Clinical Assessment

CLINICAL ASSESSMENT Psychological assessment refers to a procedure by which clinicians, using psychological tests, observation 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 patients symptoms by following a clearly defined system such as DSM-IV-TR or ICD-10 (International Classification of Diseases)published by the World Health Organization The Relationship between Assessment and Diagnosis It is important to have an adequate classification of the presenting problem for a number of reasons. In many cases, a formal diagnosis is necessary before insurance claims can be filed. Clinically, knowledge of a person's type of disorder can help in planning and managing the appropriate treatment. Administratively, it is essential to know the range of diagnostic problems that are represented among the patient or client population and for which treatment facilities need to be available. If most patients at a facility have been diagnosed as having personality disorders, for example, then the staffing, physical environment, and treatment facilities should be arranged accordingly. Thus the nature of the difficulty needs to be understood as clearly as possible, including a diagnostic categorization if appropriate Taking a Social or Behavioral History For most clinical purposes, assigning a formal diagnostic classification per se is much less important than having a clear understanding of the individual's behavioral history, intellectual functioning, personality characteristics, and environmental pressures and resources. That is, an adequate assessment includes much more than the diagnostic label. For example, it should include an objective description of the person's behavior. How does the person characteristically respond to other people? Are there excesses in behavior present, such as eating or drinking too much? Are there notable deficits, for example, in social skills? How appropriate is the person's behavior? Is the person manifesting behavior that is plainly unresponsive or uncooperative? Excesses, deficits, and appropriateness are key dimensions to be noted if the clinician is to understand the particular disorder that has brought the individual to the clinic or hospital. Personality Factors

Assessment should include a description of any relevant long-term personality characteristics. Has the person typically responded in deviant ways to particular kinds of situations-for example, those requiring submission to legitimate authority? Are there personality traits or behavior patterns that predispose the individual to behave in maladaptive ways? Does the person tend to become enmeshed with others to the point of losing his or her identity, or is he or she so self-absorbed that intimate relationships are not possible? Is the person able to accept help from others? Is the person capable of genuine affection and of accepting appropriate responsibility for the welfare of others? Such questions are at the heart of many assessment efforts. The Social Context

It is also important to assess the social context in which the individual operates. What kinds of environmental demands are typically placed on the person, and what supports or special stressors exist in his or her life situation? For example, being the primary caretaker for a spouse suffering from Alzheimer's disease is so challenging that relatively few people can manage the task without significant psychological impairment, especially where outside supports are lacking. The diverse and often conflicting bits of information about the individual's personality traits, behavior patterns, environmental demands, and so on, must then be integrated into a consistent and meaningful picture. Some clinicians refer to this picture as a "dynamic formulation;’ because it not only describes the current situation but also includes hypotheses about what is driving the person to behave in maladaptive ways. At this point in the assessment, the clinician should have a plausible explanation for why a normally passive and mild-mannered man suddenly flew into a rage and started breaking up furniture, for example. The formulation should allow the clinician to develop hypotheses about the client's future behavior as well. Knowledge of the patient's strengths and resources is important Trust and Rapport between the Clinician and the Client In order for psychological assessment to proceed effectively and to provide a clear understanding of behavior and symptoms, the client being evaluated must feel comfortable with the clinician. In a clinical assessment situation, this means that a client must feel that the testing will help the practitioner gain a clear understanding of her or his problems and must understand how the tests will be used and how the psychologist will incorporate them into the clinical evaluation. The clinician should explain what will happen during assessment and how the information gathered will help provide a clearer picture of the problems the client is facing. Clients need to be assured that the feelings, beliefs, attitudes, and personal history that they are disclosing will be used

appropriately, will be kept in strict confidence, and will be made available only to therapists or others involved in the case. An important aspect of confidentiality is that the test results are released to a third party only if the client signs an appropriate release form. In cases in which the person is being tested for a third party such as the court system, the client in effect is the referring source-the judge ordering the evaluation-not the individual being tested. In these cases the testing relationship is likely to be strained, and rapport is likely to be difficult. Of course, in a court-ordered evaluation, the person's test-taking behavior is likely to be very different from what it would be otherwise, and interpretation of the test needs to reflect this different motivational set created by the client's possible unwillingness to cooperate. Clients being tested in a clinical situation are usually highly motivated to be evaluated and like to know the results of the testing. Interestingly, when patients are given appropriate feedback on test results, they tend to improvejust from gaining a perspective on their problems from the testing.

ASSESSMENT OF THE PHYSICAL ORGANISM In some situations and with certain psychological problems, a medical evaluation is necessary to rule out the possibility that physical abnormalities may be causing or contributing to the problem. The medical evaluation may include both a general physical examination and special examinations aimed at assessing the structural (anatomical)and functional (physiological) integrity of the brain as a behaviorally significant physical system The General Physical Examination In cases in which physical symptoms are part of the presenting clinical picture, a referral for a medical evaluation is recommended. A physical examination consists of the kinds of procedures most of us have experienced in getting a "medical checkup." Typically, a medical history is obtained, and the major systems of the body are checked (LeBlond, DeGowin, & Brown, 2004). This part of the assessment procedure is of obvious importance for disorders that entail physical problems, such as somatoform, addictive, and organic brain syndromes. In addition, a variety of organic conditions, including various hormonal irregularities, can produce behavioral symptoms that closely mimic those of mental disorders usually considered to have predominantly psychosocial origins. Although some long lasting pain can be related to actual organic conditions, other such pain can result from strictly emotional factors. The Neurological Examination Because brain pathology is sometimes involved in some mental disorders (e.g., unusual memory deficits or motor impairments), a specialized neurological examination can be administered in

addition to the general medical examination. This may involve the client's getting an electroencephalogram (EEG) to assess brain wave patterns in awake and sleeping states. An EEG is a graphical record of the brain's electrical activity. It is obtained by placing electrodes on the scalp and amplifying the minute brain wave impulses from various brain areas; these amplified impulses drive oscillating pens whose deviations are traced on a strip of paper moving at a constant speed. Much is known about the normal pattern of brain impulses in waking and sleeping states and under various conditions of sensory stimulation. Significant divergences brain function such as might be caused by a brain tumor or other lesion. When an EEG reveals a dysrhythmia (irregular pattern) in the brain's electrical activity (for example, that adult males with ADHD or adult hyperactivity disorder show abnormal brain activity), other specialized techniques may be used in an attempt to arrive at a more precise diagnosis of the problem. Anatomical Brain Scans

Radiological technology, such as computerized axial tomography, known in brief as the CAT scan, is one of these specialized techniques. Through the use of X rays, a CAT scan reveals images of parts of the brain that might be diseased. This procedure has aided neurological study in recent years by providing 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 then interpret. CAT scans have been increasingly replaced by magnetic resonance imaging (MRI). The images of the interior of the brain are frequently sharper with MRI because of its superior ability to differentiate subtle variations in soft tissue. In addition, the MRI procedure is normally far less complicated to administer, and it does not subject the patient to ionizing radiation. Essentially, MRI involves the precise measurement of variations in magnetic fields that are caused by the varying amounts of water content of various organs and parts of organs. In this manner the anatomical structure of a cross-section at any given plane through an organ such as the brain can be computed and graphically depicted with astonishing structural differentiation and clarity. MRI thus makes possible, by noninvasive means, visualization of all but the most minute abnormalities of brain structure. It has been particularly useful in confirming degenerative brain processes as shown, for example, in enlarged areas of the brain. The major problem encountered with MRI is that some patients have a claustrophobic reaction to being placed into the narrow

cylinder of the MRI machine that is necessary to contain the magnetic field and block out external radio signals.

PET Scans

Another scanning technique is positron emission tomography, the PET scan. Although a CAT scan is limited to distinguishing anatomical features such as the shape of a particular internal structure, a PET scan allows for an appraisal of how an organ is functioning (Mazziotta, 1996). The PET scan provides metabolic portraits by tracking natural compounds, such as glucose, as they are metabolized by the brain or other organs. By revealing areas of differential metabolic activity, the PET scan enables a medical specialist to obtain more clear-cut diagnoses of brain pathology by, for example, pinpointing sites responsible for epileptic seizures, trauma from head injury or stroke, and brain tumors. Thus the PET scan may be able to reveal problems that are not immediately apparent anatomically. Moreover, the use of PET scans in research on brain pathology that occurs in abnormal conditions such as schizophrenia, depression, and alcoholism may lead to important discoveries about the organic processes underlying these disorders, thus providing clues to more effective treatment (Zametkin & Liotta, 1997). Unfortunately, PET scans have been of limited value thus far because of the low-fidelity pictures obtained The Functional MRI

The technique known as functional MRI (fMRI) has been used in the study of psychopathology for more than a decade. As originally developed and employed, the MRI could reveal brain structure but not brain activity. For the latter, clinicians and investigators remained dependent upon positron emission tomography (PET) scans, whose principal shortcoming is the need for a very expensive cyclotron nearby to produce the short-lived radioactive atoms required for the procedure. Simply put, in its most common form, fMRI measures changes in local oxygenation (i.e., blood flow) of specific areas of brain tissue that in turn depend on neuronal activity in those specific regions (Morihisa, 2001). Ongoing psychological activity, such as sensations, images, and thoughts, can thus be "mapped:' at least in principle, revealing the specific areas of the brain that appear to be involved in their neurophysiologic mediation. Because the measurement of change in this context is critically timedependent, the emergence of fMRI required the development of high-speed devices for enhancing the recording process, as well as the computerized analysis of incoming data. These improvements are now widely available and will likely lead to a marked increase in studies of

disordered persons using functional imaging. Optimism about the ultimate value of fMRI in mapping cognitive processes in mental disorders is still strong. There are some clear methodological limitations that can influence fMRI results. For example, both MRI and fMRI are quite sensitive to artifacts as a result of slight movements of the person being evaluated (Davidson,Thomas, & Casey, 2003). Additionally, the results of fMRI studies are often difficult to interpret. Even though group differences emerge between a cognitively impaired group and a control sample, the results usually do not provide much specific information about the processes studied. Fletcher (2004) provided a somewhat sobering analysis of the current status of fMRI in contemporary psychiatry, noting that many professionals who had hoped for intricate and unambiguous results might be disappointed with the overall lack of effective, pragmatic methodology in fMRI assessment of cognitive processes. At this point the fMRI is not considered to be a valid The Neuropsychological Examination Behavioral and psychological impairments due to organic brain abnormalities may become manifest before any organic brain lesion is detectable by scanning or other means. In these instances, reliable techniques are needed to measure any alteration in behavioral or psychological functioning that has occurred because of the organic brain pathology. This need is met by a growing cadre of psychologists specializing in neuropsychological assessment, which 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 (Franzen, 2001; Rohling, Meyers, & Millis, 2003). In many instances of known or suspected organic brain involvement, a clinical neuropsychologist administers a test battery to a patient. The person's performance on standardized tasks, particularly perceptual-motor tasks, can give valuable clues about any cognitive and intellectual impairment following brain damage .Such testing can even provide clues to the probable location of the brain damage, although PET scans, MRIs, and other physical tests may be more effective in determining the exact location of the injury. Many neuropsychologists prefer to administer a highly individualized array of tests, depending on a patient's case history and other available information. Others administer a standard set of tests that have been pre selected to sample, in a systematic and comprehensive manner, a broad range of psychological competencies known to be adversely affected by various types of brain injury. The use of a constant set of tests has many research and clinical advantages, although it may compromise flexibility.

PSYCHOSOCIAL ASSESSMENT Psychosocial assessment attempts to provide a realistic picture of an individual in interaction with his or her social environment. This picture includes relevant information about the individual's personality makeup and present level of functioning, as well as information about the stressors and resources in her or his life situation. For example, early in the process, clinicians may act as puzzle solvers, absorbing as much information about the client as possible-present feelings, attitudes, memories, demographic facts-and trying to fit the pieces together into a meaningful pattern. Clinicians typically formulate hypotheses and discard or confirm them as they proceed. Starting with a global technique such as a clinical interview, clinicians may later select more specific assessment tasks or tests. The following are some of the psychosocial procedures that may be used. Assessment Interviews An assessment interview, often considered the central element of the assessment process, usually involves a face-to-face interaction in which a clinician obtains information about various aspects of a patient's situation, behavior, and personality (Barbour & Davison, 2004; Craig, 2004). The interview may vary from a simple set of questions or prompts to a more extended and detailed format (Kici &Westhoff, 2004). It may be relatively open in character, with an interviewer making moment-to-moment decisions about his or her next question on the basis of responses to previous ones, or it may be more tightly controlled and structured so as to ensure that a particular set of questions is covered. In the latter case, the interviewer may choose from a number of highly structured, standardized interview formats whose reliability has been established in prior research. Structured and Unstructured Interviews

Although many clinicians prefer the freedom to explore as they feel responses merit, the research data show that the more controlled and structured type of assessment interviews yields far more reliable results than the flexible format. There appears to be widespread overconfidence among clinicians in the accuracy of their own methods and judgments (Taylor & Meux, 1997). Every rule has exceptions, but in most instances, an assessor is wise to conduct and interview that is carefully structured in terms of goals, comprehensive symptom review, other content to be explored, and the type of relationship the interviewer attempts to establish with the person. The reliability of the assessment interview may also be enhanced by the use of rating scales that help focus inquiry and quantify the interview data. For example, the person may be rated on a 3-, 5-, or 7-point scale with respect to self-esteem, anxiety, and various other

characteristics. Such a structured and preselected format is particularly effective in giving a comprehensive impression or “profile” of the subject and his or her life situation and in revealing specific problems or crises-such as marital difficulties, drug dependence, or suicidal fantasies-that may require immediate therapeutic intervention. Clinical interviews can be subject to error because they rely on human judgment to choose the questions and process the information. Evidence of this unreliability includes the fact that different clinicians have often arrived at different formal diagnoses on the basis of the interview data they elicited from a particular patient. It is chiefly for this reason that recent versions of the DSM (that is, III, III -R, IV, and IV-TR) have emphasized an "operational" assessment approach, one that specifies observable criteria for diagnosis and provides specific guidelines for making diagnostic judgments. "Winging it" has limited use in this type of assessment process. The operational approach leads to more reliable psychiatric diagnoses, perhaps at some cost in reduced interviewer flexibility. The Clinical Observation of Behavior One of the traditional and most useful assessment tools that a clinician has available is direct observation of a patient's characteristic behavior (Hartmann, Barrios, &Wood, 2004). The main purpose of direct observation is to learn more about the person's psychological functioning through the objective description of appearance and behavior in various contexts. Clinical observation is the clinician’s objective description of the person's appearance and behavior-his or her personal hygiene and emotional responses and any depression, anxiety, aggression, hallucinations, or delusions he or she may manifest. Ideally, clinical observation takes place in a natural environment (such as observing a child's behavior in a classroom or at home),but it is more likely to take place upon admission to a clinic or hospital (Leichtman, 2002)..Some practitioners and researchers use a more controlled, rather than a naturalistic, behavioral setting for conducting observations in contrived situations. These analogue situations, which are designed to yield information about the person's adaptive strategies, might involve such tasks as staged role-playing, event reenactment, family interaction assignments, or think-aloud procedures(Haynes, 2001). In addition to making their own observations, many clinicians enlist their patients' help by providing them instruction in self-monitoring: self-observation and objective reporting of behavior, thoughts, and feelings as they occur in various natural settings. This method can bea valuable aid in determining the kinds of situations in which maladaptive behavior is likely to be evoked, and numerous studies also show it to have therapeutic benefits in its own right.

Alternatively, a patient may be asked to fill out a more or less formal self-report or a checklist concerning problematic reactions experienced in various situations. Many instruments have been published in the professional literature and are commercially available to clinicians. These approaches recognize that people are excellent sources of information about themselves. Assuming that the right questions are asked and that people are willing to disclose information about themselves, the results can have a crucial bearing on treatment planning. Rating Scales As in the case of interviews, the use of rating scales in clinical observation and in self-reports helps both to organize information and to encourage reliability and objectivity (Aiken, 1996). That is, the formal structure of a scale is likely to keep observer inferences to a minimum. The most useful rating scales are those that enable a rater to indicate not only the presence or absence of a trait or behavior but also its prominence or degree. The following item is an example from such a rating scale; the observer would check the most appropriate description. Sexual Behavior

___ 1. Sexually assaultive: aggressively approaches males or females with sexual intent. ___ 2. Sexually soliciting: exposes genitals with sexual intent, makes overt sexual advances to other patients or staff, masturbates openly. ___ 3. No overt sexual behavior: not preoccupied with discussion of sexual matters. ___ 4. Avoids sex topics: made uneasy by discussion of sex, becomes disturbed if approached sexually by others. ___ 5. Excessive prudishness about sex: considers sex filthy, condemns sexual behavior in others, becomes panic-stricken if approached sexually. Ratings like these may be made not only as part of an initial evaluation but also to check on the course or outcome of treatment. One of the rating scales most widely used for recording observations in clinical practice and in psychiatric research is the Brief Psychiatric Rating Scale (BPRS).The BPRS provides a structured and quantifiable format for rating clinical symptoms such as somatic concern, anxiety, emotional

withdrawal, guilt feelings, hostility, suspiciousness, and unusual thought patterns .. It contains 18 scales that are scored from ratings made by a clinician following an interview with a patient. The distinct patterns of behavior reflected in the BPRS ratings enable clinicians to make a standardized comparison of their patients' symptoms with the behavior of other psychiatric patients. The BPRS has been found to be an extremely useful instrument in clinical research especially for the purpose of assigning patients to treatment groups on the basis of similarity in symptoms. However, it is not widely used for making treatment or diagnostic decisions in clinical practice. The Hamilton Rating Scale for Depression (HRSD) a similar but more specifically targeted instrument, is one of the most widely used procedures for selecting clinically depressed research subjects and also for assessing the response of such subjects to various treatments 2004) Psychological Tests Interviews and behavioral observation are relatively direct attempts to determine a person's beliefs, attitudes, and problems. Psychological tests are a more indirect means of assessing psychological characteristics. Scientifically developed psychological tests (as opposed to the recreational ones sometimes appearing in magazines or on the Internet) 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. From these comparisons, a clinician can then draw inferences about how much the person's psychological qualities differ from those of a reference group, typically a psychologically normal one. Among the characteristics that these tests can measure are coping patterns, motive patterns, personality characteristics, role behaviors, values, levels of depression or anxiety, and intellectual functioning. Impressive advances in the technology of test development have made it possible to create instruments of acceptable reliability and validity to measure almost any conceivable psychological characteristic on which people may vary. Moreover, many procedures are available in a computer-administered and computer interpreted Although psychological tests are more precise and often more reliable than interviews or some observational techniques, they are far from perfect tools. Their value often depends on the competence of the clinician who interprets them. In general, they are useful diagnostic tools for psychologists in much the same way that blood tests, X-ray films, and MRI scans are useful to physicians. In all these cases, pathology may be revealed in people who appear tobe normal, or a general impression of "something wrong” can be checked against more precise information.

Two general categories of psychological tests for use in clinical practice are intelligence tests and personality tests(projective and objective). Intelligence Tests

A clinician can choose from wide range of intelligence tests. The Wechsler Intelligence Scale for Children-Revised (WISC-III) and the current edition of the Stanford-Binet Intelligence Scale (Kamphaus& Kroncke, 2004) are widely used in clinical settings for measuring the intellectual abilities of children. Probably the most commonly used test for measuring adult intelligence is the Wechsler Adult Intelligence Scale-Revised (WAIS-III) (Zhu, Weiss, Prifitera, &Coalson. 2004). It includes both verbal and performance material and consists of 11 subtests. Projective Personality Tests A projective test, in psychology, is a personality test designed to let a person respond to ambiguous stimuli, presumably revealing hidden emotions and internal conflicts. This is different from an "objective test" in which responses are analyzed according to a universal standard (for example, a multiple choice exam). The responses to projective tests are content analyzed for meaning rather than being based on presuppositions about meaning, as is the case with objective tests. Projective tests in general rely heavily on clinical judgement, lack reliability and validity and many have no standardized criteria to which results may be compared. These tests are still used frequently, however, despite the lack of scientific evidence to support them and their continued popularity has been referred to as the "projective paradox".Projective tests have their origins in psychoanalytic psychology, which argues that humans have conscious and unconscious attitudes and motivations that are beyond or hidden from conscious awareness.Prominent among the several projective tests in common use are the Rorschach Inkblot Test, the Thematic Apperception Test and sentence comletion tests The Rorshach Test

The Rorschach test is a psychological test in which subjects' perceptions of inkblots are recorded and then analyzed using psychological interpretation, complex scientifically derived algorithms, or both. Some psychologists use this test to examine a person's personality characteristics and emotional functioning. It has been employed to detect an underlying thought disorder, especially in cases where patients are reluctant to describe their thinking processes openly. The test takes its name from that of its creator, Swiss psychologist Hermann Rorschach

The tester and subject typically sit next to each other at a table, with the tester slightly behind the subject.[22] This is to facilitate a "relaxed but controlled atmosphere". There are ten official inkblots, each printed on a separate white card, approximately 18x24 cm in size.[23] Each of the blots has near perfect bilateral symmetry. Five inkblots are of black ink, two are of black and red ink and three are multicolored, on a white background.[24][25][26] After the test subject has seen and responded to all of the inkblots (free association phase), the tester then presents them again one at a time in a set sequence for the subject to study: the subject is asked to note where he sees what he originally saw and what makes it look like that (inquiry phase). The subject is usually asked to hold the cards and may rotate them. Whether the cards are rotated, and other related factors such as whether permission to rotate them is asked, may expose personality traits and normally contributes to the assessment. As the subject is examining the inkblots, the psychologist writes down everything the subject says or does, no matter how trivial. Analysis of responses is recorded by the test administrator using a tabulation and scoring sheet and, if required, a separate location chart.[22] The general goal of the test is to provide data about cognition and personality variables such as motivations, response tendencies, cognitive operations, affectivity, and personal/interpersonal perceptions. The underlying assumption is that an individual will class external stimuli based on person-specific perceptual sets, and including needs, base motives, conflicts, and that this clustering process is representative of the process used in real-life situations.[28] Methods of interpretation differ. Rorschach scoring systems have been described as a system of pegs on which to hang one's knowledge of personality. Thematic Apperception Test

The TAT is popularly known as the picture interpretation technique because it uses a standard series of provocative yet ambiguous pictures about which the subject must tell a story. The subject is asked to tell as dramatic a story as they can for each picture presented, including: •

what has led up to the event shown

•

what is happening at the moment

•

what the characters are feeling and thinking, and

•

what the outcome of the story was.

If these elements are omitted, particularly for children or individuals of limited cognitive abilities, the evaluator may ask the subject about them directly. There are 31 cards in the standard form of the TAT. Some of the cards show male figures, some female, some both male and female figures, some of ambiguous gender, some adults, some children, and some show no human figures at all. One is completely blank. Although the cards were originally designed to be matched to the subject in terms of age and gender, any card may be used with any subject. Most practitioners choose a set of approximately ten cards, either using cards that they feel are generally useful, or that they believe will encourage the subject's expression of emotional conflicts relevant to their specific history and situation. ]. Declining adherence to the Freudian principle of repression on which the test is based has caused the TAT to be criticised as false or outdated by many professional psychologists. Their criticisms are that the TAT is unscientific because it cannot be proved to be valid (that it actually measures what it claims to measure), or reliable (that it gives consistent results over time, due to the challenge of standardising interpretations of the stories produced by subjects). Some critics of the TAT cards have observed that the characters and environments are dated, even ‘old-fashioned,’ creating a ‘cultural or psychosocial distance’ between the patients and these stimuli that makes identifying with them less likely Also, in researching the responses of subjects given photographs versus the TAT, researchers found that the TAT cards evoked more ‘deviant’ stories (i.e., more negative) than photographs, leading them to conclude that the difference was due to the differences in the characteristics of the images used as stimuli. Sentence Completion

Sentence completion tests are a class of semi-structured projective techniques. Sentence completion tests typically provide respondents with beginnings of sentences, referred to as “stems,” and respondents then complete the sentences in ways that are meaningful to them. The responses are believed to provide indications of attitudes, beliefs, motivations, or other mental states. There is debate over whether or not sentence completion tests elicit responses from conscious thought rather than unconscious states. This debate would affect whether sentence completion tests can be strictly categorized as projective tests. A sentence completion test form may be relatively short, such as those used to assess responses to advertisements, or much longer, such as those used to assess personality. A long sentence

completion test is the Forer Sentence Completion Test, which has 100 stems. The tests are usually administered in booklet form where respondents complete the stems by writing words on paper. The structures of sentence completion tests vary according to the length and relative generality and wording of the sentence stems. Structured tests have longer stems that lead respondents to more specific types of responses; less structured tests provide shorter stems, which produce a wider variety of responses. test was used as part of an intelligence test Carl Jung’s word association test may also have been a precursor to modern sentence completion tests.

Objective Personality Tests MMPI

The original MMPI was developed in the late 1930s using an empirical keying approach, which means that the clinical scales were derived by selecting items that were endorsed by patients known to have been diagnosed with certain pathologie.The difference between this approach and other test development strategies used around that time was that it was atheoretical (not based on any particular theory) and thus the initial test was not aligned with the prevailing psychodynamic theories of that time. The atheoretical approach to MMPI development ostensibly enabled the test to capture aspects of human psychopathology that were recognizable and meaningful despite changes in clinical theories. However, because the MMPI scales were created based on a group with known psychopathologies, the scales themselves are not atheoretical by way of using the participants' clinical diagnoses to determine the scales' contents. MMPI-2

The first major revision of the MMPI was the MMPI-2, which was standardized on a new national sample of adults in the United States and released in 1989. It is appropriate for use with adults 18 and over. Subsequent revisions of certain test elements have been published, and a wide variety of subscales was also introduced over many years to help clinicians interpret the results of the original clinical scales, which had been found to contain a general factor that made interpretation of scores on the clinical scales difficult. The current MMPI-2 has 567 items, all

true-or-false format, and usually takes between 1 and 2 hours to complete depending on reading level. There is an infrequently used abbreviated form of the test that consists of the MMPI-2's first 370 items. The shorter version has been mainly used in circumstances that have not allowed the full version to be completed (e.g., illness or time pressure), but the scores available on the shorter version are not as extensive as those available in the 567-item version. Clinical Scales Scale 1: Hypochondriasis (Hs) - This scale was originally developed to identify patients who manifested a pattern of symptoms associated with the label of hypochondriasis. Scale 2: Depression (D) - This scale was originally developed to assess symptomatic depression. The primary characteristics of symptomatic depression are poor morale, lack of hope in the future, and a general dissatisfaction with one's own life situation. Scale 3: Hysteria (Hy) - This scale was developed to identify patients who demonstrated hysterical reactions to stress situations. . Such people generally maintain a facade of superior adjustment and only when they are under stress does their proneness to develop conversion-type symptoms as a means of resolving conflict and avoiding responsibility appear. . Scale 4: Psychopathic Deviate (Pd) - This scale was originally developed to identify patients diagnosed as psychopathic personality, asocial or amoral type. Scale 5: Masculinity-Femininity (Mf) - Scale 5 was originally developed by Hathaway and McKinley to identify homosexual invert males. Scale 6: Paranoia (Pa) - This scale was originally developed to identify patients who were judged to have paranoid symptoms such as ideas of reference, feelings of persecution, grandiose self-concepts, suspiciousness, excessive sensitivity, and rigid opinions and attitudes Scale 7: Psychasthenia (Pt) - This scale was originally developed to measure the general symptomatic pattern labeled psychasthenia. . Psychasthenia was originally characterized by excessive doubts, compulsions, obsessions, and unreasonable fears. The person suffering from psychasthenia had an inability to resist specific actions or thoughts regardless of their maladaptive nature.

\Scale 8: Schizophrenia (Sc) - This scale was originally developed to identify patients diagnosed as schizophrenic. The items in this scale assess a wide variety of content areas, including bizarre thought processes and peculiar perceptions, social alienation, poor familial relationships, difficulties in concentration and impulse control, lack of deep interests, disturbing questions of self-worth and self-identity, and sexual difficulties. Scale 9: Hypomania (Ma) - This scale was originally developed to identify psychiatric patients manifesting hypo manic symptoms. Hypomania is characterized by elevated mood, accelerated speech and motor activity, irritability, flight of ideas, and brief periods of depression. Scale 0: Social Introversion (Si) - This scale was originally designed to assess a person's tendency to withdraw from social contacts and responsibilities. The Advantages of Objective Personality Tests

1) Unlike projective tests, objective test's counter, objective tests are quite economical. This is a certain upside since the cost of health care is rising and mental health facilities are looking for new methods of cutting costs while still providing the services the community needs. Since objective tests present a fixed set of questions and answer choices, they make available the option of group testing. A therapist can even allow a patient to complete such personality tests as the MMPI-2 alone and bring it back to them. Additionally, in today's day and age it is possible to have a computer score the test as opposed to having the therapist go over it, which can be an extremely time-consuming process.

2) the scoring is objective, allowing for easier interpretation of data. Whereas projective tests require a great deal of interpretation skill on the part of the clinician,objective assessments make it easier on the clinician to interpret the score into something meaningful for diagnosis and treatment. However, this is not to say that testers need not be well trained and skilled. The simplicity of scoring and administration can often lead to errors and misuse, one major flaw of objective exams. These flaws and misuse can greatly affect the validity and reliability of the assessment, so it is important to take into consideration the experience and skill of the test giver in any psychological testing situation. Disadvantages of Objective Personality Test

1) Some clinicians argue that there is little to gain from an objective exam if the goal is not behavioral. Gaining an understanding of motives or the dynamics of personality are virtually impossible using most objective assessment since the questions are generally "behavioral in nature" (Trull, 2005). Meaning, several different interpretations may be made as to why different people do the same thing.. There are so many possibilities as to what the motives for one's actions are, and this is the aspect of personality that objective tests tend to miss. 2) Next, some tests offer only one score for a range of different questions. Questions based on behavior, cognitions, and needs all receive only a single score. This scoring system leaves much to be desired as it eliminates the option for alternate interpretations to the answers given. Grouping them all together can reflect different combinations of behaviors, cognitions, and needs and thus a client may be misinterpreted by the overall score. 3) Client faking is also easy on an objective exam, however, newer versions of such tests as the MMPI have put in place validity scales to check for faking and malingering. Still, testtaker faking still has to be kept in mind, and taken very seriously. Another serious problem is the self-knowledge aspect of objective exams. For some, knowing themselves is extremely easy, for others, answering the types of questions found on objective exams can be extremely hard. Since not all questions or answers given may match the test-taker exactly, and they aren't allowed to elaborate on their answer, the tests can be frustrating and inaccurate.

THE INTEGRATION OF ASSESSMENT DATA As assessment data are collected, their significance must be interpreted so that they can be integrated into a coherent working model for use in planning or changing treatment. Clinicians in individual private practice normally assume this often arduous task on their own. In a clinic or hospital setting, assessment data are often evaluated in a staff conference attended by members of an interdisciplinary team(perhaps a clinical psychologist, a psychiatrist, a social worker, and other mental health personnel) who are concerned with the decisions to be made regarding treatment. By putting together all the information they have gathered, they can see whether the findings complement each other and form a definitive clinical picture or whether gaps or discrepancies exist that necessitate further investigation. This integration of all the data gathered at the time of an original assessment may lead to agreement on a tentative diagnostic classification for a patient. In any case, the findings of each

member of the team, as well as the recommendations for treatment, are entered into the case record so that it will always be possible to check back and see why a certain course of therapy was undertaken, how accurate the clinical assessment was, and how valid the treatment decision turned out to be. New assessment data collected during the course of therapy provide feedback on its effectiveness and serve as a bases for making needed modifications in an ongoing treatment program. As we have noted, clinical assessment data are also commonly used in evaluating the final outcome of therapy and in comparing the effectiveness of different therapeutic and preventive approaches.

ETHICAL ISSSUES IN ASSESSMENT The decisions made on the basis of assessment data may have far-reaching implications for the people involved. A staff decision may determine whether a severely depressed person will be hospitalized or remain with her or his family or whether an accused person will be declared competent to stand trial. Thus a valid decision, based on accurate assessment data, is of far more than theoretical importance. Because of the impact that assessment can have on the lives of others, it is important that those involved keep several factors in mind in evaluating test results: 1. POTENTIAL CULTURAL BIAS OF THE INSTRUMENT OR THE CLINICIAN:

There is the possibility that some psychological tests may not elicit valid information for a patient from a minority group . A clinician from one socio cultural background may have trouble assessing objectively the behavior of someone from another background, such as a Southeast Asian refugee. It is important to ensure-as Greene, Robin, Albaugh, Caldwell, and Goldman (2003) and Hall, Bansal, and Lopez(1999) have shown with the MMPI-2-thatthe instrument can be confidently used with persons from minority groups. 2. THEORETICAL ORIENTATION OF THE CLINICIAN:

Assessment is inevitably influenced by a clinician's assumptions, perceptions, and theoretical orientation. For example, a psychoanalyst and a behaviorist might assess the same behaviors quite differently. The psychoanalytically oriented professional is likely to view behaviors as reflecting underlying motives, whereas the behavioral clinician is likely to view the behaviors in the context of the intermediate or preceding stimulus situations. Different treatment recommendations are likely to result. 3. UNDEREMPHASIS ON THE EXTERNAL SITUATION:

Many clinicians overemphasize personality traits as the cause of patients' problems without paying enough attention to the possible role of stressors and other circumstances in the patients' life situations. An undue focus on a patient's personality, which some assessment techniques encourage, can divert attention from potentially critical environmental factors. 4. INSUFFICIENT VALIDATION:

Some psychological assessment procedures in use today have not been sufficiently validated. For example, unlike many of the personality scales, widely used procedures for behavioral observation and behavioral self-report and the projective techniques have not been subjected to strict psychometric validation. 5. INACCURATE DATA OR PREMATURE EVALUATION:

There is always the possibility that some assessment data-and any diagnostic label or treatment based on them-may be inaccurate or that the team leader (usually psychiatrist) might choose to ignore test data in favor of other information. Some risk is always involved in making predictions for an individual on the basis of group data or averages. Inaccurate data or premature conclusions not only may lead to a misunderstanding of a patient's problem but also may close off attempts to get further information, with possibly grave consequences for the patient.

CLASSIFYING ABNORMAL BEHAVIOR In abnormal psychology, classification involves the attempt to delineate meaningful sub varieties of maladaptive behavior. Like defining abnormal behavior, classification of some kind is a necessary first step toward introducing order into our discussion of the nature, causes, and treatment of such behavior. Classification makes it possible to communicate about particular clusters of abnormal behavior in agreed-upon and relatively precise ways. For example, we cannot conduct research on what might cause eating disorders unless we begin with amore or less clear definition of the behavior under examination; otherwise, we would be unable to select, for intensive study, persons whose behavior displays the aberrant eating patterns we hope to understand. There are other reasons for diagnostic classifications, too, such as gathering statistics on how common the various types of disorders are and meeting the needs of medical insurance companies(which insist on having formal diagnoses before they will authorize payment of claims).Keep in mind that, just as with the process of defining abnormality itself, all classification is the product of human invention-it is, in essence, a matter of making generalizations based on what has been observed. Even when observations are precise and carefully made, the

generalizations we arrive at go beyond those observations and enable us to make inferences about underlying similarities and differences. For example, it is common for people experiencing episodes of panic to feel they are about to die. When "panic" is carefully delineated, we find that it is not in fact associated with any enhanced risk of death but, rather, that the people experiencing such episodes tend to share certain other characteristics, such as recent exposure to highly stressful events. It is not unusual for a classification system to be an ongoing work in progress as new knowledge demonstrates an earlier generalization to being complete or flawed. It is important to bear in mind, too, that formal classification is successfully accomplished only through precise techniques of psychological, or clinical, assessment-techniques that have been increasingly refined over the years. Reliability and Validity

A classification system's usefulness depends largely on its reliability and validity. Reliability is the degree to which a measuring device produces the same result each time it is used to measure the same thing. If your scale showed a significantly different weight each time you stepped on it over some brief period, you would consider it a fairly unreliable measure of your body mass. In the context of classification, reliability is an index of the extent to which different observers can agree that a person's behavior fits a given diagnostic class. If observers cannot agree, it may mean that the classification criteria are not precise enough to determine whether the suspected disorder is present. The classification system must also be valid. Validity is the extent to which a measuring instrument actually measures what it is supposed to measure. In the context of classification, validity is the degree to which a diagnosis accurately conveys to us something clinically important about the person whose behavior fits the category, such as helping to predict the future course of the disorder. If, for example, a person is diagnosed as having schizophrenia, we should be able to infer the presence of some fairly precise characteristics that differentiate the person from individuals who are considered normal, or from those suffering from other types of mental disorder. The diagnosis of schizophrenia, for example, implies a disorder of unusually stubborn persistence, with recurrent episodes being common. Normally, validity presupposes reliability. If clinicians can't agree on the class to which a disordered person’s behavior belongs, then the question of the validity of the diagnostic classifications under consideration becomes irrelevant. To put it another way, if we can’t confidently pin down what the diagnosis is, then whatever useful information a given diagnosis

might convey about the person being evaluated is lost. On the other hand, good reliability does not in itself guarantee validity.

DIFFERING MODELS OF CLASSIFICATION There are currently three basic approaches to classifying abnormal behavior: the categorical, the dimensional, and the prototypal (Widiger & Frances, 1985).

THE CATEGORICAL APPROACH The categorical approach, like the diagnostic system of general medical diseases, assumes that (1) all human behavior can be divided into the categories of "healthy" and "disordered;’ and that (2) within the latter there exist discrete, non overlapping classes or types of disorder that have a high degree of within-class homogeneity in both "symptoms" displayed and the underlying organization of the disorder identified. THE DIMENSIONAL APPROACH The dimensional and prototypal approaches differ fundamentally in the assumptions they make, particularly with respect to the requirement of discrete and internally homogeneous classes of behavior. In the dimensional approach, it is assumed that a person's typical behavior is the product of differing strengths or intensities of behavior along several definable dimensions such as mood, emotional stability, aggressiveness, gender identity, anxiousness, interpersonal trust, clarity of thinking and communication, social introversion, and so on. The important dimensions, once established, are the same for everyone. People are assumed to differ from one another in their configuration or profile of these dimensional traits (each ranging from very low to very high), not in terms of behavioral indications of a corresponding” dysfunctional" entity presumed to underlie and give rise to the disordered pattern of behavior(Miller, Reynolds, & Pilkonis, 2004; Widiger, Trull, Clarkin,Sanderson, & Costa, 2002). "Normal" is discriminated from "abnormal;' then, in terms of precise statistical criteria derived from dimensional intensities among unselected people in general, most of whom may be presumed to be close to average, or mentally "normal." We could decide, for example, that anything above the ninety-seventh normative percentile on aggressiveness and anything below the third normative percentile on sociability would be considered” abnormal" findings.

Dimensionally based diagnosis has the incidental benefit of directly addressing treatment options. Because the patient’s profile of psychological characteristics will normally consist of deviantly high and low points, therapies can be designed to moderate those of excessive intensity (e.g., anxiety) and to enhance those that constitute deficit status (e.g., inhibited selfassertiveness). . THE PROTOTYPAL APPROACH A prototype is a conceptual entity depicting an idealized combination of characteristics that more or less regularly occur together in a less-than-perfect or standard way at the level of actual observation. Prototypes are actually an aspect of our everyday thinking and experience. No member of a prototypal defined group may actually have all of the characteristics of the defined prototype, even though it will have at least some of the more central of them. Also, some characteristics may be shared among differing prototypes-for example, many animals other than dogs have tails. As we shall see, the official diagnostic criteria defining the various recognized classes of mental disorder, although explicitly intended to create categorical entities, more often than not result in prototypal ones. The central features of the various identified disorders are often somewhat vague, as are the boundaries purporting to separate one disorder from another. Much evidence suggests that strict categorical approach to identifying differences among types of human behavior, whether normal or abnormal, may well be an unattainable goal. Bearing this in mind as we proceed may help you avoid some confusion. For example, we commonly find that two or more identified disorders regularly occur together in the same psychologically disordered individuals-a situation known as co morbidity.

Formal Diagnostic Classification of Mental Disorders Today, there are two major psychiatric classification systems in use: the International Classification of Disease System (ICD-1 0), published by the World Health Organization, and the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. The ICD-10 system is widely used in Europe and many other countries, whereas the DSM system is the standard guide for the United States. Both systems are similar in many respects, such as in using symptoms as the focus of classification and in defining problems into different facets (the multiaxial system to be described below). Certain differences in the way symptoms are grouped in these two systems can sometimes result in a different classification on the DSM -IV than on the ICD-l O. We will focus on the DSM system in our discussion of what is to be considered a mental disorder. This manual specifies

what subtypes of mental disorders are currently officially recognized and provides, for each, a set of defining criteria in the United States and some other countries. As already noted, the system purports to be a categorical one with sharp boundaries separating the various disorders from one another, but it is in fact a prototypal one with much fuzziness of boundaries and considerable interpenetration, or overlap, of the various "categories" of disorder it identifies. The criteria that define the recognized categories of disorder consist for the most part of symptoms and signs. The term symptoms generally refers to the patient's subjective description, the complaints she or he presents about what is wrong. Signs, on the other hand, are objective observations that the diagnostician may make either directly (such as the patient's inability to look another person in the eye) or indirectly (such as the results of pertinent tests administered by a psychological examiner). To make any given diagnosis, the diagnostician must observe the particular criteria-the symptoms and signs that the DSM-IV indicates must be met. THE EVOLUTION OF THE DSM The DSM is currently in its fourth edition (DSM-IV), with some recent modifications, referred to as "DSM-IV-TR;' having been made in 2000. This system is the product of a five-decade evolution involving increasing refinement and precision in the identification and description of mental disorders. The first edition of the manual (DSM -I) appeared in 1952 and was largely an outgrowth of attempts to standardize diagnostic practices in use among military personnel in World War II. The 1968 DSM-II reflected the additional insights gleaned from a markedly expanded postwar research effort in mental health sponsored by the federal government. Over time, practitioners recognized a defect in both these early efforts: The various types of disorders identified were described in narrative and jargon-laden terms that proved too vague for mental health professionals to agree on their meaning. The result was a serious limitation of diagnostic reliability; that is, two professionals examining the same patient might very well come up with completely different impressions of what disorder(s) the patient had. To address this clinical and scientific impasse, the DSM-III of 1980 introduced a radically different approach, one intended to remove, as far as possible, the element of subjective judgment from the diagnostic process. It did so by adopting an "operational" method of defining the various disorders that would officially be recognized. This innovation meant that the DSM system would now specify the exact observations that must be made for a given diagnostic label to be applied. In a typical case, a specific number of signs or symptoms from a designated list must be present before a diagnosis can properly be assigned. The new approach, continued in the DSM-III's

revised version of 1987 (DSM-III-R) and in the 1994 DSM-IV, clearly enhanced diagnostic reliability. As an example of the operational approach to diagnosis, The number of recognized mental disorders has increased enormously from DSM -I to DSM-IV, due both to the addition of new diagnoses and to the elaborate subdivision of older ones. Because it is unlikely that the nature of the American psyche has changed much in the interim period, it seems more reasonable to assume that mental health professionals view their field in a different light than they did 50 years ago. The DSM system is now both more comprehensive and more finely differentiated into subsets of disorders.

THE FIVE AXES OF DSM-IV-TR

DSM-IV-TR evaluates an individual according to five foci, or "axes." The first three axes assess an individual's present clinical status or condition: Axis I. The particular clinical syndromes or other conditions that may be a focus of clinical attention. This would include schizophrenia, generalized anxiety disorder, major depression, and substance dependence. Axis I conditions are roughly analogous to the various illnesses and diseases recognized in general medicine. Axis II. Personality disorders. A very broad group of disorders, Axis II provides a means of coding for long-standing maladaptive personality traits that mayor may not be involved in the development and expression of an Axis I disorder. Mental retardation is also diagnosed as an Axis II condition. Axis III. General medical conditions. Listed here are any general medical conditions potentially relevant to understanding or management of the case. Axis III of DSM -IV-TR may be used in conjunction with an Axis I diagnosis qualified by the phrase "Due to [a specifically designated general medical condition]" On any of these first three axes, where the pertinent criteria are met, more than one diagnosis is permissible and in fact encouraged. The last two DSM-IV-TR axes are used to assess broader aspects of an individual's situation.

Axis IV. Psychosocial and environmental problems. This group deals with the stressors that may have contributed to the current disorder, particularly those that have been present during the prior year. The diagnostician is invited to use a checklist approach for various categories of problems-family, economic, occupational. legal, etc. For example, the phrase "Problems with Primary Support Group" may be included where a family disruption is judged to have contributed to the disorder. Axis V. Global assessment of functioning. This is where clinicians indicate how well the individual is coping at the present time. A 100-point Global Assessment of Functioning (GAF) Scale is provided for the examiner to assign a number summarizing a patient's overall ability to function

THE LIMITATIONS OF DSM CLASSIFICATION The real problems of real patients often do not fit into the precise lists of signs and symptoms that are at the heart of the modern DSM effort. The clinical reality is that the disorders people actually suffer are often not so finely differentiated as the DSM grid on which they must be mapped. Increasingly fine differentiation also produces more and more recognized types of disorder. Too often, we believe, the unintended effect is to sacrifice validity in an effort to maximize inter diagnostician agreement-reliability. This makes little sense. For example, blends of anxiety and depression are extremely common in a clinical population, and they typically show much overlap (correlation) in quantitative scientific investigations as well. Nevertheless, the DSM treats the two as generically distinct forms of disorder, and as a consequence, a person who is clinically both anxious and depressed may receive two diagnoses, one for each of the supposedly separate conditions.

THE PROBLEM OF LABELING The psychiatric diagnoses of the sort typified by the DSM-IV system are not uniformly revered among mental health professionals The diagnostic label describes neither a person nor any underlying pathological condition ("dysfunction") the person necessarily harbors but, rather, some behavioral pattern associated with that person's current level of functioning.

Yet once a label has been assigned, it may close off further inquiry. It is all too easy-even for professionals to accept a label as an accurate and complete description of an individual rather than of that person's current behavior. Clearly, it is in the disordered person's best interests for mental health professionals to be circumspect in the diagnostic process, in their use of labels, and in ensuring confidentiality with respect to both.

REFERENCES 1. Carson Robert C, Butcher James N.(2007). Abnormal Psychology.13th Edition. South Asia : Pearson Education Inc 2. Sarason Irwin G. (1972). Abnormal Psychology-the problem of maladaptive behavior. New Jersey: Prentice Hall. 3. http://en.wikipedia.org/wiki/Minnesota_Multiphasic_Personality_Inventory 4. http://en.wikipedia.org/wiki/Rorschach_test 5. http://en.wikipedia.org/wiki/Thematic_Apperception_Test 6. http://www.psychologicaltesting.com/objectiv.htm