PhD/PsyD Assessment of possible psychotic disorder

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erg923

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First, if anyone answers this this with "give a Rorschach", I will stab you. 🙂

Have patient who I have seen for 4 sessions. Time is running out and we have gotten NOWHERE. I suspect schizophrenia (brother has it), possibly still subthreshold at this time. Can anyone suggest something besides MMPI or PAI to further assess his beliefs/thought processes/perceptions, as this person will not tolerate such lengthy inventories. I can't get much from him via interview.
 
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I don't think you're going to get much outside of history and interview. As far as I know, the self report measures lag far behind the sensitivity/specificity of the presence of symptomatology. If it's in the subthreshold stage, there should still be some negative symptoms evident at times.
 
I don't think you're going to get much outside of history and interview. As far as I know, the self report measures lag far behind the sensitivity/specificity of the presence of symptomatology. If it's in the subthreshold stage, there should still be some negative symptoms evident at times.

My hypothesis is that this guy cannot keep his thoughts together, literally. The proverbial unthreading and disorganization often seen in the former disorganized subtype. I really do wonder what is happening inside his head. I want to have a student work this case, but frankly, I am not sure what, if anything, to do. Plus, this is just my clinical hypothesis based on the family history and the rather schizoid quality of his personalty style.
 
Fair enough, I just don't know what predictive validity you're going to get outside of what you already have. What is he presenting for in the first place?

Depression/anxiety (anx not really acknowledged at first) and subjective cognitive complaints (also endorsed sensitivity to light and sound). Npsych eval last year ruled out that any of this was due to a mTBI 4 years ago. No personality testing was done with that npsych eval though.
 
Wont (ie., refuses). Not can't.
 
Depression/anxiety (anx not really acknowledged at first) and subjective cognitive complaints (also endorsed sensitivity to light and sound). Npsych eval last year ruled out that any of this was due to a mTBI 4 years ago. No personality testing was done with that npsych eval though.

Yeah, we pretty much only use the MMPI for the validity indicators in the mTBI groups these days. Any evidence of symptom exaggeration? Given the context, any inventory may be misleading anyway.
 
Yeah, we pretty much only use the MMPI for the validity indicators in the mTBI groups these days. Any evidence of symptom exaggeration? Given the context, any inventory may be misleading anyway.

Exaggeration, no. But differential task engagement was behavioral noted in the exam. My guess is that he is experiencing a blossoming psychiatric disturbance and is/was attributing symptoms to the head injury. Time of mTBI would have been right at the age where schiz sx first start to bloom. But, I would like to get some kind of solid lead/data on my gut feeling here.
 
Wont (ie., refuses). Not can't.
I don't have time for a beating (stabbing, etc. right now), but why not some sort of projective thatis less threatening than a ROR, TAT, or HTP-KF (don't laugh I'm serious) FOR THE SOLE PURPOSE OF FACILITATING ENGAGEMENT, followed by a personality measure that has more validation that you are comfortable with (like MMPI, PAI, or even Sentence Completion- why did you not want them...too lenthgy? If the person is already engaged after TAT and, say, PAI questions are asked allowed (all can be done by your student BTW), then you will inadvertently (I'm being optimistic & ideal here) get the personality assessment to corroborate evidence you have from other measures, history, interviews to make a thorough evaluation and give/write a report.

Does this sound doable? I'm not licensed yet, and just starting internship but it seems like something I would see some do, after the WAIS and some sort of visual motor test, like Bender-Gestalt, etc.

As I hit 'Post Reply,' I boldly go where no man/woman has gone before...on SDN.
 
Well, its my license on the line, so has to be something I am comfortable with interpreting and supervising, etc. A rotter actually does seem like a good idea. I'll dig up a pans, BPRS, and SIRS too. most likey. I don't need IQ. He got all that good stuff last year.
 
The CAARMS is helpful for figuring out sub threshold psychosis.
 
Thanks, need to check that out. Can't recollect hearing about that one before.
 
Also, collateral information from a family member would be very helpful. I've also found the verbal subtests of the WAIS/WASI to be helpful for picking up tangential thinking, loose associations, etc. that can be found in psychotic thought processes. It doesn't sound like he will sit for them though.
 
Fair enough. But a pure projective personality test, like the TAT usually puts someone at easy b/c the tasks are so easy (tell me what you see), and the prompts for further inquiry (thoughts, feelings, actions) are simplistic to answer that a person is less-defensive (if I say so myself) and less threatened when you begin probing into his/her self-experience. But, if you are not comfortable supervising or interpreting these types of personality instruments (or they lack the evidence-base data to justify administration)...then, you are correct: Leave well-enough alone.
 
Fair enough. But a pure projective personality test, like the TAT usually puts someone at easy b/c the tasks are so easy (tell me what you see), and the prompts for further inquiry (thoughts, feelings, actions) are simplistic to answer that a person is less-defensive (if I say so myself) and less threatened when you begin probing into his/her self-experience. But, if you are not comfortable supervising or interpreting these types of personality instruments (or they lack the evidence-base data to justify administration)...then, you are correct: Leave well-enough alone.

I would have no idea where to even get a tat... Lol. Not exactly standard inventory in a testing closet these days.
 
Ha. Call your nearest psychodynamic university-based training program or post-doc institute. My former supervisors (in AMCs and PP) all had their own 32 cards -usually choose at least 10 - same ones since 1935 😉.
 
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I just feel like there may be better ways to engage individuals than a lengthy projective that has little predictive validity over and above interview. Especially when someone is already defensive about doing something like an MMPI. Why would they be less defensive about the TAT/Rorschach? I usually find that explaining that I am doing a cognitive assessment puts people more at ease than if I am doing a purely psychological assessment.
 
Has anyone mentioned asking the patient if they are psychotic? Specifically, what I like to ask is "Are you crazy?" and "Has anyone called you crazy?"

If yes to either, give a Rorschach to confirm. 😀
 
Well, IME the ROR can be unsettling to someone who is actively psychotic because the images are inkblots (and references to the objectives must be created in one's own psyche), but TAT has some cards that 'pull' for the person's interpretation of the relationships or determination of the images' characters in an obvious way. Therefore, if the person says (of the card that shows the image of the young man and old man together) "The old man wants to stab the younger man" (using erg's 'stabbing' reference): And you probed further by asking what are the characters thinking? And you are met with "The old man is thinking about how he's going to stab the young man, and the young man is thinking the old man is going to stab me because I'm dumb." Then clinically (because in this card, there are no weapons, aggressive facial expressions, etc), you begin to see themes of aggression, persecution, derogatory thoughts INVOLVED IN THE STORY-TELLING TASK when asked about characters/images presented. You would NOT infer that these emotional constructs are evident in the person's life, until it is validated by a more predictive instrument with more reliability. Hence, the projective data would corroborate themes that are apparent in the patient's clinical picture.

And WisNeuro, the person may be defensive of all methods, but again, you are initially asking him/her to focus on external stimuli (the cards & subsequent interpretation of those cards), rather than internal stimuli (their own thoughts, actions, behaviors), which can be less threatening. Plus TAT does not have to be a lengthy administration (maybe 30-45 min - really depending on the complexity of the responses) but facilitates engagement before you tackle 400-some questions of another measure that will explicitly ask "Do you hear voices?"

Heck, I was going to suggest House-Tree-Person-Kinetic Family (just need 4-5 unlined sheets of paper & pencil w/o an eraser)...when erg 923 said he did not have TAT materials. Children & adolescents love it/Adults are sometimes apprehensive because it is a drawing task but it also introduces themes that can be used clinically if you are clear in your report to say where the data came from once the other measures show these themes in significant ways. Therefore if there is a line in the clinical findings section of your report that says "The abovementioned clinical findings were also demonstrated by the patient in the drawing task administered when asked 'what is the family drawn doing?' The patient replied "the Dad is getting ready to stab the family." Oh, a lot can be left up to interpretation, but you don't report your interpretation of the projective material, only the data from salient themes and let the (report) reader make the interpretation. Plus they will only read the summary section anyway.

I cannot wait until I begin at my Northeastern VA because I'm curious about their protocol for use of projectives....but again, I am suggesting non-threatening ways to initially engage a person in a clinical personality assessment that he may be otherwise resistant to, and therefore digging in my toolbox for suggestions.

But again, erg made an extremely valid point that it is your licenses/reputation on the line...don't use these techniques for engagement if not fully trained in administration and interpretation, it would be a waste of everyone's time.
 
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What are the specific instructions given to the person before first TAT card? Are there standardized instructions? Is there any research in behavioral correlates of responses? Any validation studies, in other words?

I'm still not giving the thing because am wholly unfamiliar with it. But I am thinking about discussing the pros and cons regarding using this assessment in this case with my student. For what it's worth cheetah, this phd student knows even less about the TAT than I do. That may tell you something about training models and attitudes in this part of the country.
 
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The cons I see with all that, cheetah, is from a cost containment/utilization management perspective, more so than a clinical perspective.

Law of diminishing returns. Seems like a lot of labor, that you are presumably charging someone for, for a giant case of: "meh, could be this, could be that, could be nothing." The only people that like hearing **** like that is other psychologists.
 
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Also, collateral information from a family member would be very helpful.

I need an ROI for that. I asked for one long ago. No go.

I may ask our npsych to see his raw WAIS data though. Sounds like great task for a student. 🙂
 
An MCMI is a much shorter personality inventory that can be finished inside of one therapy session the vast majority of the time (175 items, 20-30 minutes). I find it to be very good at addressing personality in a way that informs treatment, and it also does a good job at characterizing thought disorder, personality and defensiveness.
 
I'm not too sold on the MCMI. It's validity indicators are terrible, and it's diagnostic validity lags behind many things. I believe that some studies were performed on the MMPI, MCMI, and the Rorschach and found that the MCMI was worse than a coin flip in predicting psychosis and led to a lot of misclassification errors.
 
I had a competency assessment that I was doing during practicum where that guy was doing a fairly good job "holding it together". I administered the Rorschach and he did fine with the simple cards, but he started becoming very agitated as the cards became more complex and then began responding to internal stimuli and began presenting much more as psychotic. It took him a day to get it back together. Since you mention that he has difficulty keeping his thoughts together, that might be the key not necessarily the Rorschach which I have issues with, as well *ducks to avoid knife*), but maybe observe how he does in complex unstructured environments that would challenge that. I think the RISB could be a possibility, but I would suspect that all you would get are simple, concrete answers. I think interviewing might still be the best approach and it could help a student to develop some skills at working with withholding patients. Discussing strategies for how to get at the psychotic processes might be fruitful for supervision. Also, patient might tell me nothing but then tell someone else who he trusts a lot more. I am used to being the person they trust so I sometimes forget about using this tool.
 
BPRS was the first thing that came to mind for me, but if he's shutting down during interview, I don't know how well he'd handle it. Then again, maybe the semi-structured nature would appeal to him, as most of the answers only require yes/no responses and that might get him engaged enough for you to then follow-up afterward.
 
Since he's refusing the BPRS may be most helpful since it's not a self-report and you could obtain collateral information from family in order to assess severity of symptoms if your observations do not suffice.
 
I think you have it backwards. He hasnt refused BPRS, but has refused granting ROIs for family/collaterals.
 
I think you have it backwards. He hasnt refused BPRS, but has refused granting ROIs for family/collaterals.

I think Terri Dactyl may have meant that since the pt is refusing testing, a BPRS may therefore be the most helpful based on the ability to incorporate both observations and collateral report. Although that latter point isn't going to be particularly useful with no ROI.
 
have you assessed for personality disorders? schizotypal and paranoid pd come to mind. you can use questions from the SIDP semi-structured interview to guide you.
he seems reluctant/paranoid about information he provides.
 
have you assessed for personality disorders? schizotypal and paranoid pd come to mind. you can use questions from the SIDP semi-structured interview to guide you.
he seems reluctant/paranoid about information he provides.

No indication of paranoia. He doesnt like his family (long story), so I think thats the rub with the ROI. I think he is very schizoid, yes. Does he meet all the criteria? I dont know. Not sure if that even matters in the grand scheme of things. What I do know is that cluster A is a spectrum and is sometimes a prodrome to eventual psychosis. Given that the guys brother has schizophreina and there is other MH problems in the family, I am concerned that he is or will convert. I am finding the CAAMS and BRRS very helpful for this. Having my student review is raw testing data from last year for thought disorgizations, pecuilarity, etc.
 
Thanks for posting about this, erg. Very interesting.
 
UCSF has an early psychosis program with a good screener. Is he 25 or younger? Here is a general link to their program and you might inquire directly to get a copy of their screening measure which they share readily with professionals http://www.prepwellness.org/wp-content/uploads/2013/07/youth.pdf

I pulled psych ED coverage at the VA main hospital recently. And I admitted this gentleman (what are the odds of that, btw). Not exactly florid psychosis yet, but still very sad....
 
By the way, I used the CAARMS and loved it. Student and I both dug into some lit, did some good reading. Shared with the rest of the service at recent staff meeting. Great learning experience.
 
Who says you can't teach an old dog new tricks 😉
 
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