Psychological Report
Content
PSYCHOLOGICAL REPORT I. GENERAL DATA
Examinee: Sex: Age: Date of Birth: Place of Birth: Education: Address:
CMB Female 16 August 17, 1996 Makati City 2ND Year High School (not completed) Makati City
II.
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 c. Battery of Psychological Tests Revised Beta Examination Second Edition (BETA-II) January 01, 2013 Bender Visual Motor Gestalt Test Draw a Person Test Sach Sentence Completion Test` Thematic Apperception Test January 01, 2013 January 01, 2013 January 01, 2013 January 01, 2013 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. GENERAL INFORMATION
Name: Sex: Age: Date of Birth: Place of Birth: Educational Attainment: Civil Status: Area of Confinement:
Gil Joseph Dela Cruz Male 37 years old November 03, 1975 Quezon City College Graduate Single Psyche Health Home Care
II.
REFERRAL REASON
The patient is referred for further psychological assessment, proper treatment and management.
III.
ASSESSMENT PROCEDURES
a. Relevant History b. Clinical Interview c. Battery of Psychological Tests Revised Beta Examination Second Edition (BETA-II) January 09, 2013 Bender Visual Motor Gestalt Test Draw a Person Test Sach Sentence Completion Test Thematic Apperception Test January 09, 2013 January 09, 2013 January 09, 2013 January 09, 2013 January 11, 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. GENERAL INFORMATION
Examinee: Sex: Age: Date of Birth: Place of Birth: Educational Attainment: Civil Status: Area of Confinement:
Narciso P. Joaquin Male 49 years old February 21, 1963 Makati City 1st Year College (not completed) Single Psyche Health Home Care
II.
REFERRAL REASON
The patient is referred for further psychological assessment and proper treatment and management.
III.
ASSESSMENT PROCEDURES
1. Relevant History 2. Clinical Interview 3. Battery of Psychological Tests Revised Beta Examination Second Edition (BETA-II) January 09, 2013 Bender Visual Motor Gestalt Test Draw a Person Test Sach Sentence Completion Test Thematic Apperception Test January 09, 2013 January 09, 2013 January 09, 2013 January 09, 2013 January 10, 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
Examinee: Sex: Age: Date of Birth: Place of Birth: Education: Address:
CMB Female 16 August 17, 1996 Makati City 2ND Year High School (not completed) Makati City
II.
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 c. Battery of Psychological Tests Revised Beta Examination Second Edition (BETA-II) January 01, 2013 Bender Visual Motor Gestalt Test Draw a Person Test Sach Sentence Completion Test` Thematic Apperception Test January 01, 2013 January 01, 2013 January 01, 2013 January 01, 2013 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. GENERAL INFORMATION
Name: Sex: Age: Date of Birth: Place of Birth: Educational Attainment: Civil Status: Area of Confinement:
Gil Joseph Dela Cruz Male 37 years old November 03, 1975 Quezon City College Graduate Single Psyche Health Home Care
II.
REFERRAL REASON
The patient is referred for further psychological assessment, proper treatment and management.
III.
ASSESSMENT PROCEDURES
a. Relevant History b. Clinical Interview c. Battery of Psychological Tests Revised Beta Examination Second Edition (BETA-II) January 09, 2013 Bender Visual Motor Gestalt Test Draw a Person Test Sach Sentence Completion Test Thematic Apperception Test January 09, 2013 January 09, 2013 January 09, 2013 January 09, 2013 January 11, 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. GENERAL INFORMATION
Examinee: Sex: Age: Date of Birth: Place of Birth: Educational Attainment: Civil Status: Area of Confinement:
Narciso P. Joaquin Male 49 years old February 21, 1963 Makati City 1st Year College (not completed) Single Psyche Health Home Care
II.
REFERRAL REASON
The patient is referred for further psychological assessment and proper treatment and management.
III.
ASSESSMENT PROCEDURES
1. Relevant History 2. Clinical Interview 3. Battery of Psychological Tests Revised Beta Examination Second Edition (BETA-II) January 09, 2013 Bender Visual Motor Gestalt Test Draw a Person Test Sach Sentence Completion Test Thematic Apperception Test January 09, 2013 January 09, 2013 January 09, 2013 January 09, 2013 January 10, 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
