DIAGNOSTIC PROCEDURES IN PSYCHIATRY • Neurobehavioral measures may be incorrectly interpreted,

Raymond L. Rosales, MD PhD e.g., interpreting errors on sensory or motor tests

Department of Neurology & Psychiatry resulting from PNS injury -08united_irregs07-
as CNS impairment
UST Faculty of Medicine and Surgery
• Changes at a microscopic level may cause behavioral
2008SecD-USTFMS

DIAGNOSTIC PROCEDURES IN PSYCHIATRY change, but may not be visible-AsM-

with current imaging
technology.
PSYCHOLOGICAL TESTS
PSYCHIATRIC SYMPTOMS AND PERSONALITY TESTING BY
Projective Testing QUESTIONNAIRE
Potential Uses:
• Neuropsychological testing
• history taking and formulating clinical hypothesis
• Psychiatric symptoms and Personality testing by
• Screening and diagnosis of clinical problems and mental
Questionnaire
disorders
• Standardized Psychiatric Interview
• Determining appropriate referral to specialty services
NEUROIMAGING TESTS • Monitoring change and response to treatment and
• CT interventions
• MRI • Conducting research into factors associated with the
disorders
• SPECT
• Auditing and assessing clinical services
• PET
• NEUROPHYSHIOLOGIC TESTS STANDARDIZED PSYCHIATRIC INTERVIEWS (SPI):
• EEG • Necessary when collecting data for research or for
• Evoked Potentials comparing patients with those reported in the psychiatric
• Brain Mapping literature
• Desirable in everyday clinical practice because it provide a
PROJECTIVE TESTS systematic means of evaluating patients that is less
1) Rorschach: 10 inkblots subject to bias or incomplete assessment
3 categories
a) location/area of the inkblot on which response is WHAT ARE THE MOST COMMONLY USED FULLY STRUCTURED
based DIAGNOSTIC INTERVIEWS?
b) specific aspects/determinants of the blot used to • DIS (Diagnostic Interview Schedule): questions organized
form the percept by symptoms and patients are asked
c) Content of Percept 1) Whether the symptom(s) has/have ever occurred in
their lifetime
2) Thematic Apperception Test (TAT): 2) Whether the symptoms occurred within the last 1-
o 20 cards of ambiguous scenes month, 6-month or 12-month period
• Cross-sectional assessments, HAM-D/A; MADRS, BPRS, GAF
o Content analysis of story
IMPORTANT FEATURES OF BRAIN IMAGING MODALITIES
WHEN SHOULD PATIENTS BE REFERRED FOR PROJECTIVE TESTS?
CROSS SECTIONAL ASSESSMENTS
• The nature and level of depression, anxiety and/or anger
• Level and style of impulse control
• Quality and clarity of thinking
• Coping styles and capacities
• Style and capacity for relatedness to others
• Experience of others
• Style of solving problems
• Originality and integrative capacities
• Emotional responses to stress
• Emotional reactivity
• Defensiveness and style of defense
• Level of personal adjustment or ego functioning
• Ability to tolerate stress
• Adequacy of daily functioning
• Reality functioning
• Level of self-esteem
• Experience of family dynamics

CLASSIFICATION OF PROJECTIVE TESTS BASED ON THE NATURE OF

THE PROJECTIVE ACTIVITY:
1. Associations = Rorschach, word-association tests
2. Completions = Sentence completion tasks
3. Constructions = Thematic apperception test
4. Choice/Ordering = Ranking of objects to categories
5. Self-experience = Drawing tasks, Dramatic plays

NEUROPSYCHOLOGICAL TESTING
• Uses behavioral measures to assess skills and abilities that
relate to brain functioning
• Tests are fatiguing and recommended therefore in an
order of administration that:
- Intersperse easier and harder tests
- Begins testing with tasks that reduce rather than
increase anxiety
- Places tests with demanding attentional/speed
requirements when the patient is fresh and well-
rested, yet past the initial anxiety

WHY APPARENT DISCREPANCIES/CONTRADICTIONS MAY EXIST

BETWEEN NEUROBEHAVIORAL AND NEUROIMAGING STUDIES
• There may be long-standing, probably congenital,
structural abnormalities, but the patient has relatively
normal neurocognitive functioning because the brain
organized with the abnormality already in place
• The physiological changes associated with brain lesions
identified by CT or MRI may exceed the boundaries of the
structural abnormality
• Individual differences in functional brain organization are
complex and not yet completely understood