Innovations In Clinical Neuroscience

NOV-DEC 2017

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

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Page 14 of 83

15 ICNS INNOVATIONS IN CLINICAL NEUROSCIENCE November-December 2017 • Volume 14 • Number 11–12 R E V I E W with the IMPS. 11 Lorr's approach reveals much about his view of psychopathology and the place of the clinician or researcher in time and context. His overarching goal of freedom from bias was difficult to achieve, as even his multivariate analytic results were shaped by prior data, findings, and conceptualizations. 16,17 As a concluding thought in the IMPS manual, he expressed his reservations regarding the possibility of an abbreviated version of the IMPS. Lorr maintained that it was necessary to have redundancy so that each syndrome could be defined by its range of behaviors rather than be limited by a single characteristic. 8 He feared that reducing the instrument into a global scale for each syndrome weakened both its reliability and validity. The creation of such an instrument, in Lorr's opinion, would push psychiatry back a decade toward the time of the first DSM, where subtypes were characterized by a singular and unidimensional feature—the model against which Lorr was working. Despite this criticism, future scales would strike a balance between item reduction and comprehensive evaluation, highly structured interview approaches, and global summaries of symptomatology. GORHAM, OVERALL, AND THE BRIEF PSYCHIATRIC RATING SCALE In the late 1950s, John Overall was one of the first researchers to benefit from the new psychiatric training programs established post-World War II. Overall was assigned the task of evaluating existing psychometric instruments and developing new ones for use in the VA's psychiatric studies, particularly those aimed at examining the efficacy of drug treatment in comparison with other treatment methods. It was during this time that Overall began his lifelong collaboration with clinical psychologist John Gorham. Concurrent with Lorr's development of the IMPS, Overall and Gorham began a series of studies that resulted eventually in the birth of the Brief Psychiatric Rating Scale (BPRS). Gorham and Overall perceived a need for an instrument tailored to measure the efficacy of drug treatments but that would not be burdensome for the staff at psychiatric hospitals to administer. Gorham and Overall found the MSRPP, the foundational starting point for the BPRS, to be ineffective in evaluating drug efficacy because it did not possess sufficient specificity to assess changes in symptoms according to a certain type of drug. 19 Thus, they developed their own set of drug-change scales from the MSRPP that were sensitive to medication effects. In their minds, the efficiency of a brief scale depended on the inclusion of items that were especially sensitive to drug change, such as Unwarranted Suspicion, Hallucinatory Behavior, Disorientation, Tension-anxiety, Inaccurate Self-concept, Emotional Responsiveness, Conceptual Disorganization, Mannerisms and Posturing, and Guilt and Dread. The product of these efforts was an experimental version of the BPRS, in which raters were asked to make a global rating of the severity of the pathology for each symptom construct. 19 The reliability of these 14 items was tested at the VA. Gorham and Overall recommended that two clinicians jointly interview a patient using the BPRS and then have the raters make independent ratings to ensure reliability. 20 A single rating for each scale item was to be determined by consensus in instances in which scores were different. Averaging scores was not permissible, although this convention has been largely disregarded in subsequent decades. 21 Prior to publishing the BPRS, Gorham and Overall added two additional scale items to the 14 items from the experimental BPRS: "Unusual Thought Content" and "Blunted Affect." A small committee of psychologists and psychiatrists determined that these items were crucial to include even if factor analysis had minimized their significance. 22 By including a single scale to record the symptomatology of relatively independent symptom areas, Gorham and Overall created a tool for the concise and speedy evaluation of change due to treatment in psychiatric patients and provided a comprehensive description of symptom characteristics. However, the BPRS authors also stated that the Lorr scales, which had more items, should be used in instances where time permits. In 1965, Gorham and Overall added two additional items, "Excitement" and "Disorientation," to the BPRS, bringing the item total to 18. 23 While Gorham and Overall had outlined the basic structure of the BPRS interview, in 1988, Rhoades and Overall suggested a number of possible lead questions that would ensure each of the content domains would be covered during the BPRS interview process, with the understanding that interviewers would modify the questions and follow-up as each situation demanded. 24 The authors felt that this semi-structured interview methodology was consistent with the guiding principle of the BPRS wherein symptom constructs are abstract and the symptoms themselves can be more fluid, as opposed to past scales in which symptomology is rigid. The same perception of symptom manifestations and symptom constructs deterred Overall and his colleagues from officially including anchoring points for their scales or officially endorsing the anchoring point schemes proposed by others. While introducing anchoring points to the BPRS would allow researchers to predetermine threshold values on items, the arguments against this revision to the instrument stemmed from other concerns. Overall asserted that the BPRS was aimed at capturing global assessments of pathologies that were not the sum of individual ratings of symptoms and behaviors. 24 STANLEY KAY, LEWIS OPLER, AND THE PANSS By the 1980s, the discourse of psychiatry in the United States began to embrace a different epistemology—a dimensional approach to psychopathology—that steadily replaced the typological framework favored in earlier decades. The early 1980s saw the reinvigoration and elaboration of a two-dimensional model for schizophrenia, largely at the hands of British psychiatrist Timothy Crow. 25,26 Crow hypothesized the existence of a phenomenology and neurobiology based on the concepts of positive and negative symptoms that might mark separate syndromes or disease process. This dichotomous explanation of schizophrenic pathology found favor among many circles and fostered the construction of a set of measurements to determine symptom severity, such as Nancy Andreasen's Scale for Assessing Positive Symptoms (SAPS) and Scale for Assessing Negative Symptoms (SANS). These new instruments did not, however, satisfy all researchers. While treating patients at the Bronx Psychiatric Center in the late 1970s and early

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