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.

1

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.