Psychological Tests for Mentally Ill

Introduction to Psychological Testing

Psychological tests are standardized measures used to assess aspects of a person’s cognitive functioning, emotional state, personality traits, and behavior patterns. For nurses working in mental health settings, understanding these tests is crucial for comprehensive patient care, treatment planning, and monitoring progress.

Fig 1. Comprehensive framework for psychological assessment

Key Purposes of Psychological Testing:

Diagnosis: Identifying specific mental health conditions
Assessment: Evaluating symptom severity
Treatment Planning: Guiding intervention selection
Monitoring: Tracking changes and progress over time
Research: Advancing understanding of mental health conditions

Note for Nurses:

While most psychological tests require administration and interpretation by psychologists or psychiatrists, nurses play a vital role in the assessment process through observation, documentation, and assisting patients during testing. Understanding these tests helps nurses better contribute to the multidisciplinary care team.

Mental Status Examination (MSE)

The Mental Status Examination (MSE) is the psychiatric equivalent of the physical examination in general medicine. It is a structured assessment of the patient’s behavioral and cognitive functioning during the clinical interview.

Remember the components with: ASEPTIC

A Appearance and behavior

S Speech characteristics

E Emotional state (mood and affect)

P Perception (hallucinations, illusions)

T Thought process and content

I Insight and judgment

C Cognition (orientation, memory, attention)

Components in Detail:

1. Appearance and Behavior

Observe: Age, gender, race, body build, posture, grooming, hygiene, clothing, eye contact, facial expressions, psychomotor activity, and attitude toward examiner.

Example documentation: “32-year-old male appears his stated age, disheveled with unwashed hair, wearing wrinkled clothing. Poor eye contact, restless with frequent shifting in chair.”

2. Speech

Assess: Rate, volume, tone, fluency, and quantity.

Example documentation: “Speech is slow and quiet with increased latency of response. Limited spontaneous speech.”

3. Emotional State

Mood: Patient’s sustained emotional state (subjective).

Affect: Observable expression of emotion (objective).

Example documentation: “Mood described as ‘hopeless.’ Affect is constricted, primarily sad, and congruent with stated mood.”

4. Perception

Assess for: Hallucinations (sensory perceptions without external stimuli) and illusions (misinterpretations of actual stimuli).

Example documentation: “Patient reports hearing voices commenting on his actions when alone. Denies visual hallucinations or illusions.”

5. Thought Process and Content

Process: How thoughts are connected and organized (logical, tangential, circumstantial, flight of ideas, loose associations).

Content: What the patient is thinking about (delusions, obsessions, phobias, suicidal/homicidal ideation).

Example documentation: “Thought process is logical and goal-directed. Content includes persecutory delusions about neighbors monitoring his activities. Denies current suicidal or homicidal ideation.”

6. Insight and Judgment

Insight: Patient’s awareness of their condition and its implications.

Judgment: Ability to make reasonable decisions.

Example documentation: “Patient demonstrates poor insight, stating ‘There’s nothing wrong with me, I don’t need medication.’ Judgment appears impaired as evidenced by recent decision to stop taking prescribed medications without consulting provider.”

7. Cognition

Assess: Level of consciousness, orientation (person, place, time, situation), attention, concentration, memory (immediate, recent, remote), fund of knowledge, abstract thinking, and intelligence.

Example documentation: “Alert and oriented to person, place, and time. Able to recall 3/3 objects immediately and 2/3 after 5 minutes. Unable to perform serial 7s but can spell ‘world’ backward. Interprets proverbs concretely.”

Nursing Tip:

The MSE is not just a formal evaluation but a continuous assessment process. Nurses should document significant changes in any MSE component throughout patient care. This ongoing monitoring helps detect early signs of decompensation or improvement.

Depression Assessment Tools

Depression screening tools help identify patients who may be experiencing depressive symptoms and assess symptom severity. These tools assist in diagnosis, treatment planning, and monitoring response to interventions.

Assessment Tool	Items	Time to Complete	Key Features	Interpretation
Beck Depression Inventory-II (BDI-II)	21 items	5-10 minutes	Self-report inventory assessing cognitive, affective, and somatic symptoms of depression	0-13: Minimal 14-19: Mild 20-28: Moderate 29-63: Severe
Patient Health Questionnaire-9 (PHQ-9)	9 items	< 5 minutes	Brief, widely used in primary care and hospital settings, aligns with DSM diagnostic criteria	0-4: Minimal 5-9: Mild 10-14: Moderate 15-19: Moderately severe 20-27: Severe
Hamilton Depression Rating Scale (HAM-D)	17-24 items	15-20 minutes	Clinician-administered, emphasizes somatic and behavioral symptoms	0-7: Normal 8-16: Mild 17-23: Moderate ≥24: Severe
Geriatric Depression Scale (GDS)	15 or 30 items	5-10 minutes	Specifically designed for older adults, avoids somatic symptoms that may be due to aging	For 15-item version: 0-4: Normal 5-8: Mild 9-11: Moderate 12-15: Severe
Edinburgh Postnatal Depression Scale (EPDS)	10 items	5 minutes	Specifically for perinatal depression screening, avoids normal postpartum physical symptoms	Score ≥10: Possible depression Score ≥13: Likely depression Any positive response to Q10 (harm): Immediate assessment needed

Sample PHQ-9 Item Response Pattern

Not at all (0) Several days (1) More than half the days (2) Nearly every day (3)

Fig 2. PHQ-9 uses a 0-3 scale for each symptom, measuring frequency over the past two weeks

Clinical Application:

The PHQ-9 is particularly useful in nursing practice due to its brevity and accuracy. Question 9 specifically addresses suicidal ideation, providing a critical safety assessment. A positive response to this question should prompt immediate further evaluation regardless of the total score.

Remember the PHQ-9 symptom domains with: SIG E CAPS

S Sleep disturbances

I Interest loss (anhedonia)

G Guilt or worthlessness

E Energy loss (fatigue)

C Concentration problems

A Appetite changes

P Psychomotor changes

S Suicidal thoughts

Anxiety Assessment Tools

Anxiety assessment tools help identify and quantify anxiety symptoms across various disorders, including generalized anxiety disorder, panic disorder, social anxiety disorder, and specific phobias.

Fig 3. Common anxiety assessment tools and their focus areas

Assessment Tool	Items	Administration	Focus Areas	Interpretation
Generalized Anxiety Disorder-7 (GAD-7)	7 items	Self-report	Screens for and measures severity of generalized anxiety disorder	0-4: Minimal 5-9: Mild 10-14: Moderate 15-21: Severe
Beck Anxiety Inventory (BAI)	21 items	Self-report	Focuses on somatic and cognitive symptoms of anxiety, differentiates anxiety from depression	0-7: Minimal 8-15: Mild 16-25: Moderate 26-63: Severe
Hamilton Anxiety Rating Scale (HAM-A)	14 items	Clinician-rated	Assesses both psychic anxiety (mental agitation, psychological distress) and somatic anxiety (physical complaints)	0-17: Mild 18-24: Moderate 25-30: Severe
Social Phobia Inventory (SPIN)	17 items	Self-report	Assesses fear, avoidance, and physiological discomfort in social situations	0-20: No/minimal 21-30: Mild 31-40: Moderate 41-50: Severe 51-68: Very severe
Hospital Anxiety and Depression Scale (HADS)	14 items (7 for anxiety, 7 for depression)	Self-report	Developed for medical patients, avoids somatic symptoms that might be attributable to physical illness	For anxiety subscale: 0-7: Normal 8-10: Borderline 11-21: Abnormal

Nursing Application:

The GAD-7 is particularly useful in primary care and inpatient settings due to its brevity and sensitivity. When administering anxiety assessments, explain to patients that symptoms might fluctuate and reassure them that the goal is to track patterns over time, not just single measurements.

Clinical Consideration:

Many patients with anxiety disorders experience physical symptoms (palpitations, shortness of breath, dizziness) that mimic medical conditions. Always ensure appropriate medical evaluation has been completed before attributing physical symptoms solely to anxiety.

Sample GAD-7 Questions

Over the last 2 weeks, how often have you been bothered by the following problems?

Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it’s hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

Response options: Not at all (0), Several days (1), More than half the days (2), Nearly every day (3)

Psychotic Disorders Assessment

Assessment tools for psychotic disorders help evaluate the presence, severity, and characteristics of symptoms in conditions like schizophrenia, schizoaffective disorder, and other psychotic disorders. These tools assist in diagnosis, treatment planning, and tracking treatment response.

Remember the key domains of psychosis assessment with: PRISMS

P Positive symptoms (hallucinations, delusions)

R Relationship disruptions (social withdrawal)

I Insight impairment

S Self-care deficits

M Mood disturbances

S Suicidality/Safety concerns

Key Assessment Tools:

1. Brief Psychiatric Rating Scale (BPRS)

Purpose: Widely used to assess the severity of symptoms in psychotic disorders and mood disorders with psychotic features.

Format: 18-24 items rated on a 1-7 scale by clinicians after a semi-structured interview.

Domains assessed: Anxiety, depression, hostility, disorganization, negative symptoms, positive symptoms, and activation.

Sample item: “Unusual thought content” – Rates unusual, bizarre, or strange content of thoughts, from mild ideas of reference to fully developed delusions.

2. Positive and Negative Syndrome Scale (PANSS)

Purpose: Gold standard for assessment of schizophrenia, evaluating positive symptoms, negative symptoms, and general psychopathology.

Format: 30 items rated on a 1-7 scale by trained clinicians after a structured interview.

Subscales:

Positive scale (7 items): Delusions, conceptual disorganization, hallucinations, excitement, grandiosity, suspiciousness, hostility
Negative scale (7 items): Blunted affect, emotional withdrawal, poor rapport, passive-apathetic social withdrawal, difficulty in abstract thinking, lack of spontaneity, stereotyped thinking
General Psychopathology scale (16 items): Including anxiety, depression, disorientation, attention deficits

3. Scale for the Assessment of Positive Symptoms (SAPS)

Purpose: Evaluates positive symptoms of schizophrenia in detail.

Format: 34 items organized into 4 domains, rated 0-5 by clinicians.

Domains assessed: Hallucinations, delusions, bizarre behavior, and positive formal thought disorder.

4. Scale for the Assessment of Negative Symptoms (SANS)

Purpose: Detailed assessment of negative symptoms in schizophrenia.

Format: 25 items organized into 5 domains, rated 0-5 by clinicians.

Domains assessed: Affective flattening, alogia (poverty of speech), avolition-apathy, anhedonia-asociality, and attention deficits.

5. Brief Clinical Assessment Scale for Schizophrenia (BCASS)

Purpose: Offers a comprehensive yet efficient assessment of schizophrenia symptoms.

Format: 14-item scale covering key symptom domains rated on a four-point severity scale.

Advantages: More concise than PANSS while maintaining good reliability and validity.

Symptom Domain	Positive Symptoms	Negative Symptoms	Cognitive Symptoms	Affective Symptoms
Description	Additions to normal functioning	Diminished normal functioning	Deficits in information processing	Emotional disturbances
Examples	• Hallucinations • Delusions • Thought disorder • Bizarre behavior	• Blunted affect • Anhedonia • Avolition • Social withdrawal	• Attention deficits • Memory impairment • Executive dysfunction • Poor problem-solving	• Depression • Anxiety • Irritability • Mood lability
Key Assessment Tools	• SAPS • PANSS Positive Scale • BPRS	• SANS • PANSS Negative Scale • NSA-16	• MATRICS • BACS • RBANS	• Calgary Depression Scale • HAM-A • PANSS General Scale

Nursing Alert:

Many assessment tools for psychotic disorders require specialized training for proper administration and interpretation. Nursing observations of behaviors associated with these symptom domains are invaluable inputs for the multidisciplinary team, even when nurses aren’t directly administering the formal assessments.

Documentation Tip:

When documenting observations of psychotic symptoms, use objective language and direct quotes whenever possible. For example, instead of “Patient is paranoid,” document “Patient states, ‘The government has planted cameras in my room to monitor me,’ and repeatedly checked behind furniture.”

Personality Assessment

Personality assessments evaluate enduring patterns of thinking, feeling, and behaving. In mental health settings, these tools help identify personality traits or disorders that may impact diagnosis, treatment planning, and therapeutic approach.

Fig 4. Continuum of personality assessment approaches

Major Personality Assessment Tools:

1. Minnesota Multiphasic Personality Inventory (MMPI-2/MMPI-2-RF)

Purpose: The most widely used and researched standardized psychometric test for measuring adult psychopathology.

Format: MMPI-2 contains 567 true/false questions; MMPI-2-RF is a shorter 338-item version.

Scales:

Validity Scales: Detect inconsistent responding, over-reporting, and under-reporting of symptoms
Clinical Scales: 10 scales measuring different aspects of psychopathology (Hypochondriasis, Depression, Hysteria, Psychopathic Deviate, Masculinity/Femininity, Paranoia, Psychasthenia, Schizophrenia, Hypomania, Social Introversion)
Content Scales: 15 scales providing more focused assessment of specific problem areas
Supplementary Scales: Additional clinical information beyond the standard clinical scales

Note: Interpretation requires specialized training and should be performed by qualified mental health professionals.

2. Personality Assessment Inventory (PAI)

Purpose: Provides information relevant for clinical diagnosis, treatment planning, and screening for psychopathology.

Format: 344 items rated on a 4-point scale (false, slightly true, mainly true, very true).

Scales: Includes 4 validity scales, 11 clinical scales (somatic complaints, anxiety, anxiety-related disorders, depression, mania, paranoia, schizophrenia, borderline features, antisocial features, alcohol problems, drug problems), 5 treatment scales, and 2 interpersonal scales.

Advantages: More transparent item content than MMPI-2, requires only 4th-grade reading level, and takes less time to complete (50-60 minutes).

3. NEO Personality Inventory-Revised (NEO-PI-R)

Purpose: Based on the Five-Factor Model of personality, measures normal personality traits rather than psychopathology.

Format: 240 items rated on a 5-point scale.

Domains assessed: Neuroticism, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness (each with 6 specific facets).

Clinical utility: Helps understand a patient’s personality structure, which can inform treatment planning and therapeutic approach.

4. Millon Clinical Multiaxial Inventory-IV (MCMI-IV)

Purpose: Specifically designed to assess DSM-5 personality disorders and clinical syndromes.

Format: 195 true/false questions taking approximately 25-30 minutes to complete.

Scales: Includes validity indicators, clinical personality patterns, severe personality pathology, clinical syndromes, and severe clinical syndromes.

Advantage: Directly aligned with DSM-5 diagnostic criteria for personality disorders.

5. Projective Tests

Rorschach Inkblot Test: Patients describe what they see in 10 standardized inkblots, revealing aspects of personality structure and functioning that may be outside awareness.

Thematic Apperception Test (TAT): Patients create stories about ambiguous scenes depicted in 31 cards, revealing underlying motives, concerns, and patterns of thinking.

Note: Projective tests are highly dependent on the skill and training of the examiner and are more subjective than objective personality measures.

Nursing Consideration:

While nurses typically don’t administer or interpret formal personality assessments, understanding a patient’s personality profile can greatly enhance nursing care. For example, knowing that a patient scores high on neuroticism may help anticipate anxiety responses to procedures, while high conscientiousness may indicate greater medication adherence potential.

Other Important Psychological Tests

Beyond the major categories already discussed, several other psychological tests are commonly used in mental health settings to assess specific conditions or domains of functioning.

Assessment Category	Common Tests	Purpose	Nursing Implications
Cognitive Functioning	• Mini-Mental State Examination (MMSE) • Montreal Cognitive Assessment (MoCA) • Saint Louis University Mental Status (SLUMS)	Screen for cognitive impairment and dementia; assess orientation, memory, attention, language, and visuospatial skills	Guides safety interventions; helps determine patient’s capacity to understand and follow treatment plans; informs communication strategies
Substance Use Disorders	• CAGE Questionnaire • Alcohol Use Disorders Identification Test (AUDIT) • Drug Abuse Screening Test (DAST)	Screen for problematic alcohol and drug use; assess severity of substance use disorders	Helps identify need for detoxification protocols; alerts to potential withdrawal risks; informs medication adjustments
Trauma & PTSD	• PTSD Checklist for DSM-5 (PCL-5) • Impact of Event Scale-Revised (IES-R) • Trauma Symptom Inventory (TSI)	Assess exposure to traumatic events and resulting symptoms; screen for PTSD	Guides trauma-informed care approaches; helps prevent retraumatization; informs safety planning
Suicide Risk	• Columbia-Suicide Severity Rating Scale (C-SSRS) • Beck Scale for Suicide Ideation (BSS) • SAD PERSONS Scale	Assess suicidal ideation, intent, plan, and risk factors	Determines appropriate level of observation; guides safety planning; informs discharge readiness
Eating Disorders	• Eating Attitudes Test (EAT-26) • Eating Disorder Examination Questionnaire (EDE-Q) • SCOFF Questionnaire	Screen for disordered eating attitudes and behaviors; assess severity of eating disorders	Guides nutritional monitoring; informs meal supervision needs; helps monitor for medical complications

Focus on Cognitive Assessment:

Mini-Mental State Examination (MMSE) Components

Orientation (10 points)

Time: year, season, date, day, month

Place: state, county, town, building, floor

Registration (3 points)

Naming and immediate recall of three objects

Attention & Calculation (5 points)

Serial 7s subtraction or spelling “WORLD” backward

Recall (3 points)

Delayed recall of the three objects

Language (8 points)

Naming objects, repeating phrase, following commands, reading, writing

Visuospatial (1 point)

Copy of intersecting pentagons

Total Score: 30 points possible

24-30: Normal • 19-23: Mild impairment • 10-18: Moderate impairment • ≤9: Severe impairment

Remember suicide risk factors with: SAD PERSONS

S Sex (male)

A Age (young or elderly)

D Depression or hopelessness

P Previous attempt or psychiatric care

E Excessive alcohol or substance use

R Rational thinking loss (psychosis)

S Social support lacking

O Organized plan

N No spouse (divorced, widowed, single)

S Sickness (chronic illness)

Important Safety Note:

While screening tools like SAD PERSONS can help identify risk factors, they should never replace a comprehensive suicide risk assessment. Any expression of suicidal thoughts or intent requires immediate attention and appropriate safety measures.

Practical Guidelines for Nurses

Nurses play a vital role in the psychological assessment process. While most formal psychological tests require specialized training to administer and interpret, nurses contribute significantly through observation, documentation, patient support, and collaboration with the multidisciplinary team.

Best Practices for Psychological Assessment in Nursing:

Before Assessment

Create a quiet, comfortable environment free from distractions
Build rapport and establish trust with the patient
Explain the purpose of the assessment in simple, non-threatening language
Ensure the patient’s basic needs (rest, pain management, hunger) are met
Check if the patient needs reading glasses, hearing aids, or other assistive devices
Consider timing – avoid assessing during medication peak effects or when the patient is fatigued

During Assessment

Provide clear instructions and clarify any confusion
Observe and document non-verbal behaviors
Remain neutral and non-judgmental regardless of patient responses
Allow adequate time for responses, especially with cognitive impairment
Note any factors that may influence results (medication effects, physical discomfort, language barriers)
Document exact patient statements for subjective reports

After Assessment

Document findings thoroughly and objectively
Communicate relevant information to the multidisciplinary team
Incorporate assessment findings into the nursing care plan
Provide feedback to the patient about next steps
Monitor for any delayed emotional reactions to the assessment
Schedule follow-up assessments as appropriate

Communication Strategies for Effective Assessment:

Do	Don’t
• Use open-ended questions • Speak clearly and at an appropriate pace • Allow silence for reflection • Validate feelings without judgment • Maintain appropriate eye contact • Use simple, direct language • Adapt to the patient’s cognitive level	• Rush through assessments • Use medical jargon unnecessarily • Ask leading questions • Show surprise or disapproval at responses • Interrupt patient disclosures • Make assumptions about symptoms • Minimize patient concerns

Documentation Principles:

When documenting psychological assessment findings, remember these key principles:

Objective: Describe observable behaviors rather than interpretations
Specific: Include details that support your observations
Accurate: Use direct quotes when documenting patient statements
Relevant: Focus on information pertinent to the patient’s care
Timely: Document promptly to ensure accuracy

Summary

Psychological tests are valuable tools in the comprehensive assessment and care of mentally ill patients. While specialized training is required for formal administration and interpretation of many tests, nurses contribute significantly to the assessment process through careful observation, documentation, and patient support.

Key Points to Remember:

The Mental Status Examination (MSE) is a fundamental assessment tool that provides a snapshot of a patient’s current mental functioning.
Depression assessments like the BDI-II and PHQ-9 help measure symptom severity and monitor treatment response.
Anxiety assessments such as the GAD-7 and BAI evaluate different aspects of anxiety symptoms.
Psychotic disorder assessments like the PANSS and BPRS provide structured evaluation of positive, negative, and general psychopathology symptoms.
Personality assessments including the MMPI-2 and PAI help identify enduring patterns of thinking, feeling, and behaving that may impact treatment.
Specialized assessments for cognitive functioning, substance use, trauma, suicide risk, and eating disorders target specific areas of concern.

Remember your nursing role in assessment with: CARES

C Create a supportive environment

A Accurately observe and document

R Recognize changes in mental status

E Engage therapeutically with patients

S Share findings with the multidisciplinary team

Final Thoughts:

Psychological testing is just one component of a comprehensive assessment. The most effective approach integrates standardized testing with clinical interviews, behavioral observations, collateral information, and patient history. As a nurse, your holistic perspective and continuous patient contact provide invaluable insights that complement formal psychological assessments.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
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Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A., & Kaemmer, B. (1989). Minnesota Multiphasic Personality Inventory-2 (MMPI-2): Manual for administration and scoring. University of Minnesota Press.
Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276.
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Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M., & Leirer, V. O. (1982). Development and validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric Research, 17(1), 37-49.