PSYCHOLOGICAL ASSESSMENT RESULT

Name: Mr. B Age: 22 Date of Birth: March 18, 2001

Address: CSJDM Bulacan Sex: Male Date of Assessment: April 2, 2023
Date of Release:
Reasons for referral:

Mr. B was referred for a psychological evaluation to assess his challenges with decision-
making, feelings of regret and guilt, family difficulties, and interpersonal conflicts at work.

Chief Complaints:
1. Difficulties in making decisions
2. Feelings of regret and guilt related to past infidelity
3. Challenges in family environment, including parental separation and limited support from
biological parents
4. Interpersonal conflicts at work, including exclusion, betrayal, and verbal mistreatment
from colleagues and superiors.
Mental Status Examination:

During the session, Mr. B was observed to be dressed in casual attire and appeared
generally prepared. His eye contact was limited, and he exhibited signs of physical anxiety, such
as shaking knees and a tense posture. He spoke rapidly and loudly, but with some hesitancy and
pausing at times. Despite this, he communicated his thoughts with confidence and chose his
words thoughtfully. Overall, Mr. B displayed some signs of anxiety but was able to effectively
convey his thoughts and feelings during the session.

Behavioral Observation:

During the psychological testing session, Mr. B exhibited cooperative and attentive
behavior, although he displayed mild physical signs of anxiety. His knees were observed to be
shaking, and he engaged in frequent consumption of menthol candies during the testing process.
He was observed to be very talkative, speaking rapidly and loudly during the testing session, and
his grooming appeared to be in a normal casual style. Additionally, his posture was observed to
be tensed, and he displayed limited eye contact, with a mild aversion of gaze. Despite these
manifestations of anxiety, Mr. B actively participated in the cognitive assessments,
demonstrating adequate concentration and effort. He appeared motivated to provide accurate
responses and engaged in thoughtful consideration of the test items.
History (personal, family & social):

Mr. B comes from a family background where his parents separated when he was a child.
His biological mother and father do not show consistent support for his activities and decisions,
and he has experienced verbal abuse from his mother. He has limited contact with his father and
describes a strained relationship with his mother. Mr. B is an only child, but his mother has
children from outside the family, resulting in step-siblings with whom Mr. B has a complicated
and awkward relationship. However, he reports that his stepfather is the only person who
supports him in everything he does.

In his social history, Mr. B previously had a close relationship with a best friend.
However, their ties were severed after the best friend attributed blame to Mr. B for the
deterioration of their romantic relationship. This event resulted in a loss of friendship for Mr. B,
and he currently reports having only a limited number of friends in his social circle. In addition
to the aforementioned details, Mr. B also reports experiencing challenges in his relationships
with his coworkers. He has described being outcasted by his coworkers and has reported
instances of backstabbing and verbal abuse from one of his bosses at work.

Test Administered:
1. Beck Depression Inventory (BDI)
2. Beck Hopelessness Inventory (BHI)
3. Beck Anxiety Inventory (BAI)
4. Culture Fair Intelligence Test
5. Emotional Quotient Inventory
6. Sach's Sentence Completion Test
7. Basic Personality Inventory
Assessment result:

Cognitive Functioning

Based on the test results, it appears that Mr. B has difficulties in cognitive functioning,
particularly in decision-making, problem-solving, and self-awareness. This aligns with his
reported struggles in decision-making and dependence on external sources for guidance. His low
self-worth may also contribute to his poor cognitive functioning by leading to self-doubt,
insecurity, and self-criticism. As a result, making decisions can be challenging for him as he may
hesitate or feel inadequate in his ability to make the "right" choice.

Emotional Functioning
Based on the assessment results, it appears that Mr. B is experiencing challenges in
emotional functioning, specifically in the area of emotion regulation. He exhibits symptoms of
sadness, dissociation, irritability, panic attacks, and mood swings. These difficulties may
negatively impact his ability to cope with stressors and manage his emotions effectively.
Furthermore, Mr. B's severe symptoms of unresolved guilt align with his report of remorse and
regret linked to past infidelity. These emotional challenges may be contributing to his reported
issues with decision-making, interpersonal relationships, and self-worth. It is recommended that
Mr. B receives further assessment and treatment to address his emotional functioning.

Interpersonal Functioning
In terms of interpersonal relations functioning, Mr. B reports challenges in his family
environment and experiences interpersonal conflicts at work. He also displays limited empathy
and social skills, which may contribute to these difficulties in his interpersonal relationships. The
results from the personality assessment indicate high levels of emotional distress, including
hypochondriasis, depression, persecutory ideas, and anxiety, which may further impact his daily
functioning and ability to cope with stressors.

Diagnostic Impression:

The results of the assessments administered and the information provided about Mr. B
suggest a possible diagnostic impression of Major Depressive Disorder, Generalized Anxiety
Disorder, and Unspecified Personality Disorder. Mr. B presents with deficits in cognitive and
emotional functioning, as well as challenges in interpersonal relationships. These issues seem to
stem from his reported low self-worth, which may have contributed to his difficulties in
decision-making, problem-solving, and emotion regulation. Furthermore, his history of infidelity
and unresolved guilt may be contributing to his emotional distress and symptoms of depression,
anxiety, and mood swings. Mr. B also experiences interpersonal conflicts and displays limited
empathy and social skills, which may impact his ability to establish and maintain healthy
relationships.
Summary:

Mr. B, a 33-year-old male, sought assistance for struggles in decision-making, emotion

regulation, and interpersonal relationships. He disclosed a history of infidelity and unresolved
guilt, which influenced his emotional difficulties and associated symptoms of depression,
anxiety, and mood instability. Mr. B expressed a lack of support from his biological parents and
difficulties with colleagues at work. Cognitive and emotional evaluations showed deficits in
decision-making, problem-solving, emotion regulation, and limited empathy and social skills. A
provisional diagnosis of Major Depressive Disorder, Generalized Anxiety Disorder, and
Unspecified Personality Disorder was suggested based on the results of the assessments
administered. Additional evaluations may be needed to confirm this diagnosis and develop an
effective treatment plan.

Recommendation:
1. Psychotherapy: Mr. B may benefit from psychotherapy, such as cognitive-behavioral
therapy (CBT) or dialectical behavior therapy (DBT), which can help him develop coping
strategies for managing his depression, anxiety, and emotion regulation difficulties.
Therapy may also help him address his issues with low self-worth, past infidelity, and
interpersonal relationships.
2. Medication: Depending on the severity of Mr. B's symptoms, medication may be
recommended as an adjunct to therapy. A psychiatrist or primary care physician can
prescribe antidepressant or anti-anxiety medications, if deemed appropriate.
3. Support groups: Mr. B may benefit from participating in support groups or self-help
groups for individuals with depression, anxiety, or relationship difficulties. These groups
can provide a sense of community and support, and help him develop healthy coping
strategies.
4. Lifestyle changes: Mr. B may benefit from making lifestyle changes, such as improving
his sleep habits, increasing physical activity, and reducing alcohol and substance use, if
applicable.
5. Consultation with a psychiatrist: Given Mr. B's possible personality disorder, it may be
helpful for him to receive a consultation with a psychiatrist to assess the need for further
evaluation and potential medication management.

Note: Please observe strict confidentiality of this test result. Kindly disregard (shred or burn) this protocol after it serves its
purpose because a person is dynamic. This result is valid until April 2023. This will not be used in court or for any other
purposes except orphanage admission purposes only. Thank you.
 APPENDIX

Beck’s Depression Inventory (BDI)

Score Interpretation

22 Moderate Depression

Beck’s Hopelessness Inventory (BHI)

Score Interpretation

8 Mild Hopelessness

Beck’s Anxiety Inventory (BAI)

Score Interpretation

28 Moderate Anxiety

Culture Fair Intelligence Test (CFIT)

Score Interpretation

15 Poor

Emotional Quotient Inventory

Factors Category

Innovation Below Average

Self-Awareness Low

Intuition Low

Emotions Low

Motivation Low
 Empathy Low

Scoial Skills Low

Sach’s Sentence Completion Test

Areas Degree of Disturbance

ATTITUDE TOWARDS MOTHER Mildly Disturbed

ATTITUDE TOWARDS FATHER Mildly Disturbed

ATTUTUDE TOWARDS FAMILY UNIT Mildly Disturbed

ATTITUDE TOWARDS MEN/WOMEN No significant disturbance

ATTITUDE TOWARDS HETEROSEXUAL RELATIONSHIP Mildly Disturbed

ATTITUDE TOWARDS FRIENDS & ACQUIANTANCES Mildly Disturbed

ATTITUDE TOWARDS SUPERIORS AT WORK OR SCHOOL Mildly Disturbed

ATTITUDE TOWARDS PEOPLE SUPERVISED Mildly Disturbed

ATTITUDE TOWARDS COLLEAGUES AT WORK OR SCHOOL No significant disturbance

FEARS Mildly Disturbed

GUILT FEELINGS Severely Disturbed

ATTITUDE TOWARDS OWN ABILITIES No significant disturbance

ATTITUDE TOWARDS PAST No significant disturbance

ATTITUDE TOWARDS FUTURE Mildly Disturbed

GOALS Mildly Disturbed

Basic Personality Inventory

Interpretation

HYP - Hypochondriasis High

 DEP - Depression High

DEN - Denial Low

IPS - Interpersonal Problems Low

ALN - Alienation Low

PID - Persecutory Ideas High

AXY - Anxiety High

THD - Thinking Disorder High

IME - Impulse Expression High

SOL - Social Introversion Low

SDP - Self Depreciation High

DEV - Deviation High

PREPARED BY: KATHLEEN ROSE D. ALZATE DANICA M. ARCEGA

Name & Signature Name & Signature

AIRRA LYEANNE A. BALUYOT KATHYRENE M. IDA

Name & Signature Name & Signature

SHAIRA MAE C. MANIEGO

Name & Signature

NOTED BY: ANTHANETTE WEN L. SALAS, RPm

Name & Signature of Supervisor
 PSYCHOLOGICAL ASSESSMENT RESULT

Name: Jane Date of birth: December 27. 2000

Age: 22 years old Gender: Female
Address: Bignay, Valenzuela City Date of Assessment: April 25, 2023

Reasons for Referral:

Ms. Jane visited the clinic due to her concern about constantly feeling of emptiness and sadness, sleep
disturbances, and disordered eating behavior, and relapse about her traumas. She feels that her past and traumas
affect her current state.

Chief complaints:

1. Feeling of emptiness and sadness

2. Relapse from traumas
3. Sleep disturbance
4. Disordered eating behavior
5. Overthinking about her future

Mental Status Examination:

Jane was wearing age appropriate clothes and well groomed. She speaks normal and monotone. She can
do eye contact and can see that she was awkward or anxious. Her head was lied down on the desk while talking.
But she appears to follow and understand instructions. She seems to be well oriented with her identity and
surrounding.

Behavioral Observation:
During the assessment process, Jane finished the given tests in a timely manner except when answering
the Sacks Sentence Completion Test and she seems to be emotional while answering. She made few breaks during
the assessment period. But she seems to be willing in expressing her feelings and very open despite of being
anxious in the surroundings.

History:
 Ms. Jane comes from a family of five children, and she was the second child. When she was little, her
biological father died. When her father was still alive, she believed he was a wonderful person. Her mother
married her stepfather, with whom she has little contact. Her parents put a lot of pressure on her to live up to
their high expectations for her and to be successful like his brother.
Jane is a 4th year college student. She has been experiencing feeling of emptiness, sadness, helplessness,
and anxiety. She also stated that she experienced eating and sleep disturbance. She also reported that she had
relapse from her traumas. She appears to be distant with her family since she cannot tell her problems with them
because there was a time that she feels invalidated because they did not understand her.
When she was in high school, she experienced sexual abuse from her stepfather and other members of the
family. It took five years to have the courage to tell it to her mother. Unfortunately, her mother did not do any
action to protect her. However, she did not completely recall some scenarios. Her cousin had once messaged her
to ask if she remembered what had happened in previous years, but she could not recall. Last month, she had a
disturbing dream about her stepfather mistreating her. Until now, she experienced verbal abuse from her mother
and physical abuse from her stepfather. She stated that her stepfather still looks at her with desire. She also loses
trust with other people in her life which is why she only keeps those people who she believes truly love her and
there for her even on her darkest days as well as those who help her when she needs someone.

Test Administered:
1. Mental Status Examination
2. Beck Depression Inventory
3. Beck Anxiety Inventory
4. Beck Hopelessness Inventory
5. Sacks Sentence Completion Test
6. MMPI-2

Assessment Result:

Cognitive Functioning

Based on the tests administered, she shows great difficulty in making decisions. She tends to be rigid and
dislike change. She is prone to compulsive behavior. Moreover, she tends to fret, worry, ruminate over trivial
things, and have intrusive thoughts. She tends to have problems with concentration, lack of confidence and
indecisive. She has an over ideational rumination, introspection and may worry excessively. Her judgement is
likely to be poor, and some confusion evident, as her actions and planning reveal a lack of common sense. She
tends to have rich fantasy lives, especially with regard to sexual matters and spend much time daydreaming.
Sometimes, preoccupied with thoughts of death and suicide.

Emotional Functioning
Her emotional-behavioral controls are likely to be poor. She tends to be self-critical, have poor self-
esteem, and lack confidence that they have the skills to deal with their problems. She is oversensitive to criticism
and rejection. When in stressful situation, she tends to give up easily and anticipate failure. It seems hard for her
to acknowledge her strengths. Thus, she tends to have poor self-concept and have difficulty accepting
compliments. She is be dependent. Hence, she tends to suffer from feelings of inferiority, insecurity, and
inadequacy. She is likely to describe as moody, changeable, restless, unstable, and dissatisfied. She tends to be
concerned with spiritual feeling and has regret over past. Furthermore, her current behaviors appear to be strongly
influenced by her past experiences.

Interpersonal Relations Functioning

She tends to be shy and socially introverted. Thus, she do not initiate conversations. She would rather be
alone than with other people. She described her family as lacking in love, understanding and support. Hence, she
feels unhappiness toward her family. She feels rejected by her family which lacks solidarity and which has
constantly contented with difficulties. She seems to be guarded and untrusting with other people. Likewise, she
seems to be suspicious about the motives of other people. Moreover, she seems to wait for approval of others
before committing herself emotionally.

Summary
Jane is a fourth-year college student, currently struggling with feelings of emptiness, hopelessness, and
sadness, as well as anxiety, sleep disturbances, and disordered eating habits. She often struggles with decision-
making and dislikes change. She likely won't make good decisions and has trouble focusing. She has a tendency
to give up easily and assume failure in difficult situations. She seems to have a low opinion of herself and struggles
to take compliments. She is dependent and has an inclination to be socially shy and introverted. She was subjected
to sexual abuse in high school from her stepfather and other family members. The bravery to tell her mother about
it finally came five years later. Unfortunately, her mother took no steps to keep her safe. She also feels unhappy
and rejected by her family. She appears to wait for others' approval before committing emotionally, making her
wary and untrusting of other people.

Diagnostic Impression

According to all the information gathered through the psychological assessment's findings, Ms. Jane may
potentially have Posttraumatic Stress Disorder 309.81 (F43.10). She frequently makes an attempt to
avoid explicit or external cues that remind her of her trauma, sleep disturbances, and negative views about herself
made a significant impact on her academic functioning. Also, she is suffering from chronic depressive symptoms,
such as a sense of emptiness, extreme sadness, suicidal thoughts, low self-esteem, and disruptive eating habits
that have persisted for more than two years.

Recommendation

1. Report the abuse and take legal action

2. Undergo Cognitive Behavioral Family Therapy (CBFT)
3. Use coping techniques such as keeping journal or diary.
4. The client is suggested to undergo Eye Movement Desensitization and Reprocessing (EMDR)
Therapy

Note: Please observe strict confidentiality of this test result. Kindly disregard (shred or burn) this protocol after it serves its purpose because a person
is dynamic. This result is valid until April 2023. This will not be used in court or for any other purposes except orphanage admission purposes only.
Thank you.
 APPENDIX

Psychological Test Result

Beck Hopelessness Inventory Two out of Twenty (2/20). None or Minimal

Beck Anxiety Inventory (BAI) Raw-Score = 53. Severe Anxiety
Beck Depression Inventory Raw Score = 29. Moderate Depression

Psychological Test Result

Attitude towards Mother. Rating = 1. Mildly

disturbed.

Attitude towards Father. Rating = 1. Mildly

disturbed.

Attitude towards Family Unit. Rating = 2. Severely

disturbed.

Attitude towards Women/Men. Rating = 0. No

Sacks’ Sentence Completion Test significant disturbance noted in this area.

Attitude toward Heterosexual Relationship. Rating =

1. Mildly disturbed.

Attitude toward Friends and Acquaintances. Rating

= 1. Mildly disturbed.

Attitude toward Superiors at Work or School. Rating

= 1. Mildly disturbed.
Attitude toward People Supervised. Rating = 0. No
significant disturbance noted in this area.

Attitude toward Colleagues at Work or School.

Rating = 0. No significant disturbance noted in this
area.

Fears. Rating = 2. Severely disturbed.

Guilt Feelings. Rating = 2. Severely disturbed.

Attitude toward Own Abilities. Rating = 0. No

significant disturbance noted in this area.

Attitude toward Past. Rating = 2. Severely disturbed

Attitude toward Future. Rating = 0. No significant

disturbance noted in this area.

Goals. Rating = 1. Mildly disturbed

MMPI-2 RESULTS

Basic Content Supplementary

Scale Raw T Scale Raw T Scale Raw T
L 4 52 ANX 17 74 A 29 72
F 16 92 FRS 12 65 R 19 57
K 10 39 OBS 11 67 Es 15 0
MAC-
1 Hs 26 78 DEP 22 78 R 18 45
2D 35 81 HEA 21 79 AAS 3 56
3 Hy 32 73 BIZ 12 81 APS 21 44
4 Pd 33 76 ANG 9 60 MDS 9 76
5 Mf 33 57 CYN 13 56 O-H 12 44
6 Pa 19 81 ASP 7 52 Do 11 32
7 Pt 46 84 TPA 12 64 Re 21 50
8 Sc 52 90 LSE 20 86 Mt 28 72
9 Ma 23 59 SOD 15 65 GM 19 34
0 Si 41 64 FAM 20 86 GF 36 48
WRK 24 80 PK 29 81
TRT 11 64 PS 43 85
Si1 12 68
Si2 3 51
Si3 14 74
Fb 17 108
VRIN 12 78
TRIN 10 58

PREPARED BY: KATHLEEN ROSE D. ALZATE DANICA M. ARCEGA

Name & Signature Name & Signature

AIRRA LYEANNE A. BALUYOT KATHYRENE M. IDA

Name & Signature Name & Signature

SHAIRA MAE C. MANIEGO

Name & Signature

NOTED BY: ANTHANETTE WEN L. SALAS, RPM

Name & Signature of Supervisor