PURPOSE OF THE PERSONALITY EVALUATION
Questions that come to the attention of clinicians often relate to differential diagnosis (i.e., whether a patient is more appropriately assigned one Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5] diagnosis as opposed to another). However, even in this age of managed care and associated limitations on testing, psychologists are still occasionally asked to perform evaluations that characterize the patient beyond this reductionistic level and that describe the patient’s resources and liabilities, underlying conflicts, stress tolerance, and so on. Indeed, many psychologists take the position that in order to effectively assign a specific diagnostic label, it is frequently necessary to understand the functioning of the whole person.
TYPES OF PERSONALITY EVALUATIONS
Personality evaluation can be divided into three main areas. These include behavior rating scales used to assess a patient’s overt behavior and, by extension, psychological functioning; projective tests ordinarily used to describe a patient’s underlying concerns, issues, perceptions of other people, and self-attributions (the “content” of the mind, if you will); and structural tests used to characterize the patient’s psychological structure, including coping resources, typical defensive tactics, capacity for intimacy, and reasoning capacity (the “form” of the mind). A fourth group of scales is used to assess the patient’s functioning with respect to a specific diagnosis, such as depression. Table 12–18 summarizes these scales.
Table 12–18 Types of Personality Evaluation
| Evaluation Type | Function | Examples |
|---|---|---|
Behavior rating scales | Describe an individual’s functioning in everyday life | Achenbach’s Child Behavior Check List |
Projective tests | Characterize an individual’s underlying concerns | Incomplete Sentences Test Thematic Apperception Test |
Structural tests | Depict a person’s personality | Rorschach Inkblot Test Minnesota Multiphasic Psychiatric Inventory-A (MMPI-A) Millon Adolescent Personality Inventory |
Specific diagnosis scales | Assess an individual’s functioning with respect to a specific diagnosis | Children’s Depression Inventory Pediatric Anxiety Rating Scale |
Behavior Rating Scales
Behavior rating scales are used both by psychologists and by clinicians, including child psychiatrists. They describe a patient’s functioning in everyday life, as a step toward understanding the patient. Perhaps the most well-known of such scales is Achenbach’s Child Behavior Checklist. This scale requires a parent to respond to questions related to the child’s social functioning and behavioral problems. On the basis of these responses, the child is rated on a number of symptom groupings, or factors, that can be divided into two categories: those that reflect internalizing psychopathology (e.g., sadness, withdrawal, anxiety) and those that reflect externalizing psychopathology (e.g., temper outbursts, demandingness, stubbornness). Such rating scales, although perhaps limited in the amount of information obtained from the respondent, are useful in that they provide psychologists with data derived from a careful observer, namely, the parent.
Projective Tests
Projective measures assume that a subject projects unconscious issues, themes, and expectancies onto an ambiguous external stimulus, thereby providing the diagnostician with meaningful clinical data. Traditionally, such techniques have been organized on the basis of their assumed depth of exploration. For example, the Incomplete Sentences Test, which requires a patient to complete sentence stems such as “I like” or “My mother,” is assumed to gather information of which the patient is reasonably conscious or aware. Alternatively, the Thematic Apperception Test may evoke material that is deeper and less obvious in meaning to the patient. However, the latter task is hampered by the fact that such information is generally quite symbolic in nature and hence is open to misinterpretation on the part of the examiner. Moreover, data derived from projective testing often have limited connection to the specific question being posed by the referral source, which often relates to distinguishing between competing diagnostic possibilities or characterizing a patient’s psychological assets and liabilities.
The reader may note that in discussing projective measures, we have yet to describe the Rorschach Inkblot Test. During the past 20 years or so, there has been much discussion of the nature of the Rorschach task. Various authors have noted that, in fact, there are two essential Rorschach functions. First, the Rorschach may serve as a projective measure, evoking material that leads us to define a person’s idiosyncratic or specific concerns, fears, conflicts, or interests. For example, an abused teenage girl may provide the response “two men killing a little girl,” emphasizing the degree to which this particular person fears or anticipates that aggressive males may victimize her.
Second, various authors have said that the real strength of the Rorschach task lies not in its projective function but in its use as a means of evoking behavior that can illuminate the patient’s personality structure. For example, regardless of the particular content of a given protocol, one might assess the degree to which the outlines of a patient’s perceptions match the outlines of the test stimuli, based on a consensus of others. Weakness in this regard may be interpreted as an impairment in perceptual accuracy or reality interpretation. Likewise, responses may be assessed with respect to unrealistic reasoning (e.g., “looks like a bat because it’s green”). In general, most contemporary research and clinical work on the Rorschach relates to this use as a perceptual–cognitive task, as opposed to a stimulus to fantasy.
Structural Tests
I Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A) is frequently administered to young patients. A revision of the MMPI-2 for adolescents, this scale involves the original set of basic scales, which assess functioning along dimensions such as depression, hypochondriasis, rebelliousness, and social introversion. The test is published with information permitting scoring on various subscales that compose the basic scales. Finally, content scales are provided that are, for the most part, rationally derived groupings of items relating to matters such as obsessiveness, family problems, and school problems. MMPI-A administration and interpretation proceeds much like the relevant scale for adults. The patient is asked to complete almost 500 questions, and responses are then interpreted based on patterns of scale elevations.
The MMPI-A cannot be administered to children under the age of 13 years. Instead, an MMPI-like technique, the Personality Inventory for Children, may be administered. This test requires a knowledgeable adult, preferably the primary caregiver, to characterize the child by answering more than 400 questions. The responses can be scored to provide information in areas such as depression, somatic problems, delinquency, and withdrawal. Both the MMPI-A and the Personality Inventory for Children contain validity scales to evaluate the respondent’s response set (i.e., attempts to provide an unrealistically positive or negative impression).
The Millon Clinical Multiaxial Inventory was originally published as an alternative to the MMPI, which was considered to be weak in several areas. For example, the MMPI has been criticized for neglecting factors such as personality styles and disorders that may lay the groundwork for the development of other disorders such as affective disorders or anxiety disorders. Millon’s tests also offer a different definition of scale elevations. Millon has made the point that in view of the differing base rates for different forms of psychopathology, the traditional mode of interpreting personality scales is insufficient.
Specific Diagnostic Scales
In this era of managed care, an emphasis has been placed on the definition of very specific questions for the psychologist to address. Thus, scales assessing specific clinical entities are becoming used much more frequently than before. Traditional measures (e.g., the Beck Depression Inventory) are often used. So too are versions adapted for younger patients such as the Children’s Depression Inventory.
AchenbachTM, RuffleTM: The Child Behavior Checklist and related forms for assessing behavioral/emotional problems and competencies. Pediatr Rev2000 Aug;21(8):265-271. doi: 10.1542/pir.21-8-265. 10922023.
ArcherRP: MMPI-A: Assessing Adolescent Psychopathology. Mahwah NJ: Erlbaum, 1992.
ExnerJE: The Rorschach: A Comprehensive System. New York: Wiley, 1993.
HandelRW: An introduction to the Minnesota Multiphasic Personality Inventory-Adolescent-Restructured Form (MMPI-A-RF). J Clin Psychol Med Settings2016 Dec;23(4):361-373. doi: 10.1007/s10880-016-9475-6. 27752979.
MillonT: Toward a New Personology. New York: Wiley, 1990.
StrackS, MillonT: Contributions to the dimensional assessment of personality disorders using Mi’lon’s model and the Millon Clinical Multiaxial Inventory (MCMI9-III). J Pers Assess2007 Aug;89(1):56-69. doi: 10.1080/00223890701357217. 17604534.