Need education on Personality Testing

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Attending1985

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Can anyone who is knowledgeable in psychological testing like MMPI, ect. tell me what the utility of it is in diagnosing bipolar disorder or a thought disorder. I work with a therapist who frequently tells me that that so and so patient has a thought disorder or bipolar disorder based on their testing. These assessments often seem way off to me based on my experience with the patient. She's always really concerned about these results despite my feeling that they're not clinically meaningful.

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I think it can support a diagnosis, but not be the sole evidence of a diagnosis by itself. For instance, on the MMPI-2 a lot of diagnoses (like certain personality disorders and PTSD) can "trigger" elevations on scales suggestive of thought disorder. My understanding from my training is that testing data should be used more to disconfirm rather than confirm diagnostic hypotheses.

Of course, there are many people on this board with far more expertise in testing, so I'd be interested to see what they say. :)
 
Correct, it is not a measure to be used in isolation. It can be used to pick up some subtle thought disorder content, or subtle mania symptoms for example, but then that should be followed up by good clinical interviewing or other measures. Hard to say what this person is basing their diagnoses on without all of the information, but no one should be making any diagnosis based off of the MMPI alone.
 
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Thanks. It's really starting to drive me nuts. Today she was talking about all these elevations in schizophrenia for a high functioning patient who likely has borderline personality disorder and thinks her house is haunted. She feels I need to re-evaluate emergently. How can you miss a diagnosis of schizophrenia?
 
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Thanks. It's really starting to drive me nuts. Today she was talking about all these elevations in schizophrenia for a high functioning patient who likely has borderline personality disorder and thinks her house is haunted. She feels I need to re-evaluate emergently. How can you miss a diagnosis of schizophrenia?

Yeah, just because a test is standardized doesn't make it clinically relevant.
 
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Can anyone who is knowledgeable in psychological testing like MMPI, ect. tell me what the utility of it is in diagnosing bipolar disorder or a thought disorder. I work with a therapist who frequently tells me that that so and so patient has a thought disorder or bipolar disorder based on their testing. These assessments often seem way off to me based on my experience with the patient. She's always really concerned about these results despite my feeling that they're not clinically meaningful.

The clinically meaningful use of (psychometrically solid) psychological testing/personality measures for purposes of treatment planning is difficult and nuanced, and I would dare say the modal clinical psychologist is just not very good at it.

I encourage providers to use structured or semi-structured clinical interviews/interviewing and collateral history (since things like Bipolar and Schizoaffective rely on time frames of symptom onset within the context of the overall disturbance and history), with the judicious use of appropriate instruments (such as an MMPI) if treatment is just not addressing them or progressing them.
 
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The other bizarre thing is I have an obvious delusional disorder that she’s skeptical about almost buying into her delusions of persecution.
 
The other bizarre thing is I have an obvious delusional disorder.

Then this is all just a paranoid delusion. Chill. Take the haldols and go to your happy place.
 
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I work with a therapist who frequently tells me that that so and so patient has a thought disorder or bipolar disorder based on their testing.

I hope she isn't saying those words. Tests results and codetypes dont dx anyone/anything.

Thanks. It's really starting to drive me nuts. Today she was talking about all these elevations in schizophrenia for a high functioning patient who likely has borderline personality disorder and thinks her house is haunted. She feels I need to re-evaluate emergently. How can you miss a diagnosis of schizophrenia?

Ok. Then ask about the F(p) scale and the Harris-Lingoe parent scales....Bizz1 and Bizz2 are different and should not be interpreted at all without full case history/knowledge.
 
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I remember taking a psychological testing course as an undergraduate where the professor had really oversold the idea of testing, saying if that you’re going up against your clinical diagnosis vs. the testing, to always go with the testing. Took that at face value at the time. The whole funny thing about it, is the idea that you should rely on the “test(s)” and the “science” that are not as fallible and flawed as a clinical opinion, but all the test tells you is how they compare to a sample of people who have received... a clinical diagnosis.
 
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but all the test tells you is how they compare to a sample of people who have received... a clinical diagnosis.

Not exactly.

And, not everyone wears it on the sleeve, so I can see the utility of further investigation, based on the literature and on ideas of descriptive psychopathology, which is now largely lost to modern psychiatry/psychiatric practice.

The caveat here is: 1.) not everyone needs these tests to treat them (most dont). 2.) When all you have is a hammer....

It should also be noted that a common exclusionary criteria for the indication or "medical necessity" of psychological testing for most insurers is: "The testing results will be used only to confirm a diagnosis that is clinically suggested by initial evaluation."
 
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Thanks. It's really starting to drive me nuts. Today she was talking about all these elevations in schizophrenia for a high functioning patient who likely has borderline personality disorder and thinks her house is haunted. She feels I need to re-evaluate emergently. How can you miss a diagnosis of schizophrenia?

A psychiatric diagnosis should primarily be based on a thorough history and supported by findings on mental state examination. Having supernatural beliefs may point to other schizotypal personality traits, but by itself it hardly warrants an urgent re-evaluation.

I doubt that a patient who is truly thought disordered, responding to internal stimuli or exhibiting any of the other classic schizophrenia symptoms would be able to sit down and complete the 100s of questions present in an MMPI (and even if they could one would have to question it's validity and appropriateness of conducting said test). OTOH, if a psychologist told me that my patient refused to sit down and do the MMPI due to spending a lot of time checking the room for listening devices and insisting taking furniture apart... then that's a different story altogether.
 
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A psychiatric diagnosis should primarily be based on a thorough history and supported by findings on mental state examination. Having supernatural beliefs may point to other schizotypal personality traits, but by itself it hardly warrants an urgent re-evaluation.

I doubt that a patient who is truly thought disordered, responding to internal stimuli or exhibiting any of the other classic schizophrenia symptoms would be able to sit down and complete the 100s of questions present in an MMPI (and even if they could one would have to question it's validity and appropriateness of conducting said test). OTOH, if a psychologist told me that my patient refused to sit down and do the MMPI due to spending a lot of time checking the room for listening devices and insisting taking furniture apart... then that's a different story altogether.

The disorganized subtype is not the only kind. And yes, I know they did away with "subtypes" in the most recent manual.
 
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In my clinical experience a true thought disorder is not simply the presence of some bizarre thought content and sometimes it may be subtle but their thought process is also abnormal
 
A psychiatric diagnosis should primarily be based on a thorough history and supported by findings on mental state examination. Having supernatural beliefs may point to other schizotypal personality traits, but by itself it hardly warrants an urgent re-evaluation.

I doubt that a patient who is truly thought disordered, responding to internal stimuli or exhibiting any of the other classic schizophrenia symptoms would be able to sit down and complete the 100s of questions present in an MMPI (and even if they could one would have to question it's validity and appropriateness of conducting said test). OTOH, if a psychologist told me that my patient refused to sit down and do the MMPI due to spending a lot of time checking the room for listening devices and insisting taking furniture apart... then that's a different story altogether.
I just want to focus on her dysfunction which is mainly anxiety due to perfectionist thinking and sequelae of childhood abuse. I really don’t care if she has some magical thinking and believes in ghosts. Maybe it’s making her life more exciting. Why go drumming up problems.
 
The disorganized subtype is not the only kind. And yes, I know they did away with "subtypes" in the most recent manual.

Man, I know subtypes as such are maybe not super reliable or verifiable entities and should not be reified, but reading up on old school classification schemes is super helpful for me understanding the diversity of how particular conditions can present and what it can look like. I feel like some of my co-residents assert someone can't have schizophrenia because they lack frank disorganization, and I think "yeah but they're super hebephrenic (or pseudoneurotic or what have you) and meet criteria otherwise."
 
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Man, I know subtypes as such are maybe not super reliable or verifiable entities and should not be reified, but reading up on old school classification schemes is super helpful for me understanding the diversity of how particular conditions can present and what it can look like. I feel like some of my co-residents assert someone can't have schizophrenia because they lack frank disorganization, and I think "yeah but they're super hebephrenic (or pseudoneurotic or what have you) and meet criteria otherwise."

Yeah, we need to step up our psychopathology teaching game in residency programs. I think it doesn't get enough attention these days.

Personality testing can be useful because it can provide evidence to support your clinical opinion, or it can alert you to something you might have overlooked, or give useful information about the person's response style (over reporting, inconsistent, seemingly appropriately engaged, etc.). Still, it's just one piece of information among many. You have to weigh the evidence and make the final diagnostic calls.
 
Ok apparently she said she saw the ghost and talked to it. I’m still not impressed.
 
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Ok apparently she said she saw the ghost and talked to it. I’m still not impressed.
Keeps seeing shadows out of the corners of her eyes, too, should probably start some Zyprexa and emphasize the importance of compliance in the setting of weight gain.
 
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Not exactly.
More so what I’m contrasting is the idea that testing is pure and objective, and totally independent of any human observation, like a computer reading a sodium level, but fails to acknowledge that what it’s comparing with to establish any diagnosis is a normative group of people who received their diagnoses clinically and weren’t diagnosed in some alternate, non-clinical world.
 
Man, I know subtypes as such are maybe not super reliable or verifiable entities and should not be reified, but reading up on old school classification schemes is super helpful for me understanding the diversity of how particular conditions can present and what it can look like. I feel like some of my co-residents assert someone can't have schizophrenia because they lack frank disorganization, and I think "yeah but they're super hebephrenic (or pseudoneurotic or what have you) and meet criteria otherwise."
Just wanted to be annoying and point out hebephrenic schizophrenia is basically the disorganized type most closely approximated and pseudoneurotic schizophrenia is a form of borderline personality disorder. It’s been a while since I’ve put that dx in anyone’s chart but I have done before
 
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Psychological assessment doesn’t directly lead to a diagnosis except for maybe cognitive tests and intellectual or learning disabilities. We can’t measure psychopathology, the test just provides how someone responds to questions about various symptoms. Just another data point to add to interview, careful observation, and history.

Also, a belief in ghosts is not a very good indicator of a psychotic disorder in my experience. Also, for various cultures, it is a fairly normal experience. I hate it when clinicians over-pathologize. If someone is so good at hiding their schizophrenia that a psychiatrist can’t see it, then do they really have it? Now if the person was having a conversation with the ghosts and the whole thing didn’t make much sense and was difficult to follow while I’m just trying to get a basic history, then I might be thinking that we have a psychotic disorder on our hands and start running through some of the differentials.
 
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Just wanted to be annoying and point out hebephrenic schizophrenia is basically the disorganized type most closely approximated and pseudoneurotic schizophrenia is a form of borderline personality disorder. It’s been a while since I’ve put that dx in anyone’s chart but I have done before

I have seen older literature use those terms very differently so I am not sure I agree with you.
 
The disorganized subtype is not the only kind. And yes, I know they did away with "subtypes" in the most recent manual.

Indeed, and I did allude to the paranoid type as well :). While they have now mixed them altogether, I do think that schizophrenia subtypes still have clinical and explanatory utility. The point I was making was that a psychologist who uses a personality inventory to come up with a diagnosis from a check box process is likely to have missed other aspects of one's clinical presentation that may support or rule out said diagnosis.

In the OP's case, the psychologist is either drawing the incorrect conclusions based on an incomplete knowledge base, or they are always trying to one-up the OP and there is some kind of unhealthy dynamic going on that we're not aware of.

Man, I know subtypes as such are maybe not super reliable or verifiable entities and should not be reified, but reading up on old school classification schemes is super helpful for me understanding the diversity of how particular conditions can present and what it can look like. I feel like some of my co-residents assert someone can't have schizophrenia because they lack frank disorganization, and I think "yeah but they're super hebephrenic (or pseudoneurotic or what have you) and meet criteria otherwise."

You can certainly have paranoid schizophrenia without any kind of disorganisation. I believe that hebephrenic was used interchangeably with disorganised (ICD10 F20.1) , and I've only seen pseudoneurotic used in some very old texts. ICD 10 has it under Schzoptypal personality disorders (ICD 10 F21), although I can't remember hearing about it outside of a history of psychiatry lecture I went to years ago.
 
Indeed, and I did allude to the paranoid type as well :). While they have now mixed them altogether, I do think that schizophrenia subtypes still have clinical and explanatory utility. The point I was making was that a psychologist who uses a personality inventory to come up with a diagnosis from a check box process is likely to have missed other aspects of one's clinical presentation that may support or rule out said diagnosis.

In the OP's case, the psychologist is either drawing the incorrect conclusions based on an incomplete knowledge base, or they are always trying to one-up the OP and there is some kind of unhealthy dynamic going on that we're not aware of.



You can certainly have paranoid schizophrenia without any kind of disorganisation. I believe that hebephrenic was used interchangeably with disorganised (ICD10 F20.1) , and I've only seen pseudoneurotic used in some very old texts. ICD 10 has it under Schzoptypal personality disorders (ICD 10 F21), although I can't remember hearing about it outside of a history of psychiatry lecture I went to years ago.

I guess I also think about hebephrenic/seen it used to describe, early on, a sort of child like silliness in the context of psychosis that eventually becomes more classic disorganization but in someone on the younger end of things might get missed. I recognize this is probably not how it was universally understood, which I suppose is why the subtypes fell out of fashion.
 
I guess I also think about hebephrenic/seen it used to describe, early on, a sort of child like silliness in the context of psychosis that eventually becomes more classic disorganization but in someone on the younger end of things might get missed. I recognize this is probably not how it was universally understood, which I suppose is why the subtypes fell out of fashion.

You aren't actually incorrect on that either - in ICD (p80, link) it is described as follows:
A form of schizophrenia in which affective changes are prominent, delusions and hallucinations fleeting and fragmentary, behaviour irresponsible and unpredictable, and mannerisms common. The mood is shallow and inappropriate and often accompanied by giggling or self-satisfied, self-absorbed smiling, or by a lofty manner, grimaces, mannerisms, pranks, hypochondriacal complaints, and reiterated phrases. Thought is disorganized and speech rambling and incoherent. There is a tendency to remain solitary, and behaviour seems empty of purpose and feeling. This form of schizophrenia usually starts between the ages of 15 and 25 years and tends to have a poor prognosis because of the rapid development of "negative" symptoms, particularly flattening of affect and loss of volition.

In addition, disturbances of affect and volition, and thought disorder are usually prominent.
Hallucinations and delusions may be present but are not usually prominent. Drive and
determination are lost and goals abandoned, so that the patient's behaviour becomes
characteristically aimless and empty of purpose. A superficial and manneristic preoccupation
with religion, philosophy, and other abstract themes may add to the listener's difficulty in
following the train of thought.
 
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You should never diagnose based off one assessment. EVER

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Depends on the assessment, really. A SCID is technically an assessment, and you would definitely base diagnoses off of that. And, let's be honest, in most healthcare settings, diagnoses are based off far less than something like an MMPI or other assessment all of the time. I'd wager something like 75%+ of mental health diagnoses are based off of brief conversations in intakes.
 
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Depends on the assessment, really. A SCID is technically an assessment, and you would definitely base diagnoses off of that. And, let's be honest, in most healthcare settings, diagnoses are based off far less than something like an MMPI or other assessment all of the time. I'd wager something like 75%+ of mental health diagnoses are based off of brief conversations in intakes.
IMO a good clinical interview is better than any one assessment measure

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IMO a good clinical interview is better than any one assessment measure

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Good clinical interviews are great, which is what the SCID is, but it's too bad that good clinical interviews are so very rarely done in mental health.
 
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Depends on the assessment, really. A SCID is technically an assessment, and you would definitely base diagnoses off of that. And, let's be honest, in most healthcare settings, diagnoses are based off far less than something like an MMPI or other assessment all of the time. I'd wager something like 75%+ of mental health diagnoses are based off of brief conversations in intakes.

"You remind me of this person I treated before one time so you probably have the same diagnosis."
 
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"You remind me of this person I treated before one time so you probably have the same diagnosis."
Which is the gold standard! And is absolutely how we do things in medicine- and is fine assuming the initial diagnosis is correct. It is slightly trickier applying this kind of reasoning in psychiatry of course and formulation is usually much more important than diagnosis. We should also hopefully continue to revisit and revise our formulation as we gather more information and learn more about the patient. The idea of slapping a dx on a patient the first time we meet them is a very recent development in psychiatry.
 
Which is the gold standard! And is absolutely how we do things in medicine- and is fine assuming the initial diagnosis is correct. It is slightly trickier applying this kind of reasoning in psychiatry of course and formulation is usually much more important than diagnosis. We should also hopefully continue to revisit and revise our formulation as we gather more information and learn more about the patient. The idea of slapping a dx on a patient the first time we meet them is a very recent development in psychiatry.

Certainly, if the clinical history matches up to support the diagnosis. But, I assume clausewitz meant something else, as in providers will be reminded of something in a patient that is clinically irrelevant that reminds them of another patient when making that diagnosis. Far too often, diagnoses nowadays are made with a minimal amount of data, more with insurance reimbursment and ease of documentation in mind rather than accuracy in diagnostic criteria.
 
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You should never diagnose based off one assessment. EVER

Tell that to the insurance companies. But I disagree anyway. Sometimes you can make a very good diagnosis based on a single interview. And sometimes you can make a very bad diagnosis based on many encounters. You also have to consider the risk of delaying treatment for sake of more diagnostic clarity alongside risk of initiating the wrong treatment for the wrong diagnosis.
 
Tell that to the insurance companies. But I disagree anyway. Sometimes you can make a very good diagnosis based on a single interview. And sometimes you can make a very bad diagnosis based on many encounters. You also have to consider the risk of delaying treatment for sake of more diagnostic clarity alongside risk of initiating the wrong treatment for the wrong diagnosis.
I think this is a good point. For billing purposes, I do have to diagnose quickly and often times I end up reformulating as treatment progresses. That being said, I feel way more comfortable diagnosing after a 1.5 hour clinical interview than I do after reviewing the results of one MMPI

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I think this is a good point. For billing purposes, I do have to diagnose quickly and often times I end up reformulating as treatment progresses. That being said, I feel way more comfortable diagnosing after a 1.5 hour clinical interview than I do after reviewing the results of one MMPI

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I think we were debating the specific statements and interpretations made by the psychologist, and the possibly treatment relevance of the assessment in this particular case. I don't think anyone suggested the psychologist was doing "blind interpretation." Do people still even do this? Isn't Ralph R. dead?
 
The idea of slapping a dx on a patient the first time we meet them is a very recent development in psychiatry.

This!

Although, there are certainly many times I would hope any reasonably psychologist would return with a dx statement (assuming they are spending more time doing more through or objective assessment, and gathering more collateral than the modal psychiatrist), this notion that we have to be certain of X, Y, Z before we treat this person is nuts!

Its a recent development, and I don't know what inept person helped perpetuated such a myth for treatment in psychiatry. I see this all the time in the form of "must establish dx for treatment planning."
 
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Which is the gold standard! And is absolutely how we do things in medicine- and is fine assuming the initial diagnosis is correct. It is slightly trickier applying this kind of reasoning in psychiatry of course and formulation is usually much more important than diagnosis. We should also hopefully continue to revisit and revise our formulation as we gather more information and learn more about the patient. The idea of slapping a dx on a patient the first time we meet them is a very recent development in psychiatry.

Unfortunately, my charting doesn't allow for "meh, not really sure yet" in the dx part of the coding slip
 
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So I saw the patient again today. She has been terrified since her appointment with the therapist who told her that her testing indicated that she may be schizophrenic. I educated her that she is not schizophrenic and she was really relieved. We talked about the possibility of BPD, her anxiety and the relationship with that to some past trauma. I can't believe that therapist told her she was schizophrenic. What a joke and harmful to an already anxious patient. I'm not sure if it's even safe to refer people to her.
 
So I saw the patient again today. She has been terrified since her appointment with the therapist who told her that her testing indicated that she may be schizophrenic. I educated her that she is not schizophrenic and she was really relieved. We talked about the possibility of BPD, her anxiety and the relationship with that to some past trauma. I can't believe that therapist told her she was schizophrenic. What a joke and harmful to an already anxious patient. I'm not sure if it's even safe to refer people to her.
I would ask the psychologist to send me a copy of the report to see what it really says. Either the psychologist is a quack or the patient might be taking some things out of context and/or doing some splitting. The report would be enough to let you know, especially if you had another psychologist take a look at it. It is always easier to spot the quacks in our own bailiwick.
 
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I would ask the psychologist to send me a copy of the report to see what it really says. Either the psychologist is a quack or the patient might be taking some things out of context and/or doing some splitting. The report would be enough to let you know, especially if you had another psychologist take a look at it. It is always easier to spot the quacks in our own bailiwick.
The patient is telling the truth because she told me she thought the patient was schizophrenic I just didn’t think she told her that flat out. Regardless of what the testing showed it’s an inappropriate assessment if you actuallly talk to the patient.
 
Also, a belief in ghosts is not a very good indicator of a psychotic disorder in my experience. Also, for various cultures, it is a fairly normal experience. I hate it when clinicians over-pathologize. If someone is so good at hiding their schizophrenia that a psychiatrist can’t see it, then do they really have it? Now if the person was having a conversation with the ghosts and the whole thing didn’t make much sense and was difficult to follow while I’m just trying to get a basic history, then I might be thinking that we have a psychotic disorder on our hands and start running through some of the differentials.

This is very true, and especially if it isn't causing distress or impairment.
 
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