CHAPTER 3

Psychological Assessment^*

John F. Clarkin, Ph.D.

Joel McClough, Ph.D.

Steven Mattis, Ph.D.

The current approach to psychiatric diagnosis, the growing specificity of treatment planning for both medication and psychosocial interventions, and the nature of the health care delivery system all influence the context that determines the use of psychological tests and rating scales to inform assessment, treatment planning, and monitoring of treatment response. Psychological assessment has evolved under these influences, resulting in a diversification of assessment approaches and foci. A new factor is the introduction of DSM-5 (American Psychiatric Association 2013), with its emphasis on dimensional assessment of key pathological dimensions rather than exclusive focus on categorical classification (Hyman 2011). In this chapter we discuss the objectives, forms, and utility of psychological assessment and provide an outline for considering the major areas of assessment with related assessment tools.

Definition and Development of Psychological Assessment Instruments

Types of Instruments

Three types of instruments are currently used in the assessment of patient functioning: psychological tests, rating scales, and semistructured interviews.

Psychological tests are standardized methods of sampling behaviors in a reliable and valid way. The test stimuli, the method of presenting these stimuli, and the method of scoring the responses are carefully standardized to ensure reliability. The actual test stimuli can be constructed in numerous ways. For example, test items on the Wechsler Adult Intelligence Scale—4th Edition (WAIS-IV; Wechsler 2008), a widely used intelligence test, consist of factual questions (e.g., "What does -ponder mean?"), with scores graded to successively better answers (e.g., 0 for "to fret," 1 for "to wonder," or 2 for "to contemplate"). Items on the restandardized Minnesota Multiphasic Personality Inventory—2 (MMPI-2; Butcher et al. 1989), a highly developed and widely used symptom and personality test, consist of true/false questions about presence or absence of specific feelings, thoughts, and experiences (e.g., "I usually feel that life is worthwhile," an item on Scale 2). Test stimuli on the Rorschach (Rorschach 1949), a projective test of personality styles and characteristics, are amorphous inkblots. The patient is asked to tell the examiner what the blots look like or what they remind the patient of. The response is recorded verbatim and scored with a standardized system.

Rating scales are standardized instruments that allow various informants or observers (e.g., therapists, nurses on clinical inpatient units, relatives, trained observers) to rate the behavior of the patient in specified areas. To aid the observer in a reliable rating of the behavior, anchor points are provided. Semistructured interviews are standardized by controlling 1) the questions, including specifying what kind of probes can be used, and 2) the scoring of the patient's response, often by using rating scales. Although developed for research, these interviews have clinical usefulness in the reliable assessment of diagnostic criteria.

Standards for Reliability and Validity

The science of assessment depends on the development of instruments that meet certain standards. Chief among these standards are those for reliability and various types of validity.

Standardization of administration and scoring to minimize the influence of factors unrelated to the area of assessment is essential for establishing reliability. The degree to which a test meets acceptable standards for reliability is evaluated by readministering the test at later times to determine if individual scores remain stable (i.e., test-retest reliability) ; developing alternative forms of the test that, when compared, provide roughly equivalent scores for an individual (i.e., alternate-form reliability ); and demonstrating that any subgroup of items from the test yields a score comparable to that produced from any other equivalent subgroup of items (i.e., split-half reliability,).

Establishing a test's validity requires demonstration that the test measures what it is intended to measure. Three major types of validity can be assessed: content validity, criterion-related validity, and construct validity. Content validity can be achieved only if the content of the test can be said to adequately sample the area of interest. For example, an intelligence test must contain items that tap several areas of intellectual functioning, such as knowledge of words, arithmetic ability, abstracting ability, knowledge of social conventions, and so forth. Criterion-related validity refers to the test's relationship to independent criteria of an individual's ability in a particular area (i.e., concurrent validity) or to the ability of the test to make predictions about future behavior (i.e., predictive validity). For example, a test of the severity of depressive symptoms would achieve concurrent validity if scores on the test were closely related to a trained observer's rating of the severity of the depression, and it would achieve predictive validity if scores on the test were found to be related to the likelihood that a given individual would respond to a specific treatment for reducing depressive symptoms. Construct validity can be achieved only by demonstrating that the test specifically measures a theoretical construct of interest and that scores on the test are unrelated to similar areas.

Sources of Bias Related to Instruments or Assessments

Cultural bias in testing exists when there is consistent differential performance between different groups or populations that is more likely to reflect cultural difference than differences in the variable being measured. Efforts to explain differential performance usually look at the characteristics of the individual test taker, the test-taking environment, and the characteristics of the test or the test items (for reviews, see Gregory 2004, Scheuneman 1985, and Walfish et al. 2012).

Bias in construct validity addresses the question, "Does the test measure what it is intended to measure?" If the construct (e.g., motivation, intelligence, self-esteem) being measured yields significantly different results for test takers from different cultures, there may be bias (Jensen 1980). For example, if you are trying to measure the construct of intelligence but the test taker is not proficient in the language of the test, then you are no longer measuring intelligence, but rather language proficiency. The test taker might know the answer if the question were presented in a language he or she could understand.

Bias in item selection is present when an item or subscale is relatively more difficult for members of one group versus another (Reynolds 1998). For instance, if people who have never been exposed to the sport of cricket are asked to "describe the difference between cricket and baseball," their lack of experience and exposure would put them at a disadvantage. In addition, item selection bias is present when the items selected are based on the language of the dominant group or when the test author arbitrarily decides that there is only one correct answer, whereas members of a different culture might answer the question differently.

Bias in method deals with factors surrounding administration of the test that may influence the results (e.g., test environment, test length, level of assistance provided).

Goals of Assessment

Common assessment goals include initial patient screening, clarification of diagnostic uncertainty, informing treatment decisions, and monitoring the progress of treatment. The areas or dimensions of human functioning that seem most central for diagnosis and treatment planning include 1) symptom constellations, as well as specific symptom areas; 2) personality traits and disorders; 3) psychodynamics; 4) cognitive functioning; and 5) environmental demands and social adjustment. In the subsections that follow, we review the best available instruments in each of these five areas.

Assessment of Symptom Constellations

Omnibus Measures of Symptomatology

As psychiatric nomenclature has undergone revision, assessment tools have been developed that rely on interviews and self-reports (Table 3-1), providing data that are immediately relevant to symptom patterns. The semistructured interviews that focus on symptom disorders are now out of date with the changes in DSM-5. As the reconceptualized DSM-5 gains acceptance in clinical practice and research, the semistructured interviews will be revised to accommodate the changes.

The MMPI-2 (Hathaway and McKinley 1989) and its recent alternative, the MMPI-2 Restructured Form (MMPI-2-RF; Ben-Porath and Tellegen 2008/2011), are probably the most widely used assessment instruments in existence. There are several reasons for the MMPI's extensive use, including its efficiency, its extensive normative base, the use of validity scales that indicate the patient's test-taking attitude, and its impressive cross-cultural validation. Although labeled as a personality test, the MMPI was constructed to assess what are now categorized as symptom diagnoses and, to a lesser extent, a few dimensions of personality. In 2003, the Restructured Clinical (RC) Scales (Tellegen et al. 2003) were added to the published MMPI-2. This effort was undertaken to address the known psychometric flaws in the original clinical scales that complicated their interpretability and validity. More recently, with the RC Scales as its foundation, the MMPI-2-RF was created. This restructuring of the scales was done because it has long been recognized that the clinical scales were not psychometrically optimal due to their high intercorrelations, substantial item overlap, and heterogeneous, overinclusive item content. The MMPI-2-RF is marketed by its publisher as an alternative to the MMPI-2, rather than a replacement.

The Symptom Checklist-90—Revised (SCL-90-R; Derogatis 1994) is a revision of a much-used self-report instrument designed to provide information about a broad range of complaints typical of individuals with psychological symptomatic distress. The Brief Symptom Inventory (BSI; Derogatis 1993) is a 53-item self-report form of the SCL-90-R that assesses the same nine symptom dimensions and three global indices. The psychometric properties of the BSI are comparable with those of the SCL-90-R, and the BSI has the advantage of increased ease of administration, taking only 8-10 minutes to complete. Another widely used rating scale for a range of psychiatric symptoms is the Brief Psychiatric Rating Scale (Overall and Gorham 1962), which was developed mainly for the assessment of symptoms with an inpatient population.

Specific Areas of Symptomatology

In addition to the omnibus measures of symptomatology, a number of instruments have been developed to assess one area of symptomatology in depth (Table 3-2). The major constellations of symptoms that may require assessment are 1) substance abuse, including abuse of alcohol and drugs; 2) eating disorders; 3) affects, such as anxiety, elation, and depression; 4) aggression; 5) thought disorder; and 6) suicidal intentions and behaviors.

Substance abuse. Psychological distress and dysfunction arising from the abuse of a wide variety of substances is a frequent reason for seeking psychological or psychiatric treatment. General psychiatric semistructured diagnostic interviews provide substance-specific DSM diagnoses when administered by a trained professional. Other structured interviews focus exclusively on the misuse of substances. For instance, the Alcohol Use Disorders and Associated Disabilities Interview Schedule, DSM-IV Version (Grant et al. 2001), assesses dependence-related symptoms (e.g., withdrawal, craving, tolerance), familial and medical risk factors, and amount of drug and alcohol consumption.

The University of Rhode Island Change Assessment (McConnaughy et al. 1983) is a measure developed to assess a patient's readiness to change in relation to the use of drugs, alcohol, and nicotine. Treatment recommendations can be based on the patient's stage of change readiness. For a more in-depth review of commonly used measures of substance abuse (including screening measures), the reader is directed to Tucker et al. (2010).

Eating disorders. The most widely used semistructured interview for eating disorders is the Eating Disorder Examination, 16th Edition (EDE; Fairburn et al. 2008). The current version of the EDE includes a module to diagnose binge-eating disorder, a new free-standing diagnosis in DSM-5. The Eating Disorder Examination Questionnaire (Fairburn and Beglin 2008) is the self-report version of the EDE.

Affects. The content, range, and management of emotional expression constitute a symptomatic area of focus for the evaluation of a wide variety of psychiatric disorders. The main affects of interest are anxiety, depression, and elation.

The Beck Anxiety Inventory (Beck et al. 1988) is a 21-item self-report questionnaire with a focus on somatic anxiety symptoms, such as heart pounding, nervousness, inability to relax, and dizziness or light-headedness. This measure takes approximately 5 minutes to complete and was designed specifically to discriminate between anxiety and depression. The Beck Depression Inventory—II (Beck et al. 1996) is probably the most widely used self-report inventory of depression. The inventory includes 21 items to assess mood, pessimism, crying spells, guilt, self-hate and accusations, irritability, social withdrawal, work inhibition, sleep and appetite disturbance, and loss of libido. For further review of self-reports, semistructured interviews, and rater assessments of depression and its sequelae, the reader is referred to Dozois and Dobson (2010).

Aggression. Aggressive behavior, including aggressive imagery and hostile affect, is an important area in treatment planning. The Buss-Durkee Hostility Inventory (Buss and Durkee 1957) is a 75-item self-report questionnaire that measures different aspects of hostility and aggression. Some norms exist for clinical populations. Megargee et al. (1967) developed an overcontrolled hostility scale using MMPI items. The revised State-Trait Anger Expression Inventory—2 (Spielberger 1999) takes about 10 minutes to complete. This 57-item scale divides behavior into state anger (i.e., current feelings) and trait anger (i.e., disposition toward angry reactions).

The Overt Aggression Scale—Modified (Coccaro et al. 1991) is a semistructured clinician interview that assesses aggression, irritability, and suicidality in the past week. The Anger, Irritability, and Assault Questionnaire (AIAQ; Coccaro et al. 1991) is a 42-item self-report questionnaire designed to assess several aspects of impulsive aggression putatively related to serotonergic function. The instrument focuses primarily on the inability to control aggression. The AIAQ's Irritability, Assault, and Labile Anger subscales are adapted from the Buss-Durkee Hostility Inventory (Buss and Durkee 1957) and the Affective Lability Scales (Harvey et al. 1989). Available psychometric data suggest fairly strong short-term test-retest reliability as well as adequate construct validity with related measures.

Thought disorder. One approach to the reliable assessment of cognition is the use of semistructured interviews such as the Schedule for Affective Disorders and Schizophrenia (Endicott and Spitzer 1978) and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II; First et al. 1997). The presence or absence of disorders of thinking such as thought derailment or frank hallucinations or delusions is determined during the course of an extensive interview. However, many individuals may not wish to reveal frank delusional experiences, or they may be unaware of the presence of more subtle varieties of disordered thinking. Although other commonly used measures of disordered thinking, such as the Positive and Negative Syndrome Scale (Kay et al. 1987) and the Scale for the Assessment of Positive Symptoms (Andreasen 1984), supplement the information obtained from the clinical interview with collateral information from caretakers, review of clinical records, and direct behavioral observation prior to rating the presence or absence of a symptom, problems in the accuracy of judgments remain. To avoid these pit-falls, an alternative approach is to obtain a sample of the thought process. The test most widely used in examinations for thought disorders has been the Rorschach inkblot test, which was developed by the Swiss psychiatrist Hermann Rorschach. In this test, a relatively ambiguous stimulus (a colored or achromatic "inkblot") is used, and, without additional instruction, individuals are asked to state what the blot looks like to them. Exner (1974, 1978) developed a scoring system for the Rorschach test that attempts to integrate the best aspects of prior systems.

Philip Holzman and colleagues have published extensively on the relationship of various forms of thought disorder and its severity to psychiatric diagnosis and treatment. Although their scoring scheme can be applied to any record of verbal production, its most frequent application has been in the context of verbal records from the administration of such tests as the WAIS and the Rorschach. In its present version, the Thought Disorder Index (Solovay et al. 1986) considers 22 forms of thought disturbance ranging across four levels of severity as the basis for a total score. The total score has been found to distinguish patients with and without psychotic dis-orders, and more severe forms of thought disorder have been most frequently associated with schizophrenic disorders.

Suicidal behavior. Suicide threats, suicidal planning and/or preparation, suicidal ideation, and recent parasuicidal behavior are all direct indicators of current risk and should be assessed thoroughly and specifically in the clinical interview (Simon 2006). In addition, self-report instruments that focus specific and detailed attention on known predictors of suicidal behavior are sometimes clinically useful. Suicidal assessment instruments that are frequently used include the Beck Hopelessness Scale (Beck et al. 1974b), the Suicide Intent Scale (Beck et al. 1974a), the Index of Potential Suicide (Zung 1974), and the Suicide Probability Scale (Cull and Gill 1986). In addition, the revised Koss-Butcher critical item set on the MMPI-2 is a list of 22 items related specifically to depressed suicidal ideation (Butcher et al. 1989; Koss and Butcher 1973).

One of the most widely used measures is the Scale for Suicide Ideation (SSI; Beck et al. 1979), a clinician-administered, 21-item rating scale that assesses the intensity of a patient's current attitudes, behaviors, and plans to commit suicide on the day of the interview. The SSI consists of five screening items related to the wish to live or die and the desire to commit suicide. If the respondent reports any active or passive desire to attempt suicide, then an additional 14 items are administered. The SSI takes about 10 minutes to administer. The Beck Scale for Suicide Ideation (BSI; Beck and Steer 1991) is a 21-item self-report instrument designed as the self-report version of the clinician-administered SSI. The Modified Scale for Suicide Ideation (MSSI; Miller et al. 1986) is a revised version of the SSI that uses 13 items from the SSI and 5 new items related to intensity of suicidal ideation, courage and competence to attempt, and talking and writing about death. The Suicidal Behavior Questionnaire-14 (SBQ-14; Linehan 1996) is a comprehensive (up to 34 items) self-report measure of past and future suicidal ideation, past suicide threats, future suicide attempts, and the likelihood of dying in a suicide attempt. Although the Reasons for Living Inventory (RFL; Linehan et al. 1983) does not directly assess suicidal behavior, examination of the beliefs and expectations that lead a person to refrain from committing suicide has yielded valuable insight into the differences in reasons for living among patients who engage in suicidal behavior and those who do not. This instrument can also be useful as a measure of change in beliefs about reasons for living as a result of treatment. For a comprehensive review of suicide assessment measures, see Brown (2001).

Assessment of Personality Disorders

In the process of assessing and developing a treatment plan for an individual patient, clinicians assess personality and personality functioning for various reasons. Personality dysfunction or disorders may 1) be the focus of intervention, 2) exacerbate or be related to the incidence of certain symptoms (e.g., depression), or 3) influence the development of a therapeutic relationship with the patient. Table 3-3 lists commonly used instruments for assessing personality traits and disorders.

A number of semistructured interviews enable the reliable assessment of personality disorders, including the International Personality Disorder Examination (Loranger 1999) and the SCID-II (First et al. 1997). For treatment planning, clinicians are interested in the patients' dysfunctional personality processes. The Severity Indices of Personality Problems (Verheul et al. 2008) is a promising self-report questionnaire that assesses five higher-order factors of self-control, identity integration, relational capacities, responsibility, and social concordance. In the interpersonal tradition, Benjamin (1988) developed an instrument for the assessment of interpersonal behavior, the Structural Analysis of Social Behavior (SASB), and a computer-based scoring system, marketed under the trade name INTREX, which is self-administered. The SASB can also be used by clinicians to record their impressions about the patient. A related coding scheme has been developed for use by trained observers to record the patient's actual interactions with others, such as family members, during the course of treatment.

The assessment of maladaptive personality traits has been extensively developed. The most promising instruments of this type include the Millon Clinical Multiaxial Inventory—III (Millon et al. 1997), a useful self-report instrument that covers personality disorders. Several self-report questionnaires that assess personality and personality pathology have been carefully constructed with attention to psychometric properties. These include the Schedule for Nonadaptive and Adaptive Personality (SNAP) and its revision, SNAP-2 (Clark et al. 1993), and the Dimensional Assessment of Personality Pathology—Basic Questionnaire (DAPP-BQ; Lives-ley and Jackson 2009). The DAPP-BQ is a self-report questionnaire that consists of 290 items that assess 18 dimensions, including, among others, affective lability, anxiousness, identity problems, insecure attachment, intimacy problems, and suspiciousness. The SNAP is a 375-item, true/false self-report questionnaire that assesses three broad temperament dimensions of negative affectivity, positive affectivity, and disinhibition versus constraint. The revised version of the Neuroticism, Extroversion, and Openness Personality Inventory (Costa and McCrae 1992) is a carefully constructed instrument measuring five central facets of personality: neuroticism, extraversion, openness, agreeableness, and conscientiousness.

The Shedler-Westen Assessment Procedure (SWAP-200; Westen and Shedler 1999) is an innovative assessment tool that uses the Q-sort method to summarize material from a clinical interview. The SWAP-200 consists of 200 personality descriptive statements that clinicians sort into eight categories of varying degrees of relevance to the patient under assessment. Psychometric studies support the validity of the instrument for assessing personality disorders.

A very useful instrument for assessing interpersonal difficulties is the self-report Inventory of Interpersonal Problems (IIP-64; Horowitz et al. 1988). This 64-item questionnaire asks the respondent in a straightforward way about interpersonal difficulties that he or she experiences. The IIP-64 assesses interpersonal problems in eight domains: domineering/controlling, vindictive/self-centered, cold/distant, socially inhibited, non-assertive, overly accommodating, self-sacrificing, and intrusive/needy.

Assessment of Psychodynamics

The assessment of factors relevant to psychodynamic and psychoanalytic theory and treatment approaches has a long history in the clinical psychological literature. The development of the "standard battery," including the WAIS-IV, the Rorschach, and the Thematic Apperception Test (Murray 1943), has its origins in the efforts of clinical psychologists to provide an assessment of such psychodynamic factors as drives, unconscious wishes, conflicts, and defenses.

The most widely used assessment procedure for the examination of patients over a range of ego functions and dynamic factors is the Rorschach inkblot test, described earlier in the section "Thought Disorder." Scoring systems have been developed by many authors, and Exner (1974, 1978) created a scoring system that attempts to integrate the best aspects of earlier systems. From these scores, inferences are drawn concerning the patient's self-image, identity, defensive structure, reality testing, affective control, amount and degree of fantasy life, degree of thought organization, and potential for impulsive acting out.

The Thematic Apperception Test is another widely used projective process for assessing the patient's self-concept in relation to others. Originally developed by Murray (1943), the test consists of a set of 30 pictures depicting one or more individuals. The patient is asked to make up a story based on each picture. The stories generated are then scored for the individual's needs as reflected in the feelings and impulses attributed to the major character in each story and the interactions with the environment leading to a resolution.

Emerging Measures in DSM-5

The authors of DSM-5 (American Psychiatric Association 2013) have included "emerging measures" in Section HI. These instruments are not reviewed in detail here, as they require further development in the form of reliability and validity studies and the generation of norms. However, the instruments deserve mention because they indicate the spirit of DSM-5 in several ways. First of all, acknowledging the issue of symptom overlap and the failure to define clear boundaries between diagnostic categories, there are several cross-cutting symptom measures designed to help clinicians identify additional areas of inquiry that may aid in treatment planning. There are instruments to measure symptoms that extend across diagnoses. This includes both patient and informant ratings for symptoms such as depression, anger, and mania for adults and children. In addition, acknowledging the accumulating evidence in support of dimensional models of psychopathology, there are several disorder-specific measures that assess the dimensions of severity, frequency, intensity, and duration for disorders such as depression, panic disorder, and PTSD. For example, the Severity Measure for Depression—Adult covers 9 items that are rated for frequency of occurrence. This rating can yield a "severity of depression" score for clinical use. In addition, there are disorder-specific severity measures for specific disorders such as depression, panic disorder, etc. The package of emerging instruments also includes personality inventories, ratings of early development and home background, and cultural formulation interviews. As an example, the Personality Inventory for DSM-5—Brief Form contains 25 items that are rated on frequency of occurrence. It measures five personality traits: negative affect, detachment, antagonism, disinhibition, and psychoticism, with each domain consisting of five items. These emerging measures are intended to be administered at intake and throughout treatment in order to track progress, aid in treatment planning, and inform prognostic decision making. The instruments are easy to administer and may be useful for clinical use, but need further development for utilization in research. The instruments reflect the spirit of DSM-5 in acknowledging dysfunctions that extend across diagnoses, and emphasize severity of symptoms or dysfunctions as related to treatment planning.

Assessment of Cognitive Functioning

Neuropsychology is that branch of psychology that investigates brain-behavior relations. In clinical practice the neuropsychologist assesses changes in cognition, affect, and behavior that reflect changes in brain functioning. The ability of current imaging procedures to determine the locus of a lesion and connectivity between brain regions has changed the nature of referrals for neuropsychological evaluation. The current referring questions usually request information concerning the profile of cognitive and behavioral strengths and weaknesses to aid in the development of treatment plans. Representative neuropsychological tests are described in the following subsections and listed in Table 3-4. For a more complete discussion of neuropsychological tests, see Lezak et al. (2004).

Attention

Disorders in attention take many forms, ranging from the simple inability to focus on a stimulus (often impaired in delirium) to impairment of more complex forms of attention, such as the ability to sustain attention over an extended time, to divide attention over more than one stimulus, and to maintain attention under conditions of interference. Inattention to the contralateral side of personal space can occur with lesions in either the left or right cerebral hemisphere but is most common and persistent with right-hemisphere lesions. Other forms of attentional disorders are common after traumatic brain injury, stroke, neurodegenerative disorders, and even normal aging. Information processing speed is a related function and is impaired in many brain disorders as well as mood disorders.

Different instruments are used to measure attention, depending on the aspect of attention under investigation. One of the most frequently used tests is the WAIS-IV Digit Span test. A measure of "attention span," this test requires the patient to repeat a series of digits that increase in length. Asking an individual to repeat the digits in reverse or to report the series of digits in ascending numerical order requires the individual to hold the information in mind briefly while mentally manipulating or reorganizing it. The process of holding information in mind, often referred to as "working memory," requires both maintenance of attention and temporary memory storage. Deficits in working memory occur particularly with lesions of the prefrontal cortex.

The Visual Search and Attention Test (Trenerry et al. 1990) is a cancellation test with rows of characters of which some are the target character to be cancelled. On the most difficult test trial, a variety of symbols are printed in different-colored inks, and the target is defined by both the symbol and color, thus requiring attention to two dimensions. In addition to yielding a total score, the test is scored separately for left- and right-side performance to assess for unilateral neglect.

The computerized Conners' Continuous Performance Test II (Conners 2000) is a measure of the ability to sustain attention. The test requires that the subject press a key whenever any letter except the letter "X" appears on the screen. During the 14 minutes of the test, stimuli are presented at random intervals so that presentation times cannot be anticipated. Scores are provided for a number of measures, including reaction times and errors of omission and commission.

Memory

For an individual to remember an event or a specific fact, the incident must be encoded in sufficient detail to be stored with similar information and organized for ease of retrieval. Disorders of remote memory are rarely due to focal lesions but eventually do occur with dementias. By contrast, the ability to learn and retrieve new information frequently is vulnerable to disruption by emotional and neurogenic factors. Learning and retention are mediated by the medial temporal lobe, particularly the hippocampus and adjacent cortices, and the diencephalon. Any disorder that affects these brain regions can produce impairment in forming new memories. Verbal memory deficits are more pronounced with left-hemisphere damage, whereas nonverbal, such as visuospatial, memory deficits are more pronounced with right-hemisphere damage, although these differences may not always be evident. Although many verbal tests are available to specifically assess the presence of a dominant hemisphere lesion, the only nonverbal measures that appear to demonstrate impairment with right temporal lesions are those that use faces as the target stimuli.

Memory tests designed to assess new learning and retention often involve lists of words, stories, faces, or designs. Patients who have a pronounced impairment in immediate memory may have failed to register or encode the material in sufficient detail for efficient retrieval. However, patients with intact immediate or working memory may demonstrate rapid forgetting or the intrusion of associated events. Memory tests that include both free recall and recognition memory often can identify patients whose problems are mainly retrieval and not encoding; in these patients, recognition memory is intact but free recall is impaired. Moreover, a patient with a unilateral lesion may have a disorder in only verbal or nonverbal memory. Careful selection of memory tests may help identify the underlying problem. Patients with marked depression can perform as poorly as patients with dementia on delayed recall tests but demonstrate quite robust recognition memory.

The California Verbal Learning Test II (Delis et al. 2000) is a word-list learning test designed to assess the use of encoding strategies. Each of the 16 words belongs to one of four categories, and the category items are presented in random order. Patients who utilize the intrinsic association of words within a category to cluster several words have a strategic advantage for later recall. Recall of the words is tested under both uncued and cued conditions, and both free recall and recognition memory are assessed.

Reproduction of complex designs is often used as a measure of nonverbal or visuospatial memory. Tests such as the Wide Range Assessment of Memory and Learning, 2nd Edition (Sheslow and Adams 2003), and the Wechsler Memory Scale, 4th Edition (WMS-IV; Wechsler 2009), provide geometric designs of increasing complexity for the patient to reproduce after a brief interval and offer delayed recall and recognition memory trials. The Complex Figure Test (Rey 1941) presents an intricate design that is first copied and then reproduced from memory 30 minutes later.

The Warrington Recognition Memory Test for Faces (Warrington 1984) presents 50 faces and then presents a pair of faces; in this forced-choice procedure, the patient must select the one that was previously presented. The WMS-IV presents a series of 24 faces and then presents 48 faces one at a time and requires the patient to determine whether each face was or was not previously presented.

Language

Right-handed individuals and most left-handed individuals who have incurred damage to the left cerebral hemisphere will manifest some aspect of a language disorder—that is, an aphasia. The more anterior the lesion, the more likely.it will be associated with disorders of the rate, prosody, and fluency of speech. Temporal lobe lesions, especially those proximal to the first temporal gyrus, are most likely to result in disturbances in language comprehension in the presence of well-articulated speech. Lesions to the left parietal lobe and arcuate fasciculus are likely to result in disorders in syntax and the ability to repeat sentences. A sensitive index of left-hemisphere impairment is an inability to retrieve the exact word that is intended. In general, lesions to the left frontal lobe result in slow, halting speech generating few words per minute, speech sound sequencing errors, and poor prosody, whereas lesions to posterior areas result in language comprehension deficits and expressive language in which the speech sounds are well articulated but contain many semantic and syntactic errors, as well as neologisms.

A comprehensive examination for aphasia tends to include tests of word finding, speech fluency and prosody, language comprehension, expressive syntax and grammar, the ability to repeat sentences, reading, and writing. The Boston Diagnostic Aphasia Examination (Good-glass et al. 2000) and the Multilingual Test of Aphasia (Benton and Hamsher 1989) include sufficient numbers of subtests to provide a comprehensive examination of discrete verbal skills. Many language tests focus on only one language function. The Token Test assesses language comprehension using multistep commands that increase in syntactic complexity (De Renzi and Faglioni 1978). The Boston Naming Test (Goodglass and Kaplan 2000) is a confrontational naming test sensitive to the presence of word finding difficulty. Speech fluency can be assessed by requesting the patient to repeat polysyllabic words (e.g., Methodist-Episcopal or aluminum-linoleum). Speech fluency can also be assessed by requesting the patient to generate words rapidly; for example, the controlled oral word association test (Benton and Hamsher 1989) asks the patient to generate in a minute as many words as possible that begin with a given letter. Other fluency tests ask the patient to generate words belonging to a specific category, such as animals.

Perception

A wide range of reliable visual perceptual tests have been developed, although fewer have been designed to study auditory, tactile, and olfactory perception. Spatial perception in the most basic form can be examined with the Judgment of Line Orientation Test (Benton et al. 1994), which assesses the perception of angular relationships using matching of straight lines presented at the same angles. The perception of formed objects often is examined with matching tasks in which the patient indicates which of a series of forms matches a target form. The forms may be geometric figures or faces (Benton et al. 1994). Speed in matching forms is examined with the WAIS-IV Symbol Search subtest. The more complex task of synthesizing parts into a whole is measured with the Hooper Visual Organization Test (Hooper 1983), in which disarranged fragments of drawings of an object are presented for recognition.

Constructional Abilities

Like any complex activity, constructional tasks require several skills. In the case of visual constructional tasks commonly used in neuropsychological evaluations, these skills include visual processing, planning, and organization in the execution of a drawing or a construction. Many of these tests have a prominent spatial component. Patients with right-hemisphere lesions often produce fragmented constructions with serious distortions. Lesions in other brain regions may affect other features of the production. For instance, patients with frontal lesions may use a disorganized approach and repeat elements. Understanding the qualitative feature of the performance is important for understanding the nature of the deficit.

A task that provides insight into the type of breakdown in constructional ability is the Complex Figure Test, sometimes called the Rey-Osterreith Complex Figure Test (Corwin and Bylsma 1993). A complex geometric design is presented for copy. The copy can be approached in many different ways, and the relative lack of structure of the task is one of its best features. The approach to copying the design gives information about visuospatial processing, planning, organization, and other qualitative features.

Another commonly used constructional task is Block Design from the WAIS-IV. The task is to reconstruct with blocks two-color designs as presented in a booklet. Patients with visuospatial deficits find this test very challenging, whereas those whose major problems are with organization and planning may perform this test better than the Complex Figure Test because Block Design is more structured—that is, there are fewer options for approaching the task.

Executive Functions

Higher-order cognitive processes such as goal setting, planning, organization, adaptive responding, and self-monitoring fall under the umbrella of executive functions. Often, executive functions are assumed to be mediated by the frontal lobes, but many executive tests are sensitive to damage in other parts of the brain. Patients with psychiatric disorders often have executive impairment.

A wide range of tests have been developed to measure specific executive domains. Fluency tests are used to assess initiation and maintenance of behavior. In these tasks, subjects are asked to produce as many items of a designated type as they can think of, which requires initiation and maintenance of strategies for successful performance. In addition to the verbal fluency tests described in "Language" earlier in this section, design fluency tests look at the ability to generate unique designs according to the requirements of the tests. The Ruff Figural Fluency Test (Ruff et al. 1988) presents a series of squares with five dots in each and asks the subject to make patterns by connecting any two or more dots. The object is to make as many unique designs as possible within the time limit.

As mentioned earlier, the Complex Figure Test is a good measure of planning and organization, at least for visuospatial material. Traditionally, planning has been examined with mazes, but various tower instruments have come into favor. These are similar to the familiar Tower of Hanoi puzzle. Tower tasks have in common a series of dowels, usually three, and discs or beads of graduated size. The discs are placed on the dowels, and the patient must move these discs so that they all form a tower of discs of decreasing diameter on one dowel. One can move only one disc at a time and never put a large disc on a smaller disc. The object is to plan ahead so that the task is solved with the lowest number of moves possible (Goel and Grafman 1995).

The ability to form conclusions, draw inferences, and make judgments depends on logical thought. The more severe the brain dysfunction, the more likely reasoning is affected. Many neuropsychological tests of reasoning, such as the Category Test (Reitan and Wolf son 1993), also assess concept formation and cognitive flexibility. To succeed at this test, the subject must identify the Target feature in a set of designs that produces correct responses based on feedback for each response. The correct principle differs for each of the six problem sets. A related test of concept formation and cognitive flexibility is the Wisconsin Card Sorting Test (Grant and Berg 1948). Subjects match cards according to feedback about the correctness of their sorts. A key feature is that after 10 correct sorts, the sorting principle changes without warning, and subjects must change their sorting strategy accordingly. Because of the lack of warning about the change, this test requires the ability to induce a sorting principle; to monitor the adequacy of this solution; and, when the solution is no longer applicable, to note the error, gain perspective, and arrive at a new solution.

Another concept formation test that uses semantic as well as perceptual features as sorting principles is the Delis-Kaplan Executive Function System Sorting Test (Delis et al. 2001). Six cards, each with a word and several distinct perceptual features, are presented to the subject, who is asked to sort the cards into two piles so that the cards in each pile have a common characteristic. The object is to sort the cards as many ways as possible. The main measures are the number of correct sorts and the quality of the description of the sorts.

One reasoning test, the WAIS-IV Picture Completion subtest, has specific application in a psychiatric setting. The patient is shown a picture in which an essential detail is missing. The object is to identify the essential missing feature in each of a series of pictures. As an example, the patient might be shown a picture of a leaf in which an important part of the leaf is missing. If the patient does not focus on the missing detail in the leaf but states instead, for example, that a branch or the tree is missing, then it is inferred that the patient has difficulty distinguishing between the essential and nonessential factors necessary to solve problems. Poor performance on this task is highly correlated with the clinical judgment that the patient's reality testing is poor.

Assessment of Functional Capacity, Social Functioning, and Adjustment

Although the concepts of functional capacity, disability, activities of daily living, social adjustment, and quality of life are overlapping and interrelated in the daily functioning of the individual, each has specific meaning and measurement instruments. The World Health Organization's International Classification of Functioning, Disability, and Health (ICF; World Health Organization 2001) distinguishes impairment (deviations from population norms resulting from psychological and physical symptoms) from activity limitations (difficulties in executing life activities) and from disability (decrements in functions). Patient functioning can be assessed using direct observation, self-report, caregiver or proxy report, and performance-based measures.

The World Health Organization Disability Assessment Schedule 2.0 (WHO-DAS 2.0; Ustün et al. 2010) is a 36-item self-report questionnaire used to assess the individual's activity limitations and participation restrictions for the prior month. The functional roles assessed include understanding and communication, self-care, mobility, interpersonal relationships, work and household roles, and community and civic roles.

The Independent Living Skills Survey (ILSS; Wallace et al. 2000) has a self-report version and an informant's version. The ILSS covers 10 domains of functioning, including personal hygiene, appearance and care of clothing, food preparation, and so on. The Independent Living Scales (Loeb 1996) is a self-report measure of an individual's competency to perform daily activities and self-care.

In working with patients with psychosis, reports by caregivers (when present) are useful because patients with severe pathology such as schizophrenia are often inaccurate in their report of functioning. Most accurate are performance-based skills instruments, such as the UCSD Performance-Based Skills Assessment (Patterson et al. 2001), which assesses the capacity to perform five skill domains critical to independent living (i.e., planning and organization, managing finances, communication, transportation, and household management).

The concept of social adjustment indicates the skill of the individual in handling interpersonal situations, whether at home, in school, or in the work setting. The term has been used more narrowly to indicate the community and social adjustment of diagnosed psychiatric patients, who often have severe illnesses such as schizophrenia and major affective disorder. Notable assessment instruments in this area include the Katz Adjustment Scale—Relative's Form (Katz and Lyerly 1963), the Social Adjustment Scale—Self-Report (Weissman and Both-well 1976), and the Dyadic Adjustment Scale (Spanier 1976). The Social Support Questionnaire (Sarason et al. 1983) is an efficient method for assessing social satisfaction. This instrument provides information about available resources of support and the patient's level of satisfaction with this support system.

Several widely used scales of overall psychosocial functioning (i.e., symptoms, social and occupational functioning) that rate patients on a hypothetical continuum from psychological sickness to mental health are the Global Assessment Scale (Endicott et al. 1976), the Global Assessment of Functioning Scale (American Psychiatric Association 2000), and the Social and Occupational Functioning Assessment Scale (Goldman et al. 1992). All three rating scales are extremely easy to use, are appropriate for use in numerous contexts, and have been shown to be reliable.

The construct of quality of life is multidimensional in nature and includes the psychological, social functioning, and physical domains (and their combinations). Quality-of-life measures such as the Quality of Life Interview (Lehman 1988), the Quality of Life Scale (Heinrichs et al. 1984), and the Wisconsin Quality of Life Index (Becker et al. 1993) are disease specific and intended for patients who are severely or persistently mentally ill. Generic measures appropriate for use with any patient group in-elude the Quality of Life Enjoyment and Satisfaction Questionnaire (Endicott et al. 1993) and the Quality of Life Index (Ferrans and Powers 1985). The Psychosocial Adjustment to Illness Scale (Derogatis 1986) and the Spitzer Quality of Life Index (Spitzer et al. 1981) are health-related measures and assume that the patient is dealing with a medical condition.

Psychological Assessment in the Contemporary Health Care Climate

Once treatment has begun, routine, standardized psychological assessment can track the progress and impact of treatment among individuals and groups (see Overington and Ionita 2012 for a recent review). Clinicians are typically optimistic about the patient's treatment response and at times are inaccurate in their optimism and unaware of treatments that are not working. Many efficient, easy-to-ad-minister omnibus measures have been developed that can quickly (via computerized databases) assess changes in patients' symptoms, behaviors, quality of life, and functional levels during the treatment process. Instruments typical of this type include the Clinical Outcomes in Routine Evaluation Outcome Measure (Barkham et al. 2001), Outcome Questionnaire—45 (Lambert et al. 2004), and Partners for Change Outcome Management System (Miller et al. 2005). These instruments are easy to administer (e.g., taking from 2 to 15 minutes to complete), and they typically cover the three domains of symptoms, well-being, and functioning. These instruments are designed to alert the clinician when the patient is not progressing as expected. With these data, informed decisions can be made about whether the current treatment is effective or whether another treatment should be considered. Possession of such indicators would enable the clinician to flexibly adapt treatment to patient progress and to communicate convincingly with reviewers about the current treatment's effectiveness and the continued need for treatment.

In regard to the ongoing impact of treatment, outcome assessment addresses the immediate and long-term stability of improvements in patients and groups. At the end of treatment and after, psychological assessment can be used to address questions such as "How permanent are the patient's improvements in symptoms of depression?" and "With improvements in mood, has the patient's ability to work and have relationships (functional level) improved?"

Key Clinical Points

• Three types of instruments are used in the assessment of patient functioning: psychological tests, rating scales, and semistructured interviews.
• Tests should meet the standards of both reliability and validity.
• Establishing a test's reliability requires demonstration that the test items are sufficiently closely related to one another to provide relatively stable measurements. Three major types of reliability can be established: test-retest reliability, alternate form reliability, and split-half reliability.
• Establishing a test's validity requires demonstration that the test measures what it is intended to measure. Three major types of validity can be established: content validity, criterion-related validity, and construct validity.
• Major content areas of assessment include symptom constellations, personality disorders and related traits, psychodynamic issues, cognitive functioning, and functional capacity and social functioning.

^* We wish to thank the authors who assisted on previous versions of this chapter: S.W. Hurt, E. Fertuck, and D. Howieson.

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Suggested Readings

Anthony MM, Barlow DH (eds): Handbook of Assessment and Treatment Planning for Psychological Disorders, 2nd Edition. New York, Guilford, 2010

Beutler LE, Groth-Marnat G (eds): Integrative Assessment of Adult Personality, 2nd Edition. New York, Guilford, 2003

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Hersen M (ed): Psychological Assessment in Clinical Practice. New York, Brunner-Routledge, 2004

Maruish ME (ed): The Use of Psychological Testing for Treatment Planning and Outcomes Assessment, 3rd Edition, Vol 3. Mahwah, NJ, Lawrence Erlbaum, 2004

Rush AJ, First MB, Blacker D (eds): Handbook of Psychiatric Measures, 2nd Edition. Washington, DC, American Psychiatric Publishing, 2008