Final Test and Assessment

Final Test and Assessment

Name

University

Date

Running Head: FINAL TEST AND ASSESSMENT 1

FINAL TEST AND ASSESSMENT 6

Client: Barbara B.

Date of birth: 2/20/1993

Evaluated by:

Case No.: 1234

Date of Evaluation: 3/25/15

Date of Report: 2/25/18

PURPOSE FOR EVALUATION:

Barbara is a 22-year-old recent college graduate. She is currently employed as an entry-level account representative in a large advertising agency, a job she recently started about three months ago in a large city in the Northeast. She made a self-referral for assessment, reporting that she has been feeling tired and lacking in energy for about four weeks. Barbara reported that two months ago she started missing college life and friends and was also feeling a dislike for her job. She further reported a loss of interest in socializing, making new friends, performing daily routines such as exercising and trouble with concentration. Barbara also found herself questioning her vocational choice and finds she has difficulty keeping her mind on her work. Barbara recognizes that this is not normal and realized the need to refer herself for professional help. A psychological assessment was requested to gain more information about her present functioning and to aid in a diagnosis and treatment plan for Barbara.

BEHAVIORAL OBSERVATIONS

Barbara arrived for her appointment on time and was open in discussing her history and present concerns. She did note that she had overslept and rushed to keep the appointment, so she had not eaten that morning. She completed the assessments in a thoughtful manner, occasionally asking clarifying questions. She had some difficulty in responding to the projective tests, stating she was worried she would give incorrect answers.

ASSESSMENT PROCEDURES

Weschler Adult Intelligence Scale – Fourth Edition

Clinical Assessment of Depression (CAD)

Myers-Briggs Type Indicator® Personal Impact Report

Sentence Completion Test

House Tree Person Test

Holland Code Career Test

INFORMATION ASSESSMENT TECHNIQUES

Development History Form

Interviews

Primary Sources Inventory

Review of medical reports

BACKGROUND INFORMATION

Family/Social:

Barbara reports no family history of emotional, behavioral, educational, substance or medical difficulties.

Education History:

Barbara finished elementary and high school with no reported issues and grades consisted of A’s and B’s. Barbara completed college and received her BA and reported grades of A’s and B’s. There was no history of learning or behavioral problems in school.

Medical History:

Barbara reports normal birth with no prematurity. No difficulties reported in birth. No reported use of alcohol or drugs while in utero. All developmental milestones were reached as normal. Barbara reports no history of injury or illness.

Current medical concerns Barbara reports are fatigue, sleep problems and low energy.

Psychiatric History:

Barbara reports no psychiatric family history of mental illness.

Barbara reported no further psychiatric history of

MENTAL STATUS EXAMINATION:

Focus on YOUR observations and impressions.  This section of the report should focus on your objective evaluation.  Avoid quoting the patient’s opinion of his own mood, affect, etc. It’s also best to avoid mixing in background information or test information with this section.  A typical MSE for a ‘normal’ patient might read:

RESULTS OF EVALUATION:

In this model results are focused on possible answers to the referral question(s).  The idea is to present a hypothesis in the “PURPOSE FOR EVALUATION” section, then present data systematically to support or refute the hypothesis. The strength of this model lies in its efficiency and concise focus on the referral problem.

Weschler Adult Intelligence Scale – Fourth Edition:

The WAIS-IV groups an individual’s ability into four global areas: Verbal Comprehension Index (VCI), which measures verbal ability; Perceptual Reasoning Index (PRI), which involves the manipulation of concrete materials or processing of visual stimuli to solve problems nonverbally; Working Memory Index (WMI), which measures short- term memory; and Processing Speed Index (PSI), which measures cognitive processing efficiency. All of the indexes have standard scores with a mean score of 100, with the scores of 90 to 110 falling into the Average range. Each of the four Indexes has subtests that comprise the Index score. All of the subtest scaled scores have a mean score of 10, with the scores of 7 to 13 falling into the Average range.

Barbara obtained a Full Scale IQ (FSIQ) score of 112 (87th percentile), which places her intellectual functioning in the high average range. There was a 95% confidence interval of 108-116, which means that if she were tested 100 times, 95 of them would fall in this range. Barbara obtained a Verbal Comprehension Index (VCI) score of 112 (79th percentile), with a 95% confidence interval of 106-117, which places her verbal ability in the high average range. She obtained a Perceptual Reasoning Index (PRI) score of 117 (87th percentile), with a 95% confidence interval of 110-122, which places her nonverbal ability in the high average range. She obtained a Working Memory Index (WMI) score of 111 (77th percentile), with a 95% confidence interval of 104-117, which places her memory in the high average range. She obtained a Processing Speed Index (PSI) score of 97 (42nd percentile), with a 95% confidence interval of 89-106, which places her processing speed in the high average range.

Clinical Assessment of Depression (CAD):

The Measure of depression being used is the Clinical Assessment of Depression (CAD). 50 item self reported test that may be done by hand or entered on the computer. It is designed for people ages 8-79. The CAD is also meant to assist in intervention planning and the monitoring of treatment progress. The CAD includes a Total Scale score that reflects an overall level of depressive symptomatology and four symptom-based scales including Depressed Mood, Anxiety/Worry, Diminished Interest, and Cognitive and Physical Fatigue. In addition, the CAD contains Inconsistency, Negative Impression, and Infrequency validity scales. Internal consistencies (coefficient alpha) and standard errors of measurement for the CAD Total Scale and symptoms scales were computed for the total sample (n = 1,900). By age group, coefficient alphas for the CAD Total Scale ranged from .96 (8-11 and 18-25 years) to .97 (12-17 and 26-79 years).

Myers-Briggs Type Indicator® Personal Impact Report:

Sentence Completion Test:

House Tree Person Test:

The house is small and runs off the edge of the paper. It appears to lack warmth and detail, suggesting the Barbara might be. The front door lacks a door handle, this might indicate inaccessibility. The house has an absence of windows on the first floor, which suggest that Barbara could be withdrawn, and inaccessible, or possibly suspicious. The absence of a pathway indicates Barbara may be closed, distant and removed. The missing chimney suggests passivity or a lack of psychological warmth in a Barbara’s home life. The tree lines that are heavily reinforced suggest defensiveness and the noteworthy lack of detail in the overall drawing suggests Barbara is withdrawn and experiencing a decline in energy (House Tree Person Interpretation Elements. n.d.).

Holland Code Career Test:

SUMMARY/RECOMMENDATIONS:

Begin by specifically answering the questions you posed under “PURPOSE FOR EVALUATION.” Then elaborate as much as needed to present your conceptualization of the case. It’s fine to include DSM diagnostic impressions, but your summary of the patient’s psychological makeup is far more important. If you do include DSM labels, be sure you’ve provided enough detail in the body of the report to support the diagnostic criteria as described in DSM. Any recommendations for treatment can also go here. For example:

Results of psychological evaluation reveal an extended history of alcohol abuse and a psychotic disorder characterized primarily by disturbance of thought content, with relative integrity of thought process and no clear indication of perceptual disturbance. The current clinical presentation appears to represent an acute exacerbation of a chronic psychotic disturbance which had its onset approximately 8 years ago. Currently, Mr. Jones appears to remain extremely distressed, anxious, paranoid, and delusional, despite self-reports to the contrary. He lacks sufficient capacity/ motivation to rely on external supports and lacks sufficient personal insight to cope independently at present. The patient appears to be attempting to cope with his illness using extreme guardedness and withdrawal. During recent months he has shown no signs of aggressive ideation and is not believed to be a physical risk to himself or others at present.

It is recommended that efforts to establish a trusting relationship with this patient be continued, in order to help him cultivate a more adaptive coping/defensive pattern. Individual therapy will be more productive than group interventions. Once his guardedness has been relaxed, it will likely be beneficial to explore psychosocial issues present at the time Mr. Jones lost his job, as these appear to have partially precipitated the current psychotic exacerbation. Additionally, the patient will benefit from encouragement to explore the social and adaptive significance of his substance abuse history.

References

House Tree Person Interpretation Elements. (n.d.). Retrieved from http://www.academia.edu/6520325/House_Tree_Person_Interpretation_Elements

Bradley-Levine, J. (2015). Qualitative research.

Koocher, G. P., & Keith-Spiegel, P. (2016). Ethics in psychology and the mental health professions: Standards and cases.

Miles, M. B., Huberman, A. M., & Saldaña, J. (2014). Qualitative data analysis: A methods sourcebook.

Sheet1

VCI Subtests Scaled Score PRI Subtests Scaled Score
Similarities 13 Block Design 14
Vocabulary 13 Matrix Reasoning 11
Information 11 Visual Puzzles 14
WMI Subtests Scaled Score PSI Subtests Scaled Score
Digit Span 9 Symbol Search 12
Arithmetic 15 Coding 7
VCI = 112 PRI = 117 WMI = 111 PSI = 97 FullScale IQ = 112

VCI Subtests Scaled Score PRI Subtests Scaled Score Similarities 13 Block Design 14 Vocabulary 13 Matrix Reasoning 11 Information 11 Visual Puzzles 14

WMI Subtests Scaled Score PSI Subtests Scaled Score Digit Span 9 Symbol Search 12 Arithmetic 15 Coding 7

VCI = 112 PRI = 117 WMI = 111 PSI = 97 FullScale IQ = 112

VCI Subtests Scaled ScorePRI SubtestsScaled Score

Similarities13Block Design 14

Vocabulary13Matrix Reasoning 11

Information11Visual Puzzles 14

WMI Subtests Scaled ScorePSI SubtestsScaled Score

Digit Span 9Symbol Search 12

Arithmetic 15Coding 7

VCI = 112PRI = 117WMI = 111PSI = 97FullScale IQ = 112