I have a question for the listserve: a psychiatrist asked me to evaluate an 80 year old woman who was noncompliant with her meds and in her interaction with the psychiatrist. I gave the woman the WAIS-IV, WMS-III , Bender gestalt, MMPI-2 and Rorschach. On the WAIS-IV her scores were: VCI 80, PMI 100, WMI 100, PSi 117 and Full Scale 95. On the WMS, the scores ranged between 88 (Visual Immediate to 105 on Auditory Delayed). The Bender gestalt protocols were accurately drawn. But, the MMPI-2 was returned as "an invalid profile because F and VRIN were equal to or greater than 100 and 80, respectively." Likewise, her Rorschach is invalid because almost every answer was a bat. Aside from the fact that this woman did not want to be tested and was resistant to the testing procedures, any diagnostic suggestions?

Eileen, Ph. D.

Possibly a Histrionic PD?  

CH

Eileen:

Just outa curiosity: What did she have to say about taking medication and what did she have to say about the psychiatrist?

PS: When I'm 80, in a few years, no tellin' what kind of responses I might give you to the R. While I haven't administered the BVMGT in many years, I sometimes doodle the designs while talking on the phone, so my reproductions might be pretty good.

pjd

It's hard to say form the data. On the basis of the information you provided, Eileen, I'd venture to say that the Rorschach responses indicate lack of cooperation/oppositional tendency. The F and VRIN scores are both borderline valid, and it would help to know the rest of the validity indicators and the clinical scores elevations, as well as the context of assessment and some history.

Milan, Ph.D., C. Psych.

Not enough info. What are her symptoms? Why does she not want to take meds? What is her symptom history? What is her presentation?

Jeff, Ph.D.

She is demented.

Floyd, JD, PhD

One idea would be that she is self-conscious about her declining abilities. Her PSI is up because it's simple and she knows she can do it and she exerts. But otherwise, when it's not obvious which answers are correct, she skims. Grief work on loss of ability and cognitive work on what she wants to do with the rest of her life. Maybe the meds mean, "I'm not what I used to be," so she finds them aversive.

Michael

angry at psychiatrist who gave her meds , she might not have wanted and sent her to an extensive battery of testing she didn't want... dx:pissed off

Stephen, Ed.D.

Based on the data available, that would be my assessment too.

Dr. Jack

IMO the test data doesn't suggest Dementia, however.  She did well enough on the neuropsych stuff not to warrant that.  She may have been pissed off, but she appears to have given some pretty good effot on the WAIS and WMS.  

CH

Her husband died about 8 years ago and shortly after that, she went to live and take care of her sister who had Parkinson's and died one year ago. Although she did not say it directly, she resented taking care of her sister. The family recognized this and saw that the mother was becoming depressed and that is what got to see the psychiatrist. As for taking the meds, she would take them one and "forget" the next.

T scores: VRIN 102, TRIN 95, F 120, FB 120, FP 120,L 52, K 35, S 45. Hs 54, D 57, Hy 38, Pd 51, Mf 65, Pa 74, Pt 73, Sc 93, Ma 85, Si 56. MAC-R 72, APS 36, AAS 61, PK 77, Ho 71.

Eileen, Ph. D.

Floyd, her memory scores are not that bad. Granted it could be cognitive, but dementia seems a stretch.

Your reasons?

Jeff

Eileen, in your first post, you said that her "F and VRIN were equal to or greater than 100 and 80, respectively." Now you say that F is 120 and VRIN 102--that is a big difference. Taken together with FB and FP in this range, I'd say that the protocol is uninterpretable. I agree with Chad that it does not look like dementia--she is just not cooperating.

Milan, Ph.D., C. Psych.

Well the MMPI is not much use. Maybe she would benefit from a good therapist as well as (or instead of) the psychiatrist. Absent more data I would explore the resentment and anger in her life. I would also look at the possibility of passive -aggressive PD.

Jeff

You are correct. What I said in the first post came off the top of the graph from Pearson. Then someone had asked for more details and then I wrote the specific scores. I also do not think she has dementia. But what she has, aside from being angry and uncooperative is a puzzle.

Eileen, Ph. D.

what is she taking her meds for? Maybe she does not have anything...?

Milan, Ph.D., C. Psych.

On second thought, it is stupid to offer a wild *&^ hunch as if it had either merit, or basis in fact. That's why it might be better to put one's head in gear before one's tongue.

Floyd, JD, PhD

As soon as you learn how to do that consistently, Floyd, please share it with the rest of us. Happy holidays to everyone.

Dr. Jack

Do you have additional data that would suggest that being angry and uncooperative (at least with a task as boring as the MMPI-2, as opposed to a WAIS and WMS, which are not quite so monotonous) are not sufficient to explain the data you have?

Dr. Jack

No other data. During the testing, she constantly groaned and grunted. When she started to complain that she could not do the MMPI (well, actually, she began complaining when I gave her the first test, the Bender--the MMPI was much later in the exam), I asked what was the cause of her distress. She essentially ignored me and said that she could not do this. I said why not (do the protocols) and she said they were too much. I asked what she meant and she ignored me. The grunting continued throughout the testing. I tried to engage her, but she would have none of that--and I am usually able to engage people.

Eileen, Ph. D.

A "noncompliant woman with her meds and in her interactions with the psychiatrist."  This basically says she's not doing what she's told to do--and surprise, she responded in a like manner on the MMPI-2.  Her "noncompliance" may reflect more the relationship she has with the psychiatrist rather than her own pathology.  How does she feel about taking medications and being sent to a "shrink" or two?  Maybe she's just independent and doesn't want to take medications that cause side-effects?  The diagnosis may be more apt for the psychiatrist than the patient.  Narcissism anyone?  

Rodney, Ph.D.

In my experience, I have gotten that type of response in two sets of circumstances. One is when there is a dysfunction (with the people I tested usually dementia and usually of the Alzheimer's type) that the person is trying to hide and uses fatigue or whatever as an excuse or a cover. However, some of her scores seem too high for that conclusion, especially the WMS. The other circumstance is a person who doesn't want to be doing this, has little motivation or incentive for doing it, feels pressured by someone else to be there, and simply could not care less, so gives the process minimal effort. I'm guessing she falls in that latter category. Add to that that she may have some fairly chronic feelings of resentment, with some more recent resentment about her treatment (and the assessment process), and you get someone who may well groan and grunt a lot.

Dr. Jack

If I might make the fundamental attribution error, I'd say this sounds like a case of "Driving Miss Daisy," which IMO involved a character with classic Obsessive-Compulsive PD, exacerbated by her life situation.  The situation is of course one of aging and becoming more dependent and not wanting to relinquish one's independence.   All that's a pretty big jump from what you presented, Eileen, but it may be consistent with other things in her life I don't know about.  Her age, non-compliance, and presentation are certainly consistent with it IMO.  

CH

But what she has, aside from being angry and uncooperative is a puzzle.

sometimes, anger and frustration trump a great many other things. I know it does for me... once the possible anger and frustration , maybe even feeling 'put upon" is dealt with then one can find out if there is anything wrong. what did the MD dx with per medications? i wonder why she is continuing to see the MD if she isn't med compliant and why she agreed to see you , if she was resistant.

s, Ed.D.

Two additional thoughts:

1. I don't have a cite handy, but there is a fair amount of research suggesting that the main reason for non-compliance is side effects. With some SSRI's, side effects can occur quite early, long before there is a therapeutic effect. I'd ask about that as well.

2. Before jumping to negative conclusions about the psychiatrist, consider that good psychiatry requires time. You need time to explain the medication, to understand barriers to taking medication, to select the right medication for an individual, and to convince the person that the medication might help. These days, psychiatrists are seldom reimbursed for the time it would take to do their job the way they'd like to do it.

Joel, Ph.D., ABPP (Forensic)

Maybe she wants someone to talk to about being angry and frustrated and is hoping someone will empathize with  her about what she's endured instead of trying to find out what's wrong with her.  Did you ask review her critical item responses with her?  From her 6 and 8 it looks like she endorsed a lot of "interesting" phenomena.  Maybe you will then be able to determine if she was putting down a lot of "trues" due to being oppositional/pissed off versus paranoid/psychotic versus confused/tired.  

Susan, Ph.D., HSPP

the biggest 'why" for me is why she complied with the testing request. the second is 'why' she went to see the MD in the first place.

Steve, Ed.D.

Rather than solving the psychometric puzzles and uncertainties in order to formulate some sort of a diagnosis which may or may not be applicable to a person of her age, perhaps it would be more clinically effective and beneficial to the patient to simply develop a way to communicate with her and find out the cause of her anger, fear, saddness, pain, vision problems, incontinence, musculoskeletal difficulties, cognitive issues, agitated depression, or whatever else may be going on her life at present. Test scores listed are problably meaningless unless the normative samples of the tests administered are representative of the type of client described here - old, angry, uncooperative, noncompliant with pharmacological regimen(s), etc., etc. Is there collaterla medical data and what does it show?

RC

Having an 80 yr old sit in one session for this battery of tests seems a bit much, I would not sit there that long?

Jim

Eileen wrote During the testing, she constantly groaned and grunted. When she started to complain that she could not do the MMPI (well, actually, she began complaining when I gave her the first test, the Bender--the MMPI was much later in the exam), I asked what was the cause of her distress. She essentially ignored me and said that she could not do this. I said why not (do the protocols) and she said they were too much. I asked what she meant and she ignored me. The grunting continued throughout the testing. I tried to engage her, but she would have none of that--and I am usually able to engage people.

Perhaps you could enlist the assistance of a helpful relative in the assessment process. ...

Here is the first question. "Are you uncomfortable meeting new people?" Well, I think that's a yes, don't you agree? "Should sex education be taught outside the home?" I would say no, wouldn't you, Harold? Yeah, we'll give a D there. "Should women run for president of the United States?" I don't see why not. Absolutely yes. "Do you remember jokes and take pleasure in relating them to others?" Well, you don't do that, do you, Harold? Absolutely not. "Do you often get the feeling that perhaps life isn't worth living?" What do you think, Harold? A? B? We'll put C - not sure. "Is the subject of sex being overexploited by our mass media?" Well, that would have to be yes, wouldn't it? "Is it difficult for you to accept criticism?" No. We'll mark D. "Do you sometimes have headaches or backaches after a difficult day?" Yes, I do indeed. "Do you go to sleep easily?" I'd say so. "Do you believe in capital punishment for murder?" Yes, I do indeed. "In your opinion, are social affairs usually a waste of time?" Heavens, no! "Can God influence our lives?" Yes, absolutely yes. "Does your personal religion or philosophy include a life after death?" Yes, indeed. That's absolutely. "Did you enjoy life when you were a child?" Yes, you were a wonderful baby, Harold. "Do you think the sexual revolution has gone too far?" It certainly has. "Do you find the idea of wife-swapping distasteful?" I even find the question distasteful. "Do you..." Harold, please! "Do you have ups and downs without obvious reason?" That's you, Harold! http://www.script-o-rama.com/movie_scripts/h/harold-and-maude-script-transcript.html

It seems likely the MMPI-2 results may be a product of fatigue rather than "noncompliance."  

RT, Ph.D.

To clarify, the testing was done over a matter of several days so fatigue is not really a factor.

Any how, thanks for all of your help with this tricky matter.

Eileen, Ph. D.

Add to Steve's excellent list of 2 questions a third:

She isn't consistently non-compliant. Reportedly, she takes one dose, then forgets the next, and so on. If this were non-compliance, why not refuse the meds altogether? Consider instead the possibility that she has alternating waves of hope and despair, like most Americans these days. Or, maybe she really does forget. People who forget things are not necessarily demented, as whatchamacallit (it's on the tip of my tongue) found in his unforgettable study.

With tidings of comfort and joy (comfort and joy),

Joel, Ph.D., ABPP (Forensic)

Eileen, any time you are dealing with the person who is at the far extremes of the testing sample(s), interpretation of normative data is of little use. In addition to age, you don't mention if education or sensory problems might have complicated...

But the bigger question is - Why would you not just ASK the person what the problems are? I don't understand why psychologists have to take a little problem and make a much bigger one out of it. I would have asked the following questions-

- why do people think that she NEEDS to be compliant? - what problems are the medications attempting to solve? - how effective are those meds in solving those problems? - why did she answer the individual F-scale questions in the way she did? - what was her understanding of the questions?

Bruce

Date: Wed, 23 Dec 2009 11:10:02 -0600
From: PM
Subject: Re: Diagnostic puzzle

I'm with Bruce on this (and the others who made similar comments). I think this discussion is a good example of our tendency to "test first and ask questions later." The referral issue was that she wasn't getting along with her shrink, she wasn't taking her meds, and the shrink couldn't figure out what was going on.

The problem is that the testing in this case started with the assumption that it's something wrong with her, and/or that the problem involves a diagnostic mystery. The problem is starting with the assumption that if the shrink can't work it out, it must be because there is something wrong with her.

This is a case, like most, that should be approached not with tests, but by simply talking to the client. You should ask her about what her life has been like and how she is doing now.

Later, and only later, and if you find some particular and specific question that can only be answered or that can best be answered by a test, that is when to administer it.

Talk more, test less.

paul, ph.d.

Date: Wed, 23 Dec 2009 12:13:24 -0500
From: BB
Subject: Re: Diagnostic puzzle

Roger Greene, in "The MMPI-2", on page 432, notes that the normal sample group contained only 140 persons who were age 70+. I suspect that the group of 80+ persons was quite small, and likely so dissimilar to the normative group to make interpretation invalid. You might try a Caldwell interpretation - it states that his clinical group contained almost 500 persons aged 70+.

BB

Date: Wed, 23 Dec 2009 12:16:11 -0500
From: EM
Subject: Re: Diagnostic puzzle

Bruce, In the same vein, I find that there is often good information to be had through the use of a structured interview like the MINI and you can always give other rater inventories like the Coolidge. But I agree that the first place to go is to hang out and talk. Offering coffee and a snack often helps a great deal.

EM, Ph.D., ABPP (Forensic)

Date: Wed, 23 Dec 2009 09:21:35 -0800
From: RT
Subject: Re: Diagnostic puzzle

Bruce, You stated, in reference to the MMPI-2 standardization sample, "likely so dissimilar to the normative group to make interpretation invalid.."  On what scientific basis do you make such a suggestion? 

RT, Ph.D.

Date: Wed, 23 Dec 2009 09:23:25 -0800
From: PCFA
Subject: Re: Diagnostic puzzle

Excellent comments Bruce! Subjecting an 80-year old with irregular psychopharmaceutical regimen, and what seems as all sorts of clinical issues to hours and hours of psychometric acrobatics, and then wandering why the results are "questionable" seems to me to be nothing more than an abdication of clinical wisdom and common sense.

RC

Date: Wed, 23 Dec 2009 12:26:47 -0500
From: BB
Subject: Re: Diagnostic puzzle

IMO, generally, other sources of information (such as testing, collateral info, etc.) best serve to corroborate or contrast to our clinical judgment. Testing should not supplant our clinical judgment as the primary source of diagnostic consideration / problem solving. Nomothetic analysis compares this person to the sample group, but first, we must know something about this particular case/issue/person, IN ORDER TO select the appropriate tests, sample groups, etc. Blindly applying a persons scores on any instrument to the population at large removes any analysis of special cases which could invalidate the true problem.

For example, when in doubt about why a client scored high on a particular scale, ASK THEM what their understanding of the questions were. I had a recent case, a termination of parental rights case. The other psychologist insists that nomothetic analysis of MCMI III testing is the only appropriate way to interpret the results. This, despite the fact that she has an IQ of about 70, speaks primarily Spanish, never finished high school, and has a limited work hx. When I asked this person what her understanding of certain questions were, it was clear that she either did not understand the question at all, or interpreted the questions in an idiosyncratic manner - thus providing spurious and invalid results.

BB

Date: Wed, 23 Dec 2009 12:30:08 -0500
From: BB
Subject: Re: Diagnostic puzzle

I thought it would have been obvious, sorry. OK, let's say your comparison group is persons 80+. Let's say that there are 20 (I'm just guessing, there is no data other than 140 ppl in the 70+ group) people in the normative sample in that group. A sample of 20 is so small that you cannot obtain any meaningful statistics from it.

BB

Date: Wed, 23 Dec 2009 10:08:06 -0800
From: RK
Subject: Re: Diagnostic puzzle

I totally agree with all of Paul's points here. It is very common for the "real issue" to have little to do with how the referral question is posed. That is true in many clinical situations, as well as in forensic settings.

Our strength as psychologists is the ability to view a set of problems through multiple "lenses" or perspectives. Tests are a tool, one of many we have.

RK, Ph.D.

Date: Wed, 23 Dec 2009 13:10:55 -0500
From: JD
Subject: Re: Diagnostic puzzle

Roger Greene, in "The MMPI-2", on page 432, notes that the normal sample group contained only 140 persons who were age 70+. I suspect that the group of 80+ persons was quite small, and likely so dissimilar to the normative group to make interpretation invalid. You might try a Caldwell interpretation - it states that his clinical group contained almost 500 persons aged 70+.

Date: Wed, 23 Dec 2009 13:30:34 -0500
From: BB
Subject: Re: Diagnostic puzzle

Joel said: I'm not sure that's enough to know, Bruce. For example, wouldn't you also want to know if the results for the 70+ group were similar to or different from the results reported overall? Wouldn't you also want to know that about the specific finding(s) on which your opinion rests? They are good points, but what I am saying is that we don't have enough information to know IF/WHETHER the results might be comparable to the entire normative group. Even though you might be able to compare a 70-ish person to the 'adult' sample (based on a sample size of 140), you might not be able to do that with an 80+ group, of 20, 30, 40, or whatever it is. BTW, it looks like you could compare a 70-ish person to the normative group on F. There is only ~8 point difference between the entire sample and 70+ (57.5 to 49.8). However, Caldwell reports a 10.6 point difference for his clinical group (65.9 to 55.3). One of the largest differences was scale 9 (hypomania) which was a 14.5 point difference (reduction).

Date: Wed, 23 Dec 2009 11:33:53 -0800
From: RT
Subject: Re: Diagnostic puzzle

I believe the appropriate question would be whether or not any score differences related to actual differences between the samples.

Date: Wed, 23 Dec 2009 15:43:44 -0500
From: EK
Subject: Re: Diagnostic puzzle

Wait a second, she wrote, wondering if she was being defensive--and realizing her response might sound that way. Why would anyone presume that I did not try to talk with the patient first? When I do an evaluation, I talk to the person first and ask some basic questions like, do you know why you are here.etc Then I usually ask them to tell me about themselves and I ask questions along the way. Then I proceed with whatever tests I feel may be appropriate and take it from there.

The dilemma for me is that I have tested many, many elderly adults (and people in other age groups) and was perplexed by this patient's responses. It was a no brainer that she was angry, but I asked my question to make certain that I had not missed anything. As for the psychiatrist, her specialty is geriatrics and she had seen this patient for over six months before she asked me to do the eval. I don't it is true that she is not getting along with her shrink, but that she is not getting along with herself (anger turned inward

EK, Ph. D.

Date: Wed, 23 Dec 2009 18:56:02 -0500
From: JD
Subject: Re: Diagnostic puzzle

Eileen - This is why case-specific consultations are so difficult on a list serve. It is almost impossible to provide all of the relevant information, and if you did it might violate confidentiality by identifying the subject. People didn't make negative assumptions about you; they just responded to what you wrote, and not to what you left out. I usually recommend that people get a real consultation over the phone from a respected and trusted colleague. Many people will do these for free if they know you'll reciprocate or "pay it forward."

Joel, Ph.D., ABPP (Forensic)

Date: Wed, 23 Dec 2009 20:30:17 -0500
From: EK
Subject: Re: Diagnostic puzzle

Dear Joel, That's fine with me. I will pay if forward. Can I take you up on the offer? Incidentally, what I put in my responses was all that I have. Any suggestions on either a diagnosis or reason for the differences between the cognitive measures and the personality stuff?

Eileen, Ph. D.

Date: Wed, 23 Dec 2009 19:04:52 -0700
From: RM
Subject: Re: Diagnostic puzzle

Eileen, I sorted through the various messages on this thread and summarized the data (immediately below my email signature).

Looking just at the test data, while it has already been said that the MMPI-2 clinical scales are not likely an accurate description of your person's psychiatric status other than that she is distressed; you also do not have enough information to know if her cognitive test data accurately reflects her cognitive status because there are no effort measures.

I concur with the various other list-folk that asking her questions about why she even bothered to show for the testing, how she feels about her psychiatrist, and in other ways asking her what her specific concerns are comprise your current best methods. To the extent you have done that already and she hasn't yet told you, this might argue for simply asking her again, possibly in a somewhat different way now that you are more familiar with her.

Bob, Ph.D.,

Date: Wed, 23 Dec 2009 20:21:57 -0700
From: JT
Subject: Re: Diagnostic puzzle

I'll be happy to speak with you, but frankly, I'm not sure that there aren't other list members far more qualified to help. But feel free to give a call....

Date: Wed, 23 Dec 2009 22:41:27 -0800
From: CH
Subject: Re: Diagnostic puzzle

...Our strength as psychologists is the ability to view a set of problems through multiple "lenses" or perspectives...

Just to provide some balance, there's always the chance that you're dealing with a personality disorder, so is the psychiatrist, and talking to her will only reveal more of these issues that she may be relatively unaware of because they're woven into the fabric of who she is.  Perhaps her demeanor with you and her attitude toward the testing *is* the issue.  

CH

Date: Thu, 24 Dec 2009 14:11:28 -0500
From: BB
Subject: Re: Diagnostic puzzle

Eileen, this case still appears to be a diagnostic puzzle. I know I have sometimes 'thrown' (metaphorically speaking) an MMPI or PAI at a client, and it is true that sometimes clients have a much easier time opening up to the test than they are to openly, (brazenly?) say it out loud to another person. I would say that you got the same kind of response on the MMPI and Rorschach as you did in person.

So, if the patient is not going to be a good source of (immediate/current) information, where can you get it? One would be collateral sources - friends, family, etc., and another would be historical information. This is usually easier to do than asking current thoughts/emotions, because people do not see the patterns of their behavior in relationships, and do not know that you can see it, or that you can view their current relationships and emotional state out of those patterns.

For example, let's say this person is passive-aggressive. If so, careful elucidation of significant events in their life (termination of jobs and relationships, family and friends) will demonstrate such a pattern. You just get past the persons 'spin' and get into the details, and you will likely see a pattern emerge....

BB, Psy.D.