly
Speech is pressured (seems compelled to speak quickly)
Speech is not readily understandable
Uses words poorly or has a poor vocabulary
Emotional state
Mood Describes feeling depressed (low, hopeless, helpless, suicidal) or manic (high, euphoric, irritable)
Affect Shows decreased (blunted, restricted, or flat) external expression of mood
Congruence Described mood and visible affect are dissimilar
Appropriateness Is laughing while telling a sad story
Thought and perception
Form or process (associations between thoughts) Flight of ideas
Perseveration
Echolalia
Has thoughts that move rapidly from one to the other
Repeats thoughts over and over
Responds to the rhyming sounds rather than to the meaning of a word
Content Compulsions
Obsessions
Phobias
Delusions
Idea of reference
Cannot refrain from performing an act (e.g., washing his hands)
Cannot get a thought out of his head (e.g., his hands have germs all over them)
Has irrational fears (e.g., is afraid to eat in a public place)
Has a false belief (e.g., is convinced that spies are after him)
Believes that things in the outside world refer to him (e.g., is sure that an actor in a movie is talking about him)
Perception Illusions
Hallucinations
Depersonalization and derealization
Misinterprets reality (e.g., thinks that a toy on the floor in a dark room is a live pet)
Has false sensory perceptions (e.g., feels insects crawling on his skin when none exist)
Has a feeling of being outside of himself or the environment (e.g., believes he is watching himself in a play)
Judgment and insight
Judgment and insight Judgment
Insight
Gives an unusual response to a hypothetical situation (e.g., says she would discard a stamped, addressed letter found on the sidewalk)
Does not realize that her thoughts and perceptions are not rational (e.g., says that she washes her hands excessively because they have “germs all over them”)
Reliability and impulse control Truthfulness
Aggressive and sexual impulses
Provides incorrect information about previous hospitalizations (based on information from family or friends as well as clinical judgment)
Cannot control impulses (based on the history and current behavior)

Table 10.4 Glossary of Psychophysiology States

Mood
Euphoric mood: strong feelings of elation
Expansive mood: feelings of self-importance and generosity
Irritable mood: easily annoyed and quick to anger
Euthymic mood: normal mood, with no significant depression or elevation of mood
Dysphoric mood: subjectively unpleasant feeling
Anhedonic mood: inability to feel pleasure
Labile mood (mood swings): alternations between euphoric and dysphoric moods
Affect
Restricted affect: decreased display of emotional responses
Blunted affect: strongly decreased display of emotional responses
Flat affect: complete lack of emotional responses
Labile affect: sudden alterations in emotional responses not related to environmental events
Fear and anxiety
Fear: fright caused by real danger
Anxiety: fright caused by perceived danger
Free-floating anxiety: fright not associated with any specific cause
Consciousness and attention
Normal: alert, can follow commands, normal verbal responses
Clouding of consciousness: inability to respond normally to external events
Somnolence: abnormal sleepiness
Stupor: responds only to shaking, shouting, and prodding
Coma: total unresponsiveness to stimuli

Rating scales for depression

The BDI-II is a commonly used self-rating scale containing 21 items (Table 10-5). Each item on the BDI-II has four possible answers scored from 0 to 3 (lowest to highest level of depression); 63 is the highest total score. For example, for item number 5, guilt, the patient must choose one of the following four choices:

  • I do not feel particularly guilty = 0 points
  • I feel bad or unworthy a good part of the time = 1 point
  • I feel quite guilty = 2 points
  • I feel as though I am very bad or worthless = 3 points

Table 10.5 Items in the Beck Depression Inventory-II (BDI-II)

1. Sadness
2. Pessimism
3. Sense of failure
4. Dissatisfaction
5. Guilt
6. Expectation of punishment
7. Dislike of self
8. Self-blame
9. Suicidal ideation
10. Episodes of crying
11. Irritability
12. Social withdrawal
13. Indecisiveness
14. Negative body image
15. Inability to work
16. Insomnia
17. Fatigability
18. Loss of appetite
19. Loss of weight
20. Preoccupation with health
21. Low level of sexual interest

Because the BDI-II asks about the presence of depression directly and is easy to administer, it is particularly useful in primary care.

Other rating scales of depression include the Zung, Hamilton, and Raskin scales. Using the Zung Self-Rating Depression Scale, the patient rates herself with respect to symptom severity. With the Hamilton Rating Scale for Depression (HAM-D), the examiner interviews and rates the patient from 0 to 4 on characteristics such as work and activities, anxiety and somatic symptoms, and feelings of guilt, helplessness, hopelessness, and worthlessness. On the Raskin Depression Scale, the patient is rated using his or her own verbal report and on displayed behavior and secondary symptoms.

Intelligence

Intelligence versus achievement

Intelligence and achievement, although related, are different entities. Achievement is a culture-specific measure of knowledge and skills acquired from education and experience. In contrast, intelligence is a measure of an individual’s innate potential for learning. Intelligence is quantified by the ability to reason; to think logically and come to a conclusion; to understand abstract concepts; to assimilate, recall, analyze, and organize information; and to meet the special needs of new situations.

Determinants of intelligence

Monozygotic twins tend to have equivalent intelligence even if they are raised in separate households. Approximately one-half of the difference between one person’s intelligence test score and the scores of unrelated others (the variance) can be explained by genetic factors [Bouchard et al., 1990]; [Weiss, 1992]; [Plomin et al., 1994]. Biological factors that negatively affect intelligence include poor nutrition and illness early in life. Environmental factors (such as exposure to educational enrichment), social factors (such as a good parent–child relationship), and emotional factors (such as a positive response to a testing situation) can influence performance on intelligence tests.

Ethnic differences can affect performance on intelligence tests. Comparisons between the two largest ethnic groups suggest that white Americans tend to score higher than African Americans. Because intelligence tests use culture-specific language and tend to reflect the values and knowledge of American middle-class white culture, this difference in test performance has been attributed primarily to cultural and socioeconomic factors [Helms, 1992].

In the absence of brain pathology, intelligence is relatively stable throughout life. Although an individual’s intelligence is essentially the same in old age as in childhood, a characteristic decrease in processing speed with age can affect performance on timed aspects of standardized intelligence tests.

Mental age, chronological age, and IQ

Many instruments have been developed to assess intelligence. One of the first, devised by Alfred Binet, presented the construct of mental age (MA). In this view, MA reflects a person’s level of intellectual functioning. For example, a child with a test score that reveals an MA of 8 is functioning like an average 8 year old. Because MA has an obvious relationship with actual or chronological age (CA), Binet’s scale was later adapted to include the age variable, and the concept of intelligence quotient (IQ) was produced. Operationally, IQ is the ratio of MA to CA times 100; an equation expressed as MA/CA × 100 = IQ. Because an equal numerator and denominator result in 1, an IQ of 100 means that the person’s MA and CA are equivalent. A 10-year-old child with an MA of 10 years thus has an IQ of 100. A 10-year-old child with an MA of 9 has an IQ of 90. Because normal IQ varies within the range of 90 to 109, both of these children are considered average or normal. A child of age 10 years with an MA of 12 has an above-average IQ at 120.

Case 10.1

The Patient

A 25-year-old medical student is brought to the hospital by his brother after he accused his parents of trying to kill him. The brother says that the patient has been behaving strangely for the past 2 weeks, ever since he failed a microbiology examination. The patient is unkempt, unshaven, and agitated but shows no evidence of drug or alcohol abuse. When given the MSE (see Table 10-5), the patient listens and responds to the examiner with understandable speech. He is oriented times 3 (to person, place, and time) and, although he seems distracted, shows immediate, recent, and remote memory function. Although he cannot spell the word “world” backward, he reads a paragraph clearly and is able to multiply 3 times 8. When asked how an apple and an orange are alike he says that they are both globes and that a voice in his head told him not to eat anything cold. Medical examination and laboratory testing are unremarkable.

Comment

This student is showing evidence of psychotic thinking, such as paranoia (belief that he will be killed), hearing voices, inability to concentrate (inability to spell the word “world” backward), and poor abstraction ability (explaining that an apple and an orange are both globes) despite normal consciousness and memory. Because the symptoms have been present for only 2 weeks and began after a stressful life event (the exam failure), the best diagnosis at this time is brief psychotic disorder. If the symptoms persist for 1 to 6 months, the diagnosis changes to schizophreniform disorder. Persistence longer than 6 months suggests schizophrenia (see Chapter 12).

Management

The emergency room management of psychotic patients like this young man typically involves use of antipsychotic medication. Although high-potency dopamine-2 receptor antagonists such as haloperidol (Haldol) work quickly, atypical agents such as risperidone (Risperdal) and olanzapine (Zyprexa) have better side effect profiles than haloperidol, particularly in young men (see Chapter 19).

Because MA does not increase measurably after age 15 years, 15 is usually the highest number used in the denominator of the IQ formula. For example, a 20-year-old man with an MA of 10 years has an IQ of 10/15 × 100 = 67 (not 10/20 = 50).

The standard deviation (see Appendix) in IQ scores is about 15 points. Although other factors such as level of social functioning are considered, a person with an IQ that is more than two standard deviations below the mean (IQ = 70) fits into the category of mental retardation or intellectual disability (see Chapter 2). An IQ score between 71 and 84 indicates borderline intellectual function, and a person with an IQ more than two standard deviations above the mean (IQ ;130) has superior intelligence. DSM-IV-TR classifications of intellectual disability are

  • Mild (IQ 50 to 70): Function at about sixth grade level
  • Moderate (IQ 35 to 55): Function at about second grade level
  • Severe (IQ 20 to 40): Function below grade school level
  • Profound (IQ ; 20): Function significantly below grade school level

The overlap or gap in IQ in these categories is related to differences in testing instruments.