Proverbs and the modern mental status exam

Abstract

ROVERB INTERPRETATION is an interesting and often enjoyable process that has found a place in both standardized tests and in the mental status exam. One area of standardized testing where proverbs are firmly established with adequate reliability and validity are in intelligence tests, such as those developed by Wechsler.’ Proverbs have also been used in standardized tests to measure psychological variables. Gorham was at the forefront of developing proverb interpretation into a standardized psychological test. In schizophrenics he reported test retest reliabilities ranging from 0.67 to 0.96,* and in normals he reported correlations between different forms of his proverbs test ranging from 0.71 to 0.81.’ Gorham found the test highly successful in differentiating schizophrenics from normals.3 He also reviewed the large amount of work in using standardized proverb interpretation in psychological testing.4 Gorham achieved both reliability and validity with his particular testing population and stimulated interest in the field. In mental status exams proverbs are seldom given in a standardized fashion and often without using scoring sorting criteria. The question can be raised about the usefulness of proverbs in such a situation. Andreason addressed this very point5 She examined schizophrenics, depressives, and manics using five scales to score proverbs using multiple raters. In her Table of Interrater Reliability of 24 raters in Proverb Assessment no correlation was above 0.55 and most were significantly lower. Her kappa values for reliability of proverb measurement never reached 0.6 in any category. However, when mean values of all raters were used, depressives and schizophrenics were significantly distinguished in all five categories of measurement, depressives and manics were significantly distinguished in all five categories of measurement, and manics and schizophrenics were differentiated significantly in three out of five categories of measurement. She stated in her discussion,’ “Thus at best, proverb interpretation may have relatively good validity but poor reliability . . . at worst, therefore, the validity of using proverbs in a clinical situation is somewhat questionable” (p. 471). She concluded the widespread use of proverbs in mental status exams should be discontinued. These findings of validity in standardized situation and possible validity in clinical situations with no reliability in clinical situations seems to be irreconcilable with a statement of Spitzer and Fleiss.6 “There is no guarantee that a reliable system is valid, but assuredly an unreliable system must be invalid” (p. 341). Either validity is truly not present in clinical situations or reliability can be achieved. The goals of this article are to: (1) examine whether proverb