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Some life care planners and vocational consultants rely on data from self-administered questionnaires completed by plaintiffs in personal injury litigation. Questions often arise about the validity and reliability of these data. In this blog post, we discuss a few self-administered questionnaires providers commonly use to assess psychological and neurocognitive conditions.
The purpose of self-administered questionnaires is to gauge how patients feel or see themselves. These are screening tools that do not have embedded validity measures. The self-reported data are subjective measures and cannot be considered objective data. A positive screening could show a need for an additional assessment by a clinician.
None of the screening tools below by themselves are a sufficient basis for a diagnosis. except in combination with tests with performance and symptom validity measures administered by a neuropsychologist or qualified physician.
The Patient Health Questionnaire (PHQ-9)
The PHQ-9 is a screening test for depression.[1] The questionnaire specifically addresses symptoms for the last two weeks.[2] Any reporting of symptoms older than two weeks are outside the guidelines of the questionnaire.
The person responds to each of nine phrases on a scale of 0 (not at all), 1 (several days), 2 (more than half the days), or 3 (nearly every day):
(Sample Questions for PHQ-9)
- Little interest or pleasure in doing things
- Feeling down, depressed, or hopeless
- Feeling tired or having little energy
- Feeling bad about yourself, or that you are a failure, or have let yourself or family down
- Thoughts you would be better off dead or of hurting yourself in some way
Total scores range from 0 to 27. The higher the score, the more severe the depression.[3]
Rivermead Post-Concussion Symptom Questionnaire (RPQ)
The Rivermead Post-Concussion Symptom Questionnaire is intended to screen for post-concussive symptoms. There are sixteen items with three categories: physical, cognitive, and behavioral symptoms. The test is intended for people age 18 and up.
The questionnaire asks the evaluee, “Compared with before the accident, do you now (i.e., over the last 24 hours) suffer from:” The patient rates each item on a 5-point scale: not at all (0); No more of a problem (1); mild problem (2); moderate problem (3); severe problem (4).
(Sample items for the RPQ)
- Headaches
- Dizziness
- Noise sensitivity
- Poor concentration
- Poor memory
The score is totaled with results of 0 (best) to 64 (worst).
General Anxiety Disorder 7 (GAD-7)
Questions on the GAD-7 pertain to patients’ experiences over the last two weeks. The test asks, the patient assigns a score of 0, 1, 2, or 3 to each of the response categories below and sums the responses to arrive at the total score.
Over the last two weeks, how often have you been bothered by the following problems?:
(Sample Questions for the GAD-7)
- Feeling nervous, anxious, or on edge
- Not being able to stop or control worrying
- Worrying too much about different things
- Becoming easily annoyed or irritable
- Feeling afraid, as if something awful might happen
Additional questions are asked about to how difficult the above experiences make working, taking care of things at home, or getting along with other people.
The total score on the GAD-7 ranges from 0 to 21, with scores of 0 to 4 indicating minimal, 5 to 9 mild, 10 to 14 moderate, and 15 to 21 severe.[4] The lower the score, the lower the patient’s anxiety.
Posttraumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5)
The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) is a DSM-correspondent, self-reported screening for PTSD symptoms. This test lists twenty problems people sometimes have in response to stressful experiences. It comes in two versions: one rates symptoms for the past month,[5] the other for the past week.[6]
The patient ranks each of the 20 questions question with one of five ratings; not at all (0), a little bit (1), moderately (2), quite a bit (3), and extremely (4).
In the past week/month, how much were you bothered by:
(Sample questions for the PCL-5)
- Repeated, disturbing, and unwanted memories of the stressful experience?
- Repeated, disturbing dreams of the stressful experience?
- Avoiding memories, thoughts, or feelings related to the stressful experience?
- Blaming yourself or someone else for the stressful experience or what happened after it?
- Loss of interest in activities you used to enjoy?
A score of 38/80 suggests an association with PTSD.[7]
Montreal Cognitive Assessment (MoCA)
MoCA is a screening tool intended for use with those ages 55-85, to screen for mild cognitive impairment or mild Alzheimer’s disease.[8] It is a 30-point scale with items that assess delayed word recall (5 points), visuospatial/executive function (7 points; includes clock-drawing), language (6 points), attention/concentration (6 points), and orientation (6 points). Cutoff points for significant cognitive impairment include years of formal education.
The average score for mild cognitive impairment (MCI) is 22, and the average score for mild Alzheimer’s disease is 16. Results follow these ranges:
- 26–30: normal
- 18–25: mild cognitive impairment
- 10–17: moderate cognitive impairment
- Less than 10: severe cognitive impairment
While MoCA has the above published ranges for results, they note on their information page that research for these severity ranges has not yet been established.[9]
MoCA reported observations of significant differences in total scores on patients they repeated testing on 1-2 months after previous assessments outside the MoCA Clinic and Institute. Because of these differences in scoring, they implemented a mandatory one-hour training and certification beginning in September 2019.[10]
These tests were not normed or validated on patients who are plaintiffs in personal injury litigation. There are no scientific studies discussing the validity of responses on the screeners of how someone would answer questions and if they are someone who may be magnifying symptoms for financial gain. Due to the nature of self-assessments, the ability to over and under report answers to questions, and the lack of validity measures, these tests are generally of limited value in life care planning and vocational assessments in litigation. The possibility always exists that a plaintiff will be tempted to over report their symptoms. However, the results of the screeners may be used to assess the need for additional neuropsychological testing by a qualified provider who can administer tests with validity measures.
[1] “Patient Health Questionnaire (PHQ-9 & PHQ-2),” American Psychological Association, https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/patient-health, accessed April 13, 2022.
[2] Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, et al., “Patient Health Questionnaire-9 (PHQ-9).”
[3] “PHQ-9 Questionnaire for Depression Scoring and Interpretation Guide,” University of Michigan Health System Depression Guideline, August 2011.
[4] “GAD-7 Anxiety,” Anxiety & Depression Association of America, https://adaa.org/sites/default/files/GAD-7_Anxiety-updated_0.pdf, accessed April 13, 2022.
[5] “PTSD Checklist for DSM-5 (PCL-5),” National Center for PTSD, https://www.ptsd.va.gov/professional/assessment/documents/PCL5_Standard_form.PDF, accessed April 10, 2022.
[6] “PTSD Checklist for DSM-5 (PCL-5),” National Center for PTSD, https://www.ptsd.va.gov/professional/assessment/documents/PCL5_Standard_form_week.PDF, accessed April 10, 2022.
[7] Jitender Sareen, “Posttraumatic Stress Disorder in Adults: Epidemiology, Pathophysiology, Clinical Manifestations, Course, Assessment, and Diagnosis,” UpToDate, updated September 20, 2021, https://www.uptodate.com/contents/posttraumatic-stress-disorder-in-adults-epidemiology-pathophysiology-clinical-manifestations-course-assessment-and-diagnosis?search=posttraumatic%20stress%20disorder%20(PTSD)%20checklist%20(PCL-5)&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3, accessed April 13, 2022.
[8] “About Us,” MoCA Cognitive Assessment, https://www.mocatest.org/about/, accessed April 13, 2022.
[9] “Frequently Asked Questions,” MoCA Cognitive Assessment, https://www.mocatest.org/faq/, accessed April 13, 2022.
[10] Do You Avoid Common MoCA errors?, MoCA Cognitive Assessment, https://www.mocatest.org/moca-news, accessed April 19, 2022.
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