When do you get psychological testing on a patient?

[reca]

Hey. I'm halfway through my PGY-3 year and I'm still confused on what the indications are for psychological testing. I've brought it up with my supervisors and really haven't gotten a satisfactory response. It seems the most common reason we refer someone to psychology for testing is because we've run out of time in the 60 minute intake session to hone in on a diagnosis because there's a lot to the patient's history. That seems like not the best reason to refer for testing. I was wondering if anyone had some insight on when they refer for psychological testing?

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[FatherPsychiatry]

That seems like an odd reason for a psych (neuropsych testing?) referral. What we do is an extended eval, ie have another appt in a few days to a week later to further go through details. Although I heard someone say if an intake that much time to figure out a diagnosis, its "Axis 2 (TOO) much time!"

 

[AcronymAllergy]

From a psychology perspective: we receive requests for assessment in complex patients and/or when the patient isn't responding to treatment, both of which often also involves suspicion of personality disorder. Sometimes this includes situations when the referring provider doesn't have availability for multiple sessions to complete the interview, or if the referral source suspects symptom exaggeration (the latter of which may or may not be an appropriate reason for referral).

 

[whopper]

Neuropsych testing for cognition in TBIs. Each TBI can present vary differently.

When I see really "out there" patients who don't easily all into any of the DSM IV/V diagnoses categories. E.g. I had a patient that was in his 60s, no prior episodes of mania or psychosis, full time job, then was in the hospital because just all of a sudden become psychotic, then it went away for about 1-2 days, then he was psychotic again. After thorough evaluation my best theory was he had Antiphospholipid Antibody Induced Psychosis. I requested the testing cause I couldn't peg what this was for several days and hoped the testing would give me something I couldn't detect on my own.

While in inpatient, I had them done on patients where I saw little hope of them getting better anytime soon in the hope it may yield some type of direction on where to go.

I've also used malingering testing in several forensic cases.

 

[erg923]

Hey. I'm halfway through my PGY-3 year and I'm still confused on what the indications are for psychological testing. I've brought it up with my supervisors and really haven't gotten a satisfactory response. It seems the most common reason we refer someone to psychology for testing is because we've run out of time in the 60 minute intake session to hone in on a diagnosis because there's a lot to the patient's history. That seems like not the best reason to refer for testing. I was wondering if anyone had some insight on when they refer for psychological testing?

First and foremost. you don't refer for "Psychological Testing." It is essentially a referral for a "second opinion" to an allied medical/health provider.

You are referring because you (presumably) don't know what **** is going on with this patient in order to treat them optimally. This may, or may not, necessitate psychological tests to clarify. Unless you are extraordinary opinionated and informed about the issue (which most psychiatrists certainly aren't), whether they are given any "tests" is not your call to make. And "running out of time" as a reason for referral would be an abrogation of your duty and probably not acceptable to your patients, or to any third-party payors. I would advise to never document such a thing.

Various medical necessity criteria would say:
You have done a thorough, textbook, psychiatric evaluation. You have collateral data if available. You are stuck between various diagnoses for which one would create a vastly different treatment plan than the other(s) Its time to call in a second opinion. Again, I say "second opinion" because psychologists can use various instruments to get at things if they have too. It doesn't mean they have to. Sometimes all you need a second pair of eyes. Any diagnostic disagreements can then be discussed and shared (test data or not). Then go from there. I have done many evaluations in which I have simply taken the time to do more structured diagnostic procedures and interviews (CAPS, SCID, SAD, PANNS, ADI-R etc.) and an accompanying record review than the initial psychiatric evaluation did in order to inform diagnosis and treatment. No "tests' needed.

Personally, I would add:
If the report from the psychologist "muddy's the waters" more than helps, don't send any more patients to them. There is indeed such a thing as too much data/too many points of data for rendering a diagnostic opinion. Parsimony.

 

[Sushirolls]

Cognitive decline in geriatrics. You pick up some some symptoms, patient is not receptive to talking about dementia and planning for it. Send them off for Neuropsych testing to help delineate how impaired they are, and now you have a tool to further a difficult discussion. That then can help point out their deficits and need to respond to it, or even be the nudge to let the DMV know its time to test them for driving/license (pending on state laws).

If suspect there may be a learning disability in college age adult, or an older adult who just wants to truly know if they have one, which can shape referrals for coping skills.

If I'm unable to nail down the axis II, and hoping for an MMPI to assist.

Someone who continues to say they have memory troubles, and my usual work up and management hasn't helped, then clarity if memory is or isn't impaired.

Post TBI to clarify deficits and help ascertain functional impairments and if disability is needed. Occupation Therapy overlaps with this, too.

Post stroke to clarify deficits and help ascertain functional impairments and if disability is needed. Occupation Therapy overlaps with this, too.

Mixed clinical ADD/ADHD history and mixed results on scales like Adult ADHD rating scale or Wender UTAH, possibly reach out for additional data if ADD or any other confounding learning disorders present. Haven't done this in a few years.

 

[whopper]

I recommend all psychiatrists partner-up with a psychologist that does extensive testing. These people, like radiologists for surgeons, get thorough training in an area where our own training hardly touches.

We will at times need to refer to a psychologist and the testing can help.

In the antiphospholipid antibody (APA) case I mentioned above it helped tremendously. E.g. the psychosis scales were very high, the malingering was very low (and I had no reason to think he was malingering, being in the hospital was costing him an arm and a leg and he wanted to get better when he was coherent), but it also helped just to have another highly trained expert to look at the case using a very different angle using a different methodology in such a rare and weird case. I couldn't tell at first if the patient was having delirium because his symptoms were sometimes off and on, but there wasn't confusion, just psychosis (paranoia, halluciations, delusions), and all of his labs were normal except for labs that would've been positive in APA, and after hours of lit-searching I found cases where this disorder could very rarely cause psychosis.

I still am not 100% sure my hypothesis was correct. What ended up happening as does in such cases where APA psychosis is going on is simply treating APA only usually has significant benefits in the psychosis even without antipsychotics giving the clinician a strong sign it was APA-induced psychosis. I gave him meds for APA and he showed some improvement, but not convincingly to the point where it was conclusive it was APA, and I wanted to continue the APA treatment for several days to rule out other etiologies but his insurance kept threatening to pull the plug so I was forced to try to get him better ASAP at the cost of figuring out the cause and started antipsychotic treatment with APA meds about day 3-4. Then he completely cleared up with the addition of the antipsychotics and I had to discharge the patient.

I specifically had him referred to a psychiatrist that I knew would be on top of it and called that psychiatrist to put him up to speed and take the case over cause it was so weird.

 

[comp1]

Testing can help with so many things! My first go to is to clarify personality pathology. It can be really hard to separate out the exact personality disorder even with a textbook diagnostic interview and testing is much better than just labeling something "unspecified personality disorder." In general, good testing should have validity scales, so you can learn a lot even if the test is invalid. For example, are they trying to look better than they likely are or worse? Are they inconsistent? If so, could there be a missed cognitive component? If there is a cognitive component, you can get exactly at where their strengths and weaknesses so that you can design a treatment program that they can actually do. Finally, malingering or factitious disorder. There are overendorsement specific tests for practically anything from PTSD to schizophrenia and it can really help back up your suspicions in a more formal and less gut impression kind of way. I definitely second the partnering up with a psychometrician if you aren't already.