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Psychological Report

A Psychological Report

Course

Abnormal Psychology (PSY 213A)

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Don Honorio Ventura Technological State University

Academic year: 2019/2020

Listed bookDSM-IV-TR

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PSYCHOLOGICAL

REPORT

Submitted to the College of Social Sciences and Philosophy

Department of Psychology

Don Honorio Ventura State University

In Partial Fulfillment of the Requirements

In

PSYCH213- ABNORMAL PSYCHOLOGY

1 st Semester, A 2019-

Submitted By:

Pike, Christelle Heaven C.

Submitted To:

QUINCY G. TANHUECO

Subject Adviser

PSYCHOLOGICAL REPORT

I. IDENTIFYING DATA:

Name : SM Age : 19 Sex : Female Birthday : April 10, Address : Magsaysay, Guagua, Pampanga Religion : Methodist Citizenship : Filipino Civil Status : Single Occupation : Student Language/Dialect Spoken : Kapampangan, Tagalog, English Education : Elementary : Magsaysay Elementary School

Secondary : San Roque Dau High School (Junior)

Don Honorio Ventura State University (Senior) Tertiary : Don Honorio Ventura State University Others(Pls. specify) :

II. ADMISSION:

The client agreed to submit herself to series of interviews,

observations, and psychological tests due to academic purpose

only.

III. CHIEF COMPLAINT AND PRESENT PROBLEM:

The client complained about experiencing two problems on which both are suspected to be psychological in nature. First is

relationship with his father. At that school year, she also got bullied by her other classmates and some of her friends did not hang out with her. The other complaint was way back in 2008 – when she was in grade 1. It was summer time and whenever they do not have class her family always going to their grandparents and they will have good time there. The client said that she had this one cousin that always want to play with her. He will tell SM to go to their room and play there. At that moment, the client thought they were just playing little did she know her cousin was touching her already in her private part. She said “Hindi ko naman alam na ganoon na pala ang ginagawa niya sa akin at hindi ko rin alam na masamang laro iyon” (I did not know that he is already harassing me, I did not know that at that time that was a bad game”. She also said in the interview that she forgot some of the details but she remember that her cousin told him to secret all of the things he is doing to her. Later on the client realizes that it was not good but still she did not say anything to her parents or anyone. At that time, whenever they are going to their grandparents she is not leaving her mother’s side and she stops playing with her cousin. After that incident, the client said that until now she still remember that moment even though she wants to forget it, she also said that maybe that incident was the reason why she can not trust anyone and she had having hard time to trust man. She had having hard time to entertain any suitors because she was scared and afraid that they will do the same thing as her cousin did to her.

V. PERSONAL HISTORY:

Family Background:

SM was born in Pampanga on April 10 , 2001. She is a middle child and has youngest and eldest sisters. Her parents has a small business in Pampanga and her father is a Pastor in their

church. She considered her mother as the most influential person in her life and her main inspiration. She wanted her parents and family to be proud of her that’s why she keeps focusing on her studies and achievements. She has 2 siblings. She has a little sister in 3rd grade and a sister in. SM and her siblings are staying with her parents. Their parents provides all of their needs specially in their education. The client described her family as ordinary and not idealized kind of family if compared to others. Although she is experiencing a simple and happy family life, she is still remembering her pasts which became her inspiration to become the person she is wishing to be right now.

History of Parents and Grandparents:

The client’s parents met in Manila in boarding house. Her mother at that time was working in the office and her father was studying and both were college graduates. His father had a good life to support his college as well as her mother. The client describe her father as a hardworking parent, caring, supportive and the strict one. She described her mother as a protective, loving, understanding and supportive mom. The mother raised the client with discipline and God fearing person. The client said that she was close to her grandmother in her mother side. She did not have a chance to see his grandfather in her mother’s side. The grandmother is loving and supportive. She also said that she was close to her grandmother in her father’s side but she did not had a chance to see his grandfather to his father’s side. The client said all of her grandparents are loving and supportive to her.

Early Childhood:

The client said, she did not had any difficulties or hard time learning how to walk and talk. She was about 2 years old when she started walking on her own. The client said she was a very independent growing child and learned a lot of things on her own but her mother told her that she always cries whenever her mom in not around or when she can not see her. The only thing she remembers vividly during those times was that she always play with her friends and cousins.

Childhood:

I feel safe and secure whenever I am with him) , that was the time she started to trust someone.

VI. PHYSICAL EXAMINATION:

Height: 5'6ft or 168 cm Weight: 68kg or 150lbs BMI: 24 kg/lbs Vision: Normal Hearing: Normal Overall consciousness: Normal Medical history: N/A

VII. BEHAVIORAL OBSERVATION:

All throughout the course of the interview, the client revealed a cooperation, focused and an open individual. On the first meeting (November 09, 2020), the client's appearance was neat, she was well groomed and maintains eye contact during the interview. She has inclined interest by being alert and attentive during the interview. She answered questions in a normal rate and volume. She was patient and could get back to focus easily once distracted. Later on, she started to mentioned about her sexual harassment and her being emotional.

On the last meeting (November 10,2020), while answering the series of tests administered to her, the client seemed to be relaxed and comfortable with the activity and seeing honesty. She finished each test within the given time limit, and did not require any additional help nor seek assistance in understanding some situational tests.

VIII. MENTAL STATUS EXAMINATION:

General Appearance o The client typically appears to be normal with her age. She wears a proper attire on the time of assessment. A tall girl, normal body, long haired, and light complexion. She was not wearing any cosmetics and accessories. 19 year old lady who always smiles. She is friendly and co-operative and maintains eye contact.
Psychomotor Behavior o The client’s posture is static and stiff and the rate of movement is considerably normal.
Mood and Affect o The client shows congruence with what she feel and what she appears to be. She said she is feeling okay but a little nervous. She seems happy while in the interview. She answers with openness but suspicion is still notable. She shows mild anxiety while sharing her personal stories.
Speech o The client’s rate of speech is normal. She seemed a little hesitant in sharing personal issues but she answers with normal rate of voice. The volume of her voice is soft and a little shaky.
Cognition o The client’s attention is adequate and reveals clear memory about the past and previous events of her life. She’s able to display legitimate judgment and considers uniquely by concluding on her possess individual issue, she is completely mindful around her issue
Thought Patterns o The client’s thought processes is normal she is consistent and keeps up pertinence within the interview. Her reaction is generally ordinary with quick respons es to the questions and shows consistent thought that is aligned to the reality.
Level of Consciousness o The client is totally responsive to hearing stimuli. Since the interview was conducted through online, the interviewer tried ask something in a lower volume and immediately responds appropriately on the stimulus applied.

IX. TEST ADMINISTRATION AND INTERPRETATION:

TEST ADMINISTERED DATE ADMINISTERED

Mental Status Exam (MSE) 10 November 2020
Client Interview 09 November 2020
Background Information 10 November 2020
A Projective Test: The TAT 10 November 2020
Personality: Describing Yourself 10 November 2020
Personality Test 10 November 2020
Full-Scale Intelligence Test 10 November 2020

concerns which means that she tend to worried about some aspects of her life and have the ability to judge others negatively as well. 4. Personality Test: To assess any serious psychological problems, this report is designed to be objective, not necessarily pleasing or flattering. Result: It revealed that among the twenty-seven-factor trait, Whitey gained high scores in Sociability and Emotional Stability factor traits. It shows that the client has a social connection as she mentioned in her interview she tend to go with her friends and do social activities with them and enjoys being with them. The client mentioned that sometimes feel emotional and nervous about the things that are related to her childhood experience by her cousin that she was harassed and her dad by beating her and caused her unstable emotions. 5. Full-Scale Intelligence Test: To measure the human cognitive ability. Result: The results of her Full-Scale IQ Test are 128, it means that she has a average intelligence or above average IQ. It is a categorization of intelligence where in a person has an above average cognitive ability

SUMMARY OF TEST RESULTS:

Results of psychological evaluation revealed a healthy and meaningful life, tend to socialize with other people and has a social connection with others. However, she has a signs of inferiority feelings phobias and traumas characterized by mild feelings of insecurity, feelings of anxiety connected to the previous experience of feelings of extreme embarrassment, sexual harassment and trauma in her childhood. Inferiority feelings motivate the client for self improvement by surrounding her self with the love, care and support of her family, friends, and other people. And looking different aspects in life and by being positive in everything that she do makes her independent and optimistic to achieve her goals in life.

X. OVERALL IMPRESSION:

Based on the series of the interviews, observations, and psychological tests, the client, SM, is experiencing anxiousness

towards trusting others and trauma and mild feeling of insecurities because of her previous history. She has the ought to develop self-esteem. The personality she reveals towards other people was same characteristics with social anxiety disorder. Because she experienced extreme embarrassment through her father and bullies.

The other personality she exhibits was the borderline personality disorder, she has some of the characteristics of this personality disorder. The clients overall impression indicates social and psychological help. Her feelings of anxiety and not trusting other people can be seen as a ordinary reaction to her past encounters and requires counseling to continuously construct trust to others. The diagnosis for Social Anxiety Disorder and Borderline Personality Disorder ought to be subjected for psychotherapeutic interventions. Looking for the different aspects in life and support of her loved ones and family will help the client to improve her mental health.

XI. PROGNOSIS AND RECOMMENDATION:

a. Areas of Concern b. Treatment Plan

Areas of Concern Treatment Plan

1. Social Anxiety

2. Trauma

1. The client may submit herself to the wo most common types of treatment for social anxiety disorder are psychotherapy also called psychological counseling or talk therapy or medications or both.

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