Assessment and Training
Scales
The development of reliable techniques for assessing diagnosis and psychopathology
has been one of the major advances in psychiatry during the past several decades.
Investigators at Iowa have been prominent contributors to these advances. Dr.
Andreasen has been involved in developing instruments to assess psychopathology
since the 1970s; her early instruments to measure disorders of language and thought
in psychosis are still widely used (Andreasen 1979a, b), and her instruments
for evaluating positive and negative symptoms have provided a foundation for
hundreds of articles that have been based on those assessment techniques (Andreasen
1983; Andreasen 1984; Andreasen et al 1992a). She was also involved in the development
and reliability testing for most of the instruments used in the NIMH Collaborative
Study of the Psychobiology of Depression, such as the Scale for Affective Disorders
and Schizophrenia (SADS) (Endicott and Spitzer 1978) as well as the Family History
Research Diagnostic Criteria (FH-RDC) (Andreasen et al 1977). Complementing this
work on the assessment of psychopathology, Dr. Andreasen and colleagues have
made substantial contributions in the area of diagnosis of psychotic disorders.
Dr. Andreasen was on the Task Force that crafted DSM-III (American Psychiatric
Association 1980)
and chaired the "Schizophrenia and Other Psychotic Disorders" Work Group for
DSM-IV (American Psychiatric Association 1994). She and Dr. Flaum played a major
role in drafting the criteria (Flaum and Andreasen 1991b), carrying out the field
trials (Flaum et al in press), and authoring the text for that section of DSM-IV.
Dr. Flaum is now taking responsibility for updating the text of the Psychotic
Disorders section, in a project being undertaken by the APA.
The development of measurement instruments and the evaluation
of the reliability and validity of diagnoses, dimensions, and symptoms
leads inevitably to a strong interest in assessment and training. Instruments
and diagnostic systems are only useful if they are applied in a standard
and consistent way, so that measurements are calibrated and consistent
over time. The Assessment and Training Core Unit is the portion of the
MH-CRC that supervises the assessment of psychopathology, the assignment
of diagnoses, and the administration of psychological tests. It seeks to
insure that the data collected to describe the clinical presentation of
patients and controls in CRC-related protocols are both comprehensive and
of high quality.
The primary evaluation instrument is the Comprehensive Assessment of Symptoms and History (CASH), a semi-structured interview designed for research in the major psychoses. A copy appears in the Appendix. It was designed in order to provide a comprehensive description of phenomenology in patients suffering from the broad range of psychotic disorders, including schizophrenia spectrum disorders, affective spectrum disorders, and all types of substance abuse. It provides sufficient information to make diagnoses according to a wide variety of diagnostic systems, including DSM-III, III-R and - DSM-IV criteria, as well as RDC (Spitzer et al 1975) and ICD-10 criteria (World Health Organization, 1992). The rationale behind the CASH, however, is that diagnostic criteria and diagnostic categories are subject to continual change, based in part on increased understanding about the underlying neurobiology of major mental illnesses. Thus, a major emphasis of the CASH is to provide a comprehensive overview of the broad range of phenomena that occur in patients suffering from major mental illnesses. Consisting of almost 1,000 variables, it includes a comprehensive summary of psychotic, disorganized, and negative symptoms, mood symptoms, and substance abuse history, as well as basic sociodemographic information, premorbid adjustment (adapted from Gittelman-Klein et al 1969), handedness (adapted from Benton 1967), cognitive function (as assessed by the Mini-mental Status Examination (Folstein et al 1975)) and the Global Assessment Scale (Endicott et al 1976). It covers both current and lifetime symptoms. A shortened version, the CASH-UP, is available for regular follow-up evaluations. Many of the instruments embedded in it, such as the Scale for the Assessment of Negative Symptoms and the Scale for the Assessment of Positive Symptoms (SANS and SAPS), are suitable for repeated weekly ratings in order to monitor change over time.
The first extensive published description of the CASH appeared in 1992 (Andreasen et al, 1992a), although it had been in development for the previous decade, and the instrument itself achieved final form in 1987. It is now being used in full or in part by many investigators world-wide. Large segments of it were included in the Diagnostic Interview for Genetic Studies (DIGS), the instrument used for the NIMH multi-site genetic studies. It has been, or is being, translated into several different languages, including Japanese, Korean, German, Spanish and Turkish. Investigators see its comprehensiveness as its main strength. Unlike the SCID (Spitzer et al 1984), it is not tied to a specific set of diagnostic criteria. Unlike the SADS, it attempts to provide a comprehensive coverage of the symptoms of both schizophrenia and affective illness, as well as a relatively comprehensive evaluation of substance abuse, cognition, and sociodemographic background variables. Its modular nature (i.e., the fact that it contains "embedded" instruments such as the SANS, SAPS, Mini-Mental Status, and GAS which can be repeated on a weekly basis) is apparently another source of appeal. While the CASH is the major "backbone" of our phenomenological assessment, a variety of other instruments are used as well, each of which is described briefly below:
The PSYCH and PSYCH-UP (acronyms for "Psychosocial
Status You Currently Have" and "Psychosocial Status You Currently Have--On
Follow-up") were developed in order to record indices of psychosocial functioning
and quality of life, both at the time of intake and at follow-up evaluations.
These instruments cover areas such as social and occupational functioning
and satisfaction, sources of financial support, as well as health resource
utilization.
Birth and Developmental History: This
instrument follows the format developed by DeLisi et al (1988) and records
information concerning complications during pregnancy, delivery, and infancy.
Pregnancy complications include variables such as maternal substance use
during pregnancy (both "recreational" and prescribed drugs), as well as maternal
medical or psychiatric illness (e.g., viral illness, depression). Perinatal
variables include delivery complications, birth weight, prematurity, and
post-natal problems. Indices of early development are also quantified, including
age at which major language and motor milestones were achieved.
Family History Interview: We have adapted the FH-RDC (Andreasen et al
1977) so as to make diagnoses according to DSM criteria on all first degree
relatives of MH-CRC inpatients. We have chosen to limit the data to first-degree
relatives because of concerns regarding the validity of making diagnoses without
direct interviews of more distant family members.
A Neurological Examination is done in a standardized fashion with each
patient in order to determine whether localizing signs or abnormalities are
present. In addition, patients are evaluated for the presence of so-called "soft
signs," including subtle motor and sensory abnormalities and abnormal developmental
reflexes.
Medical History Checklist documents any significant medical or neurological
illness and treatment.
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