Assessment/testing?

[scubadoc78]

If possible, could somebody briefly explain what testing and/or assessment entails? I understand it takes hours to administer and interpret.

How do you choose which tests to give? What are they like? How do you interpret them?

If this is a reposted question, sorry!

Thanks!

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[erg923]

The answer is it depends what the referal question is.

Test selction also depends on many many many factors, including refferal question, what you want to know and figure out, what you're tring to rule out, appopriatness/availability of the tests norms, age range of the patient, ability/functional level of the patient, etc etc.

There are many many many assessment instruments used by psychologists and neuropsychologists. Some are self report, many are clinician admisinstered however.

If interpretation could be explained via a post on a message board, one would not need a Ph.D. for this profession. There are many levels to interpretation both by individual instrument, and to integrate it into a cohernt whole picture.

If you ask a more specific question, Im sure it your question be will be answered more thoroughly.

 

[scubadoc78]

The answer is it depends what the referal question is.

Test selction also depends on many many many factors, including refferal question, what you want to know and figure out, what you're tring to rule out, appopriatness/availability of the tests norms, age range of the patient, ability/functional level of the patient, etc etc.

There are many many many assessment instruments used by psychologists and neuropsychologists. Some are self report, many are clinician admisinstered however.

If interpretation could be explained via a post on a message board, one would not need a Ph.D. for this profession. There are many levels to interpretation both by individual instrument, and to integrate it into a cohernt whole picture.

If you ask a more specific question, Im sure it your question be will be answered more thoroughly.

well, primarily i'm trying to understand why there is such a rift between what psychologists do and what psychiatrists do. why do they disagree on diagnoses so often?

my psychology friends tell me they rely primarily on testing/assessment whereas i've primarily been trained using the dsm and mse as starting points.

 

[Ollie123]

We operate within the DSM framework as well, so that's certainly not it.

One reason they frequently disagree is that psychiatric disorders are generally not clear-cut. Two people can look at an X-Ray and say "Yup, that's a broken arm", but its a good bit harder for us. 2 psychiatrists or 2 psychologists will disagree on diagnoses quite often as well.

My other reason is, I openly admit, highly biased, but I feel like the VAST majority of psychiatrists in practice (or at least those I have come across) simply do not bother with trying to diagnose accurately. In some cases, it can make sense - if you are writing a Rx and not doing therapy, it often wouldn't make sense to spend hours delineating the depression from the anxiety if you're just going to hand them Prozac no matter what the outcome. However, I feel like that attitude leads to people not doing it when it DOES matter. I think people often diagnose to the medication...for example, bipolar disorder seems to be an increasingly popular diagnosis now that we have effective mood stabilizers that aren't quite as harsh as Lithium It seems to be popular even in people who show no trace of evidence they have ever had a manic episode

I guess what does it for me, is that its often "just" clinical interviewing with psychiatrists. The end-result of that is often misleading diagnoses, especially given the pressure from managed care to keep things as short as possible. Clinical interviewing is critical, but its also VERY easy to be misled, especially since the very nature of the sort of patients we see means they are less likely to be reporting very accurately. Again, acknowledging my bias, on the average, I would trust psychological diagnoses over psychiatric ones based off strict diagnostic criteria. If nothing else, chances are the psychologist spent way more time arriving at the diagnosis and that alone increases the odds that it is accurate. Whether a more "accurate" diagnosis would change anything in terms of pharmacological treatment is much less certain.

 

[erg923]

Well psychologists follow the DSM as well, at least in the US. I find that diagnosis is often disagreed upon among mental health professionals. I dont know if there is much empirical evidence to support the notion that psychologists and psychiatrists disagree at a differentially greater rate than what is normal. At least for pure psych diagnosis. This may just happen to be your personal experience thus far. That said, I think psychologists may be in a better postion to rule out malingering or symptom exaggeration because there are many psychmetrically sound instruments (and validity scales within scales) that can asssit with this process that psychiatrists are not trained on. I also think psychlogists may be better (or more clinically cautious rather) about assigning personality disorders, as we typically spend more time with patients and have a number of psychometrically sound instruments (ie., MCMI-III) that assist with teasing these issues out from a complex clinical picture.

I also think "clinical judegment" may be used somwewhat differentially between the 2 proffesions at times. For example, if I am doing a SCID and I ask the first critria for MDE in Module A ("have you been feeling down or deprssed everyday most of the day this past month, etc) and the person anwers yes, I dont take that at face value and jsut move on. I contuinue to digg and ask questions until I am satisfied that they truely met that critria as it is meant clinically. In otherwords, I make the judegment, not the patient. I dont generally take what they say at face value right off the bat and put a chech mark next to it an move on. I am sure most psychiatrists take the time do do this as well, but I have seen many that do not.

Lastly, neuropsychologists are often called upon for differential diagnosis of complex neurologic and cognitive disorders such as AD and other dementias because many neuropsychological tests can establish what parts of the brain are being affected. Thus suggesting the undelying neuropathology, and giving hints about what disease process is taking palce. Obviously, this presents a benefit over something like the MMSE, since it is a global meaure of impairment (kinda like the Glascow Coma Scale) and has zero specificity for any one condition. In other words, the MMSE can tell you that the pt is having a problem, but cant tell you why, or what brain systems are effected. Hence, it doesnt tell you anything about ther disease process. This is why many neurologists will refer to a clinical neuropsychologist for more indepth testing that will help pinpoint the specific systems that are imapired in order to get a differential diagnosis.

UPDATE: I think OLLIE makes a great point. Spending time delineating the anxiety from the depression is not very fruitful if you are simply gonna provide a short supportive check up and write a prescription for zoloft or Wellbutrin. However,for psychotherapy, the inteventions for the 2 issues will be quite different, and the 2 might have very differrent triggers and origins. Hence why psychogists (since they are primarily the ones doing long therapy these days) will want to spend more effort teasing apart these issues.

 

[scubadoc78]

Well psychologists follow the DSM as well, at least in the US. I find that diagnosis is often disagreed upon among mental health professionals. I dont know if there is much empirical evidence to support the notion that psychologists and psychiatrists disagree at a differentially greater rate than what is normal. At least for pure psych diagnosis. This may just happen to be your personal experience thus far. That said, I think psychologists may be in a better postion to rule out malingering or symptom exaggeration because there are many psychmetrically sound instruments (and validity scales within scales) that can asssit with this process that psychiatrists are not trained on. I also think psychlogists may be better (or more clinically cautious rather) about assigning personality disorders, as we typically spend more time with patients and have a number of psychometrically sound instruments (ie., MCMI-III) that assist with teasing these issues out from a complex clinical picture.

I also think "clinical judegment" may be used somwewhat differentially between the 2 proffesions at times. For example, if I am doing a SCID and I ask the first critria for MDE in Module A ("have you been feeling down or deprssed everyday most of the day this past month, etc) and the person anwers yes, I dont take that at face value and jsut move on. I contuinue to digg and ask questions until I am satisfied that they truely met that critria as it is meant clinically. In otherwords, I make the judegment, not the patient. I dont generally take what they say at face value right off the bat and put a chech mark next to it an move on. I am sure most psychiatrists take the time do do this as well, but I have seen many that do not.

Lastly, neuropsychologists are often called upon for differential diagnosis of complex neurologic and cognitive disorders such as AD and other dementias because many neuropsychological tests can establish what parts of the brain are being affected. Thus suggesting the undelying neuropathology, and giving hints about what disease process is taking palce. Obviously, this presents a benefit over something like the MMSE, since it is a global meaure of impairment (kinda like the Glascow Coma Scale) and has zero specificity for any one condition. In other words, the MMSE can tell you that the pt is having a problem, but cant tell you why, or what brain systems are effected. Hence, it doesnt tell you anything about ther disease process. This is why many neurologists will refer to a clinical neuropsychologist for more indepth testing that will help pinpoint the specific systems that are imapired in order to get a differential diagnosis.

UPDATE: I think OLLIE makes a great point. Spending time delineating the anxiety from the depression is not very fruitful if you are simply gonna provide a short supportive check up and write a prescription for zoloft or Wellbutrin. However,for psychotherapy, the inteventions for the 2 issues will be quite different, and the 2 might have very differrent triggers and origins. Hence why psychogists (since they are primarily the ones doing long therapy these days) will want to spend more effort teasing apart these issues.

How many patients does a psychologists usually carry? How long do they seem them for at each appointment? The only interaction I have with psychologists outside hospital consults is when they work in a group practice with psychiatrists. In my experience the outpatient 'team approach' seems ideal because psychiatrists and psychologists at the same location provide for each patient.

The psychologists at the outpt setting, however, told me that they never do testing because the DSM approximates diagnosis close enough and it isn't well reimbursed? Is that your experience as well?

In my experience the approach of psychiatrists/psychologists working as a team works great because they're able to consult right next door. Can you guys think of any downsides to the team approach?

 

[erg923]

Can you guys think of any downsides to the team approach?

Im sorry but I have to do it. Please read, although im sure the first 4 or 5 pages is enough for you the get the idea.
http://www.psych.umn.edu/faculty/meehlp/099CaseConferences.pdf

 

[scubadoc78]

Im sorry but I have to do it. Please read, although im sure the first 4 or 5 pages is enough for you the get the idea.
http://www.psych.umn.edu/faculty/meehlp/099CaseConferences.pdf

This cannot possibly be what the majority of psychologists believe about psychiatry.

 

[erg923]

no, its not. Meehl was an eccenctric fellow. But I think that article is hilarious. Obviously its exaggerated, but im sure you seen at least a couple of those fallacies commited when you're in a treatment team meeting, I know I have. Not even the best of us can escape "group-think" at times. And plus, i didnt really noticed a bias towards psychaitrists, i think he slams every profession equally in that article, from nurses, to socal workers, to psychologists, to psychiatriasts.

 

[erg923]

How many patients does a psychologists usually carry? How long do they seem them for at each appointment?

In what setting and for what purpose? Therapy, treatment plannning, testing? As Im sure you know, the standard individual therapy appointment is 50 minutes. The others will vary depending on what is being done?

The psychologists at the outpt setting, however, told me that they never do testing because the DSM approximates diagnosis close enough and it isn't well reimbursed? Is that your experience as well?

Psychological tests are not needed to diagnose most psych conditions. They work an adjucts and sometimes as diagnostic clarifiers. None by itself is diagnostic. Any good clinican should be able to come up with an adaquate working diagnosis sufficient enough to begin treatment using a structured or semi-structured interview. MMPIs or other personality or psychopathology measures/assessments may be added later if it is felt that they can further inform treatment and/or diagnosis.

Neuropsychological testing is a different story however, as the quatifying of cognitive domains is the backbone of the dicipline because the information is required in order to inform the differntial diagnosis of various cognitive disorders (Alzheimers, MCI, vascialr dementia, etc). Clinical Neuropsychologists are specially trained psycholgists (2 year fellowship after ph.d in clinical psych) in neuroscience, functional neuroanatomy, and the assessment of cognitive functions using various objective psychometric methods.

 

[scubadoc78]

In what setting and for what purpose? Therapy, treatment plannning, testing? As Im sure you know, the standard individual therapy appointment is 50 minutes. The others will vary depending on what is being done?

Good point. I should have been more specific. I've been frustrated at how psychiatry is practiced here in the midwest where I'm in school. It's an EXTREMELY biological model of psych which leads to a reductionist approach leading to rapid med checks. "Let's see if the big chemistry set in your head is working today." I think for some pts it works, but in my experience that vast majority benefit from good therapy. I've been so fortunate to work with a psychiatrist on a senior research project this month who only does the 50 min therapy sessions and augments with meds as she feels appropriate. She's taken a huge pay cut but says it's worth it for her to feel she's actually moving toward a goal rather than just covering up symptoms with meds. Though I don't know much about her chosen form of therapy (existential therapy?).


Psychological tests are not needed to diagnose most psych conditions. They work an adjucts and sometimes as diagnostic clarifiers. None by itself is diagnostic. Any good clinican should be able to come up with an adaquate working diagnosis sufficient enough to begin treatment using a structured or semi-structured interview. MMPIs or other personality or psychopathology measures/assessments may be added later if it is felt that they can further inform treatment and/or diagnosis.

Is there a good intro text that reviews these different forms of tests and how they're used?


Neuropsychological testing is a different story however, as the quatifying of cognitive domains is the backbone of the dicipline because the information is required in order to inform the differntial diagnosis of various cognitive disorders (Alzheimers, MCI, vascialr dementia, etc). Clinical Neuropsychologists are specially trained psycholgists (2 year fellowship after ph.d in clinical psych) in neuroscience, functional neuroanatomy, and the assessment of cognitive functions using various objective psychometric methods.

Neuropsych testing I'm familiar with. I have put in dozens of consults for neuropsych while working on almost every inpatient ward though (due to a gazilion other requirements on clerkships) I never got the chance to visit with them about how their testing worked.

 

[Therapist4Chnge]

Neuropsych testing I'm familiar with. I have put in dozens of consults for neuropsych while working on almost every inpatient ward though (due to a gazilion other requirements on clerkships) I never got the chance to visit with them about how their testing worked.

It can definitely be beneficial (especially for neurologists and psychiatrists) to learn the basics about what neuropsych testing can provide in regard to useful clinical data. Most of the referrals that come into my neuro rotation come from physicians that took the time to learn a bit more about what neuro testing can offer, and the results have helped them gain more useful data for their cases.

 

[erg923]

"Is there a good intro text that reviews these different forms of tests and how they're used?"

http://www.amazon.com/Handbook-Psychological-Assessment-Gary-Groth-Marnat/dp/0471419796