Brief Assessment Instruments

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Brief Assessment Instruments

• William P. Wattles, Ph.D.
• Francis Marion University

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Brief therapy and assessment

• Managed Care emphasizes
• Cost containment
• Documented treatment efficacy

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Assessment

• A full test battery is not longer an option for
  most practitioners.
• Psychologists biggest challenge is demonstrating
  the financial efficacy of their services.

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3 Brief Instruments

• Treatment planning
• Outcome assessment
• Monitoring

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Brief Instruments

• Brief Symptom Inventory (BSI)
• Beck Depression Inventory (BDI)
• State Trait Anxiety Inventory (STAI)

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Brief Instruments

• Good reliability
• Adequate validity
• Good relevancy

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Beck Depression Inventory

• William P. Wattles, Ph.D.
• Francis Marion University

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• Measures self-reported depression
• Response bias may lead some to exaggerate or
  minimize (or deny) symptoms.
• Diagnosis of depression requires examination by a
  clinician.

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Beck Depression Inventory -II

• 21-item self-report instrument
• Measures severity of depression in adults and
  adolescents 13 and older
• Corresponds to criteria in DSM-IV

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History

• Created in 1961
• Revised in 1996 after 35 years
• Based on descriptive statements reported by
  psychiatric patients who were depressed but not
  by other psychiatric patients
• Resulted in 21 items
• Original version read by trained observer

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21 Items

• Mood
• Pessimism
• Sense of Failure
• Self-dissatisfaction
• Guilt
• Punishment
• Self-Dislike
• Self-Accusations

• Suicidal Ideas
• Crying
• Irritability
• Social Withdrawal
• Indecisiveness
• Body Image change
• Work Difficulty
• Insomnia

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21 Items (cont)

• Fatigability
• Loss of Appetite
• Weight Loss
• Somatic Preoccupation
• Loss of Libido

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Revision

• Items dropped
• Body Image change
• Work difficulty
• Weight loss
• Somatic preoccupation

• Items added
• Agitation
• Worthlessness
• Loss of energy
• Concentration difficulty

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Items changed

• Old item
• insomnia
• loss of appetite
• Loss of libido
• Fatigability

• New Item
• changes in sleeping pattern
• changes in appetite
• loss of interest in sex
• tiredness or fatigue

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Critical items

• The clinician should pay special attention to
  the responses to item 2 (pessimism) and Item 9
  (suicidal thoughts or wishes) as indicators of
  possible suicide risk

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Administration

• Time 5-10 minutes to complete
• Answers should be for the past two weeks
• extended from one week for DSM-IV
• Check to be sure that all items have been
  completed

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Scoring

• Each item is rated 0 - 3
• If more than one is selected choose the higher
  figure
• Scores can range from 0 to 63

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Interpreting Scores

• Choice of cut scores depends on purpose for using
  the test.

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• Sensitivity-the probability of correctly
  classifying a respondent as depressed.
• Specificity-the probability of correctly
  classifying a respondent as not depressed

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Simple thinking
Not depressed
depressed
frequency
Number of symptoms
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Simple thinking
Not depressed
depressed
frequency
Number of symptoms
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Reality
frequency
Number of symptoms
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Not depressed
depressed
frequency
Criterion
Number of symptoms
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Correct reject
False alarm
frequency
Number of symptoms
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Miss
Hit
frequency
Criterion
Number of symptoms
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Hits 97.5 84 50
False Alarms 84 50 16
frequency
Number of symptoms
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Not depressed
depressed
frequency
Criterion
Number of symptoms
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ROC Curves

• Receiver-operating characteristic curves capture
  in a single graph the various alternatives as you
  move the criterion to higher or lower levels.
• False alarm rate on the X (horizontal) axis
• Hit rate on the Y (vertical) axis

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ROC Curves
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ROC Curves

• the area under the ROC (AUR) curves for the
  BDIII was .78 (95 CI, .68 to .86)
• The AUR is an overall index of the accuracy of
  discrimination provided by a scale, and an AUR of
  .50 represents chance discrimination..
• A BDIII total cutoff score of 24 and above had
  the highest clinical efficiency (72) with a
  sensitivity rate of 74 and a specificity rate of
  70

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Hits
ROC Curves
False Alarms
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Cut score threshold

• If purpose is to detect the maximum number of
  persons with depression the cut score threshold
  should be lowered.
• For research where it is important to obtain a
  pure group, cut score should be raised to
  minimize false positives.

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Cut off scores
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Sample Results
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Psychometric characteristics

• Outpatient samples from four outpatient clinics
• 277( 55) Cherry Hill, New Jersey
• 50 (10) Bala Cynwyd, Pennsylvania
• 127 (25) Philadelphia, Pennsylvania
• 46 (9) Louisville, Kentucky

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Sample characteristics

• Gender
• Women 63
• Men 37
• Race
• White 91
• Black 4
• Asian America 4
• Hispanic 1

• Disorder
• mood dis. 53
• anxiety dis 18
• adjustment dis 16
• other dis 14

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Depression Ratings

• All patients were diagnosed by experienced
  psychologists or psychiatrists according to DSM
  criteria
• Patient participation was voluntary with informed
  consent.

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Student Sample

• 120 intro psych students
• women 67
• men 44
• Predominately white
• mean age 19.6 (SD1.84)

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Reliability

• Internal Consistency
• Coefficient Alpha
• outpatients .92
• students .93
• All items correlated significantly with the total
  score.
• outpatients ranging from .39 (Loss of interest
  in sex) to .70 (loss of pleasure)
• students ranging from .27 (Loss of interest in
  sex) to .74 (self-dislike) .

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Reliability

• Test-retest stability
• 26 Philadelphia outpatients administered BDI-II a
  week apart.
• Test-retest r .93

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Validity

• Content validity-the construction process
  consisted of 21 areas that differentiated
  depressed from non-depressed patients.
• Content validity- BDI-II reworded and added to
  assess DSM-IV criteria for depression.

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Validity

• Construct validity
• Correlation with original BDI r.93
• Mean score 2.96 points greater than original BDI

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Validity

• Convergent validity
• correlates with Beck Hopelessness Scale
• r.68
• correlates with Scale of suicide ideation
• r.37
• Hamilton Psychiatric Rating scale for depression
• r.71
• Discriminate Validity-not measured

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Validity

• The Beck Depression Inventory-II and the Reynolds
  Adolescent Depression Scale (RADS Reynolds,
  1987) were administered to 56 female and 44 male
  psychiatric inpatients whose ages ranged from 12
  to 17 years old.
• The Cronbach coefficient alpha(s) for the BDI-II
  and RADS were, respectively, .92 and .91 and
  indicated comparably high levels of internal
  consistency.
• The correlation between the BDI-II and RADS total
  scores was .84,p lt.001.

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Item-option characteristic curves

• Each item demonstrates increasing monotonic
  relationship with self-reported depression
• Items 6, 9, 11, 21 show variation in rank of
  items selected
• patients with sever depression unlikely to
  acknowledge suicidal intent

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Factorial Validity

• Identified two factors
• Somatic Affective
• loss of pleasure, crying, agitation, loss of
  interest, indecisiveness, loss of energy, changes
  in sleep, irritability, changes in appetite,
  concentration difficulty, tiredness.
• Cognitive
• sadness, pessimism, past failure, guilty
  feelings, punishment, self-dislike,
  self-criticalness, suicidal thoughts,
  worthlessness

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Race and Gender

• No differences found between white and non-white
  scores
• Women scored higher than men
• Men Mean 20.44 (SD13.28)
• Women Mean23.61 (SD12.1)

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Sleeping and eating

• Changes in sleeping pattern
• 30 sleeping more
• 50 sleeping less
• Changes in eating
• 39 decreased appetite
• 20 increased appetite

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BDI as outcome measure
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State Trait Anxiety InventorySTAI

• William P. Wattles, Ph.D.
• Francis Marion University

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State-Trait Anxiety Inventory for Adults

• The STAI is the definitive instrument for
  measuring anxiety in adults. It clearly
  differentiates between the temporary condition of
  state anxiety and the more general and
  long-standing quality of trait anxiety.

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STAI

• http//www.mindgarden.com/Assessments/Info/staiinf
  o.htm
• The STAI has forty questions with a range of four
  possible responses to each.

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STAI

• Determines anxiety in a specific situation and as
  a general trait
• Two twenty-item scales
• For individual or group administration
• Provides norms for clinical patients, high school
  and college students, and working adults
• Efficiently scored
• Can be completed in about ten minutes
• Sixth grade reading level

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The S-Anxiety scale

• The S-Anxiety scale consists of twenty statements
  that evaluate how respondents feel "right now, at
  this moment."
• 1 Not At All  2 Somewhat  3 Moderately
  So  4 Very Much So
• A. I feel at ease 1 2 3 4
• B. I feel upset 1 2 3 4

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The T-Anxiety scale

• The T-Anxiety scale consists of twenty statements
  that assess how respondents feel "generally."
• 1 Almost Never  2 Sometimes  3 Often  4
  Almost Always
• A. I am a steady person 1 2 3 4
• B. I lack self-confidence 1 2 3 4

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STAI State Anxiety

• Evaluates how respondents felt at a particular
  time in the recent past and how they anticipate
  they will feel either in a specific situation
  that is likely to be encountered in the future or
  in a variety of hypothetical situations.
• Is found to be a sensitive indicator of changes
  in transitory anxiety experienced by clients and
  patients in counseling, psychotherapy, and
  behavior-modification programs.

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STAI State Anxiety

• Assesses the level induced by stressful
  experimental procedures and by unavoidable
  real-life stressors such as imminent surgery,
  dental treatment, job interviews, or important
  school tests.
• For screening high school and college students
  and military recruits for anxiety problems, and
  for evaluating the immediate and long-term
  outcome of psychotherapy, counseling, behavior
  modification, and drug-treatment programs.

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STAI State Anxiety

• Proven useful for identifying persons with high
  levels of neurotic anxiety and for selecting
  subjects for psychological experiments who differ
  in motivation or drive level.

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STAI

• STAI-Y is a 40-item Likert scale
• Measuring State anxiety items 1-20
• And Trait anxiety items 21-40

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Scoring

• Each item weighted 1-4 with approximately half
  the items reverse scored.
• State and Trait scores can range from a
• Minimum of 20
• Maximum of 80

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STAI Reading level

• 4th or 5th grade reading level

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Interitem consistency

• Coefficient Alpha
• State .92
• Trait .90

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Test-retest Reliability

• Test-retest reliability
• State .62
• Trait .84

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Cut-off scores

• Not provided
• Trade off between
• Specificity-correctly identified anxiety-
  disordered clients
• Sensitivity-correctly identified
  non-anxiety-disordered clients

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Norms
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Clinical Norms
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Cut-off scores

• The recommended cutoff for the STAI is 2 SD
  greater than the mean raw score adjusted for age
  and gender. Grontkovsky et al. 2004

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Cut-off scores
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Cut-off scores

• A cut-off of 39-40 is normally used for
  clinically significant symptoms of a state of
  anxiety.
• In pre-operative patients the cut-off was set at
  44/45

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Cut-off scores

• Geriatric in-patients. Cut-off 54/55 optimal
• 7 false positives, 2 false negatives

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Cut-off

• I don't think any cutoffs exist. It seems that
  the measure is only scored continuously, which
  would make sense since scores vary widely
  according to normative group, and the measure
  doesn't assess a diagnosable disorder.

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• Cutoffs for an anxiety scale can be of two kinds.
  The first is just to take the top and bottom
  thirds to form contrasting groups to be
  participants in an experimental study. The second
  is the question of whether they are high or low
  anxiety. I divide the responses by the number of
  items (unless already done so in the scoring) to
  put them back on the original scale, and then
  those whose scores are above the midpoint are
  anxious and those below the midpoint are not
  anxious.
• Rich Gorsuch

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Symptom Check List

• William P. Wattles, Ph.D.
• Francis Marion University

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Symptom Check List

• The Symptom Check List (SCL-90-R)
• 6th grade reading level
• List of symptoms versus personality measure
• 90 symptoms
• 12-15 minutes
• Over 1,000 studies published

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Symptom Check List

• Descriptive rather than interpretive data make
  for a straightforward interpretation.
• T score great than 63 suggest clinically
  significant levels of psychological distress.

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Global Indexes

• Global Severity Index
• Combined rating considers intensity and number of
  symptoms
• Positive Symptom Distress Index
• A measure of intensity. An average rating for all
  symptoms
• Positive Symptom Total
• A measure of the number or breadth of symptoms.

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SCL-90-R Symptom Dimensions

• Somatization- Distress is primarily experienced
  through physical problems. Somatization is an
  ineffectual coping mechanism.
• Obsessive-Compulsive- Focuses on irresistible,
  repetive, unwanted impulses thoughts and actions.

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SCL-90-R Symptom Dimensions

• Interpersonal Sensitivity- Low self-esteem,
  negative expectations in social setttings.
• Depression- include full range of depressive
  symptoms.
• Anxiety- Focuses on apprehension, nervousness,
  and dread. Includes physical components such as
  rapid heart rate and tension.

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SCL-90-R Symptom Dimensions

• Phobic Anxiety-Excessive or irrational fear of
  person, place or thing.
• Paranoid Ideation-Hostility projection,
  grandiosity, suspiciousness, need for control.
  Delusions may be present
• Psychoticism-Person may be withdrawn, isolated
  and experiencing hallucinations.

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• The SCL-90-R test is normed on 4 groups
• Adult psychiatric outpatients
• Adult nonpatients
• Adult psychiatric inpatients
• Adolescent nonpatients

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(Brief Symptom Inventory)

• Shorter version of SCL-90-R

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The End