Evaluating psychological insight in a clinical sample using the Shedler-Westen assessment procedure

Using the Shedler-Westen Assessment Procedure (SWAP)-200 Q-Sort items in a large clinical sample of outpatients (N = 105), we developed the SWAP insight scale. The rationale, psychometric properties, and convergent validity of this insight scale are reported. Through factor analysis, six of the SWAP-200 items were identified as psychometrically optimal in the assessment of insight (presence or absence) with an alpha coefficient of 0.78. We examined the construct validity of this SWAP insight scale using independent clinical videotape ratings of the Capacity for Dynamic Process Scale, specifically the items "appears introspective" and "manifests insight." We also examined the relationship between the SWAP insight scale using independent clinical videotape ratings of the Social Cognition and Object Relations Scale-Global Ratings, specifically ratings of "complexity of representations" and "social causality." The results demonstrated significant positive correlation between the SWAP insight scale and all five of these criterion measures. Partial correlations demonstrated that, even when the effects of global psychiatric severity are controlled for, the SWAP insight scale maintains a significant relationship with independent clinical videotape ratings of patients manifesting insight during sessions. Future research directions and clinical implications of the SWAP insight scale are discussed.     

A comparison of alternative assessments of depressive symptom severity: a pilot study

This study compared the performance of an itemized symptom self-report (Inventory of Depressive Symptomatology - Self-Report; IDS-SR), patient global ratings, and clinician global ratings with an itemized clinician-rated symptom severity measure (Inventory of Depressive Symptomatology - Clinician-Rated; IDS-C) in detecting treatment effects in patients with major depressive disorder (MDD). A total of 28 inpatients (30.8% psychotic) and 34 outpatients (17.9% psychotic) with MDD began treatment that followed the Texas medication algorithm. The clinicians completed the IDS-C and a Physician Global Rating Scale (PhGRS) at each assessment visit, while the patients completed the IDS-SR and a Patient Global Rating Scale (PtGRS). Change scores from the baseline to subsequent weeks were computed for all subjects, utilizing all four measures. The IDS-SR was a significant independent predictor of the response to treatment as compared to the two global ratings. The IDS-SR was as sensitive to change as the IDS-C. While the clinician-rated itemized symptom severity rating scale remains the standard to assess the symptomatic outcome of the treatment of MDD, a self-report of identical symptomatology may be a reasonable alternative for many patients.     

A comparison of alternative assessments of depressive symptom severity: a pilot study

This study compared the performance of an itemized symptom self-report (Inventory of Depressive Symptomatology - Self-Report; IDS-SR), patient global ratings, and clinician global ratings with an itemized clinician-rated symptom severity measure (Inventory of Depressive Symptomatology - Clinician-Rated; IDS-C) in detecting treatment effects in patients with major depressive disorder (MDD). A total of 28 inpatients (30.8% psychotic) and 34 outpatients (17.9% psychotic) with MDD began treatment that followed the Texas medication algorithm. The clinicians completed the IDS-C and a Physician Global Rating Scale (PhGRS) at each assessment visit, while the patients completed the IDS-SR and a Patient Global Rating Scale (PtGRS). Change scores from the baseline to subsequent weeks were computed for all subjects, utilizing all four measures. The IDS-SR was a significant independent predictor of the response to treatment as compared to the two global ratings. The IDS-SR was as sensitive to change as the IDS-C. While the clinician-rated itemized symptom severity rating scale remains the standard to assess the symptomatic outcome of the treatment of MDD, a self-report of identical symptomatology may be a reasonable alternative for many patients.     

Screening for Autism in Young Children with Developmental Delay: An Evaluation of the Developmental Behaviour Checklist: Early Screen

The ability to identify children who require specialist assessment for the possibility of autism at as early an age as possible has become a growing area of research. A number of measures have been developed as potential screening tools for autism. The reliability and validity of one of these measures for screening for autism in young children with developmental problems was evaluated. The parents of 207 children aged 20-51 months completed the Developmental Checklist-Early Screen (DBC-ES), prior to their child undergoing assessment. Good interrater agreement and internal consistency was found, along with significant correlations with a clinician completed measure of autism symptomatology. High sensitivity was found, with lower specificity for the originally proposed 17-item screening tool and a five-item version.     

Quality of object relations versus interpersonal functioning as predictors of therapeutic alliance and psychotherapy outcome

The purpose of the study was to compare an interview measure of quality of object relations to questionnaire and interview measures of recent interpersonal functioning with respect to the prediction of therapeutic alliance and psychotherapy outcome. The sample consisted of 64 patients who had received approximately 20 sessions of short-term individual psychotherapy within a controlled, clinical-trial investigation. Ratings of therapeutic alliance were provided independently by the patient and the therapist after each session. Outcome measures, which were provided by three sources (patient, therapist, and independent assessor), covered the areas of interpersonal functioning, psychiatric symptomatology, self-esteem, and life satisfaction. Quality of object relations, which characterizes the patient's lifelong pattern of relationships, was the best predictor. It was significantly related to patient-rated and therapist-rated therapeutic alliance and to patient improvement of both general symptomatology and specific target problems. The study also replicated previous studies that have reported significant relationships between therapeutic alliance and therapy outcome. The advantages of pretherapy predictors of therapy outcome, such as quality of object relations, are discussed.     

Emotions,personality and life stresses in asthma

Forty asthma clinic patients completed a battery of tests designed to measure personality, emotional states and current life stresses as well as subjective reactions to asthma symptomatology. In addition, physicians' severity ratings, based on the amount of steroid medication needed for symptom control, and Peak Expiratory Flow Rates (PEFR), assessing lung functioning, were obtained for each patient. Analysis of the data revealed significant correlations between measures of personality, self-esteem, life problems and severity of asthma when asthma severity was measured by patients' self-reports of symptoms, but not when measured by either physicians' ratings or PEFR scores. Although there are moderate correlations between objective and subjective measures of asthma severity, the subjective measures correlated to a greater degree with a larger number of psychological variables.     

The relationship between self-awareness of neurobehavioral symptoms, cognitive functioning, and emotional symptoms in multiple sclerosis

OBJECTIVE: To examine self-awareness of neurobehavioral symptoms in multiple sclerosis (MS) across three domains of function (apathy, disinhibition, and executive control), and examine the relationship between self-awareness and cognitive functioning. METHODS: Twenty-six individuals with MS completed neuropsychological testing, measures of emotional functioning, and self-ratings of neurobehavioral symptoms using the Frontal Systems Behavior Scale (FrSBe), a 46-item questionnaire with subscales assessing frequency of symptoms in executive dysfunction, disinhibition, and apathy. Informants' ratings of the FrSBe were also obtained. Decreasing differences between patient and informant reports on each subscale of the FrSBe (concordance) indicate higher levels of self-awareness. RESULTS: Results showed significant positive correlations between cognitive abilities and self-awareness of executive dysfunction and disinhibition. In contrast, affect symptomatology (measures of anxiety and depression) were negatively correlated with self-awareness of executive dysfunction. CONCLUSIONS: Level of self-awareness of neurobehavioral symptoms in MS is related to level of cognitive impairment In addition, symptoms of depression and anxiety reduced the accuracy of self-reporting. Thus, a clinician who relies on self-reports in creating an evaluation and treatment plan should consider the patient's cognitive and emotional states.     

Comparison of electromechanical measures and observer ratings of tardive dyskinesia

Thirty-three patients with tardive dyskinesia (TD) were studied with multiple-observer consensus ratings of videotaped examinations, ultrasound counts of movement, and electromechanical frequency measures of the movements. There were statistically significant correlations between orofacial ultrasound measures and TD severity determinations made by observers. Clinical ratings did not correlate with frequency measures. Ultrasound measures substantiate observer rating scales, whereas frequency measures appear to provide information not available from clinical rating scale scores.     

Linguistic measures of the referential process in psychodynamic treatment: The English and Italian versions

Abstract

The referential process is defined in the context of Bucci's multiple code theory as the process by which nonverbal experience is connected to language. The English computerized measures of the referential process, which have been applied in psychotherapy research, include the Weighted Referential Activity Dictionary (WRAD), and measures of Reflection, Affect and Disfluency. This paper presents the development of the Italian version of the IWRAD by modeling Italian texts scored by judges, and shows the application of the IWRAD and other Italian measures in three psychodynamic treatments evaluated for personality change using the Shedler-Westen Assessment Procedure (SWAP-200). Clinical predictions based on applications of the English measures were supported.     

Problem solving therapy for the treatment of depression for a patient with Parkinson’s disease and mild cognitive impairment: a case study

The present investigation reports on the use of problem solving therapy (PST) to treat depression in an 83-year-old woman with Parkinson’s disease (PD) and concurrent mild cognitive impairment (MCI). A neuropsychological evaluation was conducted prior to the intervention and the patient demonstrated mild deficits of executive functioning and memory. The PST treatment consisted of 12 one-hour sessions that occurred weekly. Depressive symptoms were evaluated using the Hamilton Depression Rating scale and the Montgomery-Asberg Depression rating scale. At a post-treatment assessment (week 12), clinician assessment indicated that the client no longer met criteria for MDD. Weekly depression severity ratings showed significant reduction in severity of depressive symptoms over 12 weeks. Results at 1-month and 6-month follow-up demonstrated that the therapeutic gains were not only maintained, but that the client continued to improve. These results suggest that PST may be an effective treatment for the treatment of depression for individuals with a PD and concurrent MCI.     

Somatic symptoms of anxiety: comparison of self-report and physiological measures

The frequently reported absence of significant correlations between patient rating scales and physiological measures has led to the belief that patients cannot reliably perceive physiological changes that are experienced under conditions of stress. To determine whether or not this conclusion is justified for patients with clinical anxiety, self-reports and psychophysiological recordings were examined and compared in 20 patients suffering from generalized anxiety disorder. No systematic correlations were found between patient ratings and physiological measures of somatic symptomatology during periods of rest or psychological stress (Stroop Test). However, parallel directional changes in the two sets of measures were observed upon exposure to stress, indicating that patients could accurately report the direction, but not the degree, of changes in physical symptoms of anxiety. These results suggest that patient reports of physical symptoms such as sweating and rapid heart rate can be useful in clinical evaluation and research settings that do not require quantitative assessment of physiological activity.     

Generalized anxiety disorder in older adults: examining the relation between clinician severity ratings and patient self-report measures

Generalized anxiety disorder (GAD) is the most prevalent of the chronic anxiety disorders for older adults. Although a variety of self-report measures are beginning to be utilized to assess anxiety and related symptoms in older adults, there is a paucity of data regarding the convergence of self-report measures with clinician ratings of symptom severity. This situation is problematic in that interpretability of assessment data is limited, as is our broader understanding of the construct of GAD in an older adult population. To address these issues, we examined convergence across assessment modalities among 64 older adults who met diagnostic criteria for GAD. In addition to two Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) interviews conducted by independent raters, participants completed four self-report measures (Penn State Worry Questionnaire [PSWQ], Worry Scale [WS], State-Trait Anxiety Inventory [STAI], Beck Depression Inventory [BDI]) as part of a more extensive pretreatment assessment battery. Results revealed significant correlations between clinician-rated GAD severity and the BDI, STAI, and PSWQ. Regression analyses indicated that the BDI (r2 = .15) and the PSWQ (r2 = .07) were particularly useful predictors of clinician-rated GAD severity. A comorbid mood disorder, however, was identified as an important mediator of these relations. Specifically, presence of coexistent depression accounted for 17% of the variance in clinician severity ratings (CSR; P < .01), with individuals diagnosed with a comorbid mood disorder receiving higher clinician severity ratings. The only self-report measure that accounted for additional significant variance was the PSWQ (7%). The study highlights the need to address coexistent psychological conditions when examining convergence between assessment modalities, and expands upon the relatively neglected area of anxiety assessment in older individuals. Specifically, the BDI and the PSWQ are identified as particularly useful screening instruments that may be helpful in conceptualizing GAD severity within an older adult population.     

Mood disorders in left and right brain-damaged patients: comparison between ratings and self-ratings on the same adjective mood scale. Some methodological problems

In the context of recent developments of the lateralization model of emotions, this study investigates the intensity of depressive mood in left (LBD) and right (RBD) unilateral brain-damaged patients, comparing expression and experience of negative emotion through rating and self-rating scales. Seventeen BD inpatients (6 LBD, 8 RBD and 3 neurological patients without lesions) completed the Zerssen 28-item mood scale a few days after their admission to hospital. During the same period, 2 nurses, one working during the morning, the other during the afternoon and 1 clinician, a neuropsychiatrist, under the instruction of rating the patient mood state, completed independently the same mood scale. Results show that there is a strong agreement among the self-rating and the observers' total scores, which is high between the clinician and the patient but less strong between the 2 nurses and each nurse and the patient. Morever, self-rating scores are significantly different from those attributed by observers. The comparison between LBD and RBD showed that LBD rated themselves as more depressed than RBD, but the differences were statistically significant in the case of the clinician ratings only. These results have been interpreted with reference to methodological problems rather than in terms of a possible discrepancy between expression and experience of affect.     

Therapeutic alliance, cohesion and outcome in a long-term analytic group. A preliminary study

We studied the ongoing relationship of patients and their therapist in a long-term, analytic group. The therapeutic alliance was rated weekly and group cohesion was rated every month, by patients and therapist. The patients' symptoms (SCL-90-R) and interpersonal problems (IIP-C) were rated every third month during therapy (self-reports). There was a steady increase in the alliance ratings by patients and therapist during the first 2 years of therapy. This differs from findings in short-term therapies, where the alliance quickly reaches a high level and then remains stable throughout therapy. Therapist ratings of early alliance correlated significantly with positive symptomatic outcome, but did not predict interpersonal change. Patients' alliance ratings did not predict change. Early cohesion ratings did not predict change. The concordance between the patients' and the therapist's alliance ratings was highest between 16 and 30 sessions, and was essentially maintained throughout therapy. An early concordance of patient and therapist alliance ratings predicted a better symptomatic outcome. The measures of therapeutic alliance and cohesion used in this study seem to address different elements in the group process.     

Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA)

INTRODUCTION: Assessment of the effectiveness of clinical practice requires appropriate outcome measures.Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) is a recently developed measure of outcome for use in child and adolescent mental health services (CAMHS). The aims of the present study were to evaluate sensitivity to change, face validity and clinical feasibility of HoNOSCA in a Danish field trial. METHOD: A prospective design in which HoNOSCA, Global Assessment of Psychosocial Disability (GAPD) and a clinician rated global outcome measure were completed at 15 field sites. 173 patients were rated both at initial assessment and at follow-up after three months. RESULTS: HoNOSCA demonstrated satisfactory face validity. There was a strong correlation between HoNOSCA scores and GAPD scores ( r = 0.6, P < 0.001) and a highly significant association (ANOVA (F = 25.4, P < 0.001)) between change in HoNOSCA scores and global clinical ratings of change.Mean HoNOSCA scores varied between psychiatric diagnoses. CONCLUSIONS: HoNOSCA is a sensitive and valid measure of change for children and adolescents attending CAMHS.     

The effect of cognitive-behavioral therapy for bulimia nervosa on temperament and character as measured by the temperament and character inventory

Cognitive-behavioral therapy (CBT) is a successful treatment method for reducing symptomatology associated with bulimia nervosa (BN). Less is known regarding the impact of CBT on measures of temperament and character across treatment. We explore changes on the Temperament and Character Inventory (TCI) from pretreatment to 1-year follow-up in a sample of women with bulimia nervosa (BN). Ninety-one women who met DSM-III-R criteria for BN, completed pretreatment measures, and participated in a randomized clinical trial with a core treatment of CBT were available for follow-up at 1 year. Participants were assessed at pretreatment using the TCI as part of a larger assessment battery, and received eight sessions of CBT and eight sessions of exposure with response prevention or relaxation training. The TCI was readministered at the 1-year follow-up point. We compared TCI scores across the two administrations and explored the relation between clinical status at 1 year and TCI scores. Significant decreases in the TCI temperament scale of harm avoidance and increases in the character scale of self-directedness were observed between pretreatment and 1-year follow-up. Observed differences in these scales were independent of change in depression scores as well as other measures of therapeutic change (i.e., binge and purge frequency). We conclude that self-directedness and harm avoidance scores are positively affected by CBT. Higher scores on self-directedness not only predict treatment outcome for BN, but overall self-directedness is improved with CBT in women with BN. These results suggest that the elements of CBT affecting self-directedness may hold promise for enhancing the effectiveness of treatment for BN.     

Therapeutic alliance in cognitive therapy for schizophrenic and other long-term mentally ill patients: development and relationship to outcome in an in-patient treatment programme

A total of 26 schizophrenic and other long-term mentally ill patients receiving cognitive therapy sessions twice a week in the context of a comprehensive in-patient treatment programme were assessed every 5 weeks with regard to therapeutic alliance. The therapists rated the alliance according to the Psychotherapy Status Report and the patients rated it according to the Patient Collaboration Scale. The results showed either good or fair and stable therapeutic alliance for the majority of the patients throughout the treatment period. Few correlations were found between patient characteristics and initial alliance. The therapists' ratings showed a positive relationship between initial alliance and a favourable outcome of treatment at discharge.     

Cohesion, alliance and outcome in group psychotherapy

Cohesiveness has been viewed as the group psychotherapy equivalent of the therapeutic alliance in individual treatment. Although researchers have attempted to study the concept of cohesion in group treatment, understanding of this so-called "curative" group factor remains quite primitive. In this study of 12 time-limited psychotherapy groups, with a total of 90 nonpsychotic outpatients, we explore the relationships between cohesion, alliance and treatment outcome. Our cohesion measure is a new instrument, the Harvard Community Health Plan Group Cohesiveness Scale, developed for use with group therapy videotapes. To measure alliance we have modified the Penn Helping Alliance Scale (Group Alliance Scale) to be scored from videotapes of group sessions. Both of these instruments use trained observers to make ratings for the group-as-a-whole. The outcome battery for patients in these groups included a widely varied set of measures, enabling us to view change from a number of perspectives. Our findings indicate that cohesion and alliance as measured here are related concepts. We also find that both cohesion and alliance appear to have strong relationships with improved self-esteem and reduced symptomatology for patients in these groups. In addition, it appears that outcome is most related to cohesion in the first 30 minutes of a group session. Implications of these and other findings are discussed.     

Measurement of quality of life in schizophrenia: a comparison of two scales

BACKGROUND: People with schizophrenia have an impaired quality of life (QoL), and various QoL assessment scales are available. However it is not clear which scale should be used in different situations. We aimed to compare a patient-rated subjective QoL scale with an observer-rated QoL scale by measuring their degree of correlation and their respective associative profiles with outcome measures. METHOD: Patients of the UK Schizophrenia Care and Assessment Program completed a patient-rated QoL questionnaire (MANSA). Research staff completed the observer-rated QoL tool (QLS) as part of an assessment of symptomatology and functioning. RESULTS: The two QoL tools were moderately positively correlated (r = 0.39). Both scales were negatively correlated with positive and negative symptoms of schizophrenia and depressive symptoms, and positively correlated with functioning scores. However the two scales were influenced by different factors. The patient-rated QoL was more significantly influenced by depressive symptoms, and the observer-rated QoL was more heavily influenced by negative symptoms. CONCLUSIONS: Patient-rated and observer-rated QoL are moderately related, with a number of joint determinants, but the former is sensitive to depressive influences, whilst the latter is sensitive to the negative symptomatology of schizophrenia.     

Therapist ratings of achievement of objectives in psychotherapy with acute schizophrenics.

Therapist ratings of patients' achievement of objectives in psychotherapy were used to examine the impact of drugs on psychotherapy, to identify attributes of patients who achieve therapy objectives, and to assess the importance of the implementation of a crisis-oriented model of therapy. Patients were part of a project investigating the long-acting phenothiazine fluphenazine enanthate and crisis-oriented family therapy in a 6-week program of aftercare treatment for briefly hospitalized first admission acute schizophrenics. The 44 patients in this study were randomly assigned to the psychotherapy condition and to either a high or low dosage of phenothiazines. Therapist ratings of the achievement of therapy objectives were significantly related to independent ratings on two outcome measures, the Global Assessment Scale and the Brief Psychiatric Rating Scale (BPRS) factor Thought Disorder, at 6-month followup. Analyses of predictors of the achievement of therapy objectives revealed significant interactions between drug level and Venables and O'Connor ratings of paranoid symptomatology among good permorbid patients and between drug level and BPRS ratings of Hostility for the entire sample.