Mental health diagnosis and treatment or management recommendations.

Begin Psychological Assessment Report

Your report should be 5-7 pages in length.

You will continue the report that you started in Activity 5.  Incorporate any feedback that you received from other course assignments.  In addition to the tests you have already interpreted (WAIS-IV, WRAT4, and MMPI-2) you will also add your interpretation of the PAI and the WHODAS.  As before, your report will include a reason for referral (may be fictitious), discussion of the test results from the WAIS IV, WRAT 4, MMPI-2, and PAI, a brief discussion of the WHODAS 2.0,diagnostic impressions, summary and recommendations,  based on findings that refer to the referral question(s).
A description of the content for each of the main sections of your report follows:

Identification and Referral
·         Client’s name, age, marital status, ethnicity, gender.
·         Describe the setting, including where the testing took place, how the client travelled there (or if you went to the client’s home).
·         Reason for testing at this time, including the referral source (can be a self-referral or a fictitious referrer) and the information sought by the referrer.
·         Presenting problems and symptoms.
There should be one or more referral questions to be answered by your assessment.  These questions will be answered in your “Recommendations” section and the answers should flow logically from your findings.   Some common referral questions for psychological testing include:
·         Mental health diagnosis and treatment or management recommendations.
·         Disability determination – whether the client is able to work and limitations.
·         Vocational/educational assessment – what kind of work would be a good fit for the client’s abilities.
·         Learning disability assessment – is a learning disability present and what sort of limitations and accommodations are appropriate.

History
Preface your history by indicating the source (such as client’s report or family report).

Family History.  Include information about current family, current living situation and family of origin.

Educational and Vocational History.  Level of education completed, high school and college grades, any history of special education, expulsions and suspensions, occupation and jobs held, last worked, reason for any dismissals, longest time at the same job, vocational aspirations if relevant.

Medical and Mental Health History.  The non-psychiatric section should include reports of medical diagnoses and symptoms, current medications, surgeries and overnight hospitalizations, and any head injuries.  The mental health section should include psychiatric hospitalizations, outpatient mental health treatment, substance abuse treatment, history of psychotropic medication prescriptions, and suicide attempts.  When applicable, indicate that there was “no reported history of …” to show that you inquired about the areas above.

Antisocial Behavior/Substance Abuse.  Age, charge, and outcome of any arrests or other legal problems.  Current and past use of alcohol and other recreational drugs, 12-step group attendance.

Daily Functioning
Client’s mode of travel (car, bus, family rides) and ability (short trips by car, uses the bus but needs help to get to a new location, etc.).  Client’s daily living skills, including ability to groom, bathe, dress, do household chores, and manage money.  Include a general description of the client’s daily activities including job, recreational, and social activities.

Mental Status and Behavioral Observations
Use the Mental Status Exam form as a guide for your interview.  This section can be written or dictated directly from this form.

General appearance: Particularly note unusual characteristics that may provide diagnostic information – neglected hygiene, unusual dress or tattoos, or physical characteristics that may affect the person’s social interactions and abilities. Indicate if the client appeared her/his stated age or younger or older than her/his stated age.

Attitude & general behavior: Describe the person’s interaction with you and attitude toward being tested and interviewed.

Mood and affect: Obtain a quote from the client regarding recent mood.  Ask about any history of depression and anxiety.  Note the range of the client’s affect.  Ask about sleep and appetite, and inquire further about depressive or anxious symptoms if a particular disorder is suspected.  See the symptom guide at the bottom of the MSE form.  For instance, if PTSD were suspected, you would inquire about symptoms, such as nightmares, flashbacks, and startle response.

Stream of mental activity: Most clients will be described as responding in a coherent and relevant fashion and speaking at a normal pace with 100% intelligibility.  Note any deviations from this, including psychotic symptoms, slower or faster than normal speech, and problems with speech intelligibility.  Note unusual speech content and inquire into delusional thinking (paranoid, reference, control, grandiosity) if psychosis is suspected.

Sensorium and orientation: You will describe most clients as alert and aware of their surroundings; note any deviations from this.  Orientation includes awareness of elements such as person, place, time and situation.  Do not say the client was “oriented times three” as the meaning of this is not always consistent and clear.  Do report the questions you asked and the client’s responses.  For instance, “The client reported the current day of the week as Saturday rather than Monday.”

Memory.  Use simple tests to assess the client’s long- and short-term memory and report the results of those tests.  A useful test of short-term memory is to list three objects, have the client repeat them back, and then ask the client to recall them after five minutes have passed.

Fund of information.  Two or three questions will give a rough index of the client’s general knowledge.  Easy (intellectual disability suspected): “How many legs on a dog?” or “Where is your nose?”, Average: “How many days in a year?”, Above average: “What is the boiling temperature of water?”

Concentration and attention: Rate the client’s ability to attend to instructions and task persistence.  Simple concentration tasks are counting backwards from 20 or, for higher functioning clients, counting backwards from 100 by 7.  Note the time required and number of errors.  If ADHD is suspected, use the symptom guide at the bottom of the MSE form to inquire further about symptoms.

Perceptual distortions: Ask about any history of auditory or visual hallucinations and determine if they were associated with drug use or mood (mania or depression).  If there were hallucinations, note their frequency, when they last occurred, and their content.  Note if the client appears to be responding to hallucinations during the assessment.

Judgment & insight.  Use a simple, standard question to test judgment, such as “What would you do if your neighbor’s house were on fire?”  Also, note any history that would indicate impaired judgment, such as arrests or job dismissals.  Insight is whether the client has an accurate understanding of his or her mental health status.  If there are mental health problems, a client with good insight attributes symptoms to these problems, and is aware of the need for treatment.  For instance, a man diagnosed as schizophrenic would demonstrate good insight if he understands that his auditory hallucinations are caused by his illness and that psychiatric medication would help.  An alcoholic demonstrates good insight if she admits her illness and recognizes the need to attend AA or other treatment.

 

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