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Psychological report writing

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Psychological report writing

  1. 1. Psychological Report Writing **Adapted from UP-PGH format
  2. 2. 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.
  3. 3. . IDENTIFYING INFORMATION I State 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)
  4. 4. VII. BEHAVIORAL OBSERVATIONS/ MENTAL STATUS EXAMINATION Summary of the examiner’s observations & impressions derived from the interview A.) APPEARANCE/ORIENTATION Patient’s appearance & behavior during the interview; attitude towards the examiner – cooperative, attentive, evasive, guarded, etc General 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.
  5. 5. C.) MOOD AND AFFECT MOOD (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
  6. 6. D.) THINKING AND PERCEPTION FORM 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 impulses THOUGHT DISTURBANCES: delusions(thought insertion, withdrawal, broadcasting, etc) ideas of reference, persecutory delusions
  7. 7. 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.
  8. 8. 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.
  9. 9. PERCEPTUAL DISTURBANCES Hallucinations & illusions: does patient hears voices or sees visions Depersonalization and derealization: extreme feelings of detachment from self or from the environment
  10. 10. E.) SENSORIUM 1.) ALERTNESS: observation 2) 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 December 4) MEMORY IMMEDIATE- Repeat these numbers after me: 10 5 7 1 8 RECENT – 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?
  11. 11. 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?
  12. 12. F.) INSIGHT Degree of personal awareness & understanding of illness Complete 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.) JUDGMENT Social judgment: Does the patient understand the likely outcome of his or her behavior, and is s/he influenced by this understanding?
  13. 13. 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
  14. 14. 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.
  15. 15. 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)
  16. 16. 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
  17. 17. 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.
  18. 18. 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
  19. 19. Prognosis Opinion about the probable future course, extent, and outcome of the disorder; good and bad prognostic factors; specific goals of therapy
  20. 20. Biopsychosocial Model BIOLOGICAL PSYCHOLOGICAL SOCIAL PREDISPOSING PRECIPITATING PERPETUATING
  21. 21. Comprehensive Treatment Plan/Recommendation SHORT TERM AND LONG TERM GOALS -includes Pharmacotherapy, Psychotherapy Hospitalization, Psychosocial Skills Training and out-patient treatments.
  22. 22. Remember: The number one principle as future psychologist in assessing your patients/clients: YOU, YOURSELVES ARE THE TOOL.

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