877023
Begin to Write the Psychosocial History.
Due Week 2
Interview a volunteer subject and write up the Psychosocial History and MSE. You may use a friend or a family member. Please disguise all identifying information to protect the privacy of the person being interviewed.
For this assignment, download the following materials from additional resources: Interview Guide and MSE. The Interview Guide can be used to help guide your interview questions. The MSE form can be used to conduct the Mental Status Exam. The information you obtain from these forms will be integrated into writing the Psychosocial History.
Your subject should meet the criteria for at least one of the following disorders (you may need to fabricate some information):
1. Mood Disorder
2. Anxiety Disorder
3. Somatoform Disorder
4. Schizophrenic or Other Psychotic Disorders
5. Personality Disorder
6. Substance Related Disorder
7. Adjustment Disorder
See the Sample Report in Additional Resources for a guide on how to write and format the psychosocial history and mental status exam.
Your report should be 4-5 pages in length. The report must include the psychosocial history, MSE, Diagnostic Impressions, Summary and Recommendations (testing section is not required). You should generally format your report according to APA style, but there is no need for references in a report of this type. The Sample Report that is provided under the additional resources tab is a guide. Your report may be more detailed in comparison to the sample report. Please be sure to provide sufficient information of your client’s symptoms to justify the diagnosis.
All assignments MUST be typed, double-spaced, in APA style, and must be written at graduate level English.
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Jonathan Rich, Ph.D.
Psychologist PSY 10259
7545 Irvine Center Drive, Suite 200 (949) 623-9824
Irvine, CA 92618 jrich@PsychologicalTesting.com
PSYCHOLOGICAL EVALUATION
Client’s Name: Mary Smith
Date of Birth: 3/15/63
Date of Assessment: 9/2/2014
Home Street Address: 1234 Main St.
Costa Mesa, CA 92626
Telephone #: 714-555-2345
Service Coordinator: Sally Ride
Referred By: Dept. of Rehabilitation
Anaheim Branch
IDENTIFICATION AND REFERRAL:
Mary is a 51-year-old African American woman. She drove herself to the examiner’s office. She
reported that she previously received Department of Rehabilitation services to assist her in
obtaining a teaching credential. She is being reassessed because her school is asking her to obtain
additional needed coursework. She has a history of anxiety and depression. She is being assessed
to determine her current mental status and her ability to remain stable and complete additional
coursework.
HISTORY:
This history was provided by Mary.
Family History
Mary is married. She lives with her husband and her two children age 21 and 25. She reported that
her husband has a history of alcoholism, and that at one point in 2005, she insisted that he leave
the home because of this. He is presently recovering.
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Mary was raised by both parents until her father died in 1970. Her mother died three years ago.
Mary was born in Los Angeles and has always lived in Southern California.
Educational and Vocational History
Mary obtained a Bachelor’s Degree in English and Speech. Seven years ago, she obtained her
teaching credential. Prior to her teaching credential, she worked in a flower shop and as a
receptionist. She currently is teaching 9th and 10th grades. She indicated that she needs to go back
to school to obtain two courses in order to continue teaching. These courses involve teaching
English as a Second Language.
Medical and Mental Health History
Mary reported that she has been diagnosed with fibromyalgia, high cholesterol, and a slight heart
valve problem. She currently takes the medication Vivactal (a tricyclic anti-depressant), Buspar,
and Alprazolam as needed. Her only surgeries were C-sections to deliver her children and surgery
for carpal tunnel syndrome and trigger thumb.
With regard to mental health treatment, she was first started on psychotropic medications in 1990
by her general physician. In 2005, she voluntarily went to a psychiatric hospital for one week for
treatment of depression and medication stabilization. After 2005, she saw various mental health
clinicians including a marriage and family therapist, psychologist, and a psychiatrist. She has never
attempted suicide.
Antisocial Behaviors/Substance Abuse
Mary has never been arrested or charged with a crime. She reported that 28 years ago, she drank
“recreationally” and drank a lot on occasion but alcohol has never caused problems for her. She
has been abstinent from alcohol for 28 years. She has no history of illicit drug use.
Daily Functioning
Mary drives a car. She has had no recent tickets or accidents. She is able to shower, bathe, groom,
dress, and manage money independently. Describing her activities in a typical day she said that
she teaches full time. She noted that she is active in her church and choir and has an active social
life.
MENTAL STATUS:
General Appearance
Mary’s grooming and hygiene were good. She walked with a normal gait. She was well dressed.
She appeared her stated age.
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Attitude and General Behavior
Mary was pleasant and cooperative throughout the assessment. She responded well to instructions
and appeared to try her hardest on the tasks presented.
Mood and Affect
Mary demonstrated a broad range of affect. When asked to describe her mood, she said that she
has felt a little upset dealing with the Department of Rehabilitation. She occasionally wakes up
early in the morning. She stated that her appetite is normal. She stated that she has interest and
pleasure in daily activities. She denied feelings of worthlessness. She denied concentration
difficulties. She denied any suicidal thoughts or intent. She reported that she last felt markedly
depressed about two years ago.
Stream of Mental Activity
Mary responded in a coherent and relevant fashion. The rate and rhythm of her speech was normal.
Her speech was clear and 100% intelligible.
Sensorium and Orientation
Mary was alert and aware of her surroundings. She correctly stated the current date, the current
day of the week, and the city of her residence.
Memory
Mary correctly recalled her birth date, the name of the current president, and the name of the
previous president. She registered three objects after one trial and recalled two of the three objects
after a delay of 30 minutes. She repeated eight digits forward and six digits reversed.
Fund of Information
Mary’s fund of information was within normal limits. For instance, she was able to name the
capital of Italy.
Concentration and Attention
Mary demonstrated adequate ability to attend to instructions and adequate task persistence. She
counted backwards from 20 to 1 in 8 seconds with no errors.
Perceptual Distortions
Mary did not appear to be responding to internal stimuli. She denied any history of auditory or
visual hallucinations.
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Judgment/Insight
Mary’s judgment and understanding of social conventions was intact. When asked how she would
respond if her neighbor’s house were on fire, she said, “Make sure no one is in there, call the fire
department.” She has adequate insight into her current condition. She realizes the need for
psychotropic medication.
TESTS ADMINISTERED:
Wechsler Adult Intelligence Scale, 4th Edition (WAIS-IV)
Wide Range Achievement Test, Revision 4 (WRAT-4)
Minnesota Multiphasic Personality Inventory, II (MMPI-II)
TEST RESULTS:
WAIS-IV
Verbal Comprehension Perceptual Reasoning
Similarities 8 Block Design 11
Vocabulary 11 Matrix Reasoning 15
Information 12 Visual Puzzles 11
Comprehension (8)
Working Memory Processing Speed
Digit Span 12 Symbol Search 10
Arithmetic 13 Coding 9
Letter Number Sequencing (12)
Index %ile
Verbal Comp. 102 55
Perceptual Reasoning 114 82
Working Memory 114 82
Processing Speed 97 42
Full Scale IQ 108 70
On the WAIS-IV, Mary obtained a Full Scale IQ of 108. This score is in the Average Range of
Intelligence and exceeds 70 out of 100 persons her age. Her Perceptual Reasoning Index was
significantly higher than her Verbal Comprehension Index, reflecting greater facility with tasks
requiring nonverbal reasoning and performance than with tasks requiring words.
Mary’s Verbal Comprehension Index of 102 exceeds 55 out of 100 persons her age and is in the
Average range. This reflects word knowledge, fund of general information, understanding of
social conventions, and abstract verbal reasoning within an average range.
Mary’s Perceptual Reasoning Index of 114 exceeds 82 out of 100 persons her age and is in the
High Average range. This reflects relatively strong nonverbal reasoning abilities.
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Mary’s Working Memory Index of 114 exceeds 82 out of 100 persons her age and is in the High
Average range and is a relative strength. This reflects strong auditory attention and
concentration. Mary’s Matrix Reasoning is a significant strength which reflects strong non-
verbal abstract problem solving.
Mary’s Processing Speed Index of 97 exceeds 42 out of 100 persons her age and is in the
Average range. This reflects average psychomotor speed and immediate visual memory.
WRAT-4
Subtest Standard Score Percentile
Word Reading 101 53
Sentence Comprehension 81 10
Spelling 102 55
Math Computation 124 95
Reading Composite 89 23
On the WRAT-4, Mary earned a Standard Score of 102 on Spelling, which is in the Average
range and is in the 55th percentile. Reading Composite is a combination of Word Reading and
Sentence Comprehension. Mary’s Reading Composite of 89 is in the Low Average range and is
in the 23rd percentile. Mary’s Word Reading Standard Score of 101 is in the Average range and
is in the 53rd percentile. This score reflects average sight reading abilities. Mary’s Sentence
Comprehension of 81 is in the Low Average range and is in the 10th percentile. This score
reflects low average reading comprehension. She earned a Standard Score of 102 on Spelling,
which is in the Average range and is in the 55th percentile. Her Math Computation skills of 124
were in a Superior range and is in the 95th percentile. Mary was able to add, subtract, multiply
and divide whole numbers, decimals, and fractions. She was able to solve algebraic equations.
She was able to work with percentages. The discrepancy between her general level of
intelligence and her reading comprehension is sufficient to be considered a reading disorder.
MMPI-2
Scale T-Score
L(Lie)-Scale 68
F(Infrequency)-Scale 45
K(Correction)-Scale 56
1-Hs 70
2-D 55
3-Hy 65
4-Pd 40
5-Mf 53
6-Pa 48
7-Pt 59
8-Sc 54
9-Ma 48
0-Si 50
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On the MMPI-2, Mary’s responses to the items indicated that on this test administration, she
might have felt the need to present as having strong moral character or to deny having any
weaknesses. Despite this tendency to present herself in a positive light, her responses can be
considered a good reflection of her current state and the current protocol can be considered valid.
Significant elevations were seen on MMPI-II scale 1 and 3. Scale 1 reflects concern about
bodily function. Mary’s T-score of 70 suggests that she tends to have multiple vague physical
complaints and tend to convert emotional distress into physical symptoms. Mary’s T-score of 65
on Scale 3 indicates that she may be interpersonally demanding and tend to maintain shallow
relationships.
The combined elevation on scale 1 and 3 generally reflects an individual who is conforming and
conventional. Such individuals value being seen positively by others. Mary may be emotionally
over controlled and express anger and other negative feelings in indirect ways.
Scale 2 measures depression. This scale was within the normal range, suggesting that Mary’s
depressive symptoms are currently well controlled.
DIAGNOSTIC IMPRESSIONS:
296.35 (F33.41) Major Depression, recurrent, in partial remission due to medication
315.00 (F81.0) Specific Learning Disorder, with impairment in reading: Reading comprehension
SUMMARY AND RECOMMENDATIONS:
Mary is a 51-year-old African American woman who is being assessed to determine her current
mental status ad her ability to remain stable and complete additional coursework. She has a history
of depression, including one psychiatric hospitalization. At present, her depression appears to be
well controlled by medication. She reported functioning well at her job and maintaining an active
social life. She currently appears to maintain good emotional stability with the assistance of
medication. The results from the WAIS reflected intelligence in the average range, nonverbal
abilities are better developed than verbal abilities, and relative strengths with nonverbal task as
well as auditory attention and concentration. Mary’s academic testing reflects average spelling and
site reading, low average reading comprehension and strong math skills. The results from the
MMPI indicate that Mary may struggle with some physical complaints, have some difficulty with
interpersonal relationships, and her depressive symptoms are in the normal range indicating that
they may be well controlled. Considering that she successfully completed college and is currently
emotionally stable, it is likely that she could successfully complete the remaining study needed.
However, the present testing suggested that she struggles with reading comprehension, and may
need accommodations to compensate for a reading disorder.
Thank you for referring this very interesting woman for assessment.
________________
Jonathan Rich, Ph.D.