Psychological Report Writing

**Adapted from UP-PGH format

Psychological Assessment is similar to psychological testing but usually involves a more comprehensive assessment of the individual.

Psychological assessment is a process that involves the integration of information from multiple sources, such as tests of normal and abnormal personality, tests of ability or intelligence, tests of interests or attitudes, as well as information from personal interviews. Collateral information is also collected about personal, occupational, or medical history, such as from records or from interviews with parents, spouses, teachers, or previous therapists or physicians.

I. IDENTIFYING INFORMATIONState the name, age, marital status, sex, occupation, race, nationality, and

religion if applicable; previous admissions for the same or a different condition; with whom the patient lives II. REASON FOR REFERRAL/ CHIEF COMPLAINT

State the client’s chief complaint; why the client came to the psychologist, preferably in the patient’s own words or the referral’s. III. HISTORY OF PRESENT ILLNESS

Development of symptoms or behavioral changes that a precipitate in the client’s asking for assistance; how illness has affected the client’s life activities and personal relations. IV. PAST PSYCHIATRIC AND MEDICAL HISTORY

Past medical condition: name of hospital, type of treatment, length of illness, effect of treatment V. FAMILY HISTORY * genogram VI. PERSONAL HISTORY (ANAMNESIS)

History of patient’s life from infancy to the present; emotions experienced with different life periods (painful, stressful, conflictual)

VII. BEHAVIORAL OBSERVATIONS/MENTAL STATUS EXAMINATIONSummary of the examiner’s observations & impressions derived from the interview

A.) APPEARANCE/ORIENTATIONPatient’s appearance & behavior during the interview; attitude towards the examiner – cooperative, attentive,

evasive, guarded, etcGeneral description: posture, clothes, grooming, healthy,

sickly, old looking, young looking, hair, nails, signs of anxiety – restless, moist hands, perspiring hand, etc.

B. ) SPEECH

Rapid, slow, slurred, loud, whispered, echolalia, etc.

C.) MOOD AND AFFECTMOOD (a pervasive & sustained emotion that colors the person’s perception of the world) How does the patient say s/he feels – depressed, anxious, angry, irritable, euphoric, empty, guilty, anhedonic, etc.

AFFECT (the outward expression of the patient’s inner experiences) How does the examiner evaluates patient’s affect: broad, restricted, blunted or flat; is

the emotional expression appropriate to the thought content; give examples if emotional expression is

inappropriate

D.) THINKING AND PERCEPTIONFORM OF THINKING: overabundance of ideas, flight

of ideas, slow thinking, stream of thought, quotations from patient; loose associations, lack of

causal relations in patient’s explanations; incoherent speech (word salad), neologisms (development of

new words)CONTENT OF THINKING: Preoccupations about the illness, obsessions, compulsions, phobias, suicidal

ideation, antisocial urges or impulsesTHOUGHT DISTURBANCES: delusions(thought

insertion, withdrawal, broadcasting, etc) ideas of reference, persecutory delusions

Formal Thought Disorders Circumstantiality. Overinclusion of trivial or irrelevant details that impede the sense of getting to the point.

Clang associations. Thoughts are associated by the sound of words rather than by their meaning (e.g., through rhyming or assonance).

Derailment. (Synonymous with loose associations.) A breakdown in both the logical connection between ideas and the overall sense of goal-directedness. The words make sentences, but the sentences do not make sense.

Flight of ideas. A succession of multiple associations so that thoughts seem to move abruptly from idea to idea; often (but not invariably) expressed through rapid, pressured speech.

Neologism. The invention of new words or phrases or the use of conventional words in idiosyncratic ways.

Perseveration. Repetition of out of context of words, phrases, or ideas.

Tangentiality. In response to a question, the patient gives a reply that is appropriate to the general topic without actually answering the question. Example:Doctor: Have you had any trouble sleeping lately?Patient: usually sleep in my bed, but now I'm sleeping on the sofa.

Thought blocking. A sudden disruption of thought or a break in the flow of ideas.

PERCEPTUAL DISTURBANCESHallucinations & illusions: does patient hears voices or sees visionsDepersonalization and derealization: extreme feelings of detachment from self or from the environment

E.) SENSORIUM1.) ALERTNESS: observation2) ORIENTATION: What is your name? Who am I? Where are you now? Where is it located? 3) CONCENTRATION: Starting at 100, count backward by 5. Name the months of year starting with December4) MEMORY IMMEDIATE- Repeat these numbers after me: 10 5 7 1 8RECENT – What did you have for breakfast? I want you to remember these things: yellow pencil, Iphone, laptop. After a few minutes, I’ll ask you to repeat them.LONG TERM – What was your address when you were in the 6th grade? Who was your teacher? What did you do during the summer between high school & college?

5) CALCULATIONS: If you buy an apple that costs Php10.00 and you pay with a Php50.00 bill, how much change should you get?6) FUND OF KNOWLEDGE: What is the capital of the Philippines?7) ABSTRACT REASONING: Which one does not belong in this group: a dog, a lion, a dolphin, a carabao? How is an apple and an orange alike?

F.) INSIGHTDegree of personal awareness & understanding of

illnessComplete denial of illness

Slight awareness of being sick but denying it at the same time

Awareness of being sick but blaming it on others

G.) JUDGMENTSocial judgment: Does the patient understand the likely outcome of his or her behavior, and is s/he

influenced by this understanding?

A summary of six levels of insight follows:

1. Complete denial of illness

2. Slight awareness of being sick and needing help, but denying it at the same time

3. Awareness of being sick but blaming it on others, on external factors, or on organic factors

4. Awareness that illness is caused by something unknown in the patient

5. Intellectual insight: admission that the patient is ill and that symptoms or failures in social adjustment are caused by the patient's own particular irrational feelings or disturbances without applying this knowledge to future experiences

6. True emotional insight: emotional awareness of the motives and feelings within the patient and the important persons in his or her life, which can lead to basic changes in behavior.

2 kinds of Judgment

1. Social judgment: Subtle manifestations of behavior that are harmful to the patient and contrary to acceptable behavior in the culture; does the patient understand the likely outcome of personal behavior and is patient influenced by that understanding; examples of impairment

2. Test judgment: Patient's prediction of what he or she would do in imaginary situations (e.g., what patient would do with a stamped, addressed letter found in the street)

VIII. DIAGNOSIS AXIS I: Clinical syndromes (Schizophrenia, generalized

anxiety disorder, mood disorder)

AXIS II: Personality disorders

AXIS III: Any general medical conditions

AXIS IV: Psychosocial & environmental problems relevant to illness

AXIS V: Global assessment functioning exhibited by the client during the interview

Differential Diagnosis

A differential diagnosis is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are and may also refer

to any of the included candidate alternatives (which may also be termed candidate condition).

This method is essentially a process of elimination, or at least, rendering of the probabilities of

candidate conditions to negligible levels.

Differential Diagnosis

The method of differential diagnosis was first suggested for use in the diagnosis of mental

disorders by Emil Kraepelin

At least 5 or more differential diagnosis.

Key words : deferred, rule-out

Prognosis

Opinion about the probable future course, extent, and outcome of the disorder; good and

bad prognostic factors; specific goals of therapy

Biopsychosocial ModelBIOLOGICAL PSYCHOLOGICAL SOCIAL

PREDISPOSING

PRECIPITATING

PERPETUATING

Comprehensive Treatment Plan/Recommendation

SHORT TERM AND LONG TERM GOALS

-includes Pharmacotherapy, Psychotherapy Hospitalization, Psychosocial Skills Training and out-patient treatments.

Remember:The number one principle as future

psychologist in assessing your patients/clients:

YOU, YOURSELVES ARE THE TOOL.