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CLINICAL ASSESSMENT
AND DIAGNOSIS
CHAPTER 4
INTRODUCTION
Human beings have been trying to figure out the origins of
personality and behavior since ancient times. The Old
Testament states that Gideon relied on observations of men
as they trembled with fear around him to decide whether or
not they were fit for duty. He also watched how men drank
from a stream in order to decide if they were fit for duty.
Psychological assessment is one of the oldest and most
widely developed branches of contemporary psychology.
Psychological assessment – a procedure in which clinicians,
usually psychological tests, observations, and interviews,
develop a summary of the client’s symptoms and problems.
Clinical diagnosis – is the process through which a clinician
arrives at a general “summary classification” of the patient’s
symptoms by following the DSM-5 or the ICD-10
(International Classifications of Diseases), which was
published by the World Health Organization.
INTRODUCTION
Assessment is an on-going process and needs to be
evaluated at every step along the way with treatment. This
should not happen just at the beginning of treatment, but
all throughout treatment. It is also important to evaluate
the treatment and the eventual outcome.
In the initial visit, an attempt is made to identify the main
dimensions of the client’s problems and predict the course
of events. It is at this point that critical decisions need to be
made. The treatment needs to be decided, whether or not
there will be hospitalization, the role of the family, etc.
Sometimes, these decisions have to be made in emergency
situations with very little information.
Establishing a baseline is very important to see if there is
improvement. This will help to determine if therapy has
been successful or not.
THE BASIC ELEMENTS IN ASSESSMENT
What does the clinician need to know?
1) The presenting problem - What is the major symptom(s)
and behavior the client is experiencing? Is it situational
(divorce, unemployment, etc.) or is it a long-term
disorder?
2) Is there any evidence of cognitive deterioration?
3) What is the duration of the current complaint and how is
the person dealing with the problem?
4) What prior help has been sought?
5) Are there indications of self-defeating behavior and
personality deterioration or is the individual using
available personal and environmental resources in a good
effort to cope? How has this affected the person’s social
roles? Do the symptoms fit any of the DSM-5’s diagnoses?
THE RELATIONSHIP BETWEEN ASSESSMENT AND
DIAGNOSIS
It is very important to have an adequate classification.
Knowledge of the person’s type of disorder can help in
planning and managing the appropriate treatment.
It is also important to know which treatment facilities are
available.
A formal diagnosis is almost always essential because of
insurance claims and covering the costs of the treatment.
TAKING A SOCIAL OR BEHAVIORAL HISTORY
It is very important to know a person’s behavior history,
intellectual functioning, personality characteristics, and
environmental pressures and resources. This generally
includes much more than a diagnostic label.
This overview needs to be objective. How does the person
respond to other people’s behaviors? Are there excesses in
behavior present, such as eating too much or drinking too
much? Are there deficits in social skills? How appropriate
are the person’s behaviors? Is the person behaving
unresponsively? Are they uncooperative?
Excesses, deficits, and appropriateness are key to knowing
and understanding the person’s disorder and whether or
not they should be brought into the clinic?
PERSONALITY FACTORS
Assessment should include a description of any long-term
personality characteristics. Has the person responded in
deviant ways to particular kinds of situations?
Are there personality traits that predispose the individual
to behave in maladaptive ways?
Does the person become enmeshed with others to the
point of losing his or her identity, or is he or she so selfabsorbed that intimate relationships are not possible?
Is the person capable of genuine affection and of accepting
appropriate responsibility for the welfare of others.
THE SOCIAL CONTEXT
What type of environmental demands are typically placed
on this person?
What supports does this person have?
Is the person a care-taker? Are they experiencing
psychological damage?
Once all the information is gathered concerning the person’s
behaviors, social environment, and stressors…the picture is
attempted to be put together. Some clinicians refer to this
as “dynamic formulation” because it describes the current
situation, but also includes a hypothesis about what is
driving the person to be maladaptive. The clinician should
attempt to offer an explanation. The clinician should
attempt to try and predict the person’s future behavior as
well.
THE SOCIAL CONTENT
What is the likelihood of improvement or deterioration if the
person’s problems are left untreated?
What behaviors should be the initial focus of change?
What treatment methods are likely to be most efficient in
producing this change?
How much change should be expected from a particular type of
treatment?
Clinicians attempt to gain the approval of the patient with
treatment. Sometimes, clinicians have to make difficult decisions
without the consent of the patient or the family members.
What qualities does the individual bring to treatment that enhance
the chances of improvement? Assessments are only as good as the
individual and/or treatment center that are making them available.
ENSURING CULTURALLY SENSITIVE ASSESSMENT
PROCEDURES
Practitioners are increasingly being asked to conduct
evaluations with clients from diverse ethnic and language
backgrounds. In a clinical setting or court setting, a
psychologist may be referred a client who has limited English
skills and low exposure to American mores, values, and laws.
Psychologists have to be aware of culturally sensitive issues
and how this might effect the outcome of the assessment.
This increase in minority evaluations has been because of
increased immigration and refugees who have had
adjustment difficulties. The Hispanic population now makes
up 16% of the American population. This population makes up
the largest minority population in the U.S. African Americans
make up 12.9% of the population, Asians are 4.5%, and Native
Americans are 1%. They are often viewed by the majority
population as inferior. This often creates problems.
ENSURING CULTURALLY SENSITIVE ASSESSMENT
PROCEDURES
The tests that are used by psychologists to assess
psychological impact need to take into consideration the
population being examined. The test procedures taken also
need to be taken into consideration if the person taking the
test is a minority.
When a Westernized test is administered, users need to
take into account the dominant language, SES, ethnicity,
and gender of their clients. There may be differences in
tests that are provided in another language. The meanings
of words can be misinterpreted given various languages.
The most widely used personality assessment is the
Minnesota Multiphasic Personality Inventory (MMPI-2). This
test is available in many languages and in international
applications. Resent research has provided support for the
use of the MMPI-2 with minorities.
THE INFLUENCE OF PROFESSIONAL ORIENTATION
How the clinician goes about the assessment
process often depends upon their basic treatment
orientations. Depending upon the beliefs systems
of the psychologist or psychiatrist, they will
probably see the outcome of the issue from this
perspective.
A bio-psychologist will focus on the mind and
problems with the brain’s chemistry. A
psychoanalyst will look at the person’s childhood.
This will also influence what assessment they may
use. Most clinicians use a variety of methods and
believe in multiple perspectives of psychology.
RELIABILITY, VALIDITY, AND STANDARDIZATION
An assessment needs to show reliability – a term describing the degree to which an assessment measure
produces the same result each time it is used to evaluate the same thing.
Validity – is the extent to which the measuring instrument actually measures what it is supposed to measure.
This is a degree to which a measure accurately conveys to us something clinically about the person whose
behavior fits the category, such as helping to predict the future behavior of the individual. Validity
presupposes reliability. If the clinicians cannot agree to the class that the person belongs, the question of
validity of a diagnostic classification under consideration becomes irrelevant. Good reliability does not
guarantee validity, either.
Standardization – is the process by which a psychological test is administered, scored, and interpreted in a
“consistent” or standard manner. Standardized tests are considered to be more fair in that they are applied
consistently and in the same manner to all persons taking them. Individual scores are often compared to a
reference population, often referred to as a normative sample. It can also tell whether the individual’s score is
low, average, or high along the distribution of scores.
TRUST AND RAPPORT BETWEEN THE CLINICIAN AND
THE CLIENT
In order for the client to talk about all their symptoms
and issues, they need to feel comfortable with the
clinician. This is imperative. When a clinician asks for a
test, the client needs to know that it will help the clinician
help the client.
Clients need to be reassured that their beliefs, values,
attitudes, and personal history won’t be used against
them or be made to feel guilty. When an evaluation is
ordered by a judge in a court, this can be shared with
multiple sources. If the client decides to have the tests
run, these must remain anonymous.
Developing rapport with someone that has been forced
by a court to be evaluated will be difficult. In a clinical
setting people will be motivated to know the results.
When the tests results are given back, this conversation
can be very powerful. These individuals will tend to
improve just by being aware of what the results are.
ASSESSMENT OF THE PHYSICAL ORGANISM
A psychologist or psychiatrist may ask the
individual to get a physical with a medical
doctor first to rule out any physical health
problems. It is important for psychological
clinicians to take a medical history and make
sure that the doctor has completed a physical
exam.
It is important to know whether this is a
physical condition, an addiction, or an organic
brain disorder. Hormonal irregularities can
produce behavioral symptoms that closely
mimic those of mental disorders. Pain can
come from emotional disorders.
THE NEUROLOGICAL EXAMINATION
Brain pathology can be involved in mental disorders (unusual
memory deficits or motor impairments), a specialized neurological
examination can be administered in addition to seeing a doctor.
An EEG (electroencephalogram) assesses brain wave patterns in
awake and sleeping states. An EEG is a graphical record of the
brain’s electrical activity. Electrodes are placed on the scalp and
amplify the minute brain wave impulses from various brain areas.
These impulses drive oscillating pens whose deviations are traced
on a piece of thin paper that keeps moving.
Much is known about the sleeping and wake patterns under various
conditions of sensory stimulation. Significant divergences from the
normal pattern can thus reflect abnormalities of brain function such
as might be caused by a brain tumor or another lesion. When an
EEG reveals a dysrhythmia, or irregular pattern, in the brain’s
electrical activity other specialized techniques may be used in an
attempt to arrive at a more precise diagnosis of the problem.
ANATOMIC BRAIN SCANS
A CAT (computerized axial tomography) is a specialized
technique and technology that shows parts of the brain. This
has provided rapid access (without surgery) to accurate
information about the localization and extent of anomalies in
the brain’s structural characteristics. The procedure involves
the use of computer analysis applied to X-ray beams across
sections of a patient’s brain to produce images that a
neurologist can than interpret.
CAT scans have been increasingly replaced by magnetic
resonance imaging (MRI). The MRI is superior in many ways
because it can differentiate subtle soft tissue differences.
This machine does not subject the patient to ionizing
radiation.
MRI can make possible (by non-invasive means), visualization
of all but the minute abnormalities of brain structure. It is
very good with confirming degenerative diseases.
ANATOMIC BRAIN SCANS
MRI machine can be problematic in that some patients are
claustrophobic. It is necessary to put the patient in a
narrow cylinder of the MRI machine to contain the
magnetic field and block out external radio signals. There
are many experts that believe the MRI machine does not
lead to better outcomes for patients, though.
The PET (positron emission tomography) scan allows for an
appraisal of how an organ is functioning. It provides
metabolic portraits by tracking natural compounds, such as
glucose as they are used by the brain and organs. The PET
scan helps specialists to pinpoint sites responsible for
epileptic seizures, trauma from head injury or stroke, and
brain tumors. It may reveal problems that are not
immediately apparent anatomically. This may eventually aid
in treatment of the disorder. Because there are radioactive
atoms required for the procedure, it is very expensive and
not used as often.
FMRI
The functional MRI has been used in psychopathology for
years. In the beginning, it could reveal brain structure and
not brain activity. Now, fMRI can measure changes in local
oxygenation (e.g. blood flow) of specific areas of brain
tissue that depend on neuronal activity, such as sensations,
images, and thoughts ( which can be mapped) revealing the
specific areas of the brain that appear to be involved in
their neurophysiological processes. The newer models can
even analyze incoming data.
One recent study showed that psychological factors or
environmental events can affect brain processes as
measured by fMRI. The fMRI could even pick up self-critical
thinking. Some researchers think the fMRI can help greatly
in mental health care. The court systems have already ruled
that fMRI machines will not be used as lie detectors.
FMRI
There are other problems with fMRI. If the
patient moves, it could produce the look of
something that is there that isn’t there. The
error rate is quite high.
The results of fMRI are also hard to interpret.
fMRI is not effective given an assessment of
cognitive processes. Right now, the fMRI is not
considered to be a valid or useful diagnostic
tool for mental disorders. Many researchers
are optimistic that this procedures shows great
promise for understanding brain functioning.
THE NEUROPSYCHOLOGICAL EXAMINATION
Neuropsychological assessment – involves the use of
various testing devices to measure a person’s cognitive,
perceptual, and motor performance as clues to the extent
and location of brain damage.
Standardized tasks on a test can provide clues to the
probable location of the brain damage, although PET
scans, MRI’s, and other physical tests may be more
effective with this.
The Halstead-Reitan battery is composed of several tests
and variables from which an “index of impairment” can be
computed. It provides specific information about a
subject’s functioning in several skill areas.
PSYCHOLOGICAL ASSESSMENTS
Halstead Category Test – measures a subject’s ability to learn
and remember material and can provide clues as to his or her
judgment and impulsivity. A subject is presented with a
stimulus on the screen that suggests a number between 1
and 4. The person is either given a loud buzzer for an
incorrect response and a nice sounding bell for a correct
response. The person is required to determine from the
pattern of buzzers and bells what the underlying principle of
the correct choice is.
Tactual Performance Test – measures a subject’s motor
speed, response to the unfamiliar, and ability to learn and use
tactile and kinesthetic cues. The test surface is a board that
has 10 blocks of varied shapes. The subject is blindfolded and
asked to place the blocks into the correct grooves in the
board. They are asked later to draw the board and shapes
from memory.
PSYCHOLOGICAL ASSESSMENTS
Rhythm test – measures attention and sustained
concentration through an auditory perception task. It
includes 30 pairs of rhythmic beats that are presented on a
tape recorder. The subject is asked whether the pairs are
the same or different.
Speech Sounds Perception Test – determines whether an
individual can identify spoken words. Nonsense words are
presented on the tape recorder and the subject is asked to
identify the presented word in a list of four printed words.
His task measures the subject’s concentration, attention,
and comprehension.
Finger Oscillation Task – measures the speed at which an
individual can depress a lever with the index finger. Several
trials are given for each hand.
PSYCHOSOCIAL INTERVIEW
The psychosocial interview attempts to understand the
individual in their social environment. The individual’s
personality as well as their resources, stressors, and social
supports are included. The clinician listens for the first of
many interviews and attempts to put the pieces of the
puzzle together.
An Assessment Interview – involves face-to-face
interaction in which the clinician obtains information about
various aspects of the client’s situation, behavior, and
personality. The clinician may make moment to moment
decisions about their questioning line. They may also
choose to conduct a very structured interview.
The structured assessment interview yields far more
reliable results than the flexible format. Most clinicians
think that their own methods are superior to assessment
interview testing.
PSYCHOSOCIAL INTERVIEW
Structured interviews follow a predetermined set of questions
throughout the interview. Questions may include:
Have you ever had periods in which you could not sleep lately?
Have you experienced feeling very nervous about being in
public?
The interviewer cannot deviate when asking this line of
questioning. The questions are set in a way that they can be
quantified (given a score).
Unstructured assessment interviews – are typically subjective
and do not follow a predetermined set of questions. The
questions are generally tailored for their client. The questioner
decides which question is next based on the client’s answer to
the previous question. Generally, these questions are viewed
as more centered on the needs of the client and the client can
feel better with an unstructured assessment interview.
PSYCHOSOCIAL INTERVIEW
Rating scales – the reliability of the assessment interview
may be enhanced by use of a rating scale, which may ask the
client to rate a statement using 3, 5, or 7 – with respect to
self-esteem, anxiety, or other characteristics. These types
interviews may show problems that otherwise may not have
been talked about by the clinician. These problems may
include: suicidal family members, suicidal ideation, drug
dependence, marital difficulties, etc.
The DSM pushes that clinicians diagnose based upon
observable behavior or acts and use an “operational”
definition of items. The DSM helps in that it has certain
criteria that has to be met in order for the person to have
the disorder.
THE CLINICAL OBSERVATION OF BEHAVIOR
One of the most useful tools of clinicians is that they can
directly observe the behavior of their clients. By looking at
the client’s appearance and the behavior that they are
presenting, a clinician can tell much about the person. It is
important to note whether or not the client has
depression, personal hygiene issues, anxiety, aggression,
hallucinations, and/or delusions. An observation should
take part in the person’s natural settings, but this rarely is
the case. Observations tend to happen in the clinic or at
the hospital.
Some clinicians will use roleplaying, event reenactment,
family interaction assignments, or think-aloud procedures.
Clinicians tend to use self-monitoring procedures – selfobservation and objective reporting of behavior, thoughts,
and feelings as they occur in natural settings. People are
excellent sources of information about themselves. If
people are honest and want to help themselves, these
forms can be important in deciding therapy.
RATING SCALES
Self-report assignments help to both organize information
and encourage reliability and objectivity. Observer
inferences generally cannot be added to these forms.
These forms show whether or not a person has a trait
and/or behavior, but also what its prominence is.
One of the most used tools for recording observations is
the Brief Psychiatric Rating Scale (BPRS) – which provides a
structured and quantifiable format for rating clinical
symptoms anxiety, emotional withdrawal, guilt feelings,
hostility, suspiciousness, and unusual thought patterns.
This allows the clinician to rate the behavior of this
individual as compared to other psychiatric patients. This
scale is really good at assigning patients to treatment
groups.
The Hamilton Rating Scale for Depression (HRSD) is used
for assessing depression and whether or not a treatment
has been responsive.
PSYCHOLOGICAL TESTS
Psychological tests are more of an indirect means of
assessing psychological characteristics. Scientifically
developed psychological tests (not the ones in magazines)
are standardized sets of procedures or tasks for obtaining
samples of behavior. A subject’s responses to the
standardized stimuli are compared with those of other
people who have comparable demographic characteristics,
usually through established test norms or test score
distributions. The clinician can then decide how much the
behavior of the person differs from those that may have the
same or similar problems.
These tests can measure coping patterns, motive patterns,
personality characteristics, role behaviors, values, levels of
depression, etc. Impressive advances in technology of test
development have made it possible to create instruments
of acceptability reliability and validity to measure almost
any psychological characteristic on which people may vary.
They are mostly computer-generated and computerinterpreted format.
PSYCHOLOGICAL TESTS
Psychological tests are more precise and often more
reliable than interviews or some observational
techniques, they are not perfect. It is generally the
competence of the clinician that helps to interpret the
test. These tests are generally as useful to the clinician as
what a blood test would be to a doctor.
Clinicians tend to use intelligence tests and personality
tests.
INTELLIGENCE TESTING
The Wechsler Intelligence Scale for Children (WISC-IV)
and a current edition of the Standord-Binet Intelligence
Scale – are used quite often in clinical settings to
measure the intellectual abilities of children.
The most common adult test is the Weschler Adult
Intelligence Scale-Revised (WAIS-IV). It includes both
verbal and performance material and consists of 15
subtests.
It generally takes about 2-3 hours to administer, score,
and interpret. There is generally not enough time or
money to use the whole test. This testing is imperative
given brain damage or a cognitive deficiency. These forms
of intelligence testing also tell us how the person will
typically deal with a problem. Providing treatment does
not mean that these tests always have to be
administered.
PROJECTED PERSONALITY TESTS
Personality tests are generally divided into projective and
objective measures.
Projective personality tests – are unstructured and rely on
various stimuli such as inkblots of vague pictures rather than
on explicit verbal questions and the answers are not
statistically significant. People will reveal much about their
personal preoccupations, conflicts, motives, coping
techniques, etc. The thought is that individuals project their
own problems, motives, and wishes about a situation. These
personality tests can tell a lot about past learning and
personality structure and how they organize information
about their environment. The Rorschach Inkblot Test and the
Thematic Apperception Test (TAT) and sentence completion
tests are all projective personality tests.
Objective Personality Tests – are structured and generally
use questionnaires, self-report inventories, or rating scales
in which questions or items are carefully phrased and
alternative responses are specified as choices.
OBJECTIVE PERSONALITY TESTS
There are a large number of statistically significant personality
tests on the market. The NEO-PI (Neuroticism-ExtroversionOpenness-Personality Inventory – provides information on the
major dimensions in personality. The Millon Clinical Multiaxial
Inventory (MCMI-III) helps to evaluate personality measures in
those getting psychological treatment.
The most widely used measure of personality is the MMPI
(Minnesota Multiphasic Personality Inventory), which is called
the MMPI-2 because it was revised in 1989. The MMPI was
introduced for use by Starke Hathaway and J.C. McKinley and is
used in clinical settings as well as forensic settings to assess
psychopathology. It is often the test most often taught in clinical
psychology programs across the United States.
The original MMPI was a self-reporting questionnaire consisting
of 550 questions ranging from psychical conditions to
psychological states. Clients are asked to answer the questions
either “true or false”. This test also has a malingering category
where administrators can tell if someone is being honest or not.