Clinical validity of a dimensional assessment of self- and interpersonal functioning in adolescent inpatients.

The Social Cognition and Object Relations Scale-Global Version (SCORS-G) is a clinical rating system assessing 8 domains of self- and interpersonal relational experience that can be applied to narrative response data (e.g., Thematic Apperception Test [TAT; Murray, 1943], early memories narratives) or oral data (e.g., psychotherapy narratives, relationship anecdotal paradigms). In this study, 72 psychiatrically hospitalized adolescents consented and were rated by their individual and group therapist using the SCORS-G. Clinicians also rated therapy engagement, personality functioning, quality of peer relationships, school functioning, global assessment of functioning (GAF), history of eating-disordered behavior, and history of nonsuicidal self-injury. SCORS-G composite ratings achieved an acceptable level of interrater reliability and were associated with theoretically predicted variables (e.g., engagement in therapy, history of nonsuicidal self-injury). SCORS-G ratings also incrementally improved the prediction of therapy engagement and global functioning beyond what was accounted for by GAF scores. This study further demonstrates the clinical utility of the SCORS-G with adolescents.

Assessing overall functioning with adolescent inpatients.

The current study sought to evaluate the validity and reliability of a brief measure of overall functioning for adolescents. Clinicians were asked to complete the Overall Functioning Scale (OFS) for 72 adolescents consecutively admitted to the adolescent psychiatric inpatient service of a community safety net medical center. The results revealed that this new measure is related to the patients' length of stay, clinician-rated measures of social cognition and object relations, Global Assessment of Functioning (GAF) score at admission, as well as global rating of engagement in individual psychotherapy. The results also showed that the OFS was related to the patients' history of nonsuicidal self-harm as well as treatment outcome as assessed by measures of psychological health and well-being as well as symptoms. Hierarchical regressions reveal that the OFS shows incremental validity greater than the admission GAF score in predicting length of stay. The results also showed that the OFS demonstrates interrater reliability in the excellent range (intraclass correlation coefficient(1,2)) of 0.88. Clinical implications of the use of this tool and areas of future research are discussed.

Measuring outcomes in adult outpatient psychiatry.

Despite growing pressure for accountability, mental health professionals continue to debate the value of routinely measuring treatment outcomes. This paper sought to move the outcomes measurement debate forward by reviewing some of the current limitations in outcomes methodology and by providing initial strategies to address them. Using these strategies, we evaluated outcomes for a large diagnostically diverse group of adult outpatients receiving treatment as usual (TAU) within an academic medical centre. Initial self-report and clinician-rated assessments were obtained from 5546 patients, and follow-up data were obtained from 1572 (28%) patients. Using the subset of patients with the follow-up data, we determined treatment effect sizes, rates of reliable improvement (and deterioration) and rates of clinically significant improvement for all patients and for specific diagnostic groups (depression, anxiety, substance abuse, mood disorders not otherwise specified, bipolar and psychotic conditions). TAU outcomes for depression and anxiety were also compared with benchmarks derived from the randomized controlled trial literature. Lastly, the impact of patient or sample characteristics on outcome was explored. Overall, these findings generally support the benefit of TAU over no treatment while also highlighting both the utility and limitations inherent in the current approaches to evaluating treatment outcomes. Suggestions for improving outcomes measurement are provided.

Stress Inoculation Training (SIT-NORCAL), Part 1: The Development and Preliminary Evaluation of a Psychological Performance Training Protocol.

BACKGROUND: Stress inoculation training (SIT) interventions have demonstrated promise within military contexts for human performance enhancement and psychological health applications. However, lack of manualized guidance on core content selection, delivery, and measurement processes has limited their use. PURPOSE: The purpose of this study was to develop and evaluate a comprehensive SIT intervention protocol to enhance the performance and health of military personnel engaged in special warfare and first-response activities. METHODS: Multidisciplinary teams of subject matter experts (n = 19) were consulted in protocol generation. The performance improvement/human performance technology (HPT) model was used in the selection, refinement, and measurement of core skills. The protocol was trialed and refined (44 cohorts, n = =300; 2013-2020) to generate the results. RESULTS: Four primary aims were achieved: (1) The generation of a flexible, evidence-based/evidence-driven psychological performance and health sustainment hybrid, SIT-NORCAL. (2) Manualized content and process guidance. (3) The creation of multimedia materials using evidence-based methodologies. (4) The design of initial measurement systems. Preliminary quality improvement analysis demonstrated positive results using standard-of-care and performance enhancement assessments. CONCLUSION: Hybridized human performance and psychological health sustainment protocols represent a paradigm shift in the delivery of psychological performance training with the potential to overcome barriers to success in traditional care. Further study is needed to determine the effectiveness and reach of SIT-NORCAL.

Stress Inoculation Training (SIT-NORCAL), Part 2: A Pilot Study Among Explosive Ordnance Disposal Special Warfare Enablers.

BACKGROUND: Despite being a well-supported strategy, Stress Inoculation Training (SIT) has not been fully incorporated in the advancement of human performance among most military personnel. The RAND Study recommendations for maximizing SIT's potential within high-risk/ high-intensity occupational groups were used in designing the Core Training protocol targeting psychological performance, SIT-NORCAL (Part 1). PURPOSE: The current project (Part 2) sought to further develop the protocol as a health and human performance hybrid through quality improvement analysis of the content, process, and measurement elements for use in the human performance context. METHODS: Evidence-based/evidence-driven methodologies were used in collaborative design tailored to the unique needs of special warfare enablers specializing in Explosive Ordnance Disposal (n = 17). The resultant three-phase training was conducted with a novice group (n = 10) using standardized measurements of collaboration, human performance, and adaptive capabilities on identified training targets. RESULTS: Process elements demonstrated high feasibility, resulting in high collaboration and trainee satisfaction. Significant improvements in psychological performance targets were observed pre- to post-training, and during an Adaptive Environmental Simulation designed by unit members. Two weeks post-training, unit members (n = 5) responded to an actual crash of an F-16 aircraft; measurements indicated maintenance of skill set from training to real-world events. CONCLUSION: Deployment of the elements in the SIT-NORCAL protocol demonstrated early feasibility and positive training impact on occupationally relevant skills that carried over into real-world events.

Stress inoculation training outcomes among veterans with PTSD and TBI.

OBJECTIVE: Stress inoculation training (SIT) is a cognitive-behavioral treatment that has demonstrated potential as a nontrauma based intervention for veterans with posttraumatic stress disorder (PTSD). The purpose of this study was to explore the efficacy of a novel 3-phase group formulation of SIT applied to a naturalistic population of veterans with PTSD and traumatic brain injury (TBI). The goals were to reduce symptoms of PTSD and depression, improve perceived functioning, and increase treatment initiation among veterans who were reticent to initiate established evidence-based and trauma-focused therapies. METHOD: A program development and evaluation archival analysis of 65 veterans engaged in SIT over an 18-month period at an outpatient VA PTSD clinic was conducted. Participants completed baseline self-report measures of PTSD and depression symptoms, substance use, and perceived performance. RESULTS: Paired samples t tests were used to evaluate pre- to posttreatment gains and demonstrated significant reductions in PTSD (PTSD Checklist, d = 0.66) and depression symptoms (Beck Depression Inventory, d = 0.67), increases in aspects of perceived stress tolerance and performance in multiple life domains, as well as improvements in both social and occupational functioning (Situational Adaptation to Stress Scale, d = 1.26). Eighty-eight percent of the intent-to-treat sample followed through with the recommended follow-up treatment. CONCLUSIONS: The results of this study provide preliminary support for the use of this SIT protocol in reducing symptoms of PTSD and depression, improving performance, and increasing rates of treatment initiation in evidence-based and trauma-focused treatments. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Rorschach correlates of adolescent self-mutilation.

The present study examined various Rorschach variables of aggression, dysphoric affect, and disordered thinking in relation to self-mutilation in samples of self-mutilating (SM; n=16) and nonself-mutilating (N-SM; n=26) adolescent inpatients. Categorical comparisons indicated that SM patients had significantly higher mean scores for Aggressive Past (AgPast), but not for Aggressive Content (AgC), Aggressive Movement (AG), Morbid Content (MOR), Inanimate Movement (m), Sum Shading (SumY), and the Perceptual-Thinking Index (PTI), than N-SM patients. Additionally, logistic regression results suggested that PTI and AgPast were the most robust predictors of group membership. The authors propose that self-mutilating adolescents may struggle with internally directed aggression and victimized sense of self that, when coupled with disordered thinking, significantly predicts self-mutilation.

A comparison of two mental status examinations in an inpatient psychiatric sample.

This study compares the psychometric properties and clinical use of the Mini-Mental Status Exam (MMSE) and the Modified MMSE (3MS) in patients admitted to an acute medical-psychiatric inpatient unit. Internal consistencies were .56 for the estimated MMSE and .72 for the 3MS. Regression analyses revealed that the 3MS was a significant predictor of both length of hospital stay (LOS) and the need for additional services postdischarge. Regressions were also used to evaluate the contribution of the four new items contained in the 3MS: Word Generation, Similarities, Second Recall, and Date and Place of Birth. The 3MS was a significant predictor of LOS and the need for discharge services, whereas the MMSE did not contribute to any regression model. Word Generation was found to be a significant predictor of patients' needing posthospital services. Results support prior findings of the 3MS's superiority over the (estimated) MMSE and help to demonstrate the continued importance of cognitive screening in psychiatric samples.

Neuropsychological functioning and profile validity on the Personality Assessment Inventory (PAI): An investigation in multiple psychiatric settings.

Psychologists in medical settings are frequently tasked with providing comprehensive evaluations of patients with complex medical and psychiatric conditions. In order to achieve these aims, standardized measures of neurocognitive and psychological functioning are often employed to empirically assess a patient's level of functioning across an array of relevant clinical domains. However, less is known about the degree to which cognitive impairment affects a patient's ability to complete these more comprehensive assessments, raising questions about test validity. The current study sought to contribute to this growing body of literature by examining whether neurocognitive functioning is associated with profile validity on the Personality Assessment Inventory (PAI) in both outpatient (N = 321) and inpatient (N = 131) psychiatric settings. In Study 1, results indicate that while multiple cognitive domains are associated with overall profile validity in psychiatric outpatients, attentional impairment specifically was found to be a significant predictor of profile invalidity after accounting for the effects of overall intellectual functioning (accounting for 13% of the variance overall). The magnitude of attentional impairment specifically, and number of impaired cognitive domains more generally, were also found to be meaningfully associated with overall profile validity. Likewise, in Study 2, PAI profile validity was found to be meaningfully associated with gross cognitive impairment on the WMS-IV Brief Cognitive Status Examination (BCSE) in an inpatient psychiatric setting, with almost half of the patients in the most impaired group yielding invalid PAI profiles. The clinical implications of these findings are discussed.

Assessment of patient and therapist perspectives of process: a revision of the Vanderbilt Psychotherapy Process Scale.

The present study was designed to revise the Vanderbilt Psychotherapy Process Scale (VPPS), an external-rater completed measure, into both patient and therapist-rated versions. The VPPS was altered into two versions by using simple pronoun changes and then submitted to a principal components analysis in order to identify component factors. This procedure resulted in two identical forms of the VPPS, one completed by the therapist (VPPS-T) and one completed by patients (VPPS-P). These scales have identical items and factor structures. Preliminary results suggest that the VPPS-P and VPPS-T may be useful measures of psychotherapy process when perspectives of session activity is desired from both patients and therapists.

Self-mutilation, severity of borderline psychopathology, and the Rorschach.

The authors explore borderline pathology on a continuum of functioning. Rorschach variables relating to (1) aggression, (2) dependency, (3) object relations, (4) defenses, and (5) boundary disturbance were measured across a nonclinical (NC) and two clinical (borderline patients without self-mutilative behavior = N-BPD, and borderline patients with self-mutilative behaviors = SM-BPD) groups. Results demonstrated good discriminate ability (87%) between clinical and nonclinical protocols. Comparisons between N-BPD and SM-BPD groups revealed overall greater pathological scores for the SM-BPD group, specifically in dependency scores. Convergence with other studies and implications for future clinical and empirical work are discussed.

Deceptiveness on the PAI: a study of naïve faking with psychiatric inpatients.

In this study, we sought to explore the diagnostic accuracy of the Personality Assessment Inventory (PAI; Morey, 1991) Validity scales (Negative Impression Management [NIM] and Positive Impression Management [PIM]) and indexes (Malingering index, Defensiveness index [DEF]; Morey, 1993, 1996; Cashel Discriminant Function; Cashel, Rogers, Sewell, & Martin-Cannici, 1995; and Rogers Discriminant Function [RDF]; Rogers, Sewell, Morey, & Ustad, 1996) to identify differences in profiles completed by psychiatric inpatients under standardized instructions (Time 1) and after random assignment (Time 2) to a fake good (n=21), fake bad (n=20), or retest (n=21) scenario. Repeated measures analysis of variance revealed a significant interaction effect. Whereas the retest group did not show any significant changes on the PAI variables from Time 1 to Time 2, both faking groups showed changes in expected directions. Discriminant function analyses revealed that NIM, RDF, and lower scores on DEF best differentiated between the faking bad and retest groups. PIM was the only nonredundant significant score discriminating the faking good and retest groups. Cutoffs for these scales and indexes established in prior research were supported using diagnostic efficiency statistics. Results suggest that NIM and RDF in faking bad scenarios and PIM in faking good scenarios are most sensitive to unsophisticated attempts to dissimulate by inpatient psychiatric patients.

Concurrent validity of the Personality Assessment Inventory Borderline scales in patients seeking dialectical behavior therapy.

The purpose of this study was to explore the usefulness of the Personality Assessment Inventory (PAI; Morey, 1991) Borderline full scale (BOR) and subscales in the assessment of patients being evaluated for dialectical behavior therapy (DBT; Linehan, 1993). We administered 67 patients both the PAI and the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) Structured Clinical Interview for Axis II disorders (SCID-II; First, Spitzer, Gibbon, Williams, & Benjamin, 1997). Point biserial correlations showed a significant relationship between the presence of borderline personality disorder (BPD) and scores on the BOR and Schizophrenia (SCZ) scales. A regression analysis showed that among the BOR subscales, those measuring identity disturbance, self-harming behavior, and negative relationships were significantly related to the total number of SCID-II BPD criteria. Diagnostic efficiency statistics between the BOR scale and the number of SCID-II BPD criteria indicated that a T score cutoff of 65 optimally differentiates patients who do and do not meet criteria for BPD. The relationship between BOR and SCID-II BPD demonstrates the concurrent validity of the PAI and shows its usefulness in this setting.

Rorschach Aggressive Content (AgC) variable: a study of criterion validity.

This study adds to the existing literature on the clinical utility of the Aggressive Content (AgC) variable proposed by Gacono and Meloy (1994). Criterion validity is evaluated by examining the relation between AgC and behavior. Rorschach and clinical chart material taken from psychological assessments were examined for 94 patients in Exner's (1993) psychiatric reference groups. An Aggression Chart Rating Scale (ACRS) was created to score the level of aggressiveness of each patient's diagnostic report. Analyses revealed good interrater reliability (intraclass correlation coefficient = .73) for ACRS scores and Aggressive Movement (AG; kappa = .73) and excellent reliability for AgC (kappa =.88) and Morbid Content (MOR: kappa = .79). Pearson's correlation revealed significant relations between AgC and both AG and MOR. All 3 Rorschach variables were significantly related to scores on the ACRS. A stepwise regression analysis utilizing these 3 variables resulted in AgC being the only nonredundant predictor of scores on the ACRS. This suggests that AgC was more strongly related to more aggressive ACRS scores than either AG or MOR. The continued support for the clinical utility of AgC as well as recommendations for the addition of the AgC variable to Exner's (1993) Comprehensive System's list of Special Scores are discussed.

DSM-IV Major Depressive Episode criteria: An evaluation of reliability and validity across three different rating methods.

This study examined the reliability and validity of the DSM-IV Major Depressive Episode (MDE) symptoms in a sample of outpatients based on clinician ratings of assessment interviews, videotape of these interviews, and chart information. A group of 44 patients admitted to a university based outpatient community clinic were rated by trained clinicians on the nine MDE symptom criteria (A1-A9). Patients also completed a self-report measure of depressive symptomatology. Interrater reliability was found to be highest between the interview and videotape ratings. Conversely, when comparing chart ratings with those made from either interview or videotape, reliability for many of the individual criteria were found to be in the poor range of reliability. Good internal consistency was found for both the interview and videotape ratings, while internal consistency was less adequate for chart-based ratings. However, the three MDE ratings converge on a single dimension in a similar manner regardless of which source (i.e. interview, videotape, or chart) provided the rating. Additional analyses revealed a consistent relationship between the three MDE ratings (interview, videotape, and chart) with measures of patient reported depressive symptoms that exceeded the relationship between these scores with global levels/severity of psychopathology. The effects of longer interviews as well as examining depressive symptoms within the context of interpersonal functioning is discussed regarding the reliable assessment of depressive symptomatology in the mild to moderate range of severity. (Int J Psych Can Pract 2004; 8: 3-10).

Short-term psychodynamic psychotherapy for depression: an examination of statistical, clinically significant, and technique-specific change.

This study investigates the effectiveness of short-term psychodynamic psychotherapy (STPP) for depression in a naturalistic setting utilizing a hybrid effectiveness/efficacy treatment research model. Twenty-one patients were assessed pre- and post-treatment through clinician ratings and patient self-report on scales representing specific DSM-IV depressive, global symptomatology, relational, social, and occupational functioning. Treatment credibility, fidelity, and satisfaction were examined, all of which were found to be high. All areas of functioning assessed exhibited significant and positive changes. These adaptive changes in functioning demonstrated large statistical effects. Likewise, changes in depressive symptoms evaluated at the patient level utilizing clinical significance methodology were found to be high. A significant direct process/outcome link between STPP therapist techniques and changes in depressive symptoms was observed. Alternative treatment interventions within STPP were evaluated in relation to subsequent improvements in depression and were found to be nonsignificant. The present results demonstrate that robust statistical and clinically significant improvement can occur in a naturalistic/hybrid model of outpatient STPP for depression.