Psychometric Testing

Brief Overview of Commonly Encountered

Psychological Rating Scales

Wael Salame, M.D.

LAUMC-RH
 Introduction to Psychometrics…
 Psychometric tests refer to standardized tools of
measurement that have only recently been adopted as
routine practice in the fields of psychiatry and mental
health practices.

 Several factors have limited the role of standardized

testing in psychiatry including:
 Measured characteristics (quality of life, depression, anxiety,
personality…) are non-tangible.[ya3ni cant quantitative
describe, we can qualitative]
 Experiences are subjective and cannot directly be
measured.
 Bias plays a role when interpreting observable patterns of
behavior in response to rating scales.
 Introduction to Psychometrics…
 Psychometrics refers to the field of study primarily concerned
with both the theories and technique of psychological
assessment.

 In simpler terms:
 Series of instruments/procedures capable of assessing sampled
behavioral responses based on standardized scoring criteria.

 Despite standardization and normalization of psychometric

testing, several external/environmental factors are known to
impact testing performance:
 Level of motivation and test-taker’s concentration
 Physical discomfort and performance anxiety
Classification of Psychometric Tests…
 In general, psychometric tests are best classified into one
of two categories:
 Screening Tests: Determine the presence/absence of a
target disorder or condition.
Play an important role in diagnosing specific disorders

 Disorder-Specific Rating Scales: Quantify the severity of a

disorder after established presence.
May be used at any time during the natural history of a
disorder or while on treatment, to assess disease severity.

 Both screening tests and rating scales can be administered

to patients (self-report) or conducted by the clinician
(clinician-administered).
Classification of Psychometric Tests…
 Psychometric tests and rating scales can also be classified
based on the targeted disorder/diagnosis:
 Intelligence and Cognitive Functioning Scales: MMSE

 Personality Scales: Rorschach, MMPI, SCID-II

 Mood and Anxiety Scales: HamD, HamA, MADRS, Y-BOCS

 Scales used in Psychosis: QoL, AIMS, BPRS

Basic Statistical Concepts…
 Psychometric testing aims at verifying certain statistical
properties through answering the following questions:
 How reproducible are patient scores on any individual rating
scale (reliability)?

 How effectively is a rating scale truly capable of assessing the

target dimension (construct validity/dimensionality)?

 How reliable is a rating scale in determining response to therapy

(sensitivity to change)?
Intelligence and Cognitive Functioning Scales…
 Mini-Mental Status Examination (MMSE)
 Most widely used examination for assessment of gross cognitive
functioning.
 30-item examination covering orientation, registration, attention
and calculation, recall, language and copying.
 Advantages: Sensitive to dementia, easy and quick administration

 Scoring: Generally, individuals scoring less than 23 are considered

to be in need of additional testing and examination.
 Sensitivity significantly decreases when assessing individuals with
mild cognitive impairment in comparison to those severely
impaired. [test is reliable for people with normal congition,
moderate and severe cognition impairment, and test is not reliable
for those with mild cognition impariment
Intelligence and Cognitive Functioning Scales…
 Personality Rating Scales and Tests…
 The importance of early detection of personality disorders (PDs)
primarily lies in the decreased responsiveness to treatment plans
when undetected.

 Currently, most gold-standard assessment scale are lengthy and

time-consuming, thus limiting their practicality.

 Assessment tools used in the diagnosis of PDs are either:

 Objective: based on self-reported measures with no attempt at
understanding subjective intentions(yes no answers)
 Projective: based on free-response measures in response to ambiguous
stimuli.
 Advantage: Indirect stimulation is believed to limit the activation of
self-defense mechanisms, thereby demonstrating true personality
states.
Rorschach Inkblot Test
 Most commonly used projective personality scale.
 Herman Rorschach introduced the notion of inkblot
interpretation in 1911 and in 1921 published the inkblot manual
entitled Psychodiagnostik.
 It is based on the assumption that one tends to project
individual notions and person-specific perceptions onto external
stimuli, thus shedding light on motives, inner conflicts, affectivity
and cognitive functioning.
 Scoring is based on the Exner Scoring System (Rorschach
Comprehensive Scoring) developed by Dr. John Exner in 1960.
 Specific indexes for: Suicidality, depression, psychosis, obsessive
stlye, coping mechanism deficits…
 The test was developed by dropping ink onto cardboard plates that
were then folded in half to produce duplicate halves.

 Total number of plates 10. from those 10 there are 5 black and white,
2 red and gray (plates II and III) and 3 in color (plates VIII, IX and X).

 During testing, minimal instruction is provided by the examiner and

whenever necessary, answers should be vague and not directional.

 On average, more than one answer should be provided to each

depiction.
 The test is believed to provide insight into Axis I (psychopathology)
disorders or patients, in addition to providing information pertaining to
personality troubles (Axis II), thought disorders and emotional functioning.
Minnesota Multiphasic Personality Inventory (MMPI-II)
 Most widely used standardized examination for adult
personality disorders and psychopathology(for late diagnosis).

 The MMPI-I was published in 1943 and then later updated

(MMPI-II) in 1989.
 Exam includes a total of 567 items organized into 10 scale
subsets(organized into 10 section), each dealing with a specific
personality trait.
 All questions are in the true or false format and can be used on
all individuals aged 18 and above.

 Limitations: Long exam that requires between 1 to 2hours to be

completed.
Minnesota Multiphasic Personality Inventory (MMPI-II)

Scale Description Interpretation of High Scores

1 Hs Hypochondriasis Excessive bodily concern
Somatic symptoms

2D Depression Depressed; pessimistic; irritable; demanding

3 Hy Hysteria Physical symptoms of functional origin;

Self-centered’ demands attention

4 Pd Psychopathic Asocial or antisocial; rebellious; impulsive;

Deviate Poor sense of judgment

5MF Masculinity/ Male: aesthetic interests

Femininity Female: assertive and competitive; self-confident
Minnesota Multiphasic Personality Inventory (MMPI-II)

Scale Description Interpretation of High Score

6 Pa Paranoia Suspicious; sensitive; resentful; rigid

7 Pt Psychasthenia Anxious and worrisome; obsessive; lacks self-

confidence

8 Sc Schizophrenia Thinking disturbance; withdrawn;

Feels alienated

9Ma Hypomania Excessive activity; lacks direction;

Low threshold of tolerance to frustration

0 Si Social Socially introverted’ shy and sensitive;

Introversion overcontrolled; conforming
Structured Clinical Interview for the DSM IV (SCID-II)
 Efficient, standardized and user-friendly diagnostic tool.

 Accurately and reliably diagnose:

 DSM IV Axis II PDs,
 Passive-aggressive personality disorders, and
 Depressive personality disorder tendencies.

 Questionnaire is self-administered and used as a screening tool.

 Limitation: Requires specific training, time-consuming, not cost-

effective.
 Mood and Anxiety Psychometric Scales…
Hamilton Depression Rating Scale (HamD)
 One of the oldest scales developed for assessment of depression
severity.

 Originally, the HamD included a total of 21 items. The last four

items were found to be weakly correlated with depression
severity, or were uncommon: and so were removed these 4 items
are
 Diurnal variation
 Depersonalization/Derealization
 Paranoid symptoms
 Obsessive-compulsive symptoms

 The HamD rating scale is typically administered on a weekly basis.

 Mood and Anxiety Psychometric Scales…
 Considered a Gold Standard rating scale in for depression
 Limitations: he ignored limitation
 Absence of all symptom domains of MDD (neurovegetative
symptoms)
 Items measuring different constructs
 Unequal distribution of weighted points amongst items.

 Scoring:
 A score of 0 to 4 is appointed to each of the 17 items = 54points.
 Score 7 and 17 → Mild Depression
 Score 18 to 24 → Moderate Depression
 Score of 25 or greater → Severe Depression
Mood and Anxiety Psychometric Scales…
Mood and Anxiety Psychometric Scales…
Mood and Anxiety Psychometric Scales…
Mood and Anxiety Psychometric Scales…

Montgomery Asberg Depression Rating Scale (MADRS)

 Clinician-rated scale developed in the late 1970s.

 Includes a total of 10 items, targeted at identifying effects

of antidepressant medication (mainly tricyclic
antidepressants) on patients.

 The MADRS is administered on a weekly basis

Mood and Anxiety Psychometric Scales…

Montgomery Asberg Depression Rating Scale (MADRS)

 Limitations:
 Scale was not updated and thus lacks assessment of neuro-
vegetative symptoms associated with MDD.
 [Ignored point ]Unidirectional, with focus on psychological
aspects of depression with minimal rating of somatic symptoms.

 Scoring:
 Scores greater than 30 or 35 are suggestive of severe depression.
 Scores <10 suggest disease remission.
Mood and Anxiety Psychometric Scales…
Mood and Anxiety Psychometric Scales…
Mood and Anxiety Psychometric Scales…
Mood and Anxiety Psychometric Scales…

Yale-Brown Obsessive Compulsive Scale (YBOCS)

 YBOCS refers to two sets of ratings scales:

 YBOCS Symptom checklist interview
 YBOCS symptom severity scale

 The YBOCS is considered a Gold Standard measurement scale

in the assessment of OCDs.

 Administered at the beginning of treatment and then again

when patients report change with respect to OCD
symptomology.
Mood and Anxiety Psychometric Scales…
Yale-Brown Obsessive Compulsive Scale (YBOCS)
 YBOCS Symptom Checklist:
 Should be administered first.
 64-item clinician administered checklist that assesses the
presence of past and current obsessions and compulsions.
 Able to identify 36 types of obsessions and 23 types of
compulsions including:
Harming
Contamination/washing
Sexual
Hoarding/saving
Religious
Symmetry/exactness
Mood and Anxiety Psychometric Scales…
Yale-Brown Obsessive Compulsive Scale (YBOCS)
 YBOCS Symptoms Severity Index
 Clinical-administered semi-structured scale.

 Administered after the YBOCS symptoms checklist to assess

obsessive/compulsive severity.

 Obsessions and compulsions are individually rated on a scale

ranging from 0 (No symptoms) → 4 (Extremely severe symptoms)
based on:
 Time spent and interference with daily activity and functioning
 Distress and resistance
 Control over obsessions/compulsions
 Mood and Anxiety Psychometric Scales…
Yale-Brown Obsessive Compulsive Scale (YBOCS)
 Scoring:
 YBOCS symptoms checklist: no available scoring
 YBOCS symptoms severity scale: Ranges from 0 to 40.
Individual severity scores for obsessions and compulsions can be
calculated by summing up items 1 to 5, and 6 to 10, respectively.

 A score of 16 or greater is the generally accepted cut-off point for

clinically symptomatic levels of OCD.
O to 7 → Subclinical OCD
8 to 15 → Mild OCD
16 to 23 → Moderate OCD
24 to 31 → Severe OCD
32 to 40 → Extreme OCD
Mood and Anxiety Psychometric Scales…
Mood and Anxiety Psychometric Scales…
 Scales Used in Assessing Psychosis…
Quality of Life (QoL) Rating Scale
 Much attention is given to the positive symptoms of hallucinations,
delusions and formal thought disorder.

 Successful treatment of schizophrenia now places more emphasis on

psychosocial functioning and cognitive debilitation than it does on
mere symptom remissions.

 The QoL scale was developed by Heinrichs et. al (1984) with the goal
of assessing components of social performance.
 Can be used throughout clinical treatment to correlate functional
changes with treatment modifications.
 Scales Used in Assessing Psychosis…
Quality of Life (QoL) Rating Scale
 Semi-structured, clinician administered combination of 21-item scale
based on subjective report and objective data.
 To be used with community-residing outpatients with schizophrenia.

 Advantages:
 Easy to complete, taking less than an hour.
 Can be integrated as part of standard clinical interviewing.
 Capable of assessing 4 domains:
Interpersonal relations
Instrumental role functioning
Cognitive-emotional functioning
Extent of involvement with rountine daily activity.
 Scales Used in Assessing Psychosis…
Quality of Life (QoL) Rating Scale
 The QoLS has a unique ability of combining both individual
perspective and objective self assessment.
 Increased validity of testing resulting from synthesis of patient
perspective, clinician rating and purely objective measurement.

 Scoring: Items are rated on a scale of 0 to 7

 0 to 1→ Severe Impairment
 2 to 4 → Mild to Moderate Impairment
 5 to 6 → Adequate, normal or unimpaired functioning
 Scores are collected on individual domains
 Scales Used in Assessing Psychosis…
Abnormal Involuntary Movement Scale (AIMS)
 Anti-psychotic drug-induced movement disorders are a group of
neurological motor disturbances most commonly resulting from the
use of typical (1st generation) antipsychotics.

 Abnormal motor movement development may occur at any point

in therapy and are characterized by variable duration:
 Acute dystonia reactions: Shortly after initiation of treatment.
 Tremor, chorea, Parkinsonism, akathesia: appear after a variable
duration of treatment, and resolve with discontinuation of the
medication.
 Tardive dyskinesia, tardive dystonia: persist even after stopping
therapy
 Scales Used in Assessing Psychosis…
Abnormal Involuntary Movement Scale (AIMS)
 A total of 12 items:
 Individual items rated in terms of severity from 0 to 4.
 10 items screen for abnormal motor movements in specific body
regions
 2 items pertaining to dental conditions that complicate an
accurate diagnosis of dyskinesia.

 Advantages:
 Short duration making the examination user friendly
 Should be performed at least once every 6 months in individuals on
atypical antipsychotics, and every 3 months in those on typical
antipsychotics.
Scales Used in Assessing Psychosis…

Abnormal Involuntary Movement Scale (AIMS)

 Scoring:
 Gold standard Scale
 Total scores are rarely reported.
 Value of the AIMS is in temporal assessment of changes in global
severity and individual body area motor movements.
 Tardive Dyskinesia:
Extended neuroleptic exposure
No other identifiable causes of dyskinesia
Presence of mild dyskinesia in two body areas OR moderate
movement in a single body area
Scales Used in Assessing Psychosis…
Scales Used in Assessing Psychosis…
Scales Used in Assessing Psychosis…
 Scales Used in Assessing Psychosis…
Brief Psychiatric Rating Scale (BPRS)
 The BPRS was first published in 1962 and is one of the oldest
scale currently used in the assessment of psychotic
symptoms.

 Used in the assessment of positive, negative and affective

symptoms of psychosis and schizophrenia.

 Increased validity in the assessment of treatment efficiacy in

individuals with moderate to severe disease.
 Scales Used in Assessing Psychosis…
Brief Psychiatric Rating Scale (BPRS)
 Depending on the version being used, a total of 18 to 24 items
measuring psychiatric symptoms of depression, anxiety,
hallucinations and abnormal behavior are evaluated.
 Items are scored in terms of severity on a scale of 1 to 7.
 Includes self-report items and both observed behavior and
speech.

 Scoring:
 No consensus regarding a unified cut-off.
 Scale is best used to compare symptoms severity in terms of
temporal progression.
Scales Used in Assessing Psychosis…
Scales Used in Assessing Psychosis…
Scales Used in Assessing Psychosis…
Thank You