Help with DSM-IV

[RandomnessRocks]

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I'm an undergrad in Abnormal and my professor Xeroxed some of the DSM for us to learn. I don't understand a few things.

1) Major Depressive Disorder is characterized by ONE OR MORE Major Depressive Episode. If there's just *one* Major Depressive Episode, why not just call it a Major Depressive Episode? Why call it a Disorder? I'd understand if the person had a Major Depressive Episode, then had a period of normal mood (the disorder went into remission), then had another MDE (MDE #2) and could therefore be classified as having Major Depressive Disorder (because they had a few episodes)...

...but what's the deal with being diagnosed with Major Depressive *DISORDER* from just one episode? Wouldn't the one episode just be called an Episode?

2) Bipolar I disorder is characterized by ONE OR MORE Manic Episode or Mixed Episode. Okay, if there's just *one* Manic Episode or *one* Mixed Episode, why not just call it a Manic or Mixed Episode? How do you go about calling it Bipolar I? 😕

pelase help.

 

[erg923]

I understand what you are saying, but I think you are taking some of these things too literally. The term "disorder" is simply a descriptive term since the DSM is running under a medical model (as opposed to a dimensional model). Most resesrch demonstrates that "depression" is a construct that comes in periods (frequently remitting). Therefore, the decision was made to make a descriptive term that denotes the occurrence of these seperate periods of depression (i.e., "episodes"). However, these seperate periods, known as "episodes", are thought to represent a underlying pathology known as depressive disorder. Obviously, one MDE does not mean that you will have a second, so the term disorder does seems silly there. I get that. However, statistically, a person who has one MDE is a such an elevated risk for developing a 2nd MDE, it is still thought that the having only one MDE still represent an underlying "disorder"

The same logic of above applies to your question about Bipolar I. Moreover, mania is Pathognomonic of bipolar disorder. That is, once its is decided that someone has experienced a manic episode, Bipolar DO can be diagnosed. Not all Bipolars have severe periods of depression, although most still have some sort of mood fluctuating below the what we wuld call a "euthymic state."

 

[RandomnessRocks]

oh okay. My professor told us in class a person can't be diagnosed with panic Attacks. They have to have a Disorder *WITH* panic attacks, like GAD w/ Panic Attacks.

Is it the same idea here? You can't be diagnosed with a Major Disorder Episode... they have to diagnose you with the disorder? If you came in and met the criteria for the episode, you'd be labeled as having the disorder?

 

[myelin]

oh okay. My professor told us in class a person can't be diagnosed with panic Attacks. They have to have a Disorder *WITH* panic attacks, like GAD w/ Panic Attacks.

Is it the same idea here? You can't be diagnosed with a Major Disorder Episode... they have to diagnose you with the disorder? If you came in and met the criteria for the episode, you'd be labeled as having the disorder?

that's right, you can't dx a MDE or a panic attack, only the disorders. they are the ones with dignostic codes (e.g. 300.3)

 

[erg923]

Thats only half correct. You can have a diagnosis that is reflective of just panic attacks, but it is titled "Panic Disorder" NOT "Panic Attacks." However, one panic attack is not enough to get this diagnostic label. You must have had more than one within a month and had sustained fear or anxiety about having another one for at least 4 weeks. It is diagnosed with or without Agoraphobia.

Many people who have frequent panic attacks will qualify for Agoraphobia, since people will often go to great lengths to limit or totally avoid public places because the are afraid of having a panic attack in that situation ("Panic Disorder with Agroraphobia"). However, some with frequent panic attacks will just solider on and not limit their outside activities, despite the likelihood of having a panic attack (ie., Panic Disorder without Agoraphobia")

Yes, if you qualify for even one MDE, your official written diagnosis will be" Major Depressive Disorder, Single Episode, (mild, moderate, or severe)"

 

[Ollie123]

It took me quite awhile to get used to the Panic Disorder thing.

Someone can be having frequent panic attacks, but if they don't have persistent worry about future panic attacks, they don't technically meet for panic disorder. If its in response to a certain situation it will likely mean a phobia, but if it occurs at random intervals I have no idea what that would be coded as.

You'd think that would be pretty rare, but I've run across two such folks already.

 

[RandomnessRocks]

Thanks sooo much erg and myelin (like the sheath?) I have another question if anyone understands. dysthymic disorder means your depressed for 2 years

It says if you've ever had a manic or mixed episode then you can't be diagnosed with it. So in 1996, if you had a period of mania and then returned to normal for a long time, then you became depressed from 2006-2008 without any mania **ever** returning. What would you be diagnosed as? Your mania was in 1996. That can't be bipolar 2 because the two events are so many years apart.

what if you've had depression for 1 1/2 years, but not 2? They just tell you you have a NOS Disorder? It's not severe enough to be MDD, just a low-level depression always there. So not MDD, but not long enough to be dysthymic disorder.

OMG this stuff is confusing. 😱 And the midterm is huge... 6 blue book essays on this.

 

[erg923]

It took me quite awhile to get used to the Panic Disorder thing.

Someone can be having frequent panic attacks, but if they don't have persistent worry about future panic attacks, they don't technically meet for panic disorder. If its in response to a certain situation it will likely mean a phobia, but if it occurs at random intervals I have no idea what that would be coded as.

Panic attacks without situational bound triggers would still be coded as either "Panic DO w/ Agoraphobia" or "Panic DO with Agoraphobia", depending on how much they limit going out of the house for fear of having them in public. If it is in the context of a specific phobia, the can still qualify for "Panic Disorder".... in addition to the specific phobia, but I think you can code the Panic DO as "with situational triggers."

 

[erg923]

Thanks sooo much erg and myelin (like the sheath?) I have another question if anyone understands. dysthymic disorder means your depressed for 2 years

It says if you've ever had a manic or mixed episode then you can't be diagnosed with it. So in 1996, if you had a period of mania and then returned to normal for a long time, then you became depressed from 2006-2008 without any mania **ever** returning. What would you be diagnosed as? Your mania was in 1996. That can't be bipolar 2 because the two events are so many years apart.

what if you've had depression for 1 1/2 years, but not 2? They just tell you you have a NOS Disorder? It's not severe enough to be MDD, just a low-level depression always there. So not MDD, but not long enough to be dysthymic disorder.

OMG this stuff is confusing. 😱 And the midterm is huge... 6 blue book essays on this.

The reality of things in the clincial world is much different. Psych diagnosis are evolving and don't necessarily stay stable over time. In this case, I would reevaluate the patient's supposed manic episode. Things dont very fit neatly in reality, despite what DSM specifies.

However, only having one manic episode is unusual. The logic of this DSM statement is that if you have one manic episode, it it highly likely that you will have another one. Therefore, you really do have bipolar diorderr, albeit you've only had one manic episde so far. Statistically, you will probably have another one.

The example about Depressive DO and Dysthymic is correct, technically speaking. However, clinical judgment play a large role in the official diagnosis. People rarely use DSM that strictly unless its for a research study inclusion. This strange diagnostic issue would not change any treatment implications for a patient like this. That is what is most important to remember here.

 

[RandomnessRocks]

It took me quite awhile to get used to the Panic Disorder thing.

Someone can be having frequent panic attacks, but if they don't have persistent worry about future panic attacks, they don't technically meet for panic disorder. If its in response to a certain situation it will likely mean a phobia, but if it occurs at random intervals I have no idea what that would be coded as.

You'd think that would be pretty rare, but I've run across two such folks already.

Thanks Ollie. Okay, tell me if I'm right here.

1) A person was bitten by a dog. They're afraid of dogs now so they go out of their way to avoid them (they stay away from parks). Whenever they see a dog, they feel anxiety and have a panic attack. BUT they don't worry about future panic attacks. They're told they have a Specific Phobia With Panic Attacks?

2) The same person starts worrrying about Panic attacks. They think about it at night and wonder when they'll have one again. So now because they worry about future attacks, they have a Specific Phobia ****and**** Panic Disorder? Co morbid?

3) Now that person is afraid of dogs, has panic attacks, worries about future panic attacks, and they stay at home because they're afraid that as soon as they leave their house, they'll see a dog. Now they are told they have Specific Phobia with Panic Disorder with Agoraphobia?

 

[Ollie123]

Panic attacks without situational bound triggers would still be coded as either "Panic DO w/ Agoraphobia" or "Panic DO with Agoraphobia", depending on how much they limit going out of the house for fear of having them in public. If it is in the context of a specific phobia, the can still qualify for "Panic Disorder".... in addition to the specific phobia, but I think you can code the Panic DO as "with situational triggers."

True, but I was referencing someone who had regular panic attacks without situational triggers but didn't have "Persistent concern about additional attacks, worry about the implications of the attack, or a significant change in behavior related to the attacks". I have no idea what category, if any, that would land in.

 

[erg923]

Yes, I think you pretty much have it, more or less. But Id have to bust out the manual to be sure, and frankly, I dont feel like it. But, do not fall into the fallacy of conceptualizing DSM as some kind of absolute truth about diagnosis. Clinically, these situations matter little for the most part. These are primarily academic questions that do not change treatment plans for the most part. Clinically, its important to decipher if there is a phobia or a situational trigger for an individuals panic attacks, but beyond that, its of little clinical value to quibble about how specifically to write the diagnosis.

 

[erg923]

True, but I was referencing someone who had regular panic attacks without situational triggers but didn't have "Persistent concern about additional attacks, worry about the implications of the attack, or a significant change in behavior related to the attacks". I have no idea what category, if any, that would land in.

...well then you fall into the old DSM criteria of "impairment in social or occupational functioning." Clinically, I would wonder why they are not concerned about the presence of their panic attacks. If their is no distress, why are they in you office in the first place? Thats the question I would ask.

 

[RandomnessRocks]

Yes, I think you pretty much have it, more or less. But Id have to bust out the manual to be sure, and frankly, I dont feel like it. But, do not fall into the fallacy of conceptualizing DSM as some kind of absolute truth about diagnosis. Clinically, these situations matter little for the most part. These are primarily academic questions that do not change treatment plans for the most part. Clinically, its important to decipher if there is a phobia or a situational trigger for an individuals panic attacks, but beyond that, its of little clinical value to quibble about how specifically to write the diagnosis.

Thank you. I guess that makes sense. My head hurts a little. How do you like being a psychologist? Is it challenging, stressful, rewarding? Do you do it full time or do you do other things too? My professor said he can't do it full time because it drains him.

 

[erg923]

I cant give myself that title yet. I'm in grad school still. Yes, I like it. But the more you do it, the more problems you see. Problems with training models, diagnostic issues, ethical, the direction the profession is going, etc. I do not have the answers to any of these, i am just along for the ride. However, its is fascinating, and even though psychotherapy is not my niche, being so deeply involved in someones emotional experience is a humbling experience. The important thing is to love to learn it (even if you are constantly questioning some of it), and find the niche within it that you love and are most interested in.

 

[Ollie123]

...well then you fall into the old DSM criteria of "impairment in social or occupational functioning." Clinically, I would wonder why they are not concerned about the presence of their panic attacks. If their is no distress, why are they in you office in the first place? Thats the question I would ask.

Well in this case, the reason was "Because you'll pay me several hundred dollars to be in a research study unless I'm excluded for having Panic Disorder".

Which actually lead to some discussion of rehashing the protocol since we weren't sure if we wanted someone predisposed to regular panic attacks even without the disorder itself would differ physiologically from someone who did have the disorder.

 

[erg923]

Oh I see. I have seen the "professional" research subject as well in my work. So he had read up and was trying to anticipate exclusion criteria? So he might be trying to down-play his concerns and/or symptoms?

Similarly, we just recently started giving effort measures during our npsych testing of our subjects. I think we have alot of data in our archives that is potentially contaminated by suboptimal effort. I have tested people who were blatantly not putting forth full effort during testing. They got paid either way. I hounded our PIs about the issue, but there was alot of academic political pressure to use their testing anyway. Finally we changed protocols so of if they fail WMT, we simply do not continue with the neuropsych portion.

 

[myelin]

Oh I see. I have seen the "professional" research subject as well in my work. So he had read up and was trying to anticipate exclusion criteria? So he might be trying to down-play his concerns and/or symptoms?

Similarly, we just recently started giving effort measures during our npsych testing of our subjects. I think we have alot of data in our archives that is potentially contaminated by suboptimal effort. I have tested people who were blatantly not putting forth full effort during testing. They got paid either way. I hounded our PIs about the issue, but there was alot of academic political pressure to use their testing anyway. Finally we changed protocols so of if they fail WMT, we simply do not continue with the neuropsych portion.

what are you using as a measure of effort? we frequently use the digit memory test (DMT). if they fail it, we usually administer an MMPI to confirm sx exaggeration.

 

[erg923]

I assume thats similar to the Victoria Symptom Validity Test?
We use Greens Word Memory Test (WMT). And we always calculate reliable digit span and look at the Rarely Missed Items (RMI) on WMS.

 

[myelin]

I assume thats similar to the Victoria Symptom Validity Test?
We use Greens Word Memory Test (WMT). And we always calculate reliable digit span and look at the Rarely Missed Items (RMI) on WMS.

i've never calculated RMI on the WMS. it's usually at our discretion as to who's malingering (if we should give effort assessments). i think that effort testing is required for disability-seeking patients? we're pretty good at spotting them though. seriously, you can't do a 3-digit span on the WAIS and don't remember anything from that story I just read you...and you're here because you have memory problems, but you remember exactly where the snack machines and restrooms are...but you just can't remember how to get to work or pay your rent on-time...seriously grandma, you're wasting my time.

 

[erg923]

In a clinical context blatant malingering may be the case, but for our purpose, we are just screening for who's giving full effort in their testing. Performing poorly on effort measures is just that, suboptimal effort. (unless your performing below chance). Could be boredom and that they just don't care. Doesn't really matter what the reason is for us. In a research setting, we are not speculating about why. It just throws the validity of test results we would get from them into question. We don't want to use test results where we have objective indicators of poor effort....for whatever reason

 

[myelin]

oh ok, i'm talking about effort testing in a clinical setting.

 

[Therapist4Chnge]

But the more you do it, the more problems you see. Problems with training models, diagnostic issues, ethical, the direction the profession is going, etc.

So true.

I definitely want to find a way to contribute back to the profession, and hopefully help some of the above.

 

[erg923]

In a clincial setting WMT and MSVT are really gold standards. TOMM is good but has poor specificity with its current cut score, and is useless with people who are demented or have dementia like profiles on npsych tests. Moreover, people tend to feign their phenomenology (their view of what they are impaired with) and thats not always memory. So using several different measures, utilizing embedded effort indicies from existing tests, as well as FBS and RBS on the MMPI (if you give it) is best practice. If you would like some articles, I have tons. You should really be familiar with the Slick criteria as well if you are going into neuropsych. I can send you the Slick article backchannel if you like.

 

[mountaindrew]

Thanks sooo much erg and myelin (like the sheath?) I have another question if anyone understands. dysthymic disorder means your depressed for 2 years

It says if you've ever had a manic or mixed episode then you can't be diagnosed with it. So in 1996, if you had a period of mania and then returned to normal for a long time, then you became depressed from 2006-2008 without any mania **ever** returning. What would you be diagnosed as? Your mania was in 1996. That can't be bipolar 2 because the two events are so many years apart.

A 2 year long depression would be a chronic depression. The criterias for dysthymia are not exatcly like the ones for a major depressive episode.

For the bipolar question : yes, it would be bipolar disorder, type I, because any combination of certain types of episodes (mania, mixed or depressive episode) will happen in this disorder. Just like someone who has multiple depressive episodes still has a MDD.

 

[myelin]

In a clincial setting WMT and MSVT are really gold standards. TOMM is good but has poor specificity with its current cut score, and is useless with people who are demented or have dementia like profiles on npsych tests. Moreover, people tend to feign their phenomenology (their view of what they are impaired with) and thats not always memory. So using several different measures, utilizing embedded effort indicies from existing tests, as well as FBS and RBS on the MMPI (if you give it) is best practice. If you would like some articles, I have tons. You should really be familiar with the Slick criteria as well if you are going into neuropsych. I can send you the Slick article backchannel if you like.

As a student, I do the testing and scoring, and the neuropsychologist does the interpretations. I'm not sure how he assesses for effort, or if he uses the L, F, and K scales to supplement. I'd imagine he does because anyone suspected of suboptimal effort gets an MMPI. Truthfully, I find many cases interesting, but I score 100+ tests per day and forget to flag a file of interest that is suspect. It would be interesting to see confirmation of suboptimal effort to be related to the validity scales of the MMPI.

Sorry for the digression on this thread. Maybe we should split here to a thread titled "suboptimal effort on neuropsych testing"?

 

[erg923]

You're right, its the psychologists job to do the interpretation of measures, including the ones that aren't making sense or seem suspicious. Although I hope you guys check in with each other during testing regarding progress and your behavioral obs, in case changes in the test list need to be made. Although, if they are a hardcore Halstead-Reitan person, they may not do this I suppose.

By the way, F is almost useless as measure of exageration. Unless you're working in a college counseling center (where you wouldn't expect tons of psychopathology) it is not unusual to see F scales in the 70s and even 80s in clinical settings. You are going to elevate F if you have any serious psychopathology. Its really a better measure of how much psychopathology they are reporting. It does not necessarily mean they are faking anything because the F scale is composed of items rarely endorsed by normal populations. Well, in our job, we are not seeing normal pops, so its no surprise its often elevated. In other words a high F in a non-clinical setting is very suspicious, but in a clinical setting its a relatively common occurrence, so its not all that useful. On the MMPI, F(p) (items endorsed by less the 5% of clinical pops) should really be used to assess for feigning of psychiatric symptoms and FBS for suspected feigning of cognitive and physical malfunctioning. The MMPIs most recent development, the Response Bias Scale (RBS; Gervais, Ben-Porath, Wygant, & Green, 2007) can also be used for suspected cognitive exaggeration, and has been shown to correlate highly with Green's WMT as well. Lees-Haley's FBS scale is also highly correlated with failures on WMT and other effort measures.

 

[myelin]

Suprisingly, I've come across a handful of invalid profiles due to elevations on the validity scales. We do the scoring by hand, VRIN and TRIN included. As such, I remember them because if you've ever scored these by hand, you know how much of a pain it is. I've only been there for 3 months though, so I'm sure with time I'd see many more.

I believe in our situation (neurosychology clinic) we are more interested in symptom exaggeration versus serious psychopathology. This is especially important when evaluating patients for disability. Our referrals come from neurology and psychiatry, and most often, they have already had a psychological assessment. So, it would be interesting to see someone who doesn't meet DSM crieria for a psychological disorder, but then shows elevations on the validity/clinical scales on the MMPI. Or, even someone diagnosed with mild MDD who all of a sudden reports psychotic features (a 68, 86 profile). This paired with something like you suggest (suboptimal WMT) would be suggestive of malingering.

 

[erg923]

Good lord, why do they have you do it by hand! Thats just asking for errors. Not your fault or anything, they just happen. Not too mention the time it takes. Do you have to score Content and Harris-Lingoe subscales by hand to? I mean you cant even really interpret psychosis from 8 until you look at at the Harris-Lingoes and BIZ from the Content scale so see what driving the elevation on 8.

Given your referral base, I would think your supervisor utilizes the FBS from the MMPI. Neuropsych was the setting it was designed for. What validity scales are you scoring by hand, Just the old standards of F, L, K? I hope your supervisor goes beyond this when he/she does the interpretation and report writing!

 

[myelin]

I am not sure what he uses exactly, but I can tell you that he has the clinical, content, supplementary, and if any clinicals are elevated, then he also gets Harris-Lingoes. I take great pride in counting up all of those little bubbles. 😎

 

[Therapist4Chnge]

Good lord, why do they have you do it by hand! Thats just asking for errors. Not your fault or anything, they just happen. Not too mention the time it takes. Do you have to score Content and Harris-Lingoe subscales by hand to? I mean you cant even really interpret psychosis from 8 until you look at at the Harris-Lingoes and BIZ from the Content scale so see what driving the elevation on 8.

Scoring by hand is definitely tedious......another lovely part of grad school! Hopefully I land an internship site that has computerized scoring, as I feel like I'll be running a lot of these.

 

[myelin]

You're right, its the psychologists job to do the interpretation of measures, including the ones that aren't making sense or seem suspicious. Although I hope you guys check in with each other during testing regarding progress and your behavioral obs, in case changes in the test list need to be made. Although, if they are a hardcore Halstead-Reitan person, they may not do this I suppose.

By the way, F is almost useless as measure of exageration. Unless you're working in a college counseling center (where you wouldn't expect tons of psychopathology) it is not unusual to see F scales in the 70s and even 80s in clinical settings. You are going to elevate F if you have any serious psychopathology. Its really a better measure of how much psychopathology they are reporting. It does not necessarily mean they are faking anything because the F scale is composed of items rarely endorsed by normal populations. Well, in our job, we are not seeing normal pops, so its no surprise its often elevated. In other words a high F in a non-clinical setting is very suspicious, but in a clinical setting its a relatively common occurrence, so its not all that useful. On the MMPI, F(p) (items endorsed by less the 5% of clinical pops) should really be used to assess for feigning of psychiatric symptoms and FBS for suspected feigning of cognitive and physical malfunctioning. The MMPIs most recent development, the Response Bias Scale (RBS; Gervais, Ben-Porath, Wygant, & Green, 2007) can also be used for suspected cognitive exaggeration, and has been shown to correlate highly with Green's WMT as well. Lees-Haley's FBS scale is also highly correlated with failures on WMT and other effort measures.

I recently came across a statement in the Graham MMPI-2 book stating that the FBS has been quite ineffective at detecting malingering and had the worst validity of that prurpose for all of the MMPI-2 scales (Rogers et al., 2003). Graham also mentions the utility of the FBS in neuropsychological evaluations and again states that a study by Dearth et al (2005) found that the FBS was not as effective as F, Fb, Fp, or Ds2 in identifying those who are malingering during neuropsychological evaluation. Interestingly, Graham mentions that more research should be done to assess the relationship between feigining of cognitive deficits and established motivational scales such as the DMT, a measure of effort that we commonly use.

 

[KillerDiller]

By the way, F is almost useless as measure of exageration. Unless you're working in a college counseling center (where you wouldn't expect tons of psychopathology) it is not unusual to see F scales in the 70s and even 80s in clinical settings.

I just wanted to jump in here because I see this thought expressed a lot on this board. In fact, there is quite a bit of pathology seen in college counseling centers, as this is the first place most students seek mental health treatment. Full blown postive schizophrenic symptoms often don't manifest until college. You will also see severe anxiety disorders like OCD and PTSD, students who are extremely depressed and suicidal, life threatening eating disorders, substance abuse, sexual dysfunction, and pretty much all of the personality disorders. It's amazing how bright people can accomodate even severe pathology and still manage to make it through high school and beyond.

 

[Therapist4Chnge]

....there is quite a bit of pathology seen in college counseling centers, as this is the first place most students seek mental health treatment. Full blown postive schizophrenic symptoms often don't manifest until college. You will also see severe anxiety disorders like OCD and PTSD, students who are extremely depressed and suicidal, life threatening eating disorders, substance abuse, sexual dysfunction, and pretty much all of the personality disorders. It's amazing how bright people can accomodate even severe pathology and still manage to make it through high school and beyond.

Exactly what I was thinking when I read that. Often it is the beginning of the slide that you catch in college.

 

[erg923]

I recently came across a statement in the Graham MMPI-2 book stating that the FBS has been quite ineffective at detecting malingering and had the worst validity of that prurpose for all of the MMPI-2 scales (Rogers et al., 2003). Graham also mentions the utility of the FBS in neuropsychological evaluations and again states that a study by Dearth et al (2005) found that the FBS was not as effective as F, Fb, Fp, or Ds2 in identifying those who are malingering during neuropsychological evaluation. Interestingly, Graham mentions that more research should be done to assess the relationship between feigining of cognitive deficits and established motivational scales such as the DMT, a measure of effort that we commonly use.

Yes, FBS was controversial for a while. Butcher and the Minnesota crew slammed in for a while. My feeling is Butcher didnt like some outsider non-academic coming in and critizing the F family and making a new scale on his test. Moreover, I dont think many of them understood the context for which FBS was developed (none of them are neuropsychologists). Alot controversey stems from the fact the FBS was derived rationally, not emprically, like most other scales in the MMPI. After it was designed, it was testied empiricically in compensation seeking neuropsych pops. A cutting score was introduced that demonstrated high senstivity and specificity in this group. Replication of this have followed. It reliable and has high sensitivity and specificity demosntrated by emprical studies, however, its construct validity is still indeed in question. More important though is the setting for which it was designed. This is really a kep point. Compensation seeking neuro pops. It is not really known what high FBS scores mean in other settings, as no one has really looked at it. Bottom line is, the scale was made to discriminate only in this compensation seeking setting. So yes, its validity in psych pops is probably...well who knows? However, Lees-Haley has said over and over, FBS does not and was never designed to measure the same things as F and F(p). Anyway, enough research accumulated that FBS was addded to Pearons' score report (making it an offical scale) in 2006 or 2007. Caldwell's report also automatically calculates FBS.