Question for Psychiatrists who work with Neuropsychologists

[WisNeuro]

For those of you who work with and/or refer to Neuropsychology within your practice, how do you view performance and symptom validity testing. My experience is it's really bimodal. Some providers who really value the input when a patient performs at certain levels, but other providers who completely disregard the PVT/SVT findings, even when they are very clearly invalid.

Just curious as to what your general exposure to these types of instruments is and how you interact with them.

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[Shikima]

TBH I don't have a lot of knowledge in remarking on this personally. I'm sure others can. I just know if I can trust the validity of a test based on the discussion looking at the differential provided.

 

[WisNeuro]

TBH I don't have a lot of knowledge in remarking on this personally. I'm sure others can. I just know if I can trust the validity of a test based on the discussion looking at the differential provided.

Could you clarify the italicized part, I'm not sure I follow?

 

[hamstergang]

Just curious as to what your general exposure to these types of instruments is and how you interact with them.

I have no idea what you're talking about, if that answers your question.

 

[Shikima]

Could you clarify the italicized part, I'm not sure I follow?

Underline it. My eyes aren't as good as they once were.

 

[WisNeuro]

I have no idea what you're talking about, if that answers your question.

I get a fair amount of referrals from mental health and therefore psychiatrists in my daily practice. I am speaking to when performance and symptom validity tests are used. Essentially, things that identify when patients are not "fully engaged" in testing, with the etiology being fairly broad (e.g., somaticization, malingering, just not paying attention, does not want to cooperate with the evaluation).

I guess I was wondering what kind of exposure psychiatry generally gets with these types of instruments, and how they are taken when they get reports back using them.

 

[sunlioness]

I don't know how it all works. But if testing suggests the person wasn't engaged in the process or is otherwise full of crap, that's good information to have.

Back when I did inpatient, I actually ordered testing to specifically determine if a patient was malingering. Ordering testing on the unit wasn't terribly easy, but I made it happen. That patient annoyed me just that much. And the hospital administration wasn't terribly supportive of sending people out who knew what to say.

 

[WisNeuro]

Underline it. My eyes aren't as good as they once were.

Just the statement "I just know if I can trust the validity of a test based on the discussion looking at the differential provided." I just wasn't sure what you were saying there.

 

[notdeadyet]

Your average psychiatrist receives little to no real training in neuropsych testing. Without having someone walk is through how to read the results a few times, most psychiatrists misunderstand the content of the reports.

In my forensic fellowship, I came across a lot of cases of psychiatrists completely misstating the results of neuropsych testing because they did not understand what they were reading (e.g. Assume malingering based on symptom exaggeration despite comments of invalidity).


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[WisNeuro]

Fair, and I would say that by and large, psychiatrists generally seem to reach out and discuss the results with me most of the time in some of these messy cases. But, every now and then, someone reacts very negatively when I make a statement that the results cannot be interpreted due to significant validity concerns. I assumed that neuropsych testing would not be formally taught, but I was hoping that PVT/SVT/Invalidity would at least be part of a didactic experience. Although, I imagine it varies quite a bit with how much multidisciplinary integration is available in a given setting.

 

[smalltownpsych]

Fair, and I would say that by and large, psychiatrists generally seem to reach out and discuss the results with me most of the time in some of these messy cases. But, every now and then, someone reacts very negatively when I make a statement that the results cannot be interpreted due to significant validity concerns. I assumed that neuropsych testing would not be formally taught, but I was hoping that PVT/SVT/Invalidity would at least be part of a didactic experience. Although, I imagine it varies quite a bit with how much multidisciplinary integration is available in a given setting.

I wonder if some of the negative reaction is that they made a referral hoping to get some useful information and the statement results cannot be interpreted due to validity sounds frustrating. Highlighting anything helpful that was obtained might help. I am sure that you will agree that just about any assessment will provide usable information so maybe some of the psychiatrists are missing that portion. It would actually be pretty funny to see a neuro report that stated "after spending several hours with the patient administering grueling tests, I found out absolutely nothing about them."


Also, working in a medical setting, all of our tests are pretty conclusive, tox screens, liver enzymes, glucose, blood cell counts, O2 stats. All really solid and interpretable numbers and only invalid if someone screwed up. At which point they would just run 'em again. Meanwhile, we do several hours of testing and then come back with invalid results and sure as heck aren't going to run more testing.

 

[Shikima]

Thus your discussion is going to be of best use to flesh out the results based on testing and interview data.

 

[WisNeuro]

True, and in most cases, I feel myself and my colleagues do a good job of pointing out the particulars, as in vast majority of mild TBI/concussion cases resolve completely within weeks, results do not coincide with reported intact activities of daily living, yadda yadda... And still, I have some providers I just cannot reach who take everything the patient says at face value, even in the face of wildly invalid test results and active litigation.

As an aside, this is particularly salient at the moment. Going to have to have a meeting with a provider over a massive misinterpetation of the test results and going on a rant within the patient encounter note in an extremely inappropriate manner. I think the best bet may be to see if we can use part of one of our weekly team meetings to present on PVT/SVT and get other providers' feedback on how the reporting of such results may be of the best use to them.

 

[notdeadyet]

As an aside, this is particularly salient at the moment. Going to have to have a meeting with a provider over a massive misinterpetation of the test results and going on a rant within the patient encounter note in an extremely inappropriate manner. I think the best bet may be to see if we can use part of one of our weekly team meetings to present on PVT/SVT and get other providers' feedback on how the reporting of such results may be of the best use to them.

Good thoughts.

You might also consider some "teaching moments" on when and when not to even ORDER neuropsych testing.

I've brought this up before but realize it's a touchy subject. Psychiatrists often order neuropsych testing when it's just not indicated (e.g.: will the results really affect your conceptualization or treatment plan?) and are therefore bound to be blasé or disappointed in the results. But asking neuropsychologists to intentionally talk themselves out of work is a tall task. That's not a slight on neuropsych's. God knows the same can be true for forensic psychiatrists.

 

[WisNeuro]

You might also consider some "teaching moments" on when and when not to even ORDER neuropsych testing.

This is my personal drum, really. Although it's more of an issue with my section. I tend to be fairly strict in which cases I want to accept. If it's clear that the person is generally suffering from all psych and very little chance of neuro (under 50, anx or dep not treated, various psychosocial stressors, etc) I would rather not see that person. However, it's a team call, and the team would rather be more inclusive of what consults we accept rather than more discerning. I am a firm believer that healthcare in most settings tends to order many unnecessary consults/orders/procedures/referrals, and I'd rather not contribute to that, but I seem to be the minority vote in such situations.

 

[smalltownpsych]

True, and in most cases, I feel myself and my colleagues do a good job of pointing out the particulars, as in vast majority of mild TBI/concussion cases resolve completely within weeks, results do not coincide with reported intact activities of daily living, yadda yadda... And still, I have some providers I just cannot reach who take everything the patient says at face value, even in the face of wildly invalid test results and active litigation.

As an aside, this is particularly salient at the moment. Going to have to have a meeting with a provider over a massive misinterpetation of the test results and going on a rant within the patient encounter note in an extremely inappropriate manner. I think the best bet may be to see if we can use part of one of our weekly team meetings to present on PVT/SVT and get other providers' feedback on how the reporting of such results may be of the best use to them.

A doc who chooses to believe what the patient says over test results is probably headed for trouble. I also agree that criticizing other professionals in the medical record is completely unprofessional and one my colleagues and I were actually discussing that very same issue just the other day.

 

[WisNeuro]

Neuropsychologists often have themselves to blame though as many seem to really guard much of what they know or the content of these things. Obviously you don't want measures related to SVT to get out - though apparently patients are already being trained to spot these items. but I've noticed several neuropsychiatry do not seem to be keen on teaching psychiatrists about this

Also clearly PVT/SVT are really euphemistic and it is helpful for reports to spell out in plain english that the patient was not really engaging or clearly exaggerating their impairments etc. As Im often seeing people for 2nd/3rd/4th/5th opinion I read a lot of different neuropsych reports and there seems to be huge variation in the quality of the communication of the results and interpretation in a way that the average psychiatrist or neurologist can understand.

I could see the "guarding of knowledge" problem in some settings. But, at the VA placements that I have trained/worked at, these results are spelled out pretty plainly. For example, if below chance, the probability of that score even if purely guessing is given, or it will have been explained that even individuals with dementia who require 24 skilled nursing care perform above levels, therefore intact i/ADL's would argue against the patient in question being below that level in cognitive functioning. But, I will give it to you, I have read reports from outside providers that have been downright terrible. And, I can definitely see why there may be confusion when getting product from different sources.

 

[PikminOC]

I could see the "guarding of knowledge" problem in some settings. But, at the VA placements that I have trained/worked at, these results are spelled out pretty plainly. For example, if below chance, the probability of that score even if purely guessing is given, or it will have been explained that even individuals with dementia who require 24 skilled nursing care perform above levels, therefore intact i/ADL's would argue against the patient in question being below that level in cognitive functioning. But, I will give it to you, I have read reports from outside providers that have been downright terrible. And, I can definitely see why there may be confusion when getting product from different sources.

I have seen great variability in the places I have sent patients to. I now only refer to 2 places to get the evaluations done.

 

[WisNeuro]

I have seen great variability in the places I have sent patients to. I now only refer to 2 places to get the evaluations done.

Fair, but that cuts across specializations. There are psychologists, MD/DOs, OTs, PTs, etc that I will not refer to. Variability in competence and clinical product is a part of healthcare, not this specific part of it.

 

[PikminOC]

You posted this thread regarding neuropsych testing. So I'm answering it.

 

[WisNeuro]

You posted this thread regarding neuropsych testing. So I'm answering it.

Well, technically I specifically asked about views of PVT/SVTs from the other side.

 

[Merovinge]

In residency we had extensive didactics by neuropsychology, actually two lecture series over 2 different years and also shadowed a neuropsychologist for 4-12 1/2 days to get a full flavor of it. I'd like to think most of us had a good idea about PVT/SVT findings, but there certainly are some folks who's eyes glaze over at any mention of neuropsych testing even as trainees. Definitely a good thing to check with a psychiatrist about and spell out as plainly as possible.