Interest in personality assessment predates the scientific advances in psychological testing. Throughout the ages, people have evaluated their own conduct and the actions of others for the purpose of understanding and predicting behavior. Scientific personality testing has its origins in the study of individual differences through psychological measurement.
Contemporary personality and behavior measures are typically described as being either objective or projective in type. The use of the term “objective” implies that responses are objectively scored and interpreted according to normative data. Examples of the former include comprehensive objective personality tests, behavioral rating scales, and actuarial assessment techniques. We have selected examples of these types of objective personality and behavioral instruments for discussion, as they are the ones the psychiatrist is most likely to encounter in clinical practice. That is, when referring patients for personality testing, there will be a greater likelihood that many of the following will be administered and discussed in the psychologist's report. There will also be a parallel discussion of projective tests.
Comprehensive Objective Personality Tests
Comprehensive personality tests are structured paper-and-pencil self-report instruments whose items are answered in a standard format (e.g., true–false). Usually the patient is the respondent, though some tests utilize the input of significant others. They are scored in a quantitative manner, and resulting numerical scores are subjected to statistical analyses. Typically, a profile is generated that contrasts the patient's scores with those of the normative sample. Normative data are provided in the test manual, as are reliability and validity information.
Minnesota Multiphasic Personality Inventory-2
The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) is the most frequently used personality inventory in clinical practice. In the 1930s, psychiatrists and psychologists had to rely almost exclusively on interview procedures to assist them in making clinical decisions. Starke Hathaway and Charley McKinley, a psychologist–psychiatrist collaborative team at the University of Minnesota, published the original MMPI in 1943. It was developed entirely from an empirical perspective, with response items chosen solely on the basis of their ability to distinguish among cohorts of psychiatric patients with given disorders. This 566-item true-false test was designed to yield 10 clinical subscales: Hypochondriasis, Depression, Hysteria, Psychopathic Deviate, Masculinity–Femininity, Paranoia, Psychasthenia, Schizophrenia, Hypomania, and Social Introversion. For ease of communication, each scale was given an associated number. For example, Hypochondriasis = 1, Depression = 2, and so forth. Psychologists typically refer to these numbers when discussing an MMPI profile among themselves, as many scale names are clinically outdated (e.g., Psychasthenia). In addition, there are multiple validity scales available which measure the respondent's test-taking attitude (e.g., defensiveness, exaggeration of symptoms). Sets of items selected for inclusion in the test's final version differentiated a specific clinical sample (e.g., depressed patients on the Depression subscale) from the normal subjects who comprised the standardization group.
The MMPI was revised in 1989 as the MMPI-2, which consists of 567 self-descriptive statements. In the revision, several original items were reworded or deleted, and statements focusing on suicide, substance abuse, and related matters were added. The revised version also includes a standardization sample that is more representative of the U.S. population (based on census data). In 2003, an extensive project was completed that restructured the clinical scales of the MMPI-2 and anchored them in an empirically derived factor structure. Another extensive revision of the MMPI-2 is reportedly soon to be published, reducing its length and revising the primary clinical scales. These changes guarantee that the MMPI-2 and its successors will continue to play an important role in the assessment of psychopathology, though its evolution as an instrument raises many questions about validity and utility that will need to be addressed by careful research.
Interpretation of the MMPI-2 is based primarily on a profile analysis consisting of two or three highest scale elevations. Scales with T scores of 65 or above are considered clinically significant. Abnormally low scores are interpretable. Numerous books are available to help the clinician interpret specific code types. The basic profile form of a hand-scored MMPI-2 is shown in Figure 6–1. The patient's profile suggests a depressive disorder with possible cognitive changes or even psychotic involvement (elevated Depression and Schizophrenia scales) in an individual who is overly dependent, self-centered, and naïve about their own feelings and motivations (elevated Hysteria scale).
Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Profile for Basic Scales. (Copyright © 1989 the Regents of the University of Minnesota. All rights reserved. “MMPI-2” and “Minnesota Multiphasic Personality Inventory-2” are trademarks owned by the University of Minnesota. Reproduced by permission of University of Minnesota Press.)
Personality Assessment Inventory
The Personality Assessment Inventory (PAI) was constructed in 1991 by Leslie Morey, then a professor of psychology at Vanderbilt University, with the goal of closely corresponding to contemporary psychiatric concepts and diagnostic nomenclature, such as found in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The test consists of 344 items answered on a four-point Likert-type format: totally false, slightly true, mainly true, and very true. In addition to the 11 clinical scales (diagnosis), there are 5 treatment consideration scales (prognosis), 2 interpersonal scales (social support), and 4 validity scales. The clinical scales are Somatic Complaints, Anxiety, Anxiety-Related Disorders, Depression, Mania, Paranoia, Schizophrenia, Borderline Features, Antisocial Features, Alcohol Features, and Drug Features. An important feature of the PAI scales is that they are further divided into subscales that reflect specific components or subtypes of a given disorder. For example, a patient's specific manifestation of anxiety may be as excessive worry and concern (i.e., cognitive) rather than trembling hands (e.g., physiologic). The treatment scales (Suicidal Ideation, Treatment Rejection, Nonsupport, Stress, Aggression) also provide the clinician with pertinent information for treatment planning, an especially useful feature of this test.
Applications and Limitations of Comprehensive Personality Tests
The MMPI-2 and PAI are two important objective personality inventories for diagnostic classification and treatment planning. The empirically developed MMPI-2 is used primarily for spotlighting acute psychiatric (Axis I) issues and for identifying patients’ psychopathological patterns that may not be explicitly apparent to either the patient or the clinician. The PAI is a more “face-valid” test; that is, the scales correspond, often very explicitly, with current psychiatric (DSM) conceptions of Axis I disorders and Axis II personality disorder criteria. Though designed to be an improved MMPI-2, most clinicians who have used both have found each to contribute uniquely useful information to the assessment process, as reflected by the immense popularity of both instruments.
There are several advantages to using comprehensive personality measures. They are relatively simple to administer. The arduous task of data entry, scoring, and calculating scales may be accomplished by computer. Test manuals provide standardization and psychometric information (e.g., validity and reliability data) for the user, as well as guidance in clinical interpretation. Comprehensive personality instruments also have limitations. They are primarily behavioral in content and may provide inadequate information about the respondent's underlying motives or psychodynamics. For example, two patients may produce identical profiles indicating that they feel depressed and anxious. In one case the symptoms may be the result of acute situational stress (e.g., financial reversals), whereas in the other case, the symptoms may be long-standing and connected to historical issues, such as unresolved childhood trauma. Further, the prescribed objective response method (e.g., true-false or four-point scale) prevents patients from elaborating or qualifying their responses.
Butcher JN, Dahlstrom WG, Graham JR, Tellegen A, Kaemmer B: MMPI-2 (Minnesota Multiphasic Personality Inventory-2: Manual for Administration and Scoring, Revised Edition. Minneapolis, MN: University of Minnesota Press, 1989.
Morey LC: An Interpretive Guide to the Personality Assessment Inventory (PAI). Odessa, FL: Psychological Assessment Resources, 1996.
Tellegen A, Ben-Porath S, McNulty JL, Arbisi PA, Graham JR, Kaemmer B: The MMPI-2 Restructured Clinical (RC) Scales. Minneapolis, MN: University of Minnesota, 2003.
Behavioral rating scales are objective scales that may be self-administered or, especially when used with children or severely impaired individuals, rely on the reports of knowledgeable informants. These scales usually focus upon a single disease construct (e.g., depressive symptoms, obsessive–compulsive symptoms, PTSD symptoms) or upon a set of specific behaviors of interest in a given population, such as ratings of childhood behavioral problems. The scale's scores are then typically compared to normative data in the form of averages or cutoff points identified by research as optimal in predicting a given criterion. Behavior rating scales tend to be more focused on a given set of behaviors or symptoms, or are developed on a given subpopulation (e.g., children, PTSD victims) than comprehensive personality tests. As such, they may be more limited in scope, but may assist the clinician in specifically elucidating a patient's clinical presentation in a more complete fashion.
The chapters in this volume on child assessment reference some of the most widely used comprehensive child behavior rating scales (e.g., Child Behavior Checklist). Adaptive behavior rating scales for children and adults, such as the Vineland Adaptive Behavior Scale, provide standardized procedures for assessing functional abilities, key to the assessment of mental retardation, and other developmental disorders. These tests, and ones like them, are in reality collections of multiple behavior rating scales that are conormed on a single population and designed to tap several domains of behavior.
Beck Depression Inventory
One of the most widely used rating scales is the Beck Depression Inventory, now in its second version. Though often used to aid in diagnosing depression, its major utility is in measuring the severity of self-reported depressive symptoms, and in describing the particular manifestation of depression in a given patient. It contains self-rating items of all the DSM criteria of depression, as well as other changes commonly experienced in depressive patients. A simple glance at the rating form yields a wealth of information, such as the overall severity of the symptoms, and whether the patient's symptoms are more physiological, cognitive, or mood-oriented in nature.
Applications and Limitations of Behavior Rating Scales
Many advantages of behavioral rating scales have already been mentioned. They represent powerful tools in assessing the severity of psychiatric disorders and in illuminating the nature and characteristics of many behavioral syndromes. The sheer wealth of scales is almost bewildering: for nearly any given disorder, the clinician or researcher will have an array of well-researched instruments from which to choose. Their utility is in great demand whenever objective, repeatable, quantifiable data are required to assess patients’ progress in treatment, the efficacy of new research treatments, or the measurement of quality outcomes.
Their very specificity unfortunately contributes to some of their disadvantages. By focusing only on a given syndrome or symptom cluster, the use of a targeted rating scale may serve to mask initial diagnostic errors because symptoms from other syndromes may not be assessed. Perhaps their greatest weaknesses are apparent in the forensic assessment context. In most cases, the scales are so transparent (“face-valid”) that it is easily apparent to the respondent exactly what disorder or set of behaviors is being assessed by the scale. Few of the measures have acceptable validity indexes to identify the impact of potentially defensive responding or malingering. Even unintentional false reporting, such as by a frustrated parent who is at wit's end over a child's disruptive behavior, or a parent who is determined to cast their child's conduct problems in an acceptable light by over-endorsing depressive symptoms, can muddy the conclusions. In sum, the utility of these scales is quite limited in the forensic realm, and are best used in the context of a comprehensive, multimodal assessment.
Beck AT, Steer RA, Brown GK: BDI-II Manual. San Antonio, TX: Psychological Corporation: 1996.
Bellack AS, Hersen M: Behavioral Assessment: A Practical Handbook, 4th edn. Upper Saddle River, NJ: Allyn & Bacon, 1998.
Actuarial Assessment Techniques
Actuarial measures are assessment methods based purely on given patient characteristics, demographic information, and historical data that are mathematically combined to make probabilistic classifications of patients (e.g., risk of violence or likelihood of responding favorably to a given type of treatment). However, for many clinicians, the thought of basing treatment or placement decisions on actuarial descriptors or cut scores may seem foreign, if not repellent. Yet there are psychiatric evaluation contexts that sometimes require the input of such techniques. For example, the psychiatrist who assesses a patient's suicide risk by asking about history of prior attempts, current plans, intentions, means, age, level of stress, and religiosity is in fact using an informal analogue of an actuarial process to make a critical determination. Attempts to more rigorously codify systems for assessing suicidal risk have met with some success (e.g., Suicide Potential Scale).
Actuarial techniques are most often appropriate in clinical situations in which a decision must be made in one direction or the other, regardless of the quality of the data, because of the gravity of the potential outcomes. In addition to suicide risk, the most common situations requiring an estimate of risk usually revolve around violent behavior. Multiple actuarial rating systems have been researched and developed in this area, including aids to the evaluator involved in assessing risk of sexual reoffending (e.g., STATIC-99), risk of suicide (e.g., Suicide Potential Scale), and risk of violent reoffending in individuals with a known history of violence (e.g., Violence Risk Assessment Guide, or VRAG).
Violence Risk Assessment Guide
The latter technique, the VRAG, is the product of an extensive research program on violent offenders in a maximum-security institution in Ontario. The VRAG represents a typical actuarial procedure. The patient is rated on several static dimensions, such as the nature of their offense, the presence of a psychotic disorder, age, presence of childhood conduct disorder, and several other variables. The patient is also subjected to an interview with the Hare Psychopathy Checklist, a semistructured interview technique designed to identify the degree of a patient's psychopathy, or tendency to demonstrate personality characteristics shown to be related to serious acts of violence (see Table 6–1).
Table 6–1. Hare's Characteristics of Psychopathy ||Download (.pdf)
Table 6–1. Hare's Characteristics of Psychopathy
Glib, slick, and smooth in social interactions.
Possessing an inflated sense of importance and self-assuredness
Lack of remorse
Unconcerned about others’ distress, disdainful of victim's feelings
Lack of empathy
Unable to place oneself in the inner world of another person, callous
Deceitful, shrewd, cunning, manipulative
Acts without considering consequences, reckless, displays anger with little provocation
Pathological need for excitement and a sense of risk
Lack of responsibility
Parasitic lifestyle, promiscuous sexual behavior, failure to meet obligations
Lack of goals
Aimless lifestyle, no sense of purpose
Pattern of rights violations beginning in childhood or adolescence
A diverse pattern of adult antisocial behaviors, career criminality
The patient's overall score is then compared to a sample of offenders with a known recidivism rate, and a probability value of future reoffending is assigned. While marked by a large error rate, this method is considerably superior to nonquantitative clinical judgments of violence risk made by psychologists and psychiatrists. This and similar methods are now commonly used in forensic consultation, and have been accepted for use by the courts in multiple court decisions.
Applications and Limitations of Actuarial Methods
The advantages to the psychiatrist in utilizing these actuarial methods, when available, are considerable. In addition to providing a check on personal biases and minimizing the inherent inaccuracy of general impressions based on a global impression of the patient, professional risk issues are minimized. By definition, these techniques represent the standards generally accepted by the mental health community, and thus would presumably serve as a powerful protective measure in the unhappy event of liability litigation following a patient committing a violent act. Disadvantages include the fact that the error rates of these methods, though superior to clinical judgment, remain very high. Presumably, many more predictive factors or combinations thereof need to be identified in order to reduce the error rate. Such methods also do not usually take into account dynamic factors such as availability of treatment, compliance with treatment, intrapersonal changes due to the consequences of past acts of violence, or the impact of supervision and scrutiny, to name a few. Consequently, actuarial analysis is best employed as an adjunct to, not a replacement for, comprehensive psychological or psychiatric assessment.
Cull JG, Gill WS: Suicide Probability Scale Manual. Los Angeles, CA: Western Psychological Services, 1991.
Hanson RK, Thornton D: The Static-99: Improving Actuarial Risk Assessments for Sex Offenders.
User Report 99–02. Ottawa: Department of the Solicitor General of Canada (www.sgc.gc.ca
Hare RD: The Hare Psychopathy Checklist-Revised. Toronto, ON: Multi-Health Systems, 1991.
Quinsey VL, Harris GT, Rice ME, Cormier CA: Violent Offenders: Appraising and Managing Risk. Washington, DC: APA Books, 1998.
Projective Personality Tests
As opposed to objective personality testing, in projective personality testing, the individual is provided unstructured test stimuli (e.g., inkblots, incomplete sentences, pictures of human figures) and required to give meaning to them. The theoretical assumption is that the patient's responses reflect primarily a “projection” of the individual's inner needs, motivations, defenses, and drives. That is, tests are intended to elicit a projection of unconscious material from the subject's inner life. In theory, the manner in which the patient organizes and perceives the ambiguous test stimuli reveals something about his or her distinctive personality. There are objective scoring systems for some projective tests, such as the Exner Comprehensive Scoring System, one of the most sophisticated and widely used for the Rorschach. However, some clinicians prefer to make psychodynamic interpretations from the thematic content of the patient's Rorschach responses, arguing that they are achieving a much richer understanding of the patient than that provided through more sterile numerical analysis of the person. Proponents of objective personality inventories often criticize their counterparts who favor projective testing for not meeting higher standards of validity, reliability, and standardization. Many clinicians, however, utilize a test battery of both objective and projective tests when performing a psychological workup on a patient. Such a strategy will likely result in a more comprehensive evaluation of a patient and provide more confidence in replicated findings from different types of test stimuli. Three of the projective tests that have stood the proverbial “test of time” are the Rorschach Inkblot Test, the Thematic Apperception test (TAT), and the Sentence Completion test (SCT).
The Rorschach Inkblot Test was the creative effort of a Swiss psychiatrist, Hermann Rorschach, who first published the test in 1921. Out of several hundred inkblot configurations, he selected 10 cards because of the variety of responses they elicited. Five of the bilaterally symmetrical inkblots are achromatic, two have additional spots of red, and three combine several colors (Figure 6–2).
Rorschach Test Plate 1, by Rorschach H. (Copyright © 1921, 1948, 1994 by Verlag Hans Huber AG, Bern, Switzerland. Reproduced by permission.)
During the test administration, the examiner asks the patient what each card looks like (i.e., “What might this be?”). The examiner then records the patient's responses verbatim, the time it takes to generate responses, and any nonverbal reactions. After the responses are compiled, the examiner asks the patient to go through the cards again. This is referred to as the inquiry phase. In the latter phase, the examiner is attempting to identify the factors influencing the response—what parts of the blot are used and what features made the blot look a certain way (e.g., color, movement, texture, shading, and form). All of these factors are interpretable. For example, perception of movement (e.g., the percept of a bird in flight) is considered to relate to the richness of an individual's fantasy life. The form determinant (e.g., how closely the response corresponds with the selected area of the inkblot) is believed to indicate an individual's reasoning powers and reality testing. Persons with good psychological functioning tend to have refined and differentiated perceptions, whereas the perceptions of psychologically impaired persons generally fit poorly with the form of the blot associated with their response. Color responses are believed to reflect the emotional life of the respondent. For example, pure color responses (i.e., the blot color itself stimulates the respondent's associative process) are considered to reflect an individual with poorly integrated emotional reactions. Location choice (e.g., the area of the blot where the respondent associates his or her response) is also considered to reflect something about one's personality. For example, an emphasis on very small details is considered to reflect an individual who has a very critical attitude or is overly concerned with trivialities.
Responses are analyzed in terms of the number that fall into various categories (e.g., movement, form, location), the normative frequency of these categories for different clinical groups, and the relationships among determinants (i.e., ratios such as percentage of conventional form). Psychodynamically oriented examiners also interpret the content of responses in terms of symbolic meaning (e.g., perception of an island may reflect a sense of isolation). When interpreted within the respondent's specific experiences, the latter analyses are believed to reveal a great deal about an individual's unique personality style.
A number of Rorschach scoring and interpreting systems have been developed since its inception. Irving Weiner and John Exner have attempted to put contemporary Rorschach assessment on a psychometrically sound basis. For instance, the Exner Comprehensive Scoring System emphasizes structural rather than thematic content of responses. This complex scoring system involves categorizing responses in an objective manner by converting them into ratios, percentages, and other indices. Interpretations are primarily data based rather than theoretically based. The Exner system has been well received by the current generation of Rorschach testers whose graduate training has emphasized the importance of psychometric standards in assessment.
Thematic Apperception Test
The TAT was developed in 1943 by Harvard psychologist Henry Murray. The test consists of 29 pictures and one blank card. The cards have recognizable human figures (Figure 6–3), and the patient is asked to generate a story of what is happening in the scene. The subject is asked to tell what led up to the situation, what the people are thinking and feeling, and how the situation will end. There is significant variability in the scoring of TAT responses. Some examiners prefer a more intuitive approach to understanding the psychodynamic implications of a story; others favor a more complex scoring system (e.g., Murray's drive system analysis). In the former case, the psychologist attempts to identify significant emotions and attitudes projected onto the cards. Each card is intended to elicit information about a specific type of relationship (e.g., child–mother, child–father) or an important psychological area (e.g., sexuality). Themes that recur with unusual frequency are judged to reflect prominent psychological needs. As on the Rorschach, the examiner records the verbatim responses of the examinee for later analysis. Because of their real-life content, TAT stimuli are less ambiguous than are Rorschach cards.
Card 12F from the Thematic Apperception Test. (Reprinted by permission of the publishers from Henry A Murray, Thematic Apperception Test, Plate 12F, Cambridge, Mass.: Harvard University Press, Copyright © 1943 by the President and Fellows of Harvard College, © 1971 by Henry A Murray.)
Sentence Completion Tests
Like the Rorschach and the TAT, SCTs are used frequently in personality assessment. They generally consist of a number of incomplete sentences (e.g., I feel guilty when….) that are completed by the patient. They are intended to provide information about the respondent's interpersonal attitudes and relationships, personality style, and other issues that are important to the examiner. The referral questions will help determine which one of several different published SCT versions is used in a given case. Many psychologists would agree that the SCT is more likely a semiprojective test because the items are more transparent than are the Rorschach inkblots and the TAT cards. As psychologists who have reviewed these instruments have pointed out, incomplete sentences are among the least researched of projective methods. They appear to persist because, like a slot machine, there is an intermittent payoff in their usage. It may be that some patients are more comfortable communicating information to the clinician in a written form than they are in the face-to-face conversational context.
Application of Projective Personality Tests
Psychodynamically oriented psychologists use the Rorschach as part of a test battery for evaluating clinical issues such as the degree of a patient's cognitive–perceptual pathology. For example, to evaluate whether a patient has a low-grade thought disorder, the psychologist may examine the Rorschach protocol in terms of idiosyncratic responses with a distorted form level. Further, persons with a thought disorder often emit three types of pathologic responses: (1) confabulated whole responses (using a single detail as a basis for an entire response, for example, “This looks like a whisker, so the rest of the card is a cat's face.”); (2) fabulized combinations (making one incongruous concept out of two percepts in close physical proximity, for example, “This looks like a bridge and this looks like legs, so this area is a bridge with legs.”); and (3) contaminated responses (seeing two different things at the same blot area and then fusing them together, for example, “This is a dog. It's a bug. No, it's a dog-bug.”). In these responses, the patient is demonstrating inadequate conceptual boundaries, as well as confusion in thought, perception, and reasoning. The Rorschach is also useful for generating hypotheses about the individual's personality style; however, psychologists often look for collateral support for their inferences about personality style in the patient's objective personality data, interview statements, and case history. The TAT and the SCT are used primarily to generate hypotheses about an individual's family and social relationships, areas of conflict, and related Axis II issues.
Advantages and Limitations of Projective Personality Tests
Some controversy surrounds the use of projective personality tests. Many clinicians find the instruments described here as highly useful for diagnostic purposes and for evaluating personality functioning. However, results of studies examining the psychometric properties of these tests at best have yielded equivocal results, perhaps with the exception of elements of the Exner Comprehensive Scoring System for the Rorschach Inkblot Test. Nonetheless, a sizable number of clinicians continue to argue that projective personality tests should not be subject to standard psychometric evaluation and that such attempts are damaging to the potential richness of these methods for understanding an individual's distinctive personality. It is highly unlikely that these differences will be resolved anytime soon.
Exner JE: The Rorschach, Basic Foundations and Principles of Interpretation, 4th edn. New York: John Wiley & Sons, 2002.
Clinical Decision Making in Personality Assessment
Following the gathering of test data, the psychologist analyzes the materials for purposes of clinical decision making and prediction, and endeavors to address the specific referral questions. If testing included both objective and projective measures, then the examiner performs two functions—one being that of the psychometrist or actuary who minimizes subjective interpretation, and the other that of the clinician who relies heavily on clinical interpretation and behavioral observations. The objective of such a dual role is to use separate data points as a means of cross-validating the ultimate conclusions. For example, if a patient scores several standard deviations above the mean on the MMPI Schizophrenia scale, the clinician anticipates bizarre responses (e.g., contaminated responses) on the Rorschach, and would expect behavioral observations to support the presence of disordered thought and behavior. If these assumptions are correct, then there is increasing support for the presence of a psychotic adjustment. If not, then an alternative explanation is sought.
After analyzing the data, the psychologist communicates the findings, resulting clinical impressions, and any treatment recommendations to the referring psychiatrist in the form of a psychological test report. The report is crafted to communicate a meaningful picture of the patient in a format most useful for the referring physician. For example, a psychodynamically oriented psychiatrist generally prefers a report that helps him or her better understand the patient from that perspective. A psychiatrist whose practice is primarily medication focused may prefer a report that focuses on specific symptoms, suggested by objective testing, that the psychiatrist can address pharmacologically. The psychiatrist may also ask that a patient be retested after treatment to assess quantitatively the effectiveness of his or her intervention. With the psychiatrist's approval, the psychologist will review test findings with the patient. However, psychotherapy-oriented psychiatrists often prefer to have their patients discover insights for themselves, rather than from reading the psychological report.
An example of a psychological test report follows. A pretest interview was conducted with the patient, as with all testing cases. The goals of the interview are to establish rapport, gain clinically useful information, and address any concerns that the patient may have about the evaluation.
Psychological Test Report
The patient is the 19-year-old son of a hard-driving and successful attorney living in a medium-sized southeastern city. The patient's father was very concerned about his son's suspension from an Ivy League college for academic reasons. According to the father, the patient appeared depressed, withdrawn, and somewhat uncommunicative since his return home. He sought only minimal contact with long-time friends attending a local college. The patient's inability to hold down a job as a salesman in a small store owned by a family friend was embarrassing to the patient's parents. His father consulted with a physician friend who recommended that the patient be referred to a psychiatrist for a formal evaluation. The psychiatrist requested a testing consult from a clinical psychologist.
MMPI, Wechsler Adult Intelligence Scale-Revised (WAIS-R), PAI, TAT, Suicide Probability Scale (SPS), SCT, Rorschach Inkblot Test
The patient, a 19-year-old single male, was referred by his psychiatrist for psychological evaluation. The focus of this assessment was to explore whether the patient's recent emotional, academic, occupational, and social dysfunction are related to individual or family dynamic issues or are a manifestation of some other more malignant underlying pathology.
The patient reported that he was suspended by his university for academic failure after one semester but hoped to reenroll this coming fall. He noted that, despite experiencing no academic difficulties in high school, “a lot of stuff happened at [college].” He specified that motivational difficulties (inability to get out of bed) and increasing alcohol abuse contributed to his academic troubles. He denied the use of other illicit substances. He added that he initially was comfortable with the move away from home and family to a new city and college dorm life. However, he then became progressively more isolated, socially disconnected, and lonely. The patient claimed, “Even in a room full of people I would feel left out.” He further qualified that such a situation did not always distress him, as he sometimes preferred to remain aloof, withdrawn, and to “wallow in my misery.” He claimed that his pattern of isolation was long-standing, but not as frequent or severe as it became in college. He admitted to periods of depressed mood of varying severity, during which his preference for isolation was enhanced. The patient endorsed passive thoughts of suicide in the past but denied urges to act on impulses for self-harm or elaboration of a plan to do so.
The patient revealed a number of idiosyncrasies centering around social interaction. For example, he admitted to often pretending that one of his friends or acquaintances is riding in the car with him, or sitting in his bedroom with him, and he will rehearse how he would act if the person were really present. He acknowledged that such fantasy is much less threatening than social reality, as it “gives me an idea of what I’d be like in front of others and helps me boost my self-image.”
He mentioned that his deflated self-image and low self-esteem have troubled him throughout his life. He claimed that he continually worries “if I’m good enough” and that he will “mess up.” The patient stated that his parents, especially his father, often reacted to his mistakes with “a lot of yelling and shouting, and making me feel guilty.” He described his relationship with his parents and only sister to be much like his social experiences, characterized by a lack of connectedness and belongingness. In reference to his father, the patient said, “I have no real connection, I guess; I don't identify with him and don't even really talk to him.” However, the patient added that his father had “smoothed out” after having a heart attack a few years earlier, resulting in him being more talkative than volatile. Still, the patient denied the growth of a close emotional bond with his father.
The patient was employed by a local sporting goods store after being dismissed from college, but he was fired because of “disagreements with the boss.” He stated that he is not presently in a romantic relationship but has been in the past. Interestingly, he described past sexual experiences as “emotionally confusing,” adding, “I want more than just a squeeze toy, I want someone I can talk to.”
The patient achieved an estimated Full Scale intelligence quotient (IQ) score of 105 on selected subtests of the WAIS-R, which places him in the average range of intellectual functioning. His Verbal scale IQ score of 107 and Performance scale IQ score of 102 are also within the average range. Although the patient's Verbal–Performance IQ score discrepancy (5 points) is not diagnostically significant, his inter- and intratest scatter suggests the likelihood of a disruption in cognitive functioning. This is further indicated by the pattern of WAIS-R subtests on which he performs best (Vocabulary, Information) and worst (Comprehension, Similarities, and Digit Symbol). Based on these findings, one would anticipate that academically he performed best on courses depending on long-term memory (e.g., history) and poorest on those requiring complex abstraction and new learning. His social judgment is also likely poor. Finally, it appears that his cognitive inconsistency has resulted in lower-than-expected IQ scores.
On objective testing (MMPI, PAI), the patient's profiles consistently suggest someone emphasizing his problems, perhaps making a “plea for help” in the midst of intense psychological turmoil. His MMPI profile is invalid because of excessive endorsement of pathologic items. That is, he overstated his symptoms to an unusual degree. His PAI profile is remarkable for symptoms of depression, anxiety, and assent to disturbed thought processes. Individuals with similar profiles often experience feelings of hopelessness, worthlessness, and personal failure. Their affective distress is often accompanied by a backdrop characterized by social isolation and detachment. They typically have few interpersonal relationships that could be described as deep, close, and supportive. These individuals experience great ambivalence between urges to fulfill unmet needs for affiliation and belongingness and the threatening anxiety they feel related to intimate involvement.
The patient's scores on both the SPS and PAI Suicidal Ideation Scale indicate that he is experiencing intense and recurrent thoughts related to suicide. He should be considered at serious risk for self-harm.
Projective test results also suggest that the patient is experiencing substantial psychological turmoil at this time. Numerous responses on the Rorschach reflect inner disharmony, intense anger, and a possibly burgeoning paranoid cognitive process. A review of his Rorschach protocol reveals descriptors such as “frightening” and “menacing” to card 3 (see Figure 6–2) and “mad,” “angry,” “being attacked,” “decaying,” and “about to collapse” to other cards. These projections lead to speculation that the patient is externalizing the emotions and sense of deterioration that he is experiencing internally. The lack of human content perceived on the Rorschach suggests that the patient has likely established a wall between himself and others and is experiencing significant social isolation.
The patient's TAT scenarios provide rich themes of disruptive relations with each parent figure. The patient described a card depicting a father–son interaction as “two ships passing in the night as the father has no awareness or insight into the son's emotional needs.” To the family card, he referred to the figures as immersed in their own activities while the son is left to feel “lonely, depressed, and unneeded.” He responded to the mother–son card with a scenario in which the child is confused as to what he needs to do to gain his parents’ approval or positive attention. Of concern, the patient responded with an upbeat theme of contentment to a TAT card that often generates depressive and sometimes suicidal scenarios.
On the SCT, the patient also provided prominent themes of detachment from parental figures, loneliness, rumination, and social isolation. Most alarming is “Sometimes… I think about my own funeral.” After the four SCT stems “I am,” the patient responds: “lost,” “worried,” “alone,” and “exhausted.”
Although the patient denied suicidal ideation or impulses on interview, test results (SPS, PAI, TAT, SCT) consistently suggest that he may be experiencing severe and recurrent thoughts related to self-harm at this time. Close monitoring of the patient in this regard is indicated, with consideration of future hospitalization if warranted. His tendency for isolation and excessive rumination, his apparent perplexity and apprehension about his own functioning, his lack of perceived support, and his age all combine to make him a worrisome patient.
The patient's overall personality test data (including Rorschach perceptions of “decay” and things “collapsing”) likely reflect on the patient's own subjective experience of decline. The patient appears preoccupied with his symptoms and failures to the extent that he has lost all interest in others. So apprehensive is this morbid self-concern that the patient appears to be exhibiting profound passivity and social lethargy and, for all practical purposes, appears to be approaching virtual immobility. The patient reported spending much of his day in his room, withdrawn from peer or substantial familial interaction. We would also anticipate that he is moving in the direction of the bottom of the mood cycle with recurring self-annihilative thought content.
On the SPS he responded that he feels he cannot be happy no matter where he is and that the world is not worth continuing to live in. His morbidly depressed feeling tone may reflect grieving over loss of functioning or a component of a possible schizoaffective disorder. We suspect that the patient was able to function academically in a highly structured high school environment but was also perceived as “odd” by teachers and peers. However, the transition to a less-structured college situation may have highlighted how poor his adjustment actually was. Further complicating the situation are his family dynamics, which leave him feeling even further disconnected and unsupported. A major concern in this case is that the patient may be developing a chronic pattern of apathy, dysfunction, severe social disruption, and peculiarity. That is, an evolving schizophrenic or schizoaffective disorder cannot be ruled out.
In addition to pharmacologic management of his cognitive and affective disturbances, some important practical issues will need to be addressed. The patient reported that he anticipates returning to college in the fall. It is difficult at this point to envision that being anything other than another failure experience. He will likely have significant difficulty in attention, persistent concentration, and processing of complex intellectual tasks. If his condition is stabilized by medication, a less severe transition might be considered. For instance, living at home and taking a significantly reduced college course load at a less academically stressful local institution might be worth a try. However, even that might prove a stretch.
An alternative would be referral to a vocational rehabilitation service that could evaluate and direct the patient to an appropriate training or work situation that would be low pressure and highly structured. The patient would likely confront serious difficulties if he tried on his own to enter a competitive work environment. However, with his family background, if he chose the latter option, a job such as a clerk in a hospital medical records’ division might be a consideration. Perhaps this option would be more attractive to him and his high-achieving family than would blue-collar work. Further, it would entail relatively limited public contact.