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1 Brief Assessment Instruments William P. Wattles, Ph.D. Francis Marion University.

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1 1 Brief Assessment Instruments William P. Wattles, Ph.D. Francis Marion University

2 2 Brief therapy and assessment Managed Care emphasizes: –Cost containment –Documented treatment efficacy

3 3 Assessment A full test battery is not longer an option for most practitioners. Psychologists’ biggest challenge is demonstrating the financial efficacy of their services.

4 4 3 Brief Instruments Treatment planning Outcome assessment Monitoring

5 5 Brief Instruments Brief Symptom Inventory (BSI) Beck Depression Inventory (BDI) State Trait Anxiety Inventory (STAI)

6 6 Brief Instruments Good reliability Adequate validity Good relevancy

7 7 Beck Depression Inventory William P. Wattles, Ph.D. Francis Marion University

8 8 Measures self-reported depression Response bias may lead some to exaggerate or minimize (or deny) symptoms. Diagnosis of depression requires examination by a clinician.

9 9 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

10 10 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

11 11 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

12 12 21 Items (cont) Fatigability Loss of Appetite Weight Loss Somatic Preoccupation Loss of Libido

13 13 Revision Items dropped –Body Image change –Work difficulty –Weight loss –Somatic preoccupation Items added –Agitation –Worthlessness –Loss of energy –Concentration difficulty

14 14 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

15 15 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

16 16 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

17 17 Scoring Each item is rated If more than one is selected choose the higher figure Scores can range from 0 to 63

18 18 Interpreting Scores Choice of cut scores depends on purpose for using the test.

19 19 Sensitivity-the probability of correctly classifying a respondent as depressed. Specificity-the probability of correctly classifying a respondent as not depressed

20 20 frequency Number of symptoms Not depressed depressed Simple thinking

21 21 frequency Number of symptoms Not depressed depressed Simple thinking Criterion

22 22 frequency Number of symptoms depressedNot depressed Reality

23 23 frequency Number of symptoms Not depressed depressed Criterion

24 24 frequency Number of symptoms Correct rejectFalse alarm

25 25 frequency Number of symptoms Criterion MissHit

26 26 frequency Number of symptoms Hits97.5%84%50% False Alarms84%50%16%

27 27 frequency Number of symptoms Not depressed depressed Criterion

28 28

29 29 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

30 30 ROC Curves

31 31 ROC Curves the area under the ROC (AUR) curves for the BDI–II 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 BDI–II 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%

32 32 False Alarms Hits ROC Curves

33 33 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.

34 34 Cut off scores

35 35 Sample Results

36 36 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

37 37 Sample characteristics Gender –Women 63% –Men 37% Race –White 91% –Black4% –Asian America 4% –Hispanic 1% Disorder –mood dis. 53% –anxiety dis 18% –adjustment dis 16% –other dis 14%

38 38 Depression Ratings All patients were diagnosed by experienced psychologists or psychiatrists according to DSM criteria Patient participation was voluntary with informed consent.

39 39 Student Sample 120 intro psych students –women 67% –men 44% Predominately white mean age 19.6 (SD=1.84)

40 40 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).

41 41 Reliability Test-retest stability –26 Philadelphia outpatients administered BDI- II a week apart. –Test-retest r=.93

42 42 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.

43 43 Validity Construct validity –Correlation with original BDI r=.93 –Mean score 2.96 points greater than original BDI

44 44 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

45 45 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 <.001.

46 46 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

47 47 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

48 48 Race and Gender No differences found between white and non-white scores Women scored higher than men: –Men Mean= (SD=13.28) –Women Mean=23.61 (SD=12.1)

49 49 Sleeping and eating Changes in sleeping pattern –30% sleeping more –50% sleeping less Changes in eating –39% decreased appetite –20% increased appetite

50 50 BDI as outcome measure

51 51 State Trait Anxiety Inventory STAI William P. Wattles, Ph.D. Francis Marion University

52 52 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”.

53 53 STAI nfo/staiinfo.htm nfo/staiinfo.htm The STAI has forty questions with a range of four possible responses to each.

54 54 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

55 55 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 B. I feel upset

56 56 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 B. I lack self-confidence

57 57 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.

58 58 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.

59 59 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.

60 60 STAI STAI-Y is a 40-item Likert scale Measuring State anxiety items 1-20 And Trait anxiety items 21-40

61 61 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

62 62 STAI Reading level 4 th or 5 th grade reading level

63 63 Interitem consistency Coefficient Alpha –State.92 –Trait.90

64 64 Test-retest Reliability Test-retest reliability –State.62 –Trait.84

65 65 Cut-off scores Not provided Trade off between –Specificity-correctly identified anxiety- disordered clients –Sensitivity-correctly identified non-anxiety- disordered clients

66 66 Norms

67 67 Clinical Norms

68 68 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

69 69 Cut-off scores

70 70 Cut-off scores A cut-off of is normally used for clinically significant symptoms of a state of anxiety. In pre-operative patients the cut-off was set at 44/45

71 71 Cut-off scores Geriatric in-patients. Cut-off 54/55 optimal –7 false positives, 2 false negatives

72 72 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.

73 73 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

74 74 Symptom Check List William P. Wattles, Ph.D. Francis Marion University

75 75 Symptom Check List The Symptom Check List (SCL-90-R) –6 th grade reading level –List of symptoms versus personality measure –90 symptoms –12-15 minutes –Over 1,000 studies published

76 76 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.

77 77 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.

78 78 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.

79 79 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.

80 80 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.

81 81

82 82

83 83 The SCL-90-R test is normed on 4 groups: –Adult psychiatric outpatients –Adult nonpatients –Adult psychiatric inpatients –Adolescent nonpatients

84 84 (Brief Symptom Inventory) Shorter version of SCL-90-R

85 85 The End

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