128118221 Psychological Report

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PSYCHOLOGICAL REPORT
I.

II.

GENERAL DATA

Examinee:

CMB

Sex:

Female

Age:

16

Date of Birth:

August 17, 1996

Place of Birth:

Makati City

Education:

2ND Year High School (not completed)

Address:

Makati City

REFERRAL REASON

The client was referred for testing by an acquaintance. This assessment was
conducted to identify possible reasons of her lack of interest and motivation in
attending school that made her drop out twice. This is to make recommendations for
self-awareness and/or self-improvement.

III.

ASSESSMENT PROCEDURES

a. Relevant History
b. Clinical Interview

January 01, 2013

c. Battery of Psychological Tests
-

Revised Beta Examination Second Edition (BETA-II) January 01, 2013

-

Bender Visual Motor Gestalt Test

January 01, 2013

-

Draw a Person Test

January 01, 2013

-

Sach Sentence Completion Test`

January 01, 2013

-

Thematic Apperception Test

January 01, 2013

IV.

INTERVIEW AND BEHAVIORAL OBSERVATIONS

The client presented for the interview wearing age-appropriate clothing. Orientation
was intact for person, time and place. Eye contact was appropriate. Her speech was
clear and unremarkable and frequently joked about being diagnosed of having a
mental problem/ illness. She mentioned beforehand that she was quite nervous of
taking the assessment procedures but throughout the examinations, she was
cooperative. The client’s attitude was guarded during the interview. Her affect was
slightly inappropriate to verbal content. There were no signs of hostility and
irritability. Thought content showed no evidence of delusions, paranoia, and/or
suicidal/homicidal thoughts. She was alert and attentive and put forth her best effort
in the tasks presented.

V.

RELEVANT HISTORY

At the time of the examination, the client is a 16-year-old female with a recent history
of poor school performance and reckless behavior. Her biological mother was
reported to be 39 years of age and is healthy. Her biological father is 40 years old.
She is the eldest of three girls. She also has four older siblings on her father’s side.
Her parents were not married but lived together for 16 years. They have recently
separated and both now have new partners. She and her siblings currently live with
their father and his girlfriend. Their mother is not with them at the moment but visits
them every weekend.

The main reason her parents separated was because her father was an alcoholic and
oftentimes beat his mother up when they had fights. She said that her mother wasn’t
understanding and fought back with him which always made his husband snap and hit
her. Back then, their quarrels weren’t as worse and got easily resolved. She didn’t
have any academic problems when she was in elementary; in fact she was in the
honor roll every year. The client experienced school failures when she started her first

year in high school. This was the time when her parents were having serious
problems with their relationship; her mother got fed up with her father’s attitude
which led her to secretly finding herself a new partner. This resulted to her father’s
jealousy and suspicion to escalate and from then on, everything fell apart.

The client’s mother talked to the principal to let her enroll for the next school year
despite of failed subjects. The request was granted and she continued her studies as a
second year high school student, but stopped attending a month and a half later and
eventually decided to officially drop out of school. Whenever she wasn’t at school,
she was with her friends, smoking cigarettes and drinking liquor. She consumes 2-3
sticks of cigarettes per day and drinks alcoholic beverages every other day. Her liquor
intake goes up to the point of drunkenness and disorientation. She even considered
joining a sorority group; she was gone missing for a night and went home with
scratches and had been face-slapped 50 times for initiation and another 50 for
punishment because she got scared and decided to quit moments later. She had also
thought of running away from home to escape it all. The client recounted that she had
also been bullied by some of her schoolmates. She is currently not attending school.

VI.

TEST RESULTS AND INTERPRETATION
Results indicated that the client’s overall level of intelligence falls within the Average
range as tested by Revised Beta Examination II. The client demonstrates good
reflective thinking but has difficulty showing it to the social world. Her poor
discriminative thinking or judgment to reality situation makes this dilemma possible
which might indicate that this prevents her from taking proper action when necessary;
recognizing poor behavior, attitudes, and activity; and setting boundaries for herself
against these which result to her behaving in an equally bad way. The client hesitates
in making decisions based on thoughts and responding based on feelings.

The client manifests anxiety in circumstances involving her family and has poor selfconcept and is insecure. She compensates for having poor self-concept, insecurities
and continuous failures in life by being ambitious and impulsive. She has plans on
striving hard for difficult goals and aspirations and yet always falls short. The client
also displays the need for family support and attention because of feelings of
abandonment and loss.

The client is reserved and finds it slightly difficult in sustaining meaningful
interpersonal relationships for fear of not being able to handle their demands. She
tends to be superficial and tries not to get emotionally involved with others. This
might be the reason why she has peers who she lets influence her to do reckless
behaviors because she knows they will not meddle with her personal life. This makes
her vulnerable to experiencing impulsivity.

The client has clear gender identity. Reservation towards opposite sex is noted. The
client’s father might be a great factor why she feels she needs to protect herself from
men. She also has contradicting opinions about women. She thinks high of them yet
sees faults and flaws. This suggests that she also has suppressed issues with her
mother but chooses not to confront it. She still has good concept and opinions on the
intimate relationship between a male and a female which implies that she uses these
to cover up feelings of sadness.

The client tries to cope with anxiety-provoking situations through optimism. This can
be noticed in her outlook in life. She recognizes the problem but tends to give
everything a much more favorable outcome. Acting out tendencies is also observed.
She copes with the pressure to do what she believes is wrong by giving in to the
thoughtless wrongdoing.

VII.

CONCLUSIONS/IMPRESSIONS
Based on the assessment and evaluation conducted, the client’s IQ level falls within
the Average range so this indicates that she does not have any problems in intellectual
functioning. The presenting complaint does not come from an issue of not being able
to comprehend school discussions, but inclines more on the emotional aspect. She
developed poor self-concept and insecurities that root out from her parents’ broken
relationship. She fears feelings of being left out and abandoned which are also results
of her current family situation. She does not feel secure inside their home so she
resorts to finding comfort in her friends’ company. This is obviously not a good idea
because she guards herself from being emotionally attached to other people for fear of
being overwhelmed by their demands so she ends up hanging around the wrong
people. She makes up for these feelings by being ambitious, impulsive and
disregarding of possible consequences. Her reckless behavior might be an
unconscious way of calling the attention of her parents, for them to focus on her, to
give her just a little amount of their time. But since most of her actions were not
approved by them, this even downgrades her view of herself so in return, she still
behaves in an equally bad manner which she can use as excuses for hiding her issues.

VIII. RECOMMENDATIONS

To resolve conflicts and improve communication within the family members, Family
Therapy is recommended. This will improve the client’s troubled relationship with
her parents and may help her understand why certain things happen to certain people.
This will help their family learn new ways of unhealthy patterns of relating to one
another. Through this, the client may be equipped with handling current stressors in
life and may achieve a better understanding towards them. The client may also
resolve her feelings of insecurities so she will give herself more worth which will
promote a much better attitude. Family Therapy will be a way to slowly build her
trust and respect back to her parents because they are a great influence on the

development of her self-concept. If these are resolved, she will likely be able to
handle stressors that will come to her life in the future in a more mature and
responsible way.

Social skills training is recommended to build coping strategies for dealing with peer
pressure and bullying; improve social skills; and promote better social behavior. This
will enable her to make good choices in life so as a result she will not yield to any
negative influence that other people like her friends introduce to her. As a result, she
will likely behave in an age-appropriate way.

Insight Therapy is suggested to help the client discover the reasons and motivations
for his behavior, feelings, and thinking. This will help her be self-aware and increase
self-control and suggest fresh possibilities for actions she makes to deal with her
problems. This will sidetrack her in finding comfort and security to behaving
inappropriately towards newly introduced options and proper choices.

Cognitive Therapy is advised to exercise better emotional reasoning and view things
objectively. This will alleviate the client’s poor emotional control govern most of
what she thinks that often results to impulsivity.

___________________________
Jamie Ann E. Perdigon
Examinee/Psychology Intern

PSYCHOLOGICAL REPORT
I.

II.

GENERAL INFORMATION

Name:

Gil Joseph Dela Cruz

Sex:

Male

Age:

37 years old

Date of Birth:

November 03, 1975

Place of Birth:

Quezon City

Educational Attainment:

College Graduate

Civil Status:

Single

Area of Confinement:

Psyche Health Home Care

REFERRAL REASON

The patient is referred for further psychological assessment, proper treatment and
management.

III.

ASSESSMENT PROCEDURES

a. Relevant History
b. Clinical Interview

January 11, 2013

c. Battery of Psychological Tests
-

Revised Beta Examination Second Edition (BETA-II) January 09, 2013

-

Bender Visual Motor Gestalt Test

January 09, 2013

-

Draw a Person Test

January 09, 2013

-

Sach Sentence Completion Test

January 09, 2013

-

Thematic Apperception Test

January 09, 2013

IV.

INTERVIEW AND BEHAVIORAL OBSERVATIONS

The patient presented for the interview wearing typical casual clothing - plain blue
shirt and shorts. He displayed good posture but his movements were a tad slower than
the normal. Orientation was intact for person, time and place. Eye contact was
appropriate although at times he stares a little too long. His speech was slightly
incomprehensible due to stuttering. He has long-healed stitch marks on his left wrist
due to attempting suicide. The patient was calm throughout the interview. There were
no unusual movements besides his occasional mild mouth tremors. He was responsive
and open to every question asked and even went to giving each a lengthy explanation.
His mood was euthymic. Affect was appropriate to verbal content. There were no
signs of hostility and irritability. Thought content showed no evidence of delusions,
magical thinking and/or suicidal/homicidal thoughts and there were no observed
perceptual disturbances such as visual and auditory hallucinations at the time of the
interview although he admitted to having experienced each of these back then. He
occasionally displayed flight of ideas. He claims that he knows he has schizophrenia.

V.

RELEVANT HISTORY

At the time of the assessment, the patient is a 37-year-old male diagnosed of having
Schizophrenia Undifferentiated. His biological mother died at the age of 47 due to
breast cancer. His biological father is reported to be 67 years old and currently resides
in the United States. He is the eldest of three boys. He had a close relationship with
his family. He never had any problems with them despite his father being aloof and
his younger brother being jealous of his success and achievements.

The patient finished taking up Metallurgical Engineering in University of the
Philippines. He also took up Automotive for 2 years, and a Psychology course which
he was not able to finish. When he was in his college years, he was brought to a home
care for rehabilitation for 2 months because his relatives thought he was taking drugs.

He said that he was just depressed because his mother had recently died and he felt
hopeless. His drug intake was only a one-time thing. He had tried marijuana, shabu
and cough syrup. He was addicted only to cigarette smoking that started since he was
19 years old which his younger brother had introduced to him; it usually goes up to 210 sticks per day. He had been drinking alcoholic beverages almost every day back in
college. He also joined a fraternity group. Back in rehab, he smashed the glass to
create a thunderbolt because he thought he was a god and he had powers. He
allegedly tried committing suicide four times.

The patient also had problems with his excessive masturbation. It started after he got
circumcised when he was 11 years old; from then on he had been doing it almost 10
times a day. Although he felt guilty about this, he couldn’t stop doing it, his libido
was very high. His guilt feelings had been too much that it once made him try to cut
his penis off only his grandfather stopped him from doing it.
He got admitted in Psyche Health Home Care on the 6th day of June, 2006 and got
discharged in 2010. He was readmitted on the 3rd day of May, 2012. He was a street
vagrant for almost a year prior to readmission. He never had any unusual perceptual
disturbances before; it only started on his second time in the home care. He claims
that he heard his brother’s voice and it told him he was proud of him. He just talked
back. He even saw his mother in a form a butterfly. There were moving images on the
walls of his room. He also thought that the world was going to end so he tried eating a
worm, cockroach, dried leaves and even his own feces. The patient is currently
confined in Psyche Health Home Care.

VI.

TEST RESULTS AND INTERPRETATION
Results indicated that the patient’s overall level of intelligence falls within the
Borderline Range. Though he received proper and complete education, it seems that
his condition made some deterioration in his intellectual functioning. Although his

organization of perceived materials appears to be better developed, his decisionmaking skills are still somehow poor because he has problems in discriminative and
reflective thinking which help in forming conclusions to situations and making
further choices and steps. These create some impairment in his judgment to reality
situation and abstract reasoning.

The patient shows guilt feelings about his excessive masturbation. He has fears of
castration and has repressed feeling of punishment for having forbidden sexual
desires. He also has guilt feelings on being addicted to cigarette smoking.

The patient has no problems with the people around him although he shows some
resentment towards those above him. This might suggest that he has slight difficulties
interacting with authority figures because he feels that they belittle him in one way or
another. He is ambitious and thinks high of himself. He has retained his pride that had
come from his past abilities and achievements.

The patient has a clear gender identity. He has ambivalent opinions on men. This
might suggest that he idolizes his father yet has some complaints on him but chooses
not to confront him about them since he is his source of motivation and inspiration.
He has good opinions about the intimate relationship between a male and a female
since his life-long dream is to have one of his own, although he displays some
hesitation in his ability of maintaining it. He shows feelings of sexual inadequacy
which he tries to alleviate by his excessive masturbation.

The patient uses projection as a way of coping with failures. Evidences of these are
his reasons of trying drugs, alcohol and cigarette. They were all pointed out to
someone else tempting him; his brother, his colleagues, or the hospital attendants. He
also has strong fantasies that he uses to channel unacceptable desires into imagination
and to ward off self-condemnation.

VII.

CONCLUSIONS/IMPRESSIONS
The patient’s overall level of intelligence falls within the Borderline range. He is
functioning although some areas show impairment. This may be because his present
condition is affecting his intellectual capacity. He has guilt feelings towards his
excessive masturbation because of castration threats. His moralistic view of the
concept of sex contradicts with his impulsive attitude. He has high opinions about
himself which may be the reason why he experienced having grandiose delusions.
This might also be the reason why he feels some resentment towards authority
figures. The patient dissents his father for being aloof and a totalitarian but still looks
up to him. He has satisfactory opinions about the relationship of a man and a woman.
This might suggest that he uses these to cover up for his longing of his partner and his
dream of having one of his own eventually. He has a strict superego that morally
regulates and controls his needs and impulses. He uses fantasies to ward himself off
from doing these unattainable and forbidden desires. He is not experiencing any
thought and perceptual disturbances.

VIII. RECOMMENDATIONS

Since the patient is diagnosed with Schizophrenia Undifferentiated, he is advised to
continue his antipsychotic medication to manage psychosis and promote mental
wellness.

To further enhance improvement, Individual Psychotherapy is advised. This will be a
tool for him to become more able in understanding his condition, to learn about
himself and to better handle issues of his daily life. He will be better able to
differentiate what is real and, by contrast, what is not and he can acquire beneficial
problem-solving skills.

If the patient continued his medication and can be deemed as mentally stable and
highly functioning, Cognitive Therapy is recommended so he can require skills that
involve identifying distorted thinking, modifying beliefs, relating to others in
different ways and changing behaviors. It will help strengthen his emotional control
so it will not be influenced entirely by how he perceives situations given that his
decision-making skills are quite poor.
Family Counseling is for the family’s education about the patient’s condition. This is
crucial for both patient and family members. Learning how to identify changes in the
patient, how to communicate with the patient, and how to be supportive to the patient
are all skills that can be taught in family therapy.

__________________________
Jamie Ann E. Perdigon
Examiner; Psychology Intern

PSYCHOLOGICAL REPORT
I.

II.

GENERAL INFORMATION

Examinee:

Narciso P. Joaquin

Sex:

Male

Age:

49 years old

Date of Birth:

February 21, 1963

Place of Birth:

Makati City

Educational Attainment:

1st Year College (not completed)

Civil Status:

Single

Area of Confinement:

Psyche Health Home Care

REFERRAL REASON

The patient is referred for further psychological assessment and proper treatment and
management.

III.

ASSESSMENT PROCEDURES

1. Relevant History
2. Clinical Interview

January 10, 2013

3. Battery of Psychological Tests
-

Revised Beta Examination Second Edition (BETA-II) January 09, 2013

-

Bender Visual Motor Gestalt Test

January 09, 2013

-

Draw a Person Test

January 09, 2013

-

Sach Sentence Completion Test

January 09, 2013

-

Thematic Apperception Test

January 09, 2013

IV.

INTERVIEW AND BEHAVIORAL OBSERVATIONS

The patient was casually dressed and groomed when he came up for interview - he
was wearing a yellow shirt and plaid shorts. Orientation to time, place and person was
intact. Eye contact was appropriate. Sitting posture was slouched and he had a
tendency to partially cover his face with his hands. He has a broken nose which he
got from a fistfight. He was calm throughout the interview and answered all questions
asked although his attitude seemed to be guarded. His speech was clear but a little
soft at times so it was slightly straining to hear what he was saying. Affect was
restricted. There were no evidences of delusions, paranoia, suicidal/homicidal
thoughts at the time of the interview. There were no observed perceptual
disturbances. The patient said that the reason why he was admitted in the home care
was because he has psychosis.

V.

RELEVANT HISTORY

At the time of the assessment, the patient is a 49-year-old male with a history of drug
addiction and violent behavior. His biological parents are both 80 years of age. He is
the second youngest of five siblings. He was admitted in Psyche Health Home Care
last July 04, 2011; someone complained against him because he threw a stone at a 14year-old child. He was drunk and the child got on his nerves.

The patient started taking drugs when he was only 16 years old. He was a high school
student back then. He did not have any personal problems; he only tried it because he
saw his other schoolmates doing it. He had done shabu, marijuana and cough syrup
(Corex D). What he uses varies every day. He was also a cigarette smoker. He
consumes half a pack each day. From then on, he had participated in reckless acts (i.e.
aggressive behavior, failure to attend school, stealing of things). His school
performance in elementary and high school was okay; failures started in his first year
in college. He got imprisoned three times due to complaints on his behavior. There
was a time when he entered his neighbor’s house naked and he was under the

influence of shabu. In another instance, while he was in jail, he kept bothering a
prison guard asking him about his dead friend even though he had only met him.
Even if he did not take any drug, his behavior was still the same. He had smashed a
car’s windshield for no reason. He was first admitted to Plain View Home Care in
Caloocan from 2005-2011. The doctor there told him that he had psychosis. He was
admitted in Psyche Health Home Care shortly after he escaped in the former
institution. He denied having experienced any perceptual and thought disturbances
such as hallucinations and delusions ever in his whole life. He is confined in the said
institution up to this day.

VI.

TEST RESULTS AND INTERPRETATION
Results indicated that the patient’s overall intelligence level falls within the Dull
Normal range. He has good reflective thinking but his discriminative thinking skills
are poorly developed which hinders his ability to make proper judgments and avoid
jumping into conclusions without considering all the facts. His poor recognition of
destructive behavior makes it difficult for him to set boundaries for himself against
participating in it.

The patient has feeling of lack of autonomy or self-government and he has a strong
need to control threatening impulses but since his poor judgment hinders his decisionmaking, he always acts out on his impulse. He attempts to control and address
anxiety-provoking situations by being aggressive and assaultive.

He has anxiety towards his physical appearance which affects his willingness to build
a mutual relationship with anyone around him. He has a poor self-concept. He is
sensitive to criticisms so he creates a barrier between himself and the people around
him. This might be the reason why his attitude is always guarded; he allows only a
few people in his life for fear that others might not really accept him for who he is.

The patient has a clear gender identity. He is not comfortable with the idea of being
with someone intimately because of anxiety and guilt he feels towards himself.
Although he wants one of his own, he does not welcome the idea of considering
having a partner for fear of being overwhelmed by the demands.

To cope with anxiety, he tends to develop acting out tendencies. He acts out impulses
and desires in spite of his conscience and he does them with relatively little thought
instead of reflections and feelings. This behavior roots out from internal emotional
conflicts.

VII.

CONCLUSIONS/IMPRESSIONS
Patient’s overall level of intelligence falls within the Dull Normal range. He has a
poor judgment to reality situation and tends to alleviate feelings of anxiety caused by
certain situations by being aggressive and assaultive. He always acts out impulse and
gives everything little thought. He has a poor self-concept which roots out from his
guilt feelings on previous wrongdoings and anxiety towards physical appearance.
This hinders his willingness to even start out a meaningful relationship. His low selfesteem leads to self-criticism and self-doubt, anxiety and even shame. He has a clear
gender identity and although he wants one of his own, he does not really consider
having an intimate partner for fear of not being able to maintain it. He tends to
develop acting out tendencies to avoid of being conscious of the emotions that
accompany them which often results to bad behavior.

VIII.

RECOMMENDATIONS

Family Therapy is recommended for helping both the patient and his family to cope
better with his condition. After experiencing an episode of psychosis, he may rely on
his family members for care and support. While most family members are happy to
help, the stress of caring for somebody can place a strain on any family. This will

help them decide how to solve practical problems caused by psychosis – for example,
planning how to manage a future psychotic episode.

Stress Management is advised since the patient has a poor way of coping with it.
Stress worsens the patient’s ability to think rationally. His irritability and use of
alcohol and drugs back then may be a sign of poor coping. By anticipating stress, he can
prepare for it and work out how to control it when it happens.

Social Skills Training is recommended to help the patient with his difficulties in relating to

other people. When he improves his social skills or change selected behaviors, he will
raise his self-esteem and increase the likelihood that others will respond to him
favorably.

___________________________
Jamie Ann E. Perdigon
Examiner; Psychology Intern

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