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PSYCH REPORT (Sample)

PSYCH REPORT (Sample)

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Published by mspsy
This was our psychological report draft during our internship period and I decided to upload to share it to my dear readers :* Note of some grammatical errors but my purpose of uploading this is to give you ideas on how's the flow of a psychological report in a certain institution.
This was our psychological report draft during our internship period and I decided to upload to share it to my dear readers :* Note of some grammatical errors but my purpose of uploading this is to give you ideas on how's the flow of a psychological report in a certain institution.

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Categories:Types, School Work
Published by: mspsy on Apr 07, 2013
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07/06/2014

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Case Presentation

CLIENT
Age: 43 years old Date of Birth: November 25, 1969 Place of Birth: Balabak, Palawan Address: M. Dimapilis St. Anuling Lejos I, Mendez Cavite Gender: Male Religion: Roman Catholic Civil Status: Single Educational Attainment: College Graduate (3 years) Electronic Technology Occupation: Production Operator (Yazaki) Referred by: Acute Crisis Intervention Unit Purpose of referral: For evaluation Date Examined: November 29, 2012 Date Evaluated: December 01, 2012 Family History The client lives at Mendez Cavite, he is the eldest son of Mr. xxxx and Mrs. xxx. The occupation of his mother was a teacher while his father was a police. His father died 13 years ago while his mother died 7 years ago at the age of 57 and 56. They are six (6) siblings, his second brother is Mr. xxx, he is a teacher and he has own family. The third sister of the client is Mrs. xxx , she is the first one who took care of the client but her mental illness occured after she delivered her second baby. His fourth sister is Ruby, she is already a widow and her occupation is a manager. The fifth sister of the client is Lhen, she is an encoder at Makati. Lastly is his youngest sister, Mrs. xxxx, she is working at Analog Company and she is the one who accompanied the client in the institution and took care of him. According to the sister of the client, he is much close to his mother and is able to help her doing household chores as well as with his other siblings. He is strict, especially when it comes to cleaning the house, because he wanted their house to be clean and organized. Before, they used to go to church and at picnic groove to have their family bonding. He is quiet and serious on his family and he always obeys and follows his parents because he does not want to embarrass them. According to his sister, their maternal grandmother and his paternal uncle have mental illnesses. The client has his own room in their house because his mother pities him and was always worried when the client strays in their house.

Personal and Social History During the client’s childhood years he is able to play with other children but not with his siblings, they were not close with each other and his parents are quite strict to them that they are not allowed to go out sometimes. The client experienced a mild head injury that he fell into a bike and he had his forehead stitched during the holy week, a huge knife accidentally fell into his knee and caused him a mild wound. At school he always joins and participates on school activities, he has awards and his grades are good that is why he was always in the list of topnotchers at 6 th or 7th place. The client really likes to give help and follow his parents. The client graduated in Technological University of the Philippines at Salawag for 3 years with the course of Electronic Technology and he likes to be an engineer. He graduated at 18 years old but he was not able to have work immediately. He stayed at their house for almost one year because he does not have work, but he tried to apply abroad as a seaman, unfortunately he did not continue it. The client had his first and last work experience at Yazaki as a production operator together with his cousin and it lasted for almost 2-3 years. The client does not have any conflicts with his workmates. The client was generous enough to share his salary to his mother and provide some appliances for their house. He knows how to deal with other people, but he does only have limited number of friends. The client has history of vices which is smoking and drinking liquors but only minimal. History of present illness It was almost 20 years since the client is suffering from his mental illness, before he was an Out Patient Department and was a patient of Dr. xxx, at a Psychiatric Clinic at Trece Martires City, Cavite for 4 years. The client’s first episode was when he kept on asking his mother if he had a bad odor. He always take a bath and became conscious to his self even though he does not have a bad odor. There are some instances that the client try to hurt his sister, because he said that there is someone that is telling him to do it and he saw that there is some person that was hugging his sister that is why he hurt it and stabbed it. Another incident that happened, he hurt and spank the baby of his sister without any reason. The client experienced electro- convulsive- therapy. The client was able to have follow- up check up, injections and medications. He always drinks a medicine named leponex 100mg, once a day before he goes to sleep but sometimes he refused to drink it and he will throw the medicine because as he perceived its size was seems to be too big. When his parents died and his third sibling got the same mental illness, the client was not able to have his check up for almost a year due to his sister’s work that she cannot accompany the client and because the client seems to be difficult to convince to go for his check up, but his medicine was still maintained. The client seems to be violet at times especially when he saw violent scenes in the television that he used to imitate it. During the time that he does not have his own room, he always walk into different places within Cavite, but he can still go home after 3 days. In his owned room in their house, he will pee anywhere, shout, say bad words and his pillow and blanket was always put into the toilet bowl of the comfort room.

The client was admitted on November 05, 2012 at this institution. His sister brought him, because the client was unable to have a proper conversation towards other people and he cannot recognize such person. Duration of illness The client starts suffering from mental illness, almost 20 years and started at the age of 22. Behavioral Observations The client was presented to the tester wearing a green male ward uniform and pair of rubber slippers. Approximately, five (5) feet and eight (8) inches tall with an ectomorph body built and slouchy posture. He is bald and has fair skin type, he also has small stitch on his forehead, his nails are clean and trimmed, and his teeth are decaying. He can write simple words, letters, numbers and able to write his name.He can also read and identify shapes and objects. The client has good mathematical ability, visuospatial ability, and fair general information and memory. His mood is empty and affect is blunted, and he speaks in a low tone and tend to have eye contact to the tester. The client is oriented with only two spheres, the place and person. The client has flight of ideas with poor judgment, insight and reliability. The client has delusions and visual hallucination such as seeing superstitious individuals and ghost. During the testing proper, the client seems to behave accordingly and cooperative with no resistance to take the exams. He knows how to follow instructions and he performs slowly. He does not easily gets distracted by extraneous stimuli. Sometimes he fixed his hair and scratch it, his arms were closed, and he fixed himself to his chair. Tests were finished in one session and commenced tasks with his right hand.

Tests Administered Draw A Person House Tree Person Bender Visual Motor Gestalt Test Thematic Apperception Test The Forer Structured Sentence Completion Test Revised Beta Examination- Second Edition

Draw A Person Draw a person test result, shows that the client tends to have a weak personality. He is an insecure individual that lacks of opinion and his own point of view. The client may have ego- centric attitudes based on his feeling of inadequacy. It also appears that the client tends to be alcoholic. He sees the world with a little discrimination that makes him have withdrawal tendencies. He also have fantasies. It also appears that the client had low mental functions and lack of confidence that makes him to have a need to be accepted in his environment. It shows that the client have sexual concerns such as aging has effects on it. He has inadequate controls on his basic drives and impulses that flows freely. House Tree Person House tree person test, shows that the client have a lack of interest among other people but he also consider dealing with them in such situations where he act accordingly to have an acceptable interpersonal relationship toward other people. The client also feels inadequate in social situations which leads him to have introversive self absorbing tendency where he becomes aloof. Being open to vulnerability causes the client to have withdrawal tendencies and may have the possibility of losing his ability to cope with environmental pressure which may lead him to have possible aggressive roles within his environment. It also revealed that the client has to emotional immaturity that makes him have a lot of fantasies running over his mind as well as having ambivalence and no consistency in his every course of actions. At times it shows that the client have feelings of physiological and psychological immobility. Bender Visual Motor Gestalt Test Bender Visual Motor Gestalt Test, reveals that the client have difficulties when it comes to interpersonal relationship with the fact that he prefers to be alone and this may cause him to have dissociate and withdrawal tendencies. He restricts emotional insensitivity that may arise within his environment. He may seems to have disturbances that triggers because of depressive conditions. It also shown that the client may have possibilities to have hysterical personality and incipient severe personality disorder that may reflect effort in maintaining personality against disorganization.

Thematic Apperception Test Card 1: Nag- iisip kung paano malabasan yan, nag- iisip ng paraan kung paano makalabas. Si Celyo kapag may nawawala sa bahay sa kanya hinahanap. Nakaalis. May kamay na naka- hipo sa kanya. Interpretative Summary: The main hero in the story is Celyo and he wanted to be away and free from the abused. He seen the figure as a determined person enable to evade. The client has possibly experienced being abused and his determined to break away in that situations. Card 4: Parang snocker na tindahan, napadaan sa ufo ang dalawa, si superman at body guard na babae nag- hihintay sila na may dumaan at gustong matulog ng maaga, kinakatakutan ng mga kasama. Interpretative Summary: The client has flight of ideas and his story is irrelevant on the plate that had been showed. The main hero in the story is himself and it shows that he is dependent with others. Card 6 BM: Si Allan nakatira sa Cambodia, sabi ng lola maramdamin. Nag- papray sa tabi ng bahay sa kaluluwa at ibang bagay na nasa ilalim. Hindi siya masyado hinipo sa buhok. Interpretative Summary: The main hero in the story is himself and it shows that he is longing for attention but he has tendency of being abused, and he used to supress it. The client has flight of ideas and his story is irrelevant on the plate that had been showed. He has delusions and hallucination. Card 7 BM: Hirap siya na gumalaw sa ospital naranasan niya noong unang panahon na nag- tubig ang ulo. Nag- hihintay ng biyahe, parang nahuli ng camera sa isang kwarto. Nag- hihintay din minsan ng makakain tsaka para bang hindi sila pareho magkasama parati. Interpretative Summary: The main hero in the story is himself and it shows that he he wanted to be heal, the conception of environment is complicated and his having difficult to do such movements. He has flight of ideas and his story is not significant on the plates. Card 9 BM: Parang nahuli din sa camera, mga cow boy, gumagawa sila ng mga dinamita, ginagamit sa pag- pasabog sa mga tren. Sumabog siguro ang tren. Nagiisip kung saan dadaan kung sa harap o likod nahuli ng aking ama ang kanyang picture, sumabog si Janngo Herez na tumutulong sa kanilang bayan. Interpretative Summary: The main hero in the story is himself, he feels that his in the dangerous situation and he wanted to keep away and save himself. He used his cognitive todeal with the problem. The thought process of the client is flight of ideas.

Card 10: Madaling tumanda ang bata, pinormula ng kanyang anak ginamitan ng formula. Siya ay takot na takot kapag hindi nakaluto ang kanyang ina ng tinapay. Natatakot sa maraming multo kaya hindi makaluto ng tinapay. Interpretative Summary: The main hero in the story is himself and it shows that he is afraid to be failed and needs to be strong enough to handle his obstacles in life. The client has flight of ideas and the story is irrelevant on the plate. Card 12 M: Kamunti Island nagtatanim, kumain, bulkan na may krus, para gumaling ang ina. Ang kanyang ina at lola gumaling pero saglit lang dahil umiinom ng gamot. Interpretative Summary: The main hero are the grandmother and mother that want to be heal, with the environment it shows care among the family and the conflict that had revealed is that they are heal but for only a short period of time and the source of the conflicts is when one of the member of the family has sick. It also shows some flight of ideas in the story and it is not much appropriate into the plate. The outcome of the story shown unhappy because they were not able to be heal only for a short period of time. Card 13 B: Nag- iisang anak, galing sa super island si Johanna hindi nakatapos ng abogado. Nakikita ng tikbalang, kamukha, nakikita tuwing tanghalli sa cr namatay dahil sa prutas, nasirang bahay. Interpretative Summary: The main hero is a woman namely johanna and her needs is for achievement, to be graduate but unfortunately it is the source of the conflict because she feels frustrate when she did not able to finish it. The outcome of the story is unhappy due to she was not able to fulfil or attain what she wants in life, there is still a flight of ideas within the story and its not appropriate into the plates. Card 13 MF: Parang si Peter Parker, nag- tatabi ng gamit papuntang abroad, parang may napansin siya sa kanyang kwarto bago umalis yung hindi niya natabi yung tape, mahalaga yun sa kanya dahil bilin sa kanya ng ina na itabi ang tape kapag aalis. Mga pamilya, makauwe na ang kanyang anak. Lumuluha palagi kapag walang kasama, simula noong maliit pa. Ipinag- bilin sa mga madre na nag- aral si Elizabeth. Interpretative Summary: The main hero in the story is himself and it shows that he is longing for attention and love, he feels sad and alone whenener he was left alone and supervised by other person. It shows he has some flight of ideas and the outcome of his story is unhappy. Card 14: Parang isang masamang kaibigan na sundalo na nalilipatan ng utak, nag babantay ng bagoong nag- hahanap ng makakasama yata. Parang hindi palagay ang loob niya sa bahay dahil diyan siya pinatay noong maliit pa sila Peter Parker. Kasamahan sa trabaho mag- babantay ng kayamanan ni Peter Parker, naloloko sa bagoong dahil natikman niya sa ibang bansa. Peter Parker dating mahirap na biniyayaan ng kayamanan ng kapatid. Interpretative Summary: The main hero in the story is Peter Parker, it revealed that he wanted to be with somebody, he tends to become doubtful person and paranoid. His not at ease at all times. The outcome of the story shows unhappy.

Card 18 BM: Nag- mamaster sa drawing, magaling yung mga kamay niya sa pagtugtog ng piano at mag- drawing sa kabilang kamay. Siya ay matamlay dahil namatay yung anak na lalaki natuon sa ilong at bibig. Interpretative Summary: The main hero in the story is himself, who wanted to achive his needs in life and he will strive more enable to attain it but he feels not due to the death of the child. The outcome of the story shows unhappy. Card 20: May maliwanag na bagay, pero parang puro palibot na itim. Parang allien swam, lumipat sa ibang katawan. Gusto niyang tignan ang buhay ng kanyang mga kapatid sa ibang daigdig malaking pangil. Interpretative Summary: The main hero in the story is himself, he wanted to assure that his other siblings are in good and stable in lifes, his figure seen as a succorant who always give help. It also shows some flight of ideas and his story was not significant to the event. Card 16: Parang kambal ni superman sa likod, dati silang nakatira sa malayong probinsya, pinag- hiwalay ng ama ang kambal ni superman nasa ospital baon ng kanilang ninuno, gustong may maitama sa kapatid. Dati pa namin napuntahan ng mga kapatid ang magandang lugar malapit sa visaya, ate Natty Vicay Ledia kasama ni superman sa sasakyan sa tindahan lang sila nag- kahiwalay hiwalay dahil may gustong bilhin na gamit, hindi nabili dahil mahal. Nagugulat dahil may bagong damit. Interpretative Summary: The main hero in the story shows that his desire is to feel love and be with his own family. He does not want to be away and separated to his family, this situation lead him to feel sad and become weak these results his story to be unhappy though he has flight of ideas.

Summary: Based on the integration of all cards, it shows that the he has prominent ellaborative and interpretative level of the main theme. Most of the outcome of the story shows unhappy and unrealistic, his thought processes is flight of ideas. The common conflict that appear in the story is that he cannot escape to his obstacles were he gets confused and does not know how to deal with it even his trying to work on it. He also feels failure that no one arounds for him and felt being abandon. It revealed that the client is a weak, alone, dependent, tends to be paranoid at times but, he is determined person who always wanted to give help and care. It also revealed that the client is longing for love, care and attention, with this lack of love the client possibly depressed and feels neglected because his needs does not able to meet. It also shows that the client has a big heart whom he always consider the health of his family and assure that they are well fine. The client possibly experienced or witness an abused in which he can be aggressive and hurt other people but his submissive into his family which he obey and follow his parents.

The Forer Structured Sentence Completion Test Forer Structured Sentence Completion Test revealed that the client shows love protection and concern towards to his family, he perceived his mother a strong person and he has distant relationship with his father and wishes to be closer. The client feels that there is lacking with his family. He always wanted to give help and for all time he gives consideration for his siblings, his not greedy and selfish person. He wanted to be sure that his siblings is being cared and protected especially his sibling girls. The client shared to his siblings all the good things that he had learned and he is able to teach and help them. In dealing with other people, the client tends to keep away himself to others but still he wanted to have good relations with other to avoid conflicts. He is obedient and determined person. He will strive and learn more to be able to achive what he want in life. Test also shows that the client has anxiety feeling whenever one of his family member got sick and he often blame himself when these situation comes to them. The client feels very sad when his mother passed away, and it lead him to be feel depressed and frustrated. He tends to escape and repressed his feeling when his in the difficult situation but he will still try and think some possible solution to deal with it. He has guilt feelings when he did something wrong that is not accepted in the society and at times he became suspicious. The client shows some unclear responses towards love, marriage and sex but he perceived love that it should be given to everyone and deserve to be love.

Revised Beta Examination- Second Edition Total Scaled Score: 26 IQ: Less than 60% Classification: Mentally Deficient The client has an above average logical reasoning and reflective thinking, poor planning and visual motor coordination and with impaired abstraction, sensitivity to details and judgment. It also revealed that the client has less than 60% IQ level which fall in the category of mentally deficient.

Psychopathology
CONTRIBUTING FACTORS

Biological
43- Male Mental Illness (Seasonal) Has stitch on his forehead Serotonin is high Smoking and Alcohols

Psychological
Conflict with father Failed to have work after graduated Low level of frustration tolerance Low Self- concept

Social Environment
Joined fraternity, Loner Middle family status

Aloof Social withdrawal

Symptoms Delusions Visual Hallucination

Schizophrenia; Undifferentiated type

The psychopathology shows that these are the contributing factors to the client’s illness, with the biological it revealed that they have a family history of mental illness both side of his parents and it only shows that it is hereditary. Another factor that causes him to have that specific illness is a brain damage because of the stitch that he had on his forehead. The serotonin of the client is high that resulted him to be sad and depressed. He has vices such as smoking and drinking alcohols. In psychological factors it revealed that the client has conflict toward his father, they were not close to each other as well as to his siblings, there is a lackness of open communication with them. The frustration tolerance and self- concept of the client is low which lead him to feel inferior and frustrate while in the social environment revealed that he is strict serious, quiet person that keeps himself to be alone, and away in the society. He had prominent delusions and visual hallucinations, his thought processes is flight of ideas. With these symptoms it shows that the client is evident to have schizophrenic features under the undifferentiated type. Test Results and Evaluation Total Scaled Score: 26 IQ: Less than 60% Classification: Mentally Deficient The client’s intellectual functioning falls into mentally deficient. He got an above average score on logical reasoning and reflective thinking. He scored poor on planning and visual motor coordination . He got an impaired score on abstraction, sensitivity to details and judgment. Integrating the test results, it revealed that the client has difficulty in handling his own emotions and his thought process is prominent with flight of ideas. He is shy , and a quiet person that causes him to have a poor contact with others and be socially withdrawn. It also shows that he is aloof and dependent in some situations in which he tends to ask for someone on what decisions he will choose. He is hesitant and no confidence to himself that lead him to feel inferior and insecure. The client has a good heart for his family. He wants his family to have a good health that is away from any sickness because he feels depressed and blame himself when this situation arised. He is not greedy and selfish, he always give help and care towards to his siblings. The client assure that his family is being protected and away from any danger. He is a determined person to achieve his want in life but he tends to become weak when he feels losing hope. The is longing for the love,care and attention from his parents especially to father and it resulted him to have feeling of emptiness. The client shows he is

sexually abused or witness an abused that has effect to his personality and to have poor contact in the reality, he had shown a social withdrawal and depressed. The ego function of the client is weak, as well as his basic drives and impulses. He seeks satisfaction and compensation through fantasy. The client is an alcoholic. He uses repression and supression as his defense mechanism, he has low frustration tolerance. Social withdrawal, suspicious and schizophrenic are prominent features, as well as delusions and visual hallucinations. Psychological Impression Schizophrenia, Undifferentiated type tendency Recommendations  The client must maintain a prescribed antipsychotic medicine for this kind of illness to ensure that his conditions will not aggravate.  Possible therapy for the client is the psychosocial therapy. This specifically the following areas will help the client.  Illness management skills  Communication  Motivation  Self- care  Work  Establishing and maintaining relationships with others People with schizophrenia can take an active role in managing their own illness. Once they learn the basic facts about schizophrenia treatment, they can inform decisions about care. If they are taught how to monitor the early warning signs, they can learn to prevent relapses. Patient can also be taught more effective coping skills to deal with persistent symptoms. Patients who receive regular psychosocial schizophrenia therapy are adhere better to their medication schedule and have fewer relapses and hospitalizations. A positive relationship with a therapist or case manager gives the patient a reliable source of information, sympathy, encouragement and hope, all of which are essential for recovery.

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