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PSYCHOLOGICAL REPORT

I. Identifying Information

Name: Terence De Vera


Sex: Male
Age: 48 years old
Birthdate: May 31,1970
Birthplace: Quezon City
Education: Philippine Women’s University (Mass Communication)
Rogationist College

II. Referral Source


Dra. Encarnacion

III. Reason for Referral


He was referred by his mom on May 19, 2018 due to having bad-temper for
the past few days aimed at his nephew prior to the referral at Full House Custodial
Care Center (FHCCC). According to his mom, Terence brought a new mobile phone
and wanted to download an application to it; thus he asked for his nephew’s help
however, Terence said that his nephew damaged his mobile phone.

IV. Case Background


Since 2004, after the separation of Mr. Terence due to his live-in-partner
having an affair with another, he started to believe that his neighbor from where
he lives before desires to steal his belongings. As well as he thinks that people
surrounding him thinks badly of him such as having the belief that other people
sees him as having no worth as a person and they plot along with his neighbor to
commit the stealing act; to the extent that he became suspicious even to his
relatives. He also believes that the reason he lose all of his friends was because his
neighbor took pictures of him and spread rumors through social media thus
causing his reputation to be tainted as well as his relations with other people. Even
at Full House Custodial Care Center (FHCCC), he thinks that the attendants, nurses
and interns hates him and sees him the same way other people do. Additionally, he
is convinced that the attendants worked along with his previous neighbor through
mobile phones to easily commit the stealing act. As a result, Mr. Terence isolates
himself everyday and stay at his room most of the time, even unwilling to form a
friendship to his roommates because he is wary that other people might take
advantage of him thus they will be able to deceive him and commit the stealing act.
Despite of his situation, he exhibited persistent paranoia and denied auditory or
visual hallucinations. Additionally, he did not manifest any aggressive act on FHCCC
but only has beliefs that people are out to steal his belongings and thinks badly of
him.

V. Physical and Behavioral Observation


The patient stands near 6 foot in height, with a tan complexion often seen
wearing a shirt with shorts and sandals, has untidy hair and is often found holding
his green tumbler. He does not have any indication of self-harm nor tattoos. He
spends most of his time in his quarter reading the Daily Bread Bible, selectively
interacts with a few people and speaks in a slurred manner. Lastly, he has a
consistent orientation to time, date, place and recognition of person.

VI. Testing Behavior

Unfortunately Mr. Terence wasn’t able to finish the Hand Test due to the
reason that he doesn’t know what to answer anymore. Additionally, he often
scratches his head if he doesn’t know what to answer; also he often plays with his
pen, and cannot seem to sit still, an indication that he has a short attention span.

VII. Tests Administered


Revised Beta Examination II (RBE II)

Bender Visual Motor Gestalt Test (BVMGT)

Draw-A-Person Test (DAPT)

Sach’s Sentences Completion Test (SSCT)

Hand Test

Axis II Checklist

Clinical Interview

Date Tested: March 7, 2019

VIII. Test Results and Interpretation

Analysis of sub-test scores reveals that Terence is high on anticipatory ability,


while, his reflective and analytical attitude is at the average level. However, his
organization ability such as the capability for inductive and deductive perception is
slightly below average. Additionally, his visual and speed accuracy as well as his
capability to make judgment are poorly impaired. Overall, his Beta IQ is below the
mean level.

On his character nature, he tends to be impulsive on his decisions as reflected


by his history of substance abuse, chain smoking and being an alcoholic as well as
preferring the immediate comfort without thinking much of the consequences however
reflecting back on his choices, he feels guilty about his vices specifically his usage of
drugs towards his parents an indication that he has awareness of the degree on what
he had done on his life. Additionally, he regrets that he wasn’t able to complete his
education due to his vices. Despite of all, he has a positive image of the future and even
wishes to build a small business.
In social aspect, the patient often isolates himself, and is often suspicious on the
motives of other people to him thus, he tends to be mistrustful and always scrutinize
other people in order to justify his suspicion. Due to his untrusting nature, he feels the
need to be alone and in control of his life. As a result, he selectively socialize and
befriends with a few people only in the FHCCC, with them he tends to be generous in a
way that he shares his food with them as well as initiates a conversation.

At the outset, he seems to be aloof and withdrawn to people as well comfortable


with being alone. Although deep within he wants to interact with people and has good
communication skills but due to his suspicion and mistrustful nature, he tends to over
think and misinterprets the actions of people in his surroundings.

IX. Diagnostic Impression

Based on the information provided above, the case of the patient seems to point
on the direction of Paranoid Personality Disorder. Mr. Terence previous partner became
unfaithful to him and had an affair with another person. He believes that his previous
neighbor and his fellow patients, staffs and interns are out to deceive and steal his
belongings, additionally he interpret the actions of the people surrounding him in a
distorted manner that would justify his suspicion. As a result he is convinced that his
reputation is tarnished because of other people spreading rumors about him.
Consequently, he has doubts on the motives of other people to him thus avoiding to
confide his dilemmas and suspicions with other people. Hence he selectively interacts
with a few people only and has a difficult time getting along with others. However, he
does not experience any hallucination and his paranoid thought contents and beliefs are
typically-non bizarre.

X. Recommendation for Management and Treatment

Cognitive Behavioral Therapy (CBT) can help in treating Paranoid Personality


Disorder, after all it is a disorder in which there is a rigid system of fictitious beliefs and
paranoia due to misinterpretation of events and information. Thus, CBT can help in
replacing inaccurate beliefs into an accurate one thus forming the foundation for a more
correct interpretation of information. However, people with this kind of disorder cannot
detect their self as the source of problem but rather project their beliefs on other
people. Thus, building a rapport and trusting relationship on the part of therapist can be
challenging.

Tests Administered and Evaluated by:

Aquino, Maricris P.

Far Eastern University