Clinical assessment involves evaluating a patient's physical condition, diagnosing any issues, and determining a prognosis. This includes gathering information from examinations, medical history, and tests. Assessment tools fall into three categories: clinical interviews, tests, and observations. Clinical interviews involve collecting detailed personal history through structured or unstructured questioning. Tests include projective tests, personality inventories, physical exams, and intelligence tests. Together, these tools provide reliable and valid information to diagnose and treat patients.

2. Clinical Assessment
• an evaluation of a patient's physical condition and prognosis based on
information gathered from physical and laboratory
examinations and the patient's medical history.
Diagnosis
• a way of diagnosing and planning treatment for a patient that
involves evaluating someone in order to figure out what is wrong
- refers to the identification of the nature or
cause of a disease or disorder
Prognosis - refers to a forecasting or prediction about the
likely outcome or course of a disease

3. Clinical
interviews
Clinical assessment tools
fall into 3 categories:
Tests Observations

4. Characteristics of Assessment Tools
R V
eliable alid
Reliability - refers to the consistency of a test
Validity - refers to the accuracy of a test’s results

5. Clinical
interviews
Clinical assessment tools
fall into 3 categories:
Tests Observations

6. Clinical Interviews
• Face-to-face encounters
• used to collect detailed information, especially personal history, about
a client
• focus of an interview depends on the interviewer’s theoretical
orientation
✓ Unstructured Interview
✓ Structured Interview
> clinicians ask open-ended questions
> clinicians ask prepared questions
History of the Patient
Mental Status Examination

7. History of the Patient
- include the circumstances of the interview
1. Basic information
- sources of the information obtained and their reliability should
be mentioned at the beginning of the psychiatric history
2. Chief Complaint
- it should be written exactly as the patient states it; individuals
accompanying the patient can add their version of what the
patient is presenting to the physician

8. History of the Patient
- the most useful part of the history in terms of making a
psychiatric diagnosis
3. History of the Present Illness
- It should contain a comprehensive, chronological picture of the
circumstances leading up to the patient’s first encounter with the
physician.
4. Psychiatric Health
- patient’s previous encounters with psychiatrists and other
mental health therapists should be listed in chronological order
- Include details such as the first appearance of the symptoms, in
what order, and at what level of severity.

9. History of the Patient
- any medical illness, hospitalizations and surgeries should be
included along with their dates. Episodes of head trauma,
seizures, neurologic illnesses or tumors, and positive assays for
human immunodeficiency virus (HIV) are all pertinent to the
psychiatric history.
5. Medical History
6. Medications and allergies
7. Family History
- include a brief statement about the patient’s family history of
psychiatric as well as medical disorders

10. History of the Patient
- the prenatal and perinatal history of the patient; childhood
history; occupation history; marital and relationship history;
education; religion; friendship; drug and alcohol history; current
living situation
8. Social History
9. Review of Systems
- a systematic review should be performed with emphasis on
common side effects of medications and common symptoms that
might be associated with the chief complaint

11. Clinical Interviews
• Face-to-face encounters
• used to collect detailed information, especially personal history, about
a client
• focus of an interview depends on the interviewer’s theoretical
orientation
✓ Unstructured Interview
✓ Structured Interview
> clinicians ask open-ended questions
> clinicians ask prepared questions
History of the Patient
Mental Status Examination

12. Mental Status Examination
The mental status examination comprises the sum total of the
physician’s observations of the patient at the time of the
interview. This examination can change from hour to hour,
whereas the patient’s history remains stable.
1. General description
- patient’s overall appearance should be recorded including
posture, poise, grooming, and clothing; take note of signs of
anxiety such as wringing of hands, tense posture, clenched fists,
or wrinkled forehead

13. Mental Status Examination
2. Mood and Affect
Mood is the emotion (anger, depression, emptiness, guilt, etc.)
that underlies a person’s perception of the world.
Affect is the person’s emotional responsiveness during the
examination as inferred from their expressions and behavior.
3. Speech
- describe the physical characteristics of the patient’s speech;
rate, tone, volume, and rhythm should be made; note the
impairment of speech such as stuttering

14. Mental Status Examination
4. Perceptions
- Hallucinations and illusions reported by the patient should be
listed.
5. Thought processes
- this refers to the form of thinking or how a patient thinks;
Thought process can be described as logical/coherent,
circumstantial, tangential, flight of ideas, loose associations, and
word salad/incoherence.

15. Mental Status Examination
6. Thought Content
- The actual thought content section should include delusions,
paranoia, preoccupations, obsessions and compulsions, phobias,
ideas of reference, poverty of content, and suicidal and homicidal
ideation.
7.Sensorium and cognition
- This assesses organic brain function, intelligence, capacity for
abstract thought, and levels of insight and judgement.
NOTE: Almost all of the mental status examination can be made by careful observation
of the patient while obtaining a detailed, complete history. Only a few questions need to
be addressed to the patient directly, for example, those regarding the presence of
suicidal ideation and specific cognitive examination questions.

16. Mini–Mental State Examination
(MMSE) or Folstein test
- a 30-point questionnaire that is used extensively in clinical and
research settings to measure cognitive impairment. It is
commonly used in medicine and allied health to screen for
dementia. It is also used to estimate the severity and progression
of cognitive impairment and to follow the course of cognitive
changes in an individual over time; thus making it an effective
way to document an individual's response to treatment.

17. Clinical
interviews
Clinical assessment tools
fall into 3 categories:
Clinical
Tests
Observations

18. Clinical Tests
- are devices for gathering information about specific topics from
which broader information can be inferred
1.
Projective
Tests
2.
Personality
inventories
3.
Physical and
Laboratory
Tests
4. Intelligence tests

19. 1. Projective Tests
• These tests require that subjects interpret vague and
ambiguous stimuli or follow open-ended instructions
• They are used mainly by psychodynamic practitioners
• Examples:
- Rorschach test
- Thematic Apperception Test
- Sentence Completion
- Drawings
• Rorschach • Thematic
Apperception Test
• Sentence Completion
- supplementary information
- Rarely reliable and valid
- maybe biased against
minority ethnic group

20. 2. Personality inventories
- is a self-report questionnaire (a survey filled out by the client)
that asks a series of questions about thoughts, interests, feelings,
and behaviors that is aimed at developing a general profile about
a person’s personality and lifestyle.
• Examples:
- Minnesota Multiphasic Personality Inventory (MMPI)
- Myers-Briggs Type Indicator (MBTI)
- Sixteen Personality Factor Questionnaire (16PF)

21. Minnesota Multiphasic
Personality Inventory (MMPI)
• The MMPI consists of 550 self-statements describing
physical concerns; mood; morale; attitudes toward
religion, sex, and social activities; and psychological
symptoms which can be answered “true,” “false,” or
“cannot say”
• My daily life is full of things that keep me interested
• There seems to be a lump in my throat much of the time
• A person should try to understand his dreams and be guided by or
take warning from them
• I enjoy detective or mystery stories
• I work under a great deal of tension
• I have diarrhea once a month or more

22. Minnesota Multiphasic
Personality Inventory (MMPI)
• It derives ten clinical scales:
✓ Hypochondriasis (HS): Items showing abnormal concern with
bodily functions
✓ Depression (D): Items showing extreme pessimism and
hopelessness
✓ Conversion hysteria (Hy): Items suggesting that the person may
use physical or mental symptoms as a way of unconsciously
avoiding conflicts and responsibilities

23. Minnesota Multiphasic
Personality Inventory (MMPI)
• It derives ten clinical scales:
✓ Psychopathic deviate (PD): Items showing a repeated and gross
disregard for social customs and an emotional shallowness
✓ Masculinity-femininity (Mf): Items that are thought to
distinguish male and female respondents
✓ Paranoia (Pa): Items that show abnormal suspiciousness and
delusions of grandeur or persecution

24. Minnesota Multiphasic
Personality Inventory (MMPI)
• It derives ten clinical scales:
✓ Psychathenia (Pt): Items that show obsessions, compulsions,
abnormal fears, and guilt and indecisiveness
✓ Schizophrenia (Sc): Items that show bizarre or unusual thoughts
or behavior, including extreme withdrawal, delusions, or
hallucinations
✓ Hypomania (Ma): Items that show emotional excitement,
overactivity, and flight of ideas
✓ Social Introversion (Si): Items that show shyness, little interest
in people, and insecurity

25. 2. Personality inventories
- is a self-report questionnaire (a survey filled out by the client)
that asks a series of questions about thoughts, interests, feelings,
and behaviors that is aimed at developing a general profile about
a person’s personality and lifestyle.
• Examples:
- Minnesota Multiphasic Personality Inventory (MMPI)
- Myers-Briggs Type Indicator (MBTI)
- Sixteen Personality Factor Questionnaire (16PF)
- This type of inventory can be used to give a counselor or
therapist a sort of snapshot of who the client is inside; how they
live, what's important to them, how they cope with life, etc.

26. Clinical Tests
- are devices for gathering information about specific topics from
which broader information can be inferred
1.
Projective
Tests
2.
Personality
inventories
3.
Physical and
Laboratory
Tests
4. Intelligence tests

27. Physical Exam
• 1. General appearance – is the patient cachectic or well-
nourished? Anxious or calm? Alert or obtunded?
• 2. Vital signs – temperature, blood pressure, heart rate,
respiratory rate, and weight
• 3. Head and neck examination – look for evidence of
trauma, tumors, facial edema, goiter (indicating hyper- or
hypothyroidism). Cervical and supraclavicular nodes
should be palpated.

28. Physical Exam
• 4. Breast, cardiac, pulmonary, abdominal, back and
spine, and pelvic examination
• 5. Extremities and skin – The presence of tenderness,
skin edema, and cyanosis should be recorded.
• 6. Neurological examination – Patients require a
thorough assessment including evaluation of the cranial
nerves, strength, sensation, and reflexes.

29. Laboratory Tests
1. Screening tests – complete blood count (CBC), renal
function tests, liver function tests, thyroid function tests.
Also determine chloride, sodium, potassium, bicarbonate,
serum urea nitrogen, creatinine, and blood sugar levels.
Urine toxicology or serum toxicology tests should be done
when drug use by the patient is suspected.

30. Laboratory Tests
2. Test related to psychotropic drugs
Psychotropic drug: Any drug capable of affecting the mind,
emotions, and behavior.
a. CBC
b. serum electrolyte determination
c. kidney function tests
d. Fasting blood glucose determination
e. ECG
f. Platelet count
g. Serum iron levels

31. Clinical Tests
- are devices for gathering information about specific topics from
which broader information can be inferred
1.
Projective
Tests
2.
Personality
inventories
3.
Physical and
Laboratory
Tests
4. Intelligence tests

32. Intelligence Tests
Intelligence tests are designed to indirectly measure
intellectual ability and are typically comprised of a series of
tests assessing both verbal and nonverbal skills
The most popular of the intelligence tests are the Wechsler
scales (WAIS, WISC)

33. Clinical
interviews
Clinical assessment tools
fall into 3 categories:
Tests Observations

34. Observations
Naturalistic and Analog
Observation
Self-monitoring
• Naturalistic observations occur in
everyday environments, including homes,
schools, institutions (hospitals and
prisons), and community settings
• Analog observations occur when a
clinician observes a client's behavior
in a contrived environment (e.g., a
waiting room, play room, clinical
setting)
• The client observes himself and
carefully records the frequency
of certain behaviors, feelings, or
cognitions as they occur over
time.

35. Clinical
interviews
Tests Observations
1. Unstructured
interview
2. Structured
interview
Example:
HISTORY OF THE
PATIENT
Example:
MENTAL STATUS
EXAMINATION
1. Projective Tests
2. Personality
inventories
3. Physical and
Laboratory Tests
4. Intelligence tests
1. Naturalistic and
Analog Observation
2. Self-monitoring

36. Diagnosis- refers to the identification of the nature or cause of a disease or disorder
✓ Using all available information, clinicians attempt to paint a “clinical
picture”
✓ This “clinical picture” is influenced by their theoretical orientation
✓ Learn how to use the DSM - 5

37. Diagnostic and Statistical
Manual of Mental
Disorders,
5th Edition
(DSM-5)