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Psychological report writing

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  • 1. Psychological Report Writing**Adapted from UP-PGH format

2. Psychological Assessment is similar to psychologicaltesting but usually involves a more comprehensiveassessment of the individual.Psychological assessment is a process that involves theintegration of information from multiple sources, suchas tests of normal and abnormal personality, tests ofability or intelligence, tests of interests or attitudes, aswell as information from personal interviews.Collateral information is also collected about personal,occupational, or medical history, such as from records orfrom interviews with parents, spouses, teachers, orprevious therapists or physicians. 3. . IDENTIFYING INFORMATIONIState the name, age, marital status, sex, occupation, race, nationality, andreligion if applicable; previous admissions for the same or a different condition; withwhom the patient livesII. REASON FOR REFERRAL/ CHIEF COMPLAINTState the clients chief complaint; why the client came to the psychologist,preferably in the patients own words or the referrals.III. HISTORY OF PRESENT ILLNESS Development of symptoms or behavioral changes that a precipitate in theclients asking for assistance; how illness has affected the clients life activities andpersonal relations.IV. PAST PSYCHIATRIC AND MEDICAL HISTORY Past medical condition: name of hospital, type of treatment, length of illness,effect of treatmentV. FAMILY HISTORY * genogramVI. PERSONAL HISTORY (ANAMNESIS) History of patients life from infancy to the present; emotions experienced withdifferent life periods (painful, stressful, conflictual) 4. VII. BEHAVIORAL OBSERVATIONS/MENTAL STATUS EXAMINATIONSummary of the examiners observations &impressions derived from the interviewA.) APPEARANCE/ORIENTATION Patients 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, perspiringhand, etc. B. ) SPEECHRapid, slow, slurred, loud, whispered, echolalia, etc. 5. C.) MOOD AND AFFECTMOOD (a pervasive & sustained emotion that colorsthe persons 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 patientsinner experiences) How does the examiner evaluates patients affect: broad, restricted, blunted or flat; isthe emotional expression appropriate to the thoughtcontent; give examples if emotional expression is inappropriate 6. D.) THINKING AND PERCEPTIONFORM OF THINKING: overabundance of ideas, flightof ideas, slow thinking, stream of thought, quotations from patient; loose associations, lack ofcausal relations in patients explanations; incoherentspeech (word salad), neologisms (development of new words) CONTENT OF THINKING: Preoccupations about theillness, obsessions, compulsions, phobias, suicidal ideation, antisocial urges or impulses THOUGHT DISTURBANCES: delusions(thoughtinsertion, withdrawal, broadcasting, etc) ideas ofreference, persecutory delusions 7. Formal Thought DisordersCircumstantiality. Overinclusion of trivial or irrelevant detailsthat impede the sense of getting to the point.Clang associations. Thoughts are associated by the sound ofwords rather than by their meaning (e.g., through rhyming orassonance).Derailment. (Synonymous with loose associations.) Abreakdown in both the logical connection between ideas andthe overall sense of goal-directedness. The words makesentences, but the sentences do not make sense.Flight of ideas. A succession of multiple associations so thatthoughts seem to move abruptly from idea to idea; often(but not invariably) expressed through rapid, pressuredspeech. 8. Neologism. The invention of new words or phrases or theuse 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 areply that is appropriate to the general topic without actuallyanswering the question.Example:Doctor: Have you had any trouble sleeping lately?Patient: usually sleep in my bed, but now Im sleeping on thesofa.Thought blocking. A sudden disruption of thought or a breakin the flow of ideas. 9. PERCEPTUAL DISTURBANCESHallucinations & illusions: does patient hearsvoices or sees visionsDepersonalization and derealization: extremefeelings of detachment from self or from theenvironment 10. E.) SENSORIUM1.) ALERTNESS: observation2) ORIENTATION: What is your name? Who am I? Where areyou now? Where is it located?3) CONCENTRATION: Starting at 100, count backward by 5.Name the months of year starting with December4) MEMORYIMMEDIATE- 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, Ill ask you to repeatthem.LONG TERM What was your address when you were in the6th grade? Who was your teacher? What did you do duringthe summer between high school & college? 11. 5) CALCULATIONS: If you buy an apple thatcosts Php10.00 and you pay with a Php50.00bill, how much change should you get?6) FUND OF KNOWLEDGE: What is the capitalof the Philippines?7) ABSTRACT REASONING: Which one doesnot belong in this group: a dog, a lion, adolphin, a carabao? How is an apple and anorange alike? 12. F.) INSIGHTDegree of personal awareness & understanding ofillnessComplete denial of illnessSlight awareness of being sick but denying it at thesame time Awareness of being sick but blaming it on othersG.) JUDGMENTSocial judgment: Does the patient understand the likely outcome of his or her behavior, and is s/he influenced by this understanding? 13. A summary of six levels of insight follows:1. Complete denial of illness2. Slight awareness of being sick and needing help, butdenying it at the same time3. Awareness of being sick but blaming it on others, onexternal factors, or on organic factors4. Awareness that illness is caused by something unknown inthe patient 14. 5. Intellectual insight: admission that the patient is illand that symptoms or failures in social adjustment arecaused by the patients own particular irrational feelingsor disturbances without applying this knowledge tofuture experiences6. True emotional insight: emotional awareness of themotives and feelings within the patient and theimportant persons in his or her life, which can lead tobasic changes in behavior. 15. 2 kinds of Judgment1. 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 impairment2. Test judgment: Patients prediction of what he or she would do inimaginary situations (e.g., what patient would do with a stamped,addressed letter found in the street) 16. VIII. DIAGNOSISAXIS I: Clinical syndromes (Schizophrenia, generalizedanxiety disorder, mood disorder)AXIS II: Personality disordersAXIS III: Any general medical conditionsAXIS IV: Psychosocial & environmental problemsrelevant to illnessAXIS V: Global assessment functioning exhibited bythe client during the interview 17. Differential Diagnosis A differential diagnosis is a systematic diagnosticmethod used to identify the presence of an entitywhere 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. 18. Differential Diagnosis The method of differential diagnosis was first suggested for use in the diagnosis of mental disorders by Emil KraepelinAt least 5 or more differential diagnosis.Key words : deferred, rule-out 19. PrognosisOpinion about the probable future course,extent, and outcome of the disorder; good andbad prognostic factors; specific goals of therapy 20. Biopsychosocial ModelBIOLOGICAL PSYCHOLOGICAL SOCIALPREDISPOSINGPRECIPITATINGPERPETUATING 21. Comprehensive TreatmentPlan/Recommendation SHORT TERM AND LONG TERM GOALS -includes Pharmacotherapy, Psychotherapy Hospitalization, Psychosocial Skills Training and out-patient treatments. 22. Remember: The number one principle as futurepsychologist in assessing your patients/clients:YOU, YOURSELVES ARE THETOOL.