1. What Do Drawing Tasks Measure In Serious Mental Illness?
A Preliminary Analysis Using The Boston Qualitative Scoring System For The Rey Complex Figure Copy
Cathryn E. Richmond1, Bernice A. Marcopulos1, Beth C. Arredondo2,3, Julie A. Kent3 & Shannon L. Kovach1
1James Madison University, 2University of Virginia Health System, 3Western State Hospital
Example Copy Drawings
Introduction
Results
Drawing tasks are included in neuropsychological assessments due to their sensitivity to brain dysfunction and have a long history in psychiatric settings (Marcopulos & Kurtz, 2012), but what clinical construct is measured? The current analysis utilized the Boston Qualitative scoring system (BQSS) to explore drawing strategies (i.e., configurational versus piecemeal) and types of errors (e.g., omission, accuracy, confabulations, perseverations, fragmentation) on the Rey Complex Figure Test (RCFT) copy drawing in an inpatient psychiatric hospital sample. Quality of copy drawings were correlated with a number of demographic, historical, and clinical status variables to assess the relationship of these factors to drawing quality.
The majority (59%) of the drawings were rated on the BQSS with “significantly” or “extremely” poor planning. After controlling for familywise error using a Bonferroni-adjusted alpha level of , there were no statistically significant differences in performance based on age, disability, sex, race, GED, head injury/trauma, or psychiatric diagnosis.
Lower education level was significantly associated with poor planning. Earlier age of onset of illness was significantly associated with a fragmented “piecemeal” approach; i.e., the large rectangle was more likely to be absent for those with an earlier age of onset (Table 1).
Special education and intellectual disability were significantly associated with a variety of performance variables (significant correlations indicated with an asterisk in Table 2). Patients with a history of special education and/or a diagnosis of an intellectual disability had generally less accurate and disorganized drawings.
Schizophrenia; Frontal lobe atrophy, education=12, SpEd, no ID/LD, onset=23
Schizophrenia; Education=12, SpEd, ID/LD, onset=15
Methods
The sample included patients in a state psychiatric facility who were referred for neuropsychological evaluation and completed a RCFT copy drawing between 2003 and (N = 183). All drawings were re-scored using the Boston Qualitative Scoring System by coders who were blind to patient diagnosis. Patients who had secondary gain and failed a performance validity test were removed from the sample (N = 3) for a total sample size of 180.
Approximately half of the sample was male (59.56%). Age ranged from 18 to 64 (M = 37.50, SD = 13.98). Education level ranged from 6 to 20 years (M = 12.14, SD = 2.58). The sample was 80.87% Caucasian, 14.21% African American, 1.09% Hispanic, 2.19% Asian or Asian American, and 1.64% other race. Most were diagnosed with schizophrenia spectrum disorders (42.62%) and major affective disorders (36.61%). Age of onset of illness ranged from age 3 to 61 (M = 23.42, SD = 12.31, Median = 20) and duration ranged from 0 to 46 years (M = 13.90, SD = 10.48, Median = 11). IQ ranged from 56 to 123 (M = 86.62, SD = 14.33). Two-thirds (68.31%) reported a head injury or trauma. Less than one-quarter (22.40%) of the sample had a history of special education (SpEd) classes prior to age 18, and six patients were diagnosed with an intellectual (ID) or learning disability (LD). GEDs were obtained by 12.57% of the sample.
Bipolar;
Education=8, no SpEd, no ID/LD, onset=38
Schizophrenia; Education=12, SpEd, ID/LD, onset=15
Discussion
Table 1. Kruskal-Wallis Chi-Squares
Results are consistent with previous studies (Seidman et al, 2003; Kim, Namgoong, & Youn, 2008 ) showing a fragmented approach to RCFT drawing in patients with schizophrenia spectrum and major affective disorders. However, unlike previous studies, diagnosis did not predict copy accuracy. Rather, the quality and types of errors seen on the RCFT drawings suggested that drawings are more reflective of neurodevelopmental variables (e.g., Harrison & Stiles, 2009) rather than current clinical variables. The use of the BQSS for RCFT copy drawings may be helpful in assessing the cumulative impact of illness severity on current functioning, and further research is needed to examine the predictive validity of these developmental factors compared to clinical factors on current functioning, particularly in regards to copy drawings.
Kruskal-Wallis df
p-value
Planning and Education Level 14
Large Rectangle Presence and Age of Onset 48
Table 2. Kendall’s Tau Correlations
Special Education
Intellectual Disability
Large Triangle Presence
-0.12
-0.242*
Small Rectangle Fragmented
-0.005
0.046
Small Rectangle Placement
-0.221*
-0.091
Square Placement
-0.121
-0.213*
Small Triangle Accurate
-0.205*
-0.163
Diamond Placement
-0.123
-0.237*
Vertical Cross Placement
-0.222*
0.082
Horizontal Line Present
-0.234*
-0.152
Vertical Cross Connector Placement
-0.224*
0.038
Vertical Cross Connector Present
-0.175
0.061
Overdrawn Lines
-0.258*
-0.11
Asymmetry
0.042
0.22*
References
References available from the first author upon request: