Innovations In Clinical Neuroscience

NOV-DEC 2017

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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13 ICNS INNOVATIONS IN CLINICAL NEUROSCIENCE November-December 2017 • Volume 14 • Number 11–12 R E V I E W THE BIRTH OF PSYCHOMETRICS As early as in 1951, in an article published on the symptomatology of psychosis, psychologist J. R. Wittenborn stated very clearly that the culture of the researcher might have a strong influence on the science of phenomenology. He cautioned that the clustering of symptoms in his own data might have been due to "patterns of belief and techniques of examination" prevalent among contemporary New England psychiatrists. That is to say, psychiatrists who are different in cultural background might possibly rate patients so differently that the appearance of different symptom patterns would result. It is also possible that the forms of behavior by which mental illness is manifested are in some way culturally determined; this possibility can be examined only by making intercultural comparisons for symptom patterns among the mentally ill." 3 Psychometrics can be referred to as an objective, quantitative evaluation relying substantially on statistical methods. At its inception, the field of psychometrics was intended to describe and classify "abnormal behavior" with the assumption that there was a shared etiology and specific symptom expression for each disease area. Few psychometric instruments existed prior to World War II. Father Thomas Verner Moore's (1877–1969) "Scheme for the Quantitative Measurement of Abnormal Emotional Conditions" was one of the few statistically derived measures available at the time and the first one constructed via a factor analysis of patient symptomatology. 4 Moore sought to evaluate the classification and differentiation of syndromes of psychosis in the light of Kraeplin's work. He drew heavily on the statistical methods of his former classmate and colleague, Charles Spearman, particularly his idea of factor analysis, to analyze the psychometric data he collected. 5 Moore primarily collected his data from interviews and ward observation of 367 male and female patients who were functionally psychotic. His findings supported Kraeplin's classifications and further concluded that manic-depressive syndrome and dementia praecox were in reality five highly correlated syndromes (catatonic, deluded and hallucinated, paranoid irritability, cognitive defect, and constitutional hereditary depression) that all shared common etiological factors. 4 Following Moore's psychometric advances, no other instruments grounded in factor analysis of data were developed until World War II. Between 1943 and 1953, more than 15 new rating scales and checklists were developed and published to evaluate psychiatric patients on the ward or during clinical interview. 6 It was in 1951 that chlorpromazine, the first neuroleptic, was introduced. 7 The introduction of tranquilizers as treatment options helped to fuel this demand for the use of statistical measurements in comparing the efficacy of these drugs. The bulk of the investigations of new drug treatments fell to the VA. 2 MAURICE LORR'S MULTIDIMENSIONAL SCALE FOR RATING PSYCHIATRIC PATIENTS In the 1950s, VA psychologist Maurice Lorr began a series of studies with the objective of providing a more efficient framework for describing the symptomatology of psychoses, conducting therapeutic evaluation, and measuring patient change. 8 For Lorr, this required precise psychometric instruments. 9 Though Kraeplin's system was still in use during the early post-World War II era, Lorr rejected Kraeplin's typological approach and instead proposed a method in which not all elements of a syndrome needed to be present for a patient to be assessed and diagnosed. Lorr and fellow VA psychologists Richard Jenkins and James O'Connor conducted a factor analysis of data collected on the "Northport Record." This early Lorr measure comprised rating scales derived from data on functional psychotic patients at the VA hospital in Northport, New York. 10 Lorr and colleagues later revised the "Northport Record" to create a new psychometric instrument, the Multidimensional Scale for Rating Psychiatric Patients (MSRPP). The MSRPP was designed to measure symptom severity and changes in patients with psychoses who had been lobotomized. The instrument and its symptom inventory consisted of two sections: 1) an interview section rated by a psychiatrist or psychologist and 2) a ward section completed by nurses or other staff members following an observation period. The MSRPP also had an alternative form for use with outpatients. 6 Lorr was passionate about the use of rating scales for objective recording and evaluation. His review of quantitative measurements suggests he thoroughly understood that having a familiarity with the patient being interviewed was crucial to accurately understanding the patient's symptomology. 7 This measure demonstrated these beliefs and the importance of behavioral observation as part of a symptom rating scale, a feature that was adopted by the PANSS many decades later. The MSRPP and the other scales created during and directly following World War II had fundamental issues for Lorr, both in the process by which data were collected and in the manner in which those data were classified. Lorr remained uneasy with the use of interviews and observation as the key components in assessing psychopathology and its expression. The problem for Lorr was one of "developing controlled interview patterns … and of objectively recording what the trained clinician can validly or reliably observe or infer." 6 Lorr and his contemporaries reviewed, analyzed, and conducted additional studies to identify salient symptoms and to evaluate available classifications. However, the factors that Lorr had hypothesized and his rating scales had many similarities to those developed by his peers. This might have been due to the influence of authoritative prior work by Moore, the fact that Lorr and his peers all used similar methodologies, and the fact that all worked with similar patient populations. 3,10 Lorr tested his hypotheses among veteran psychotic patients from five VA hospitals. He attempted to include a representative cross-section of the patient population in terms of their symptom severity and the duration of their stay at the hospital. 6 With the study results, an additional factor analysis of the MSRPP, and results of comparisons with other studies conducted during the 1950s, Lorr condensed his list of factors from the 12 appearing in the MSRPP to the 10 he had identified in all cases. MAURICE LORR'S INPATIENT MULTIDIMENSIONAL PSYCHIATRIC SCALE The Inpatient Multidimensional Psychiatric Scale (IMPS) was designed to measure the 10 psychotic syndromes, described by Lorr, that were established by repeated factor analyses of the instrument's authors. 12 Lorr also validated the 10 hypothesized syndromes

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