Personality Assessment

About six months ago, I began to wonder whether the tremendous advances in diagnostic techniques and prescriptive medicine held any promise for those of us below the clinical cutoff point for psychological disorder, but who nevertheless sometimes feel recurrent "after-shocks" from one or another of life's little curveballs.

Would there someday be a test, for instance, whereby I could walk into a physician's office, announce that I'd been feeling out of sorts for the past, oh, two or three months, and be given an accurate diagnosis, complete with recommended treatment (medication in combination with therapy) that would have a 90-whatever percent chance to improve my condition?

That's how I got roped into the offbeat idea of going through the battery of psychophysiological, biological, and neurological tests developed by researchers at the National Institute of Mental Health, the Mt. Sinai School of Medicine, and the Bronx VA Medical Center. It's a program normally reserved for people with actual personality disorders.

Not for okay guys like me.

When I agreed to be evaluated I also agreed to an important codicil: Whatever the results, I had to publish them. Should the tests reveal some secret strain of trouble deep within my psyche, I would still have to report it. There was no backing out once the process had begun. (Since I will be writing this as a journal, I have no idea at this point what the findings will reveal about me. Perhaps life's events have taken their toll; perhaps the way I sort my socks is evidence of some disorder not immediately apparent but waiting, like Banquo's ghost, to strike on a specific cue.)

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No matter how healthy I think I am, there is a nagging suspicion on my part that these tests may "find something." As I've discovered, one doesn't ever fully recover from divorce, for example, and perhaps the mental prosthetics I've developed to compensate have been inadequate.

In any case, I'm prepared for anything. At the very least, since the program requires numerous intravenous injections and blood samples, I suspect I'll lose my phobia of hypodermic needles.

TUESDAY, SEPTEMBER 28

TEST #1: Complete physical examination and mood profile

The Bronx VA Medical Center is a stainless-steel oasis in an otherwise depressed neighborhood. Inside, it's a hospital like every other--filled with the sick and the frantic.

Mina Apovian and Irene Lopez are two researchers who work with Drs. Larry Siever and Bob Trestman in the psychiatric division. Fielding the questions posed by the two young, attractive women is uncomfortable at times. Mina asks me my height and weight, marital status, whether and how much I drink or smoke, and if there's any history of mental illness in my family. I feel like I'm on a very intense first date.

An intern enters the room and examines me, draws a blood sample for what seems like forever (while I'm lying down so I don't faint), and asks me to fill not one but two cups with urine (my own, I assume). Then she tells me that for the next two weeks (the duration of the testing protocol), I cannot drink alcohol or coffee (two of my four favorite food groups) and puts me on a strict low-sodium diet. If I'm not depressed already, I will be by a week from Saturday, when I finish up the program with a CAT scan.

I end the day with an EKG (electrocardiogram) on a cold metal table with what look like jumper cables attached to my chest and belly. When the nurse asks me which department sent me and I answer "psychiatry," the look on her face changes. Even the technician keeps a closer eye on me.

THURSDAY, SEPTEMBER 30

TEST #2: Self-report scales

The Klingenstein Building at Mt. Sinai seems a bit more forgiving in its overall demeanor--perhaps because the donut shop located right in its lobby suggests you're merely taking a short commuter ride rather than a long journey to recovery.

In a ridiculously small room, spartan as a nun's boudoir, a research assistant asks me question after question from a 50+-page document--questions ranging from my childhood ("Did I have many friends? Did I have a best friend?"), through my adolescence ("Was I ever arrested for anything? Did I drink/use drugs?"), and into adulthood ("Have I ever felt unusually up/down for a period of more than one week? Did I sleep/eat/work/have sex more or less during that time?")

A lot of the questions are vague and difficult to answer--how does one know when one is feeling "unusually up or down"? When I answer that I have many ups and downs (especially when the Mets are playing), he gives me a quizzical look.

"But they don't last long," I hurry to explain. "And they're not really 'up' ups or 'down' downs."

It occurs to me then that I'm trying to "pass" the test, as though there were such a thing. When it's over, he mumbles a few sentences, shakes my hand, and hustles me out. I feel like I've blown it, but I'm not sure what "it" is. I'm a little concerned.

TUESDAY, OCTOBER 5

TEST #3: Psychophysiological and neuropsychological testing

The maddening thing about these evaluations is how repetitive the questions are: "How am I feeling how have I been feeling any trouble sleeping?" I go through the usual answers, feeling the same reluctance to reveal so much of myself to yet another stranger.

Rachel DuPre, a research assistant, administers several tests that I later learn are called Smooth Pursuit Eye Movement (SPEM), Backward Masking (BM), and Continuous Performance Task (CPT). All three are designed to measure my levels of attention and impulsivity--the idea being that certain personality disordered patients have trouble with both.

Basically, it means I'm either visually following Xs across a computer screen (SPEM), identifying letters flashed briefly on a screen before another pattern of Xs (BM), or identifying matching sets of numbers and shapes by pressing a button whenever two in a row appear on another monitor (CPT).

On a descriptive pamphlet for these tests, the warning reads: "This procedure is without pain or discomfort to the patient, other than boredom."

It gets interesting, though, when, during the last CPT, as I'm identifying matching shapes and four-digit numbers, the image on the screen grows distorted and Rachel starts playing a tape behind my head. The room is dark, and I'm reminded briefly of that scene from The Right Stuff when Dennis Quaid is in some kind of giant test tube and the lights go out, smoke enters, and a horn blows loudly.

Before the interruptions, Quaid, like me, is ready to fall asleep. Only then Rachel starts asking me questions about the dialogue I heard on the tape, which only registered in my head as a scene from It Happened One Night with Clark Gable and Claudette Colbert. The object of the test is, you're supposed to divide your attention between the voices on the tape and the numbers/shapes. It's challenging, and I can only imagine some patients getting up and running from the room, as Quaid's partner did in Stuff.

"In fact," says Rachel, referring to some of the tests. "That's exactly what some patients do. They get so frustrated, they just walk out."

I don't. I stick around and finish them. Because I'm normal, right?

Rachel doesn't answer.

WEDNESDAY AND FRIDAY, OCTOBER 6 AND 8

TESTS #4 & #5: D-Amphetamine challenge (and placebo)

Now it gets interesting. And painful. At 8 A.M. I show up at Bronx VA, get in a hospital bed, and have an IV catheter shoved up my arm. Mina comes in and asks me more personal questions, and I feel like I'm on a very intense second date--blood tests and all. In fact, they'll draw blood from me five times over the next six hours.

At 10 o'clock, another doctor comes in and gives me a cup of orange juice that may or may not contain amphetamine (like I wouldn't know). I have to go through this twice, you see--once with the amphetamine and once with a placebo. Then Damon Mitchell, another researcher, enters and begins neuropsychological testing on me: the Wisconsin Card Sort Test, the California Verbal Learning Test, more mood scales, more personal questions.

Suddenly, the IV doesn't bother me as much. I scan the Daily News in about 20 seconds and edit an article in 2.3 minutes. You know, IVs are really fascinating, if you think about it. So are hospitals. This program really isn't so bad after all--nice people, tasty orange juice, Clark Gable....

I think I got the amphetamine today.

I'm whipping through the cards and words now, and on a mood test I recognize that my answers are a little brighter than they were a couple of hours ago. Of course, the main objective of this challenge is to test whether or not the amphetamine will stimulate the production of growth hormone, which may indicate the level of activity in my norepinephrine system, which may play a role in influencing personality traits such as impulsivity (see "Frontiers of Pharmacology," page 40).

Toward that end, Irene takes more and more blood out of my arm, replacing it with cold saline, and after a while I feel good and miserable again. Then they let me go home.

TUESDAY, OCTOBER 12

TEST #6: SPECT (Single Photon Emission Computed Tomography)

Now that I've taken amphetamine, I'm ready to move on to radiation. Excuse me? Radiation?

I meet Mina at 1 o'clock in the Nuclear Medicine department of Bronx VA, a section of the hospital that looks as foreboding as it sounds. There, another patient and I sit down, roll up our sleeves, and accept yet another IV into our veins.

Clara Schaeffer, Ph.D., stands behind a screen and administers Ceretec, a low-level radiopharmaceutical, while I'm performing the Wisconsin Card Sort Test (WCST) on a computer. The WCST is a frustrating little game in which there are no rules. Basically, you sort cards of different colors, shapes, and numbers of shapes in a trial-and-error fashion. Sometimes the cards are sorted according to color, sometimes shapes, sometimes number of shapes. The computer tells you if your choice is right or wrong. Then it changes the rules on you, and you have to figure out all over again which cards go where.

The computer does this a number of times throughout the test, and while I'm busy figuring it out, the Ceretec is attaching itself to the areas of my brain that are being used, which will then show up on the SPECT. After I finish, Dr. Schaeffer puts my head in the Tomomatic, which looks like a big hair dryer for guys named Tom but is really an elaborate camera that takes pictures of my brain.

Half an hour later, eight images appear on a computer screen--each a different slice of my brain. The areas in red are where activity has taken place. Past research with psychiatric patients who are impulsively aggressive showed reduced activity in the front and left regions of the brain. My nice distribution of Ceretec lets me off the hook there, Dr. Schaeffer reassures me--though more research is needed before anything can be stated conclusively.

FRIDAY, OCTOBER 15

TEST #7: Fenfluramine challenge

My final needle, and sort of the big finish as far as these tests go (aside from a quick CAT scan tomorrow morning). The "fen," as it's known, is thought to be an accurate indicator of serotonin activity in the brain (see page 43), so it's perhaps the most intriguing aspect of this program in light of newer serotonin-inhibiting drugs such as Prozac, Zoloft, and Paxil--all of which selectively alter the amount of serotonin made available in the brain.

Neurotransmitters such as serotonin are active when they sit in the gap, or synapse, between nerve cells in the brain. Transmission is ended when the chemical is taken back up into the transmitting cell. Drugs such as Prozac, et al, act as antidepressants by slowing this reuptake of serotonin, making it more available to the receiving cell and prolonging its effect on the brain. The trick is, they don't work on everyone, and their effects on those who do react to the drugs range from "some improvement" to "complete transformation" of personality.

Once again I crawl into a hospital bed at 7:45 A.M. while a nurse works an IV catheter into my arm. This time there'll be no neuropsych tests, just mood self-report scales every hour throughout the day and more questions from Damon. Oh yeah--and blood will be drawn 12 times from my rapidly depleted arm: every 15 minutes for the first hour and then every half hour after that, until 3 o'clock when the lest is over. Terrific.

I notice only subtle changes in my mood throughout the course of the test--some of them, I suspect, having more to do with Oprah, Sally, Phil, and their guests (the TV perched above the bed gets only local stations, and I'm not allowed to sleep). I do get more tense and grumpy, but my arm is starting to hurt, I'm hungry (no eating, either), and by this point visions of martinis are dancing in my head (this is my last day on the diet regimen).

The consent form for this test warns that the medication's side effects may include nausea and depression. I feel neither, but then I'm looking forward to getting out of this bed more than the Birdman wanted out of Alcatraz.

On my way home, the experience hits me--hard. My head feels expanded, full of pressure and hammering pain. The sunlight burns my eyes; even after they adjust from the hospital's fluorescents it still hurts to look at things. I pass a record store and the rap music sounds unbearable (even more than usual). The smell from a hotdog vendor makes me so nauseated I literally double over and hold back the vomit.

In my apartment, I have to draw the blinds and lie down. Dr. Siever's description of the experience of certain mental disorders as similar to a powerful stereo playing a beat-up album seems appropriate: Is this what some forms of mental illness feel like?

If, as Larry Siever and others suspect, the fen test is an accurate measure of serotonin activity in the brain; and if low serotonin activity indicates that a drug such as Prozac would be beneficial in alleviating distress (by prolonging the effects of whatever amount there is); and if depressed patients actually do respond well in significant numbers--then a great deal of guesswork might soon be eliminated regarding treatment for these patients, and Siever and his colleagues may really be on to something.

RESULTS

Written Evaluation Form:

"This is an essentially normal profile except for the presence of a depressive episode earlier this year and a dysthymic episode in 1990-91 (although not enduring enough to meet criteria for dysthymia). The self-report scales were normal, with the depression inventory showing no elevation. While at the margins of the normal range, the slightly elevated scores on the Hostility Index and Impulsivity Scale are compatible with a tendency to internalize or hold in hostility and anger, which may be associated with a susceptibility to depression.

"This could be seen as a very mild version of what we see in depressed patients with a tendency to direct aggression towards themselves, and who tend to have both reduced responses to serotonergic and norepinephrine challenges.

"The psychophysiologic tests were all normal, demonstrating excellent attention and information processing. There was perfect recognition on the Backward Masking test, no errors on the Continuous Performance Test, normal eye tracking, faster than normal completion of trials A and B. The vocabulary subscale test score was high, consistent with high verbal intelligence, but the block design was only average. This kind of differential is often seen in depression, but is not diagnostic. The Wisconsin Card Sort is normal although there were a few errors.

"On the D-amphetamine, the error rate was lower on the WCST; there were no pronounced psychologic changes on amphetamine although slight increases in suspiciousness and guilt and a reduction in depression. There was slight reduction in mood on the fenfluramine challenge, though the prolactin response was normal."

Verbally, Dr. Siever describes me as "disgustingly normal." But there's more, and as he talks I begin to get a blueprint of myself--some things I suspected and others I didn't.

First off, there's some degree of depression, meaning that I fall in the "high end of the norm," as Siever puts it. I also scored higher than average in anhedonia--the inability to experience pleasure in pleasurable experiences. And I tend to react less intensely to both good and bad experiences. The most cheery way to look at this is that I am steady. A less sympathetic observer might say I'm a little insulated. I prefer the former.

Oddly, I tend to internalize anger while at the same time I scored above the norm on measures of hostility. Which means that the person I may beat up the most is myself. I'm is more deliberate in my manner than many--a thinker, a planner, a muller-over of every angle before I take action. (Like writing this article?)

Basically, the findings shed new light on some aspects of my character while confirming old, nagging suspicions. Yet the implications run deeper. As a result of the tests that Larry Siever and other top researchers are working on, perhaps even the word "physical," when it regards health examinations, will be phased out. Given the current emphasis on prevention, it seems outdated already that physical and mental status are not now programmed into our routine checkups.

What we need to recognize is that with newer medications that can pinpoint specific functions of the brain while leaving others virtually untouched, more and more of us may find our family doctors writing out prescriptions rather than (or in addition to) the name of a therapist in response to our psychological complaints.

That's scary to a lot of people, of course. Overprescription is a genuine fear, as is the unreal expectation that a pill can completely replace the therapist's couch. Yet if certain drugs allow patients to begin their therapy at Point L or M rather than Point A by alleviating a good deal of initial distress; if they arm patients with the proper tools they currently lack to put their discomfort into perspective--thereby speeding up the healing process--then we may all benefit. And medical practice may be heading in the right direction.

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