Psychology Report, Assessment Example

Outline

Reason for Referral

Background

• Academic history
• Vocational History
• Psychiatric History
• Medical history
• Sexual History

Behavioral observations/Mental Health Status Examination

Test Administered

Tests Results

Summary

Diagnostic Impressions

Recommendations

Abstract

This document contains an assessment report of a clinical/diagnostic interview conducted with a pseudo/volunteer client. It includes a thorough psychosocial history, mini-mental status examination along with MSE information, suicide/homicide evaluation, multi-axial diagnostic impressions and a treatment/counseling recommendations/plan of the interaction.

Reason for Referral

Mrs. T. R was referred by her primary care physician with a history of talkativeness accompanied by intermittent periods of silence; gazing aimlessly and loud excessive talking again. Family members reported that they would hear her speaking loudly when asleep and laughing, which is considered abnormal behavior.

Background

Further background information was obtained during intake and interview with Mrs.T.R. who is a 42 year old Afro Caribbean/American female. She migrated to United States of America at age 5 with her Jamaican parents. Her father died in a car accident when she was 10 years old. Mrs. T.R was raised after then by her mother along with her other three siblings one other girl and two boys. At 23 years old she was married and bore four children, three boys and one girl. This marriage ended after 5 years in divorce when she was 33 years old.

Academic history

Mrs. T.R attended and graduated high school with honors. Immediately after graduation she enrolled at college after obtaining three scholarships. At college Ms. T.R obtained a Bachelor’s degree in nursingafter completing four years of study. Later she returned to school to further studies in psychiatric nursing where she obtained a master’s degree as an advanced psychiatric nurse.She disclosed no other significant history.

Vocational History

Mrs. T. R worked during high school placement as a transporter in a city hospital. After the second year at college she took a part time job as patient care technician at the same hospital to gain experience and earn some needed cash. After graduating as a registered nurse she worked at a city general hospital on the medical/surgical unit for three years before requesting to be placed on a psychiatric unit where he felt more comfortable working with patients with mental illnesses.

Her performance with these patients was exceptional and after two years she was recommended forspecialization in psychiatric nursing. Prior to being referred for psychiatric evaluation Mrs. T.R. worked on a psychiatric unit for over five consecutive years. For one year she did not due to developments in her personality which needed further evaluations.She disclosed no other significant history.

Psychiatric History

Mrs. M. R. admitted that after her divorcee approximately nine years ago she was severely depressed, but never took it seriously. Prayer she confirmed helped her through that storm of her life because she has a strong belief in the divine. Her primary care physician, however, had her referred to a psychologist for evaluation and later was hospitalized for stress and difficulty in concentrating. There were no suicidal thoughts neither attempt.She disclosed no other significant history.

Medical history

Importantly, Mrs. T. R was diagnosed with type 2 diabetes and essential hypertension two years ago. Since then reports are that the blood glucose levels are with diet and 5mg Glipizide once daily. The blood pressure is controlled with 25mgs hydrochlorothiazide once daily.

Sexual History

Mrs. T.R had not been sexually active two years prior to her divorcee and after. Due to the trauma she endured during the later years of her marriage she expressed loss of interest in sex and men. Besides, during the interview Mrs. T.R communicated that she did not engage in sex before marriage and had one sex partner during that time. She disclosed no other significant history.

Behavioral observations/Mental Health Status Examination

Mrs. T. R was well groomed expressing politeness during the interview. Her straitened black natural hair was combed backwards with a neat bun at the lower center back of the head. Moderate use of make-up was observed in the form of a small portion of lip gloss covering the somewhat dry lips. The body odor was pleasant with no pungent perfume or natural fumes.

Upon entering the room Mrs. T.R was smiling and seemed anxious to speak after cordially greeting me. I offered her a seat which she gracefully took and began a conversation which was a bit loud, but which could be controlled by responding in a quiet tone. She spoke extensive about her ex-husband, four children, job as a psychiatric nurse and her mother who was also a diabetic struggling with complications of the disease, but still supportive. Throughout the interview she was very talkative.

Often, it was through injection that I was able to communicate in retrieving a history from this client. During her conversation stress and fatigue in her voice/ expression could be detected; anxiety regarding the demands of daily living, bills to pay with one income seemed to be her major concern related in these extensive conversations with me and herself when it appeared that I was not listening.

After allowing Mrs. T.M to speak for about 45 minutes of the interview listening without interruptions she then addressed me directly to ask why she was referred emphasizing that she was a psychiatric trained advanced nurse. Immediately, I confirmed her expertise on the matter as she continued speaking and laughing to herself intermittently during the interview. At the same time she was reassured since she had such talent and expertise in the field it would make the evaluation much simpler since we understand each other from that perspective. She agreed, but then blurted out, ‘I have a problem, I know that, but why am I here in your office?’

‘Well to check out how the problem could be resolved since your expertise is needed in this profession,’ she chuckled and continued speaking about her ex-husband, children, mother, Job and bills which she had to pay alone since two of the children were in college. After another 20 minutes listening the interview was over and Mrs. T.R left the office accompanied by her mother and eldest 19 year old son.

Test Administered

Tests administered consisted of structuredclinical interview and mental status examination (MSE). The structured clinical interview was conducted in relation to diagnostic and statistical manual of mental disorders (DSM 1V) evaluating Axis I – V Disorders (SCID-I) (Michael, Williams, Spitzer, Gibbon, 2007). Emphasis was, however, placed on Axis 1 and 11specifically measuring major mental and personality disorders.Mental status examination (MSE) is a scientific process of describing a patient’s current state of mind through observation within the attitude, appearance, mood and affect, behavior, cognition, perception, insight, thought process; speech, thought content, cognition, and judgment domains (Owen & Harland, 2007).

Suicide evaluation was conducted utilizing Beck Scale for Suicidal Ideation (BSS). This test consists of a 19 item self-reporting scale preceded by five other screening items. These items focused on assessing Mrs. T.M’s thoughts, plans and possible intentions to commit suicide. All items adding up to 24 were given a 0-2 credit based on the specific responses offered. Positive responses are signals for further investigation. Then highest score is 48 whereas the lowest is 0 (Cochrane-Brink, Lofchy & Sakinofsky, 2000).

Tests Results

Mrs. T.R’s Mental Status Exam (MSE) scores were very high. She answered all the items accurately. The final score was 30 out of 30. This is indicative of someone who is fully oriented to time and place even though talkative; occasionally silent and even talking to herself in the absence of anyone listening. Judgment and insight were normal. She independently conducted a coherent conversation about her life concerns and correctly answered questions asked. As such it can be concluded that from this cognitive screening no significant impairments were detected. Scores ranging between 24-30 is considered to be “no cognitive impairment” observed. In the structured clinical observations section of the interaction apart from her talkativeness she did not demonstrate any significant personality disruptions. With reference to the Beck Scale for Suicidal Ideation (BSS) Mrs. T.M scored 0 indicative that there were no obvious suicidal tendencies

Summary

Mrs. T.M.s performance on both the structured clinical interview and mental status examination (MSE) did not indicate any significant cognitive neither mental derangement in terms of memory. She distinctly recalled some great experiences with her husband during their marriage as well as irresponsible financial behavior which caused the divorcee. Since then she has had the responsibility of raising four children without a father in the home in the same way her mother did. Vividly, she recalled losing her father very early in life and struggles her mother encountered in raising them without a father.

Even though she has been very successful academically subsequently obtaining a great paying job still at times Mrs. T.M would become overwhelmed by deep insecurity finding it difficult to stop talking about her troubles and joys in an effort to achieve balance ‘before going crazy as her patients’ she exclaimed. Next Mrs. T.M was very concerned about type 2 diabetes diagnosis with hypertension complication. These were the same health conditions, which caused her mother to obtain early retirement. Obviously, these fears surfaced during daily interactions with her world now that she has three teenage boys and an adolescent 12 year old girl.

Diagnostic Impressions

Diagnostic impressions form the basis of therapy in both mental health and psychological interventions. As such, clinicians must be mindful of disconfirmatory, confirmatory, and alternative hypotheses when making a diagnostic impression. Arguments have been that clinicians tend to apply disconfirmatory reasoning in testing hypotheses rather than confirmatory because the focused outcome is arriving at a plausible diagnosis and treatment intervention.Ultimately the goal is to either falsify (disconfirmatory) or verify the hypothesis/ diagnostic impressions (confirmatory) ( Gorman, Gorman, Latta & Cunningham, 2011).

Alternative hypotheses impressions leave the clinician with the issue of arriving at new or other classifying criteria, which matches neither confirmatory nor disconfirmatory. Both approaches were used in formulating this diagnostic impression since some impressions were falsified and other verified.

Axis 1: 997. 3Anxiety and panic due to underlying fear of future based on past experiences and life course of significant others.

Axis 11: V 71. 09No Diagnosis

Axis 111:None

Axis 1V: Health difficulty coping with future demands of everyday life accompanied by feelings of inadequacy

Axis V:GAF 43-50 current

Recommendations

Diagnosis: Anxiety/ panic

Goal: Develop strategies to improve coping skills related to anxious episodes

Recommendation 1: Guide Mrs. T.M into identifying new coping skills that can be used when memories of the past emerge and fears of future events tend to be overwhelming.

Objective

Client will identify at least three new coping skills that she can be utilize

Rationale:

• T.M is qualified enough into understanding the disruptions she is facing because her expertise as an advanced trained psychiatric nurse provides the knowledge. She is not cognitively impaired.
• Allowing her expertise into resolution for the anxiety would be a beneficial therapy maintaining usefulness while turning attention away from stress and fears

Recommendation 11: Assist Mrs. T.M in avoiding anxious situations

Objective

Client will recognize and plan for top five anxiety-provoking situations

Rationale

• T. M recognizes that she has a problem talking too much, but just cannot control herself into how long it must last; where and to whom it is directed.
• Asking her to design a plan of five most disturbing situations that urges the talkativeness would help her to slowly interrupt them by removing the thought process.

Recommendation 111: Encourage Mrs. T M. to extensively discuss one occurrence she fears most in the future

Objective

Client will identify feared situations and discuss at least one such situation

Rationale

• T.M expressed a number of fears, but they all seemed jumbled or cumulated.
• In identifying all of them and discussing one she would be able to differentiate real fears from one which just appear real.

Recommendation 1V:- Client must to design and maintain a sleep schedule, especially during the night.

Objective

Client will report at least six hours of sleep per night

Rationale

• Sleep is a natural way of relaxing as well as reliving stress. Mrs. T. M was found to be laughing during sleep.
• Six hours of continuous sleep is the minimum needed form resolving a day of stressful activity

Recommendation V:Encourage Mrs. T.M to participate in more group activities during the week after leaving work.

Objective

Client will participate in at least two complete groups or activities per week

Rationale

• T.M expressed association with church and the divine, but did not mention whether she did attend church regularly neither was involved in any activities outside of church and her job.
• Social integration is a strong defense for fears thoughts interacting with people other than children and parents could help relieve daily stress apart from talking out loudly for long periods

References

Cochrane-Brink, K. Lofchy, J., &Sakinofsky, I. (2000).Clinical Rating Scales in Suicide Risk Assessment.Elsevier Science Inc

Gorman, M. Gorman, E. Latta, M., & Cunningham, G. (2011).British Journal of Psychology. 75(1), 65-79

Owen G., & Harland, R. (2007) Editor’s Introduction: Theme Issue on Phenomenology and Psychiatry for the 21st Century. Taking Phenomenology Seriously.Schizophrenia Bulletin 33 (1) 105–107

Michael B., Williams, J. Spitzer, R.,& Gibbon, M. (2007). Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Clinical Trials Version (SCID-CT). New York: Biometrics Research, New York State Psychiatric Institute.