ASSESSMENTS IN CLINICAL PSYCHOLOGY

DEFINITIONS OF ASSESSMENT
• Clinical psychological assessment is the process of systematically
gathering information about a person in relation to his or her
environments so that decisions can be made based on this
information that are in the best of the individuals.
• It is formal ways of finding out what is wrong with the person,
what may have cause a problem and what is the solution of the
problem
• Clinical assessment refers to procedures for identifying the
distinguishing features of problems, disorders, or cases, as well as
relevant strengths
• In principle there are four ways in which one can gain information
about another person
• (1) ask the person him/herself;
• (2) ask someone who knows the person;

• (3)observe the person as he/ she behaves naturally and

• (4) observe the person in standardized test situations
• In clinical services, assessment is often viewed as an initial step
that then leads to diagnosis.
• Diagnosis, in turn, is shaped by classification of disease that
specify the criteria for the disorders to be diagnosed.
 IMPORTANCE OF ASSESSMENT
• Clinical psychological assessment has the following purposes

1. Diagnostic classification: implies that certain procedures or

tests are administered to an individual in order to classify
the person's problem and if possible to identify causes and
prescribe treatment.

2. Severity: assessment can determine the severity of

psychological disorders. Severity of psychological disorder
can be determined by degree of impairment that is present
in the person's daily life.
3. Screening: Clinical psychologists screen large groups of individuals,
either to identify the presence of problems or to predict who is
at greatest risk to develop a problem at some point in the future.
4. Prediction: making prediction about how a person may behave at
some point in the future.
5. Evaluation of interventions: assessment is important to develop
treatment plans.
6. To find out the supporting system that helps the clinicians in
treatment and recovery of the patients.
7. Prognosis of the patients
 CLINICAL INTERVIEWS
• Clinical interview is the most widely used means of assessment.
• The interview is usually the client’s first face-to-face contact with a
clinician.
• The interviewer encourages the client to describe the problem in her
or his own words in order to understand it from the client’s viewpoint.
• It is the oldest methods of psychological assessment.
• It is conversation between the patients and the therapists.
• A given clinical interview mainly focuses on behavioral observation,
idiosyncratic behaviors and person's (client's) reaction to his or her life
situations.
• In clinical interview you will discuss about unpleasant facts and feeling
that you do not usually talk in normal situations/conversations.
• Clinical interview helps the clinicians to obtain information that are
impossible by other means.

Clinical interview has the following objectives

• Establishing rapport
• Obtain information which couldn't be addressed by other means
• Assessing the clients strength
• Level of adjustments
• Nature and history of the problem
• To make a sound diagnosis
• To get relevant personal and family history
 • Interview Formats
• There are three general types of clinical interviews; unstructured interview,
semi structured interview and structured interview.
• Unstructured interview: the clinician adopts his or her own style of
questioning rather than following a standard format.
• Advantage of the unstructured interview
• It is spontaneity and conversational style. Because the interviewer is not
bound to follow any specific set of questions, there is an active give-and-take
with the client.
• High rapport
• The therapist can recognize how the clients organize their response
• Potential to explore the unique details of a clients history
• Disadvantage of the unstructured interview

• The lack of standardization. Different interviewers may ask questions in

different ways.
• For example, one interviewer might ask, “How have your moods been
lately?” whereas another might pose the question, “Have you had any
periods of crying or tearfulness during the past week or two?” The clients’
responses may depend to a certain extent on how the questions are
asked.
• The conversational flow of the interview may fail to touch on important
clinical information needed to form diagnostic information, such as
suicidal tendencies
• Problem with reliability and validity
• Semi structured interview: the clinician follows a general outline
of questions designed to gather essential information but is free
to ask the questions in any particular order and to branch off into
other directions to follow up on important information.
• A semi structured interview provides more structure and
uniformity, but at the expense of some spontaneity.
 Structured interview:
•the interview follows a preset series of questions in a particular
order.
•Structured interviews (also called standardized interviews) provide
the highest level of reliability and consistency in reaching diagnostic
judgments, which is why they are used frequently in research
settings.
•The Structured Clinical Interview for the DSM (SCID) includes
closed-ended questions to determine the presence of behavior
patterns that suggest specific diagnostic categories and open-ended
questions that allow clients to elaborate their problems and feelings
• Structured interview can be administered by less trained
individuals.
 Contents/components / of Clinical interview

Case history
• In case history first information should be taken from the patients
directly because if you ignore the patients the patient develops
suspicions.
• If it is found to be important to get information from key
informants we need to check key informants relationship with the
patient, concern about the patient, duration of stay with the
patients and consistency of the information.
• Generally speaking case history has the following basic
components.
1. Identification Data
• It includes Name, Age, Sex, Marital status, Education, Occupation,
Income, Residential addresses, Official address and types of family,
telephone number, racial/ethnic characteristics and religion.

2. Chief complaints
• Patients should be asked reasons for consultation.

• Presenting complaints must be recorded in their chronological

order of appearance with durations. All complaints should be
recorded in patient's own words and use of technical terms should
be avoided.
3. History of present illness
• This section of history taking provides a detail of present complaints
with durations, variations in severity from day to day and within a
day, aggravating and relieving factors, impact of complaints on
patient's social and occupational functioning.
• A detailed account of treatment received with types and doses of
drugs are also recorded in this section.

4. Past history
• Detail of past history of psychiatric illness, if any, should be recorded
in this section with types of treatment and response to it. A detail of
past medical illness, if any, needs to be noted.
5. Family history

• This part of history taking includes recording of age, status of physical

and mental health, education, occupation, income and personality of
parents and siblings. The family history of mental illness, alcoholism,
epilepsy or other significant illness should be recorded.

• Types of family, environment and socioeconomic status of the family are

also important parts of this section

6.Personal history

• This section of history helps the treating clinicians to understand the

patient's complaints in the light of patient's personal history.
Information should be gathered in the following heads:
• Antenatal history
• Menstrual history
• Childhood history
• Marital history
• Schooling history
• Substance use history
• Occupational history
• Forensic history
• Sexual history
• Religion changes
 • Pre-morbid personality
• It is important to know about patient's personality before the
onset of the illness.
• In this section various dimensions of individual's personality like
his /her social and interpersonal relationships, patient's
predominant mood, intellectual and recreational activities,
attitude toward work, energy initiative, habits and fantasy life
should be recorded.
• Information from these parameters should be gathered from
patients as well as from reliable informants.
 MENTAL STATUS EXAMINATION (MSE)

• The MSE provides a template that assists a clinical psychologist in

the collation and subsequent conceptual organization of clinical
information about a client’s emotional and cognitive functioning.

• It helps both with current diagnosis and treatment planning and

serves as a baseline for future references

• By systematically basing observations on verbal and non-verbal

behavior, the aim is to increase the reliability of the data upon
which subsequent diagnoses and case formulation are made.

• MSE collates information about the client’s (i) physical, (ii)

emotional, and (iii) cognitive state.
Table 3. An outline for a mental status examination

Appearance Physical Motor activities

Behavior
Attitude Emotional Mood and affect
Orientation Cognition Attention and concentration
Memory Speech and language
Thought (form and content) Perception
Insight and judgments Intelligence and abstraction
1. Physical states
• The description will draw attention to important aspects of the
client’s physical state.

1.1 Appearance
• A concise summary of the client’s physical presentation is given to
paint a clear mental portrait.
• The description may refer to dress, grooming, facial expression
(alert, dazed, confused, frightened), posture, eye contact, as well as
any relevant significant aspects of appearance.
• Importantly, the aim is to describe what is observed rather than your
interpretation (e.g., ‘‘he was exhausted’’)
• For instance, a clinician might note that the client ‘‘wore an expensive, but
crumpled suit. He sat slumped in the chair and was unshaven, with dark
circles under his eyes’’.

1.2 Behavior

• A description of behavior may make reference to the client’s level of

consciousness extending from alert through drowsy, a clouding of
consciousness, stupor (lack of reaction to environmental stimuli) and delirium
(bewildered, confused, restless and disoriented), to coma (unconsciousness).
It may also include reference to the degree of arousal (e.g., hyper vigilance to
environmental cues and hyper arousal such as observed in anxious and manic
states), mannerism (e.g., tics and compulsion).
1.3 Motor activity
• An account of the observed motor activity aims to describe both
the quality and the types of actions observed.
• Reductions in movement can be variously described as a
reduction in the level of movement (psychomotor retardation),
slowed movement (bradykinesia), decreased movement
(hypokinesia), or even an absence of movement (akinesia).
• Increases in the overall level of movement are referred to as
psychomotor agitation, but it is also important to note minor
increases in movement such as a tremor.
• Stereotype: repetitive fixed patterns of physical action or speech.
Mannerism: stereotyped involuntary movement.
• Echopraxia: a condition in which patients imitate the examiners
movement without being asked to do so.
2. Emotional
• Moving from the physical domain, the clinician will portray the
person’s emotional state, once again drawing upon the verbal
and non-verbal behavior of the client.
2.1 Attitude
• The clinician will also consider the way in which the client
participates in the interview as a way of gauging their manner
and outlook.
• These judgments will be based on the client’s response both to
the context of the interview and also to the interviewer.
• Identifiers may be open, friendly, cooperative, willing and
responsive, or alternatively, they may be closed, guarded, hostile,
suspicious and passive.
2.2 Mood and affect
• Although affect (an external expression of an emotional state) is
potentially observable, mood (the internal emotional experience
that influences both perception of the world and the individual’s
behavioral responses) is less apparent and will require the clinician
to depend to a greater degree on the client’s introspections.
• Descriptors of mood include euphoric, dysphoric (sad and
depressed), hostile, worried, fearful, anxious and suspicious.
• The stability of mood can also be noted, with the alternation
between extreme emotional states being referred to as emotional
lability.
• Emotional lability: The range, intensity and variability of affect can be
variously portrayed, but some important expressions are restricted (i.e.,
low intensity or range of emotional expression).

• Blunted affect: severe declines in the range and intensity of emotional

range and expression.

• Flat affect: a virtual absence of emotional expression, often with an

immobile face and a monotonous voice and exaggerated (i.e., an overly
strong emotional reaction) affect.

• The clinician will also consider the appropriateness of the affect (and
note if the emotional expression is incongruent with verbal descriptions
and behavior) as well as the client’s general responsiveness
3. Cognitive states
• The cognitive components in an MSE will be familiar to clinical
psychologists, since many components are assessed more
comprehensively and within memory tests.
• However, during the MSE, the aim is to provide a general
screening which requires interpretation using clinical judgment,
with one outcome being to recommend further formal testing.
3.1 Orientation
• A person’s orientation refers to their awareness of time, place and
person.
• Orientation for time refers to a client’s ability to indicate the current day
and date (with acceptance of an error of a couple of days).
• Orientation for place can be assessed by asking clients where they have
presented.
• Behavior should also be consistent with that expected in the setting in
which they have arrived.
• Orientation for person refers to the ability to know who you are, which
can be assessed by asking the client their name or names of friends and
family which you can verify.
3.2 Attention and concentration
• Working memory is the term now used in psychology to refer to
the constructs called attention and concentration.
• The aim is to describe the extent to which a client is able to focus
their cognitive processes upon a given target and not be
distracted by non-target stimuli.
• Digit span (the ability to recall in forward or reverse order
increasingly long series of numbers presented at a rate of one
per second) is a common way to assess attention, and normal
individuals will recall around 6 to8 numbers in digits forward and
5 to6 numbers in digits backwards.
• Another method used to test concentration is serial sevens in
which seven is sequentially subtracted from 100. Typically people
will make only a couple of errors in 14 trials.

3.3 Memory
• An MSE will typically assess memory using the categories of
short-and long-term memory. Although these categories do not
map neatly onto models of memory in recent cognitive
psychology, the aim of the MSE is to provide a concise description
of a person’s behavior and screen them in a manner that can
guide further assessment. Therefore, more sophisticated

assessments and analyses may follow.

• To assess recent or short-term memory, clients can be asked about
a recent topical event or who the President or Prime Minister is.
• Clients can also be asked to listen to three words, repeat them, and
then recall them some time later in the interview.
• Most people will usually report 2 to 3 words after a 20-minute
interval.
• Visual short-term memory can also be assessed by asking clients to
copy and then reproduce from memory complex geometrical
figures
• Long-term memory can be assessed by asking about childhood
events.
3.4 Thought - form and content
• Disturbances in the form of thought are evident in terms of the

(i) quantity and speed of thought production. The client may jump
from idea to idea (flight of ideas) or show a poverty of ideas.
Thought may be disordered in terms of (ii) the continuity of ideas.
• Circumstantialities: thinking proceeds slowly with many
unnecessary trivial details but finally the point is reached. The
client may leave a topic of conversation and perhaps return to it
much later.
• Tangentiality: patient tends to wander away from the
intended point, moving further and further away, never
returns to the original idea.
• Perseveration: pathological stimulations of same
response to different stimuli, as in a repetition of same
verbal response to different questions repetition with
the same idea, word or phrase.
• They may show a loosening of associations, where the logical
connections between thoughts are vague or bizarre.
• Problems in the content of thought also need to be noted by a

clinician. This includes delusion, delusional perception,

grandiose delusion, persecutory delusion, and erotomanic
delusion, delusion of guilt and mixed delusion.
• Delusion: is a profound disturbance in thought content in which
the client continues to hold to a false belief despite objective
contradictory evidence, despite other members of their culture
not sharing the same belief.
• Persecutory delusion: person believes that people in
environment such as family members, neighbors or friends are
working against him/her and want to harm or kill him/her
• Grandiose delusion: patient believes that he/she is an important
and extraordinary person having a lot of money, power and social
status and is able to help others or an exaggerated sense of one’s
own importance, power or significance.
• Somatic delusion: physical sensations or medical problems
• Delusion of guilt: patient believes that he /she is the biggest
sinner and has not only ruined his/her family, but is also
responsible for all calamities in the world, and insist that he/she
will rot in hell for this.
• Clients can also have delusions that are nihilistic (belief that self
or part of self, others, or the world does not exist),
• jealous (unreasonable belief that a partner is unfaithful), or
religious (false belief that the person has a special link with God).
3.5 Perception
• Hallucinations are a perceptual disturbance in which people have
an internally generated sensory experience, so that they hear, see
(visual), feel (tactile), taste (gustatory), or smell (olfactory)
• something that is not present or detectable by others.
• The most frequent hallucinations are auditory and typically
involve hearing voices, calling, commanding, commenting,
insulting or criticizing.
• Other perceptual disturbances include a sense that the external
world is unreal, different or unfamiliar (derealization),
• an experience that the self is different or unreal in that the
individual may feel unreal, that the body is distorted or being
perceived from a distance (depersonalization).
• In addition to hallucination cap grass syndrome is another
perceptual disorders in which the patient perceives family
members or other individuals whom they know as the exact copy
of the family members and someone whom they know.
• Fregoli: situations in which patients understand unfamiliar
individuals as familiar.
• Example: giving warm greeting for someone whom you have seen
for the first time as your ex-friend
3.5 Insight and judgment
• Insight is a dimension that describes the extent to which clients are
aware that they have a problem.
• A strong lack of insight can be an important indicator of
unwillingness to accept treatment.
• Insight refers also to an awareness of the nature and extent of the
problem, the effects of the problem on others, and how it is a
departure from normal.
• For instance, clients may deny the presence of a problem
altogether, or may recognize the problem, but judge the cause to

lie within others.

• Judgment is another issue that the clinician will consider during
an MSE.
• The ability to make sound decisions can be compromised for a
number of reasons.
• The clinician will try to ascertain if poor decisions are the result of
problems in the cognitive processes involved in the decision-
making process, motivational issues, or failures to execute a
planned course of action.
3.6 Speech and language
• A client’s speech can be described in terms of its rate (e.g., slow,
rapid), intonation (e.g., monotonous), spontaneity, articulation,
volume, as well as the quantity of information conveyed.
• At one end of the dimension of information conveyed is mutism
(i.e., a total absence of speech), extending through poverty of
speech (i.e., reduced spontaneous speech) to pressured speech
(i.e., extremely rapid speech that is hard to interrupt and
understand).
• Speech is a subset within the broader domain of language.
• Language also includes reading, writing and comprehension.
• Cognitive dysfunctions can be indicated by language disturbances
such as aphasia.
• Aphasia can be non-fluent, in which speech is slow, faltering, or
effortful or fluent.
• Fluent aphasia involves speech that is normal in terms of its form
(rhythm, quantity and intonation), but is meaningless, perhaps
including novel words (i.e., neologisms).
• Echolalia: psychopathological repetitions of words or phrases of one
person by another.
3.6 Intelligence and abstraction

• A general indication of intelligence can be gained from the amount

of schooling a person has had, with a failure to complete high
school indicating below average intelligence, completion of high
school indicating average intelligence and college or university
education indicating high intelligence.

• Abstraction is the ability to recognize and comprehend abstract

relationships to extract common characteristics from a group of
objects (e.g., in what way are an apple/banana or music/sculpture
alike?), interpretation (e.g., explaining a proverb).
•