Unit 4 - Psychodiagnostics

Post Graduate Institute Memory Scale (PGI-MS)

The Post Graduate Institute Memory Scale (PGI-MS) is a standardized tool developed by
Dwarka Prasad and N.N. Wig in 1976 at the Post Graduate Institute of Medical
Education and Research (PGIMER), Chandigarh. This scale was designed to assess
various components of memory as part of a larger test battery called the PGI Battery of
Brain Dysfunction.

Development and Validation

● Cultural Adaptation: The PGI-MS is a modified Indian version of the Wechsler
Memory Scale, tailored to suit the Indian population's cultural and linguistic
diversity.
● Norms: It has age- and education-specific norms for individuals aged 20 to 69
years, ensuring accurate and meaningful interpretations.
● Inclusivity: The scale is designed for individuals from any educational or language
background, including those with limited literacy.
● Administration: The PGI-MS was administered to 410 subjects divided into four
groups: normal, neurotic, psychotic, and organic.
Structure of PGI-MS
The PGI-MS is a comprehensive memory assessment tool with 10 subtests, each measuring
a specific memory domain:
1. Remote Memory: Ability to recall distant past events.
2. Recent Memory: Recall of information from the immediate past.
3. Mental Balance: Sequencing ability.
4. Attention and Concentration: Sustained focus.
5. Immediate Recall: Short-term memory through immediate reproduction.
6. Delayed Recall: Recall of information after a time delay.
7. Verbal Retention for Similar Pairs: Retention of related verbal pairs.
8. Verbal Retention for Dissimilar Pairs: Retention of unrelated verbal pairs.
9. Visual Retention: Memory for visual stimuli.
10. Visual Recognition: Ability to recognise previously presented visual information.

Psychometric Properties
● Reliability:
○ Test-retest reliability ranges from 0.69 to 0.85, ensuring consistency across
administrations.
● Validity:
 ○ The scale shows a correlation of 0.85 with the Wechsler Memory Scale,
demonstrating strong criterion validity.

Applications and Relevance

1. Clinical Applications:
○ Diagnosing memory impairments in neurological conditions like traumatic
brain injuries, stroke, and psychiatric disorders (e.g., depression, anxiety).
○ Differentiating between organic and functional memory issues.
○ Evaluating memory profiles in patients with brain dysfunction.
Research Applications:
● Traumatic Brain Injury vs. Hemorrhage (Nehra et al., 2014):
○ PGI-MS was used to assess memory impairments in traumatic brain injury and
haemorrhage patients.
○ Results showed greater memory impairment in traumatic brain injury
patients, with a 20% increase in deficits compared to haemorrhage patients.
● Memory in Depression and Anxiety Disorders (Akhouri et al., 2014):
○ Only remote, recent, and immediate memory subtests were used.
○ Findings revealed impaired immediate and recent memory in patients with
depression and anxiety, while remote memory remained intact.
Monitoring Progress:
● PGI-MS can assess improvements or changes in memory following therapeutic
interventions, rehabilitation, or treatment in clinical settings.
Conclusion
The PGI-MS is a culturally sensitive, reliable, and versatile tool for assessing memory
functions in the Indian population, accommodating diverse educational and linguistic
backgrounds. Its comprehensive structure and robust psychometric properties make it
indispensable for clinical diagnosis, research, and the evaluation of therapeutic outcomes.
NIMHANS Neuropsychological Battery (2004)

The NIMHANS Neuropsychological Battery, developed in 2004 by Shobini L. Rao, D.K.

Subbakrishna, and K. Gopukumar, is a comprehensive tool designed to evaluate cognitive
functioning in both healthy and dysfunctional brains. It assesses key psychological domains,
including cognition, emotion, and volition, to explain behavioural disturbances. This battery
is instrumental in identifying disrupted psychological components, constructing
neuropsychological profiles of strengths and weaknesses, mapping dysfunctional brain
structures, and localizing brain lesions. It employs two approaches for identifying deficits: the
ideometric approach, which involves qualitative evaluation, and the psychometric approach,
which uses quantitative norm-based comparisons.

Goals of Neuropsychological Assessment

1. The first goal is to identify the disrupted psychological component/ process/ domains
in an individual patient and arrive at a profile of adequacies and defects of
psychological functions.
2. The second goal is to identify the brain structure/functional networks, which are
dysfunctional or damaged using the neuropsychological profile that has previously
been derived.
3. Finally, this information is used to lateralise and localize the brain lesions.

Identification of a deficit in Neuropsychological tests

Ideometric approach and psychometric approach are the two methods that are used in the
identification of deficits in neuropsychological tests

Theoretical Basis (Luria’s Working Brain Model)

The battery is rooted in Luria’s (1974) Working Brain Model, which outlines three
hierarchical brain units essential for mental activities.
1. The primary projection areas are responsible for sensory input reception.
2. The secondary projection-association areas handle integration and processing.
3. The tertiary zones of overlapping regulate higher-order functions.
These units & zones, when functioning properly, work together to regulate all our behaviours,
from walking & sleeping to hearing & seeing & thinking & problem-solving.

"Each form of conscious activity is always a complex functional system and takes place
through the combined working of all three brain units, each making its own contribution
(Luria, 1974). However, when this complex functional system is damaged by an injury to any
or all of the units, the cohesion of the system is disrupted, resulting in a system which
functions in a manner markedly different than before the disruption.

Methodology and Normative Data

The battery’s norms were developed using data from healthy volunteers without mental
illness. The sample was divided into 3 categories according to age: 16-30 years, 31-50 years,
and 51-56 years. The sample was divided on the basis of gender (male & female), age, and
education. They were divided based on education i.e. subjects who were illiterate, up to 10
years of education and those with more than 10 years of education.

Assessment Domains and Tests

The NIMHANS Neuropsychological Battery includes a range of tests grouped into specific
domains to evaluate various cognitive abilities comprehensively:

Speed Tests
1. Finger Tapping Test (Motor Speed):
● Purpose: Measures motor speed.
● Procedure:
○ The test is done with the index finger of both hands without moving either
body or shoulder.
○ The subject is given a total of 5 trials lasting 10 seconds each.
● Scoring: The average number of taps per hand across the five trials is calculated.

2. Digit Symbol Substitution Test (Mental Speed):

● Purpose: Assesses visuomotor coordination, motor persistence, sustained attention,
and response speed.
● Procedure:
○ The subject substitutes numbers (1–9) with corresponding symbols using a
provided key.
○ The first 10 squares are used for practice.
○ Errors made during the test are recorded.
● Scoring: The time taken to complete the task and the total number of errors are noted.
● Duration: Approximately 7 minutes.

Tests of Attention
3. Color Trails Test (D’Elia et al., 1996):
● Purpose: Measures sustained and focused attention. The test is an analogue of the
Trail Making test and is considered to be free from the influence of language
● Procedure:
 ○ Trial 1: Requires sustained attention, perceptual tracking, and sequencing.
The test consists of a practice sheet and a test sheet for both parts.
○ Trial 2: Involves alternating between yellow and pink colours in ascending
numerical order; all the numbers from 2-8 are presented twice, once on the
pink circle and once on the yellow circle. The number 1 is presented only
once, in a pink circle. These numbers are randomly arranged in the box.
Beneath the boxes are two rows of numbers in serial order.
○ Includes practice and test sheets.
● Scoring: According to the time taken to complete Trial 1 and Trial 2.

4. Digit Vigilance Test (Lezak, 1995):

● Purpose: Assesses sustained attention.
● Procedure:
○ Numbers 1–9 are randomly presented across 50 rows (30 digits per row).
○ Target digits (6 and 9) are identified and marked by the subject.
○ The same level of mental effort or attention deployment is required over a
period of time.
○ The subject has to focus on the target digits i.e. 6 and 9 among other distracter
digits and cancel the target (by drawing/marking them).
● Scoring: Time taken and the number of errors are recorded.
● Duration: About 15 minutes.

5. Triads Test:
It was developed at NIMHANS.
● Purpose: Evaluates divided attention.
● Procedure:
○ It combines a verbal triads task with a tactual number identification task.
○ The subject is blindfolded in this test. The verbal triads task consists of 48
concrete nouns grouped into 16-word triads
○ In each triad, two words belong to one category while the third one does not.
(e.g. Mother, child, sky).
○ In the tactual number identification task, a single or double-digit number is
written on the palm of the subject's non-dominant hand. The subject identifies
the number calling it out
○ Then the subject is told that the task will be given simultaneously and
attention should be divided between both.
● Scoring: Errors for words and numbers are recorded separately (maximum of 16
errors per category). Omissions are also counted as errors.
● Duration: Approximately 7 minutes.
EXECUTIVE FUNCTION TESTS
Executive functioning is defined as “the ability to maintain an appropriate problem-solving
set for the attainment of future goals”. Executive functions include fluency, working memory,
set-shifting ability, set maintenance, planning, response inhibition, error detection,
abstraction, and organisation.

A. Fluency Tests:
● Controlled Oral Word Association (COWA):
a) Phonemic fluency test
○ Subjects asked to generate words (excluding proper nouns and names,
avoiding repetition of the same word with a suffix) beginning with the letter F,
followed by A and S each for one minute.
○ Subjects who did not know English were asked to generate words in their
mother tongue commencing with consonants ‘Ka’, ‘Pa’, ‘Ma
○ Scoring: Average number of new words generated across three trials.
○ Duration: About 5 minutes.
● Animal Names Test:
b) Category fluency test
○ The subject was asked to generate as many animal names as possible within
one minute (excluding fish, birds, and snakes).
○ Scoring: Total number of unique animal names.
○ Duration: About 3 minutes.
● Design Fluency Test:
The subject is asked to draw as many new forms as possible in a given period of time.
There are two conditions in this test: free condition and fixed condition.
○ Free Condition: Create as many novel designs as possible within 5 minutes.
○ Fixed Condition: Generate designs using exactly four straight or curved lines
within 4 minutes.
○ Scoring: Number of unique designs produced under each condition.

B. Working Memory Tests:

1. N-Back Test:
The N- Back task asses verbal working memory. The Verbal N- Back requires verbal
storage and rehearsal while the two back versions require in addition to the above,
manipulation of information.
a) Verbal working memory N Back test (12 mins): Identify consonant repetitions
(1-back) or a consonant repeating after one intervening item (2-back).
b) Visual working memory N Back test (10 mins): Subject utilizes 36 cards each of
which has one black dot placed randomly on an imaginary circle. The subject must
tap when a dot appears in the same position on a circle as a previous dot.
 ○ Scoring: Total hits and errors. Hits were the number of times the subject
tapped correctly, and errors were the number of times the subject failed to tap
or tapped incorrectly.

2. Self-Ordered Pointing Test:

The subject is seated comfortably and is told to point out any stimulus on the card and
given a constraint that the same stimulus cannot be pointed to in another card.
○ Select unique stimuli across trials without following patterns.
○ Illiterate subjects are administered only the visual working memory tests.
○ Scoring: Correct responses.

C. Planning:
1. Tower of London Test:
The test consists of two identical wooden boards with three beads each painted red,
green and blue. Each board is fitted with three round pegs of different sizes.
○ Rearrange beads to match a target configuration while following specific
rules.
○ A total of fourteen such problems are provided.
○ Scoring: Time, number of moves, and optimal solutions achieved.
Scoring is based on the average time taken to complete a problem, the average number of
moves taken for problems with 2, 3, 4 and 5 moves and the total number of problems solved
with the minimum number of moves.

D. Set Shifting:
1. Wisconsin Card Sorting Test:
Utilizes a pack of 128 cards, each card has a colour, shape and number. After placing
four stimulus cards in front of the subject, subjects are to match each successive card
from the pack to one of the four stimulus cards.
○ Cards are sorted based on changing rules (e.g., colour, shape, or number).
○ Scoring: Number of trials, errors, perseverative responses, and total categories
achieved.

E. Response Inhibition:
1. Stroop Test:
○ Name the ink colour of incongruently printed words.
○ Scoring: Stroop effect calculated as the difference in time taken for colour
naming and word reading.

Verbal Comprehension
1. Token Test:
 ● Purpose: Evaluate the ability to follow verbal instructions involving tokens of
different colours, sizes, and shapes.
● There are 6 levels of instructions, which increase gradually in difficulty as the test
progresses.
● Procedure: Instructions progress in complexity over six levels.

Learning and Memory

1. Rey’s Auditory Verbal Learning Test (AVLT):
Developed in 1964.
● Purpose: Assesses verbal learning and memory.
● Procedure:
○ The subject must recall a list of 15 words (List A) over five trials, followed by
one trial with a new list (List B).
○ Subject must perform delayed recall and recognition tasks for List A after 20
minutes. The words in List A are randomly mixed with 15 new words.
● Scoring: Learning and memory scores. In the recognition trail, the hits are scored
separately. Omissions and commissions from errors.
● Other scores are long-term percent retention which is calculated by the formula:
Delayed recall score/trail 5 × 100.
● Duration: Approximately 30 minutes.
● Tests have been translated into four languages, i.e. Kannada, Tamil, Telugu & Hindi.

Logical Memory Test/ Passage Test

This passage has been used in the NIMHANS as well as in the PGI Memory scale. The test
consists of a story with 21 facts.
● Purpose: Measures immediate and delayed recall of stories.
● Procedure: The subject must recall a story immediately; an immediate recall is taken.
After a 30-minute delay, delayed recall is taken, without prior warning.
● Scoring: Immediate recall scores and delayed recall scores, along with the number of
confabulations.
● Duration: The test takes about 10 minutes for both recall together.

Visuoconstructive Ability
1. Complex Figure Test:
Visuo-constructive ability was tested using the Rey's Complex Figure Test. Developed the
test in 1941.
● Purpose: The test consists of a complex design which is abstract & cannot be named
easily Assesses visuoconstructive and memory abilities.
● Procedure: Subjects copy a complex abstract figure and reproduce it from memory
after delays.
 ● Scoring: Time taken to copy & number of facts correctly copied forms the score.
The correctness of the reproduction is assessed according to the scoring system given
in the manual
● Duration: 10 minutes.

Complex Figure Tests:

● Procedure: Subjects copy a complex abstract figure and reproduce it from memory
after delays. The figure is drawn twice: The first time is an immediate recall 3 minutes
after the copying is completed, and the second time is a delayed recall 30 minutes
later. The figure is not exposed before the immediate recall and delayed recall.
● Scoring: A score of 0, 0.5, 1 or 2 is assigned to each unit of the copy, immediate
recall and delayed recall figures based on accuracy and placement criteria.
● Duration: 15 minutes.

Validity: The battery's validity has been tested using criterion validity, comparing
performance across clinical groups such as those with head injuries or epilepsy.

Deficit Cutoffs: Performance is scored using criteria like time, errors, and completion
accuracy. Deficit scores below the 15th percentile or error scores above the 85th percentile
indicate significant impairments.

Sensitivity and Specificity: The battery’s sensitivity and specificity are benchmarked against
normative data. Neuropsychological profiles generated through this battery identify clusters
of deficits that correspond to specific brain lesions, aiding diagnosis and intervention
planning. Clinical observations, such as agnosias, apraxias, or body schema disturbances,
supplement the quantitative data.

Administration of the Battery

● Prerequisites: The subject must have adequate sensory, motor, language, and
motivational abilities.
● Attention, Motivation and Language should be observed and rated clinically.
● The information gathered from the case file and the interview should supplement the
clinical observation
● Assessment of parietal focal signs of Body Schema Disturbances, Agnosias, Apraxias,
Unilateral Spatial Neglect, Route finding difficulty, Right-left disorientation,
Acalculia, Agraphia and Anomia's clinical examination is necessary.
● Clinical Observations: Qualitative observations, such as body schema disturbances,
agnosias, apraxias, unilateral neglect, and personality changes, are integrated into the
evaluation.
This detailed framework ensures a comprehensive assessment of cognitive and behavioural
functioning using the NIMHANS Neuropsychological Battery.
Neuropsychological Profile Interpretation:
• The quantitative scores are interpreted using percentiles.
• Scores falling below the 15th percentile are considered as deficient scores.
• The cluster of functional domains which are deficient forms the neuropsychological
syndrome.

Despite its widespread use, several limitations have been identified:

1. Cultural and Educational Bias: The battery may not fully account for the diverse
cultural and educational backgrounds of the Indian population, potentially affecting
the accuracy of assessments.
2. Lengthy Administration Time: The extensive nature of the battery can lead to
prolonged administration times, which may cause fatigue in patients and impact the
reliability of results.
3. Limited Normative Data: There is a scarcity of normative data for specific age
groups and populations, making it challenging to interpret results accurately across
different demographics.
4. Need for Specialized Training: Proper administration and interpretation of the
battery require specialized training, which may not be readily available in all clinical
settings.
5. Sensitivity to Mild Cognitive Impairments: The battery may lack sensitivity in
detecting subtle cognitive impairments, potentially leading to the underdiagnosis of
mild conditions.
6. Outdated Test Components: Some tests within the battery may be outdated,
necessitating revisions to align with current neuropsychological assessment standards.
Addressing these limitations is crucial for enhancing the battery's effectiveness and ensuring
accurate neuropsychological assessments.

Conclusion
The NIMHANS Neuropsychological Battery is an essential tool in clinical and
research settings. It plays a key role in identifying brain dysfunctions, locating lesions, and
creating cognitive profiles, making it a valuable resource for diagnosis and treatment
planning. The battery is known for its detailed methodology and normative data suited to the
Indian population, ensuring culturally relevant assessments. Lengthy administration time,
sensitivity to subtle cognitive impairments and the potential for outdated test components
highlight areas for improvement.
In conclusion, the NIMHANS Neuropsychological Battery remains a robust and
indispensable tool for clinical and research applications, significantly enhancing the
understanding of cognitive and behavioural disturbances.