Table Of ContentPractitioner's Guide
to Symptom Base Rates
in Clinical Neuropsychology
CRITICAL ISSUES IN NEUROPSYCHOLOGY
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Handbook of Cross-Cultural Neuropsychology
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International Handbook of Neuropsychological Rehabilitation
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Medical Neuropsychology, Second Edition
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Neuropsychological Interpretation of Objective Psychological Tests
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Practitioner's Guide to Evaluating Change with Intellectual Assessment
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Edited by Robert J. McCaffrey, Kevin Duff, and Holly J. Westervelt
Practitioner's Guide to Evaluating Change with Neuropsychological
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Practitioner's Guide to Symptom Base Rates in Clinical Neuropsychology
Edited by Robert J. McCaffrey, Anjali A. Palav, Sid E. O'Bryant,
and Andrew S. Labarge
Reliability and Validity in Neuropsychological Assessment, Second Edition
Michael D. Franzen
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Practitioner's Guide
to Symptom Base Rates
in Clinical Neuropsychology
Edited by
Robert J. McCaffrey
Anjali A. Palav
Sid E. O'Bryant
and
Andrew S. Labarge
State University of New York, Albany
Albany, New York
Springer Science+Business Media, LLC
Library of Congress Cataloging-in-Publication Data
Practitioner's guide to symptom base rates in clinical neuropsychology/edited by Robert J.
McCaffrey ... [et al.).
p. cm.
Includes bibliographical references and index.
ISBN 978-0-306-47829-1 ISBN 978-1-4615-0079-7 (eBook)
DOI 10.1007/978-1-4615-0079-7
1. Clinic al neuropsychology. 2. Neuropsychological tests. 3. Psychodiagnostics. 1.
McCaffrey, Robert J.
RC386.6.N48P735 2003
6l6.8-dc22
2003054689
ISBN 978-0-306-47829-1
©2003 Springer Science+Business Media New York
Origina11y published by Kluwer AcademicIPlenum Publishers in 2003
1098765432
A C.I.P. record for this book is available from the Library of Congress.
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There are many people who contributed to the success of this project and
are deserving of recognition. My wife, Maria C. Ortiz, Ph.D., and
daughters, Laura and Liliana, for their patience, Mariclare Cloutier of
Kluwer I Plenum for her support and guidance, and most especially my
friend and colleague, Jerid M. Fisher, Ph.D., ABPN, for sharing his
thoughts about the importance and utility of such a projects from walks
along Bourbon Street.
RJM
To my family for their love and support.
AP
To my parents, Tommy and Brenda O'Bryant, and fiancee, Leigh Johnson,
for never ceasing to believe in me.
SEa
Thanks to all who worked so hard to complete this project, including my
colleagues, Bob, Anjali, and Sid, Matthew Pastizzo, and the many
undergraduate assistants, and the SUNY Albany Interlibrary Loan
Department.
AL
Our sincerest thanks to the many people who made this project possible:
Matthew Pastizzo, Adam Kass, Anna Socha, Brenda Haga, Charles Natt,
Elise Eisenberg, Erin Drew, Indira Webb, Kristen Churchill, Laura Casali,
Lois Byrd, Marc Jurka, Mary Oddo, Rebecca Roth, Rebecca Weiner,
Sharone Yaron, Shawn Enides, Shawn Stevens, Stacy Goldin, Tammy
Stancavage.
Contents
I I A Brief Overview of Base Rates 1
Key for Using Tables 11
II I Medical Conditions 13
AIDS 13
AIDS Related Complex 14
Anesthesia 15
Epidural Anesthesia 15
General Anesthesia 17
Arthritis 18
Cancer Treatments 18
Chemotherapy 18
Radiation Therapy 20
Cardiac Conditions 21
Coronary Artery Graft Surgery 21
Cardiac Arrest 21
Cardiac Disease 22
Congestive Heart Failure 22
Coronary Heart Disease 23
Chronic Fatigue Syndrome 24
Excessive Daytime Sleepiness 29
Chronic Pain 30
Cirrhosis 30
Cerebrovascular Accident 31
Dementia 35
Alzheimer's Disease 38
Delirium 79
Huntington's Disease 80
Lewy Body Disease 81
Multi-Infarct Dementia 82
Vascular Dementia 83
Parkinson's Disease 84
Primary Degenerative Dementia 90
Diabetes 91
Hypoglycemia 97
Dialysis 97
Electrical Injury 99
Lightning Injury 100
Epilepsy 101
Seizures 102
Epstein-Barr 104
Fetal Alcohol Syndrome 104
Gynecological Conditions 106
Childbirth 106
Late Luteal Phase Dysphoric Disorder 107
vii
viii Contents
Menopause 108
Peri-Menopause 117
Pregnancy 119
Premenstrual Dysphoric Disorder 133
Premenstrual Syndrome 133
Headache 134
Tension Headache 134
Migraine Headache 135
Posttraumatic Headache 141
Other Headache 142
Hepatitis 143
HIV 145
Hodgkin's Disease 147
Hypertension 149
Leukemia 153
Lupus 153
Lyme Disease 156
Multiple Sclerosis 162
Myasthenia Gravis 175
Persian Gulf War Syndrome 177
Renal Disease 178
Respiratory Conditions 178
Asthma 178
Chronic Bronchitis 184
Chronic Obstructive Pulmonary Disease 188
Emphysema 190
Sleep Apnea 190
Sickle Cell Disease 192
Traumatic Brain Injury 194
Thyroid Conditions 203
Graves Disease 203
Hyperparathyroidism 204
Hyperthyroidism 205
Hypothyroidism 205
Vitamin and Mineral Deficiencies 207
Anemia 207
Vitamin Deficiencies 207
Wernicke-Korsakoff's 208
III I Psychological Conditions 211
Attention-Deficit/Hyperactivity Disorder 211
Hyperactivity 212
Affective Disorders 214
Anorexia 215
Anxiety Disorders 217
Bipolar Disorder 219
Cyclothymia 229
Hypomania 232
Mania 232
Contents ix
Bulimia 234
Conduct Disorder 235
Depression 236
Eating Disorders 263
Generalized Anxiety Disorder 264
Irritable Bowel Syndrome 268
Insomnia 270
Learning Disorder 271
Multiple Personality Disorder 271
Obsessive Compulsive Disorder 273
Panic Attack 288
Panic Disorder 291
Paranoid Psychosis 302
Paranoia 303
Psychosis 303
Posttraumatic Stress Disorder 305
Seasonal Affective Disorder 309
Schizo affective Disorder 309
Schizophrenia 309
Somatization Disorder 328
Tourette's Disorder 330
IV / Substance Use/Exposure 337
Alcohol 337
Amphetamines 345
Caffeine 346
Carbon Monoxide 350
Cocaine 352
Crack Cocaine 356
Drug Abuse 358
Hallucinogens 358
Heroin 359
Marijuana 359
Mercury 363
Metam Sodium 369
Methadone 370
Nicotine 371
Opiates 377
PCBs 378
PCP 379
Pesticides 380
Psychoactive Drug Use 380
Solvents 381
Sulfuric Acid 391
Tramadol 392
References 393
Symptom Index 415
I I A Brief Overview of Base Rates
The term "base rate" refers to the prevalence of an event, such as a symptom, sign or disorder,
within a given population. For example, the base rate of dementia in the general population
of individuals over age 85 is approximately 20% (American Psychiatric Association, 1994).
The base rate of self-reported memory problems at seven years post-injury in a sample of
hospital patients admitted following closed head injury was 38% COddy, Coughlin, Tyerman,
& Jenkins, 1985). The importance of base rates in the clinical sciences is fundamental.
Variations and covariations in symptom base rates among various populations (including the
lack of symptoms, or a base rate of 0%) inform the definitions and the diagnosis of diseases
and disorders. This aspect of the application of base rate information in clinical decision
making is commonly recognized. Even if a clinician is not thinking "base rates" per se, he
or she is aware that certain symptoms are more likely to be observed in certain disorders,
whereas other symptoms typically are not associated with the disorder. There are, however,
additional ways in which base rates can and should inform clinical decision-making that are
less generally recognized or applied. These applications of base rate information are related
to the interpretation of the significance of diagnostic test findings, such as the differentiation
between findings of statistical versus clinical significance and the determination of the
predictive value of diagnostic tests. This chapter will provide a brief overview of some
of these considerations, but will begin with a brief discussion of symptom base rates,
classification of diseases and disorders, and the process of clinical decision-making.
SYMPTOM BASE RATES, DISORDERS AND CLINICAL
DECISION-MAKING
There is no universally agreed-upon approach to the classification of diseases and dis
orders (Millon, 1991; SokaI1974). The lack of consensus is particularly striking regarding
the classification of psychiatric and neuropsychiatric disorders (Finn, 1982; First, Frances,
Widiger, Pincus, & Davis, 1992; Follette & Houts, 1996; Millon, 1991; Grove, 1985; Morey
& McNamara, 1987; Robins & Guze, 1970; Widiger, Frances, Warner, & Bluhm, 1986).
In general, however, the classification of diseases and disorders will, with varying degrees
of emphasis, consider the condition's phenomonology (including signs and symptoms),
etiology, course, and response to treatment.
Although many conditions are easily identified by structural pathology or other bio
logical or organic markers, many conditions are predominantly identified, if not defined,
by their symptom picture. This may be a single striking or pathognomonic clinical feature
or, more often, a combination or cluster of signs and symptoms thought or "known" to be
associated with one another. Regardless of whether a condition is predominantly defined by
its symptom picture or is capable of being defined by "objective" organic pathology or other
systemic markers, the starting point for most clinician decision-making is the consideration
of a patient's symptomology. Based on the patient's symptoms, together with other relevant
information typically obtained in a clinical interview such as demographic data, family
history, and so on, the clinician begins to form differential diagnoses and a strategy to rule
these diagnoses in or out. As indicated above, even if a clinician is not thinking "base rates"
per se, he or she is aware that certain symptoms are more likely to be observed in certain
disorders, whereas other symptoms are typically not associated with the disorder. In some
1
R. McCaffrey et al. (eds.) Practitioner's Guide to Symptom Base Rates in Clinical Neuropsychology
© Kluwer Academic 2003
2 I I A Brief Overview of Base Rates
cases, the presence or absence of a single or just a few symptoms can clinch a differential
diagnosis.
In attempting to make a diagnosis, the clinician is often faced with a variety of signs
and symptoms obtained from client report, medical charts, and testing. The tendency is
to be drawn to dramatic or unusual features (Nisbett, Borgida, Crandall, & Reed, 1976).
However, striking features frequently do not carry greater diagnostic value than mundane
ones (Chapman & Chapman, 1967, 1969). To increase the likelihood of accurate diagnosis,
it is critical to be aware of the validity of the signs or symptoms. Validity refers to whether
a true relationship exists between a clinical feature and a diagnosis, that is, whether the
symptom and diagnosis covary. The cluster of valid features is included in the defining phe
nomonological features of a condition (and sometimes form the sole basis for the definition
of the condition). Ultimately, the goal is to determine the cardinal features of a disease or
disorder and base diagnostic decisions on the presence or absence of these cardinal features
rather than on associated features (Faust, 1986; Faust & Nurcombe, 1989).
BASE RATES AND THE INTERPRETATION OF DIAGNOSTIC
TEST FINDINGS
Clinical Significance of "Abnormal" Findings
Although a test finding may be of statistical significance, the frequency of its occurrence
in a population (i.e., its base rate) may render questionable its clinical significance. For
example, this situation is commonly encountered by neuropsychologists examining the
discrepancy between Wechsler Adult Intelligence Scale (WAIS) Verbal and Performance
IQ scores. For individuals age 25 or over, a discrepancy of 9 points between Verbal and
Performance IQ on the WAIS-R (Wechsler, 1981) is statistically significant. Nonetheless,
the base rate for a discrepancy of that size or greater was 45.5% in the normative sample
of individuals with IQs in the average range (Matarazzo & Herman, 1985). The base rates
of findings such as this renders questionable their clinical significance (Kaufman, 1990).
As another example, Palmer, Boone, Lesser, and Wohl (1998), addressing the base rates
of "impaired" neuropsychological test performance among healthy older adults, found that
most tests had some proportion of subjects scoring in the borderline or impaired range,
and that across tests 73% of subjects scored in the borderline range on at least one test and
20% scored in the impaired range on two or more tests. As these examples illustrate, one
needs to consider the base rates of statistically or normatively "abnormal" findings in the
populations with whom one works when interpreting test results.
Base Rates and Diagnostic Effectiveness
The study of clinical judgement in psychology began in earnest in the 1950's with the
work of Meehl and Rosen and the resulting controversy over "clinical versus statistical"
decision-making (Meehl, 1954, 1957; Meehl & Rosen, 1955; Rosen, 1954). Central to this
early discussion was the fact that the diagnostic utility of a sign (i.e., for the purpose of
this discussion, a symptom, test finding, or a set of test findings) is relative to the base
rate of the diagnosis in the population of interest. (Much of this discussion is presented in
terms of a sign's usefulness in predicting the presence of a disorder. The same principles
apply, however, to a test finding's usefulness in predicting the presence of a symptom,
