PSYCHOLOGICAL

REPORT

GENERAL DATA:
Surnames and names: Romelia Castillo
Sex: Female
Age: 75
Place of birth: kerrville Tx.
Vocational nursing School
Exam date: 03/12/2021
Report date: 03/21/2021
Evaluator: Lic. Inti F. Castañon C.
Applied Techniques and Tests:
● Psychological Interview.
● Projective Test Machover
● Beck Depression Inventory
● Beck Anxiety Inventory (BAI)
● Emotional Dependency Inventory

Reason for consultation

Romelia shows up for psychological care for the anxiety she presents for reasons
related to the stay in the city of Nava Coahuila Mexico, seeking guidance and
response from her emotional state.

Process
The process lasted 6 meetings in which a number of psychological evaluation tools
were applied to determine their emotional state and the causes that cause it.

Results:

Psychological Interview
A semi-structured interview was conducted that reviewed the patient's personal
history, the configuration of her family, her relationship with her spouse, and the
attachment she presents.
 Projective test Machover
This being a projective test, aspects of the drawing are considered, as well as the history
related to drawing. Which gives us the interpretation of a persona.
- She doesn't like conflict and manifests traits of being a dependent person.
- It is determined that she suffers from depression from various traits manifested
in the drawing such as, messy hair and the absence of hands, this also
projects an emotional need for lack of affection, which due to history manifests
itself from its early stages.
- Items that suggest insecurity, nervousness, physical problems, intellectual
frustration, and the need to feel safe.

Beck Inventory (Depression).

According to Beck's Depression Inventory, he scored a 34-point result where:

- 0 to 13 is minimal depression
- 14 to 19 mild depression
- 20 to 28 moderate depression
- 29 to 63 severe depression
It is placed on a severe depression score.

Beck Anxiety Inventory (BAI)

According to Beck Anxiety Inventory, she scored 27 points where:

- 0 to 5 Minimum
- 6 to 15 Light
- 16 to 30 Moderate
- 31 to 63 Severe
It is placed on a Moderate Anxiety score.

Emotional Dependency Inventory (IDE)

Through this emotional dependency inventory
- INE Dimensions................................................ Score
o Fear of rupture........................................... 28

o Fear and Intolerance of Loneliness.............31

o Couple Priority ............................................12

o Need for Access to the Couple....................26

o Desires for Exclusivity..................................18

o Subordination and Submission.....................10

o Desires for Control and Dominion.................13

- Diagnostic Categories
Height(71-99) Moderate(51-70) Significant(31-50) Normal(1-30)
Se presumes its emotional dependence is moderate as it experiences a strong emotional
need with the following symptoms:

Intense fear of the breakdown of the relationship, the prioritization of his partner over
anything or aspect of his life, desire to spend the greatest time with him, feelings of anguish
and unease at his momentary or definitive absence, fear and intolerance of loneliness, need
to please his partner and his children, episodes of major depression and anxiety, among
others.

Conclusions

● General Remarks: White complexion, female person, overweight light

complexion, dark hair, and appears to be his chronological age. It has
adequate arrangement and personal grooming, while your clothing is
according to your age, gender and season.
She had lucid consciousness, was oriented in person, space and
time and her attention was sustained. The tone of his voice was
slightly normal, fluid language, so also in thought was shown in coherent
logical thinking and good memory. She denoted sadness, however,
showed a collaborative and cordial attitude
● Romelia is a vulnerable person with basic needs who on their own some of
these activities cannot perform due to the medications and diagnosed
diseases that are presented in your clinical record
● Emotionally she has severe depression and moderate anxiety suggesting
psychotherapeutic attention and emotional attention as evaluations have
shown that in several of these emotional spheres such as attachment and
need for attention manifest.

Recommendations
Based on the results obtained in the different tests, in addition to the interviews it is
recommended that:

Romelia Castillo, keep the emotional support her husband can provide. For the
manifestation of severe depression it turns out that her husband is a good agent and
provides her with the peace of mind she needs, although she manifests herself clinically
with that need for care, it is also advisable that she is not deprived of the opportunity to be
as long as possible with, since they are people who by age, their need for care and
protection is mutual. They can be inferred to complement each other.

It is also suggested that they establish a psychological therapy plan to address the
different emotional needs manifested in the evaluations.

_______________________________________
Signed:
Inti Fernando Castañon Campos
Bachelor of Psychology
Professional Cedula
9414459