My Writings

Saturday, July 18, 2015

My NEUROPSYCHOLOGICAL EVALUATION

  
    
NEUROPSYCHOLOGICAL EVALUATION
CONFIDENTIAL
       
  
PRINCIPAL DIAGNOSES:   
    
296.33  
Major Depressive Disorder, Recurrent, Severe     
300.02  
Generalized Anxiety Disorder  
300.23  
Social Anxiety Disorder   
301.89  
  
Other Specified Personality Disorder with mixed avoidant, dependent, and borderline features.  
    
         
REASON FOR REFERRAL     
Ms. ______ was referred for a neuropsychological evaluation by her therapist for differential diagnosis.  It was reported that she has some learning disabilities and a long history of mental health challenges.  Over the past few years, Ms. ______ has been hospitalized at least four times and has attempted suicide on at least two occasions.  At the time of the evaluation, Ms. ______  was prescribed fluoxetine 30 mg, Wellbutrin SR 100 mg, Haldol 1 mg pm, Topamax 100 mg pm, trazodone 150 mg pm, and Klonapin .5 mg bid, prn  
  
EVALUATION TIME LINE  
Ms. ______  and her parents initially met with the examiner on May 16, 2014, to review developmental, medical, and mental health history.  Testing was completed July 11, 2014, and Ms. ______  and her parents returned to review test results and discuss recommendations on July 25, 2014.    
  
 CHIEF COMPLAINT/PRESENTING PROBLEMS  
Ms. ______  has a history of mental health problems, and as was previously noted, over the past year the severity of her depression has increased to the point where she has required in-patient hospitalization and has two attempted suicide events. When asked about the purpose of testing, Ms. ______ responded, “to understand where I’m at so we know what to expect of me”.  The most important question she hoped to have answered by the evaluation was “What mental health problems do I have and how does that effect me?”  She reported that the three most debilitating symptoms at that time were, “feeling hopeless”, “anxiety”, and a “never ending cycle of depression”.     
  
TEST ADMINISTRATION  
The following instruments were included as part of the current evaluation:    
  
Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV)  
Wide Range Assessment of Memory and Learning-Second Edition (WRAML2)   
Halstead-Reitan Neuropsychological Test Battery - selected subtests  
  Grooved Pegboard  
  Finger Tapping  
  Name Writing   
Peabody Picture Vocabulary Test-Fourth Edition (PPVT-IV)  
Wisconsin Card Sorting Test (WCST)  
Writing/Drawing Sample   
Rey-Osterreith Complex Figure Drawing  
Beck Depression Inventory-Second Edition (BDI-II)  
Burns Anxiety Inventory (BAI)  
Millon Clinical Multiaxial Inventory-III (MCMI-III)  
Test of Memory Malingering (TOMM)  
Clinical Interview   
  
BACKGROUND HISTORY  
Developmental history was obtained from Ms. ______  and her parents. Ms. ______  was born on January 1, 1985 to a two-parent family.  She was unaware of any complications during her mother’s pregnancy or at the time of birth.  Both of Ms. ______ ’s parents are living, and she has resided with them since graduating from high school approximately 11 years ago.  Ms. ______  has three siblings, a brother age 27, and two younger sisters, age 22 and 20.  Within her immediate family, she has one sibling that has been diagnosed with ADHD and learning disabilities. Ms. ______  and her younger sibling have a long history of a difficult relationship; however, she reported, “things are going better between the two of us since she moved out of the house”. On the maternal side, the genetic family history is positive for learning problems, bipolar disorder, depression, suicide attempts, psychiatric hospitalization, and alcohol/substance abuse.  On the paternal side, genetic family history is positive for anxiety, unreasonable fears and phobias, depression, and eating disorders. The medical family history is positive for hypertension and stroke.    
  
MEDICAL HISTORY  
When discussing her medical history, her mother reported that at the age of 18 months, Ms. ______  pushed a small piece of gravel into her ear and she began to experience significant and chronic ear infections. These continued until 4 years of age when the gravel was discovered far within her ear canal.  Ms. ______ also had several bouts of strep throat.  As a result, she was prescribed antibiotics for long periods of time.  Ms. ______ was always slightly overweight but enjoyed dance classes until she broke her foot at the age of 17. Her parents reported that after the injury, she quit dancing, was less active and began to gain more weight.  Ms. ______  indicated no history of regular alcohol use and no drug use.  She has never used illegal or recreational drugs and she does not smoke.     
  
DEVELOPMENTAL/ACADEMIC HISTORY  
According to Ms. ______ , developmental milestones were achieved early (walking) or within the average range. However, later in the interview, it was disclosed that she had speech problems (i.e., articulation problems) and had speech therapy from preschool until 2nd grade.  She reported the following conditions as a child; developmental delays, hearing problems, frequent ear infections, and depression, which began at approximately 14 years of age. When discussing Ms. ______ ’s early developmental history, her mother reported that from the time she was an infant she was very fearful. She exhibited a fear response to anything new or unexpected, exhibited significant separation anxiety, and often had emotional meltdowns that included anger, aggressive behavior, and problems with mood regulation. As a result, she often refused to try anything new, and this often caused problems during family outings.  
  
Ms. ______ ’s father stated that throughout her childhood and continuing into her young adult years, Ms. ______ exhibited severe temper tantrums that included screaming, kicking, yelling, and hitting. He reported that living with his daughter has been extremely difficult, not only for himself but for the entire family, due to her continual problems with mood/behavior regulation. He has often felt that Ms. ______ ’s out of control behavior has also been an attempt to manipulate the situation or environment so that she is able to get her own way or obtain what she wants.    
  
In discussing her educational history, Ms. ______  stated that she did not require any special education support throughout her public education.  She reported, “I did fine in school but I had to work harder than most”.  She indicated that she experienced some social difficulties beginning in elementary school, primarily because she was extremely shy and fearful.  She indicated that other people may not have seen her extreme shyness and constant fear, but others would likely describe her as “happy creative, kind, friendly, and sweet”.    
  
Following her graduation from high school, she attended Snow College for two semesters. She stated that her first semester grades were fine, but she basically “gave up” academically during the second semester due to exacerbation of her previous mental health challenges.  In 2012, she registered as a student at Salt Lake Community College and she has taken a few classes towards becoming an accounting clerk.  Her employment history is rather sparse.  She worked as a food service worker for almost 3 years, a night security guard for approximately 10 months and as a checker at a large discount store for 9 months. She later worked as a checker at Deseret Industries, a position that she held for approximately 18 months.  Ms. ______  reported that she experienced extreme anxiety everyday she went to work, regardless of the type of employment in which she was engaged.    
  
MENTAL HEALTH HISTORY  
Due to her serious anxiety and fear along with her severe mood and behavioral regulation problems as a child, Ms. ______ ’s parents had her see a therapist for a short time to try to help with these problems. However, she usually refused to talk, so therapy was discontinued. She did not receive long-term therapy until approximately 20 years of age.  Since that time, she has worked with several therapists.    
  
When further discussing Ms. ______ ’s mental health history, she reported that although she had a few friends in elementary school, she lost some of those friendships by the time she entered Jr. High School.  She pointed out one specific experience in which she and a few friends tried out to become cheerleaders. While she did not get a position of cheerleader, her other friends did, and this led to extreme sadness and feelings of dejection. She saw her friends less and less because they became involved in “their own thing” and they drifted apart.  Because she felt so isolated and alone, she began to stay at home a great deal of the time and engaged in very few social activities and had no strong social relationships with friends.  During her ninth grade year, she developed depression, and this resulted in even less motivation to become more socially active.  She reported that she slept more than usual and did not feel happy most of the time. Ms. ______  stated that from ninth grade until her graduation from high school, she struggled academically but was able to get good grades as a result of working very hard.  She did find one new friend and noted that she maintains the friendship with this person.    
  
Ms. ______  reported that her mental health problems increased dramatically when she began to attend Snow College following high school graduation.  She lived with three roommates, and although she did well academically, she began to feel isolated and was not included or invited to any activities with the other roommates.  By the second semester of school, her depression had increased to the point that she “gave up” in school, and she did not return for a second year.  Ms. ______  also reported that she also developed a binge eating disorder while a student at Snow College, and she also had cycles of restriction followed by binge eating. She no longer restricts but continues to be a binge eater, and she has never received any mental health therapy for this disorder.    
  
Although Ms. ______  worked briefly and made some attempts at going back to school, she was not particularly successful in either of these areas, and she continued to be withdrawn and had very few social contacts or social relationships.  Her parents reported that their daughter experienced “four years of sexual abuse” during this time period, which included one-way sexual acts with a younger male whenever he requested them. Since she was older than he, this may not normally be considered a predatory situation, but her parents indicated that he took advantage of Ms. ______ ’s lack of experience and naiveté. They indicated their daughter’s emotional and social development has always been much slower than her chronological age, so she was easily coerced into this situation. When asked directly about this experience, Ms. ______ said that she did not like what was happening, but she did not know who to tell or what to do.  
  
Ms. ______ has participated in outpatient mental health therapy since 2005.  Each of her outpatient therapy relationships has continued for at least two to three years.  Beginning in February of 2014, she began meeting with her current therapist, and at the time of the evaluation she was continuing to work in outpatient therapy.    
  
Ms. ______ reported receiving a psychological evaluation at the University of Utah sometime in 2010. Although the evaluation was not available to this examiner, Ms. ______ stated that the results indicated that she exhibited many similarities to Asperger’s Disorder but “not enough to be diagnosed”.    
  
Ms. ______ stated that approximately one and a half years ago (sometime during 2012) a former acquaintance called her and apologized for his past hurtful behavior toward her.  Before that occurred, Ms. ______ said she experienced almost a year when “I felt stable”.  However, her depression slowly returned. She reported that at one point in time, she was diagnosed with bipolar disorder and prescribed lithium, but stated “it was a terrible match and made things much worse for me”.   
  
Ms. ______ ’s first suicide attempt occurred in August of 2010 when she took a combination of clonazepam, water pills, and benadryl.  Her parents found her in her room and she was taken to the University Neuropsychiatric Institute (UNI), where she stayed for approximately one week.  She reported no further hospitalizations until July of 2013 when she again began having serious thoughts of committing suicide. Although she did not directly attempt suicide, she reported her feelings to her parents, and she was hospitalized from July 19 to August 3 of 2013.    
  
Ms. ______  returned to LDS Hospital in early 2014 for medication changes so that she could be monitored during this period of time.  Following the medication change and release from the hospital, she was admitted to Pioneer Hospital in January of 2014 for approximately one week due to suicidal ideation.  She did not recall taking anything or actively attempting suicide at that time.  She returned again to Pioneer Hospital in May of 2014 after taking “a bunch of Tylenol PM”.  She remembered telling her parents shortly after she took the pills, and she was admitted for observation for a few days.  At the time of the present neuropsychological evaluation, Ms. ______  had been released from Pioneer Valley Hospital for approximately one week, and has just been placed in the UNI Wellness Recovery Center, where it was estimated she would stay for approximately 2 weeks.  She reported that shortly after being admitted to the program, she began to experience a strong urge to cut herself deeply.    
  
SUMMARY AND INTERPRETATION OF TEST RESULTS  
Note: A list of tests with numerical scores is included at the end of the narrative report. The reader is referred to this section to review specific scores.   
  
The results of testing reflect challenges that have impacted Ms. ______ ’s intellectual, cognitive, and mental health, functioning, both currently and in the past.    
  
First, testing for personality, mental health, and affective functioning were completed and reflect chronic and severe mental illness.  A diagnostic structured clinical interview was included as part of this evaluation. Ms. ______ reported that she was experiencing severe depression and a moderate level of anxiety.  She reported symptoms that included a sad mood most of the day, almost every day, loss of interest in things that use to make her happy, excessive sleeping, lack of motivation, thoughts of cutting, as well as suicidal thoughts.    

Ms. ______ was administered the Millon Clinical Multiaxial Inventory-Third Edition (MCMI-III) to further assess personality and mental health functioning.  On the basis of the test data, Ms. ______ endorsed a number of items that are reflective of an individual who is experiencing a severe mental disorder, with high elevations on the anxiety scale and Dysthymia scale. Axis I clinical syndromes suggested by the MCMI-III were Major Depression (recurrent), severe, without psychotic Features and Generalized Anxiety Disorder.  Axis II disorders that suggest deeply ingrained and pervasive patterns of maladaptive functioning including dependent personality disorder, avoidant personality disorder, with schizoid personality traits and depressive personality traits. Ms. ______ also reported psychosocial problems of low self-confidence and loneliness.    
  
Ms. ______ ’s profile on the MCMI-III indicates that she is very inclined to lean on others for support, and when stressed, she may report that even the simplest demands are too much for her.   Her profile reflected a significant issue with dependency and inability to feel confident to make decisions on her own.  Her profile on the MCMI-III also indicates a striking lack of initiative and avoidance of independence and autonomy.  She is extremely dependent and feels highly vulnerable if she is separated from those who provide her support.  In her case, her parents have always provided the support that she seeks.  She may also display anger that is directed toward her parents if she feels that they fail to appreciate her intense need for affection and nurturance.  She exhibits an underlying dysphoric mood that includes anxiety, sadness, guilt, and insecurity.  
  
Another interesting result of Ms. ______ 's responses on the MCMI-III indicates the presence of very unsophisticated ideas and simple, childlike impulses and expectations, as well as immature competencies. She seems to be preoccupied with self-doubts that include being physically unattractive, self-demeaning, and hypersensitive to her own problems. She also reported a high level of perfectionism resulting in internal punishment for her many failures. Ms. ______ yearns for acceptance and affection from others, but her hopes seem to be rapidly decreasing, leading to more and more thoughts of suicide.    
  
In addition to the information contained from the MCMI-III, the structured clinical interview with Ms. ______ reinforced her extreme shyness and feelings of isolation and severe anxiety, including social anxiety, performance anxiety, and test anxiety.  Her psychological profile also indicated that she continues to struggle with a binge eating disorder while at the same time, her ideal weight would fall within the “anorexic” range.  She displays significant avoidance tendencies as well as significant dependency on others to the point in which she feels she cannot make decisions for herself and is unable to rely on her own judgment.  She also indicated that she worries about conflict with others, and has a high need for love, although she rarely feels that in her life.  
  
Results of the intellectual functioning as measured by the Wechsler Adult Intelligence ScaleFourth Edition (WAIS-IV) reflected a full scale I.Q. score of 80 (9th percentile) falling at the low end of the “low average” range.  However, the subtest patterns reflected significant variability, with scaled scores ranging from the 1st percentile to the 84th percentile. Her verbal comprehension abilities (expressive vocabulary, verbal comprehension, knowledge of basic facts, and conceptual similarities fell within the “average” range. Her scores for perceptual reasoning skills that included block design, matrix reasoning, and visual pictures, also fell within the  
“average” range.  She struggled significantly on tasks that required working memory abilities and her processing and production scores were extremely low falling at the 1st percentile.  
  
Testing for memory and learning abilities also reflected variability, but the General Memory score on the Wide Range Assessment of Memory and Learning-2nd Edition (WRAML2) reflected scores in the “borderline” and “high average” range (5th percentile to 75th percentile).  On the verbal memory tasks, Ms. ______ had no difficulty repeating orally presented stories that contained a large number of details, and her performance on the delayed recall task reflected minimal loss of information.  However, on a verbal learning task that required her to learn a long list of words over four consecutive trials, her performance was much poorer. Although her learning curve was positive over the course of four trials, her initial repetition of words on the word list was very low (5 of 16 words), and by the fourth trial, she was only able to repeat 45% of the words contained in the word list.    
  
Her ability to remember information that was presented visually was more consistent, and her score fell within the “average” range.  She was able to reproduce geometric designs from memory as well as recall added or changed details within a series of detailed drawings.   
  
Her score on tasks that required immediate recall of information was not as strong, and her score fell within the “low average” range. She particularly struggled with recall of number/letter strings of increasing length.  On the working memory tasks of the WRAML2 her scores also reflected variability.  While she was also able to hold verbally presented information in mind, she struggled to mentally manipulate number strings or number/letter combinations.  Overall, Ms.  ______ ’s performance on the WRAML2 was similar to that of the I.Q. testing.  While she scored within the “average” range on some of the memory tasks, she had greater difficulty with tasks that required quicker cognitive processing and mental manipulation.    
  
Ms. ______ ’s developmental history as well as her performance on various tasks throughout the testing session indicated that she has never experienced significant difficulty with self-regulation of attention.  Although she may become distracted and lose focus, any problems that she might exhibit tend to result from depression and anxiety as well as lack of motivation when required to complete tasks that she shows disinterest in.  Her profile does not reflect a specific attention disorder and did not meet the criteria for a diagnosis of ADHD.  
  
In terms of self-regulation of behavior and emotions, although she had no problems within the structured testing setting, Ms. ______ ’s history reflects significant difficulty managing and self regulating both behavior and emotions, and this has been extremely problematic for her throughout her lifetime.    
  
Ms. ______ ’s developmental history reflects significant problems with executive functioning skills.  Executive functions are cognitive processes that direct and organize all behavior in pursuit of higher-level goals. Well-developed executive functioning skills are necessary to accomplish flexible, goal-directed behavior, such as planning, inhibitory control, mental flexibility, reasoning, judgment, problem solving, and emotion regulation. When completing a task that required reasoning, problem solving, and flexible thinking, Ms. ______ performed within the “average” range on some of the measures.  However, she required far more trials than average for her age and educational level in order to learn the first problem-solving set, resulting in a score below the 1st percentile.    
  
Assessment of social functioning reflects a history of social challenges and social isolation.  Due to Ms. ______ ’s long history of extreme shyness and withdrawal from social situations, she had limited opportunities to develop healthy social relationships.  Although she did report having a few friends during her childhood years, she had very few friends throughout her Jr. High and High School, and once she graduated from High School, her social relationships diminished even more. The combination of shyness, fear, and fear of rejection seemed to contribute to extreme deficits and delays in social functioning, and she has been unable to build a strong social network or develop positive social relationships throughout most of her life. At this point in time, Ms. ______ indicated that she finds it easier to be by herself, although she is often lonely and discouraged and she feels dejected and alone. She seems to want to develop social relationships but it appears that she now finds that social isolation is more comfortable for her.    
  
Screening tests for academic abilities indicated that Ms. ______ ’s word recognition and decoding skills fell at the High School level, but her spelling skills were at the 8th grade level.  Although her decoding skills were well developed, most of her spelling errors were based on lack of memorization when words differed from the basic decoding rules.  Her greatest academic deficits were reflected in poor math computation skills.  Her score reflected abilities at the 6th grade level, and although she was able to accurately complete problems that included more complex multiplication and division, she made many errors on problems that included fractions, decimals, and multiplication or addition of fractions.    
  
Ms. ______ exhibited some significant challenges on other neuropsychological measures. When completing a complex figure drawing, she exhibited difficulty with visual-spatial organization and placement of design details when completing the copy of the design. She had even greater challenges on both the immediate and delayed recall tasks.  Her performance suggested that she struggles with initial planning and organization and her inability to simplify complex visual information into simpler component parts made it extremely difficult for her to recall both the external form as well as the internal details.  She also struggled on a controlled oral word task in which she was required to verbalize as many words as she could within a short period of time based on phonological and semantic categories.     
  
CONCLUSION  
Ms. ______ is a 29-year-old female with a long history of fear, anxiety, and emotional/behavioral dysregulation. Her parents described her as being a fearful baby and she continued to exhibit fear and anxiety throughout most of her life.  She began having severe tantrums as a toddler and her parents stated that her tantrums continued until she was approximately 20 years old.  She has exhibited extremely low frustration tolerance and it does not seem to take very much to trigger her frustration, anxiety, and anger.    
  
Ms. ______ ’s therapist recommended a neuropsychological evaluation to determine if there were neurocognitive issues that might be affecting Ms. ______ 's ability to function more effectively within her environment. The results of neuropsychological testing reflected ‘average’ intellectual abilities and “average” to “low average” learning and memory skills.  Academically, she seemed to struggle much more in the area of math; however, she did not require special education services at any time during her education, and she was able to graduate from high school with adequate grades.  She has shown no significant problems with attention regulation and although testing reflected some problems with visual spatial organization and planning, none of these weaknesses would suggest neurologically based reasons for her poor level of functioning.   
  
In terms of neuropsychological functioning, Ms. ______ ’s greatest challenges relate to executive functioning abilities. She exhibits significant difficulty with flexible thinking and problem solving, reasoning, judgment, and the ability to learn from the consequences of past experiences or behaviors.  Her parents commented that she behaves much more like a young adolescent which is also apparent in her level of executive functioning, and she has not grown or developed in her abilities to self-monitor or self-regulate, which are also primary areas of executive functioning.  The results of this evaluation do support the fact that Ms. ______ exhibits serious mental health disorders, and the combination of her own temperament and personality development, significant shyness and social deficits have contributed to her inability to function.  
  
It is this examiner’s conclusion that Ms. ______ ’s restricted social development since early childhood contributed significantly to the development of her mental health challenges.  Her high levels of anxiety, extreme shyness, and social reticence resulted in restricted social relationships throughout her public school education. By the 9th grade, Ms. ______ reported her first significant period of depression that apparently was not treated medically or therapeutically. Ms. ______ ’s parents noted that although she is now 29 years old, socially and emotionally she functions more like a young adolescent. This is very likely true, as it was approximately that time in her life when she began to experience increasingly diminished opportunities to mature socially and build new social relationships. Despite her social challenges and social isolation, her profile is not consistent with an autism spectrum disorder, formerly known as Asperger’s Disorder.  
  
Over the years Ms. ______ has become increasingly isolated and is now devoid of true social connections.  Even some of her family members have found it difficult to interact with her and form close bonds, as her anger, demands, and low frustration tolerance have been targeted towards them for many years.  At the same time, Ms. ______ has continued to exhibit an unhealthy dependency on her parents, and she behaves in a way that suggests that she still has not developed a sense of self or of self-worth. As a result, she often feels hollow inside with nothing to define her or to build her confidence to the point that she believes she can develop the capacity to become more capable and more productive in her life.  
  
After so many years of this cycle, Ms. ______ exhibits severe and recurrent depression as well as a generalized anxiety disorder. She has also developed long-standing behavioral patterns that have led to inflexibility and lack of growth in her personality development, resulting in the inability to move beyond her nonfunctional ways of coping.  
  
The evaluation suggests that Ms. ______ now exhibits a personality disorder with mixed features as well. In her home environment, her extreme emotional dysregulation, frequent anger, and poor coping strategies are similar to a borderline personality disorder in which she is unable to tolerate strong negative emotions and she often becomes extremely angry at her parents or other family members when she feels they do not understand her or have failed her. Her personality disorder also includes features of extreme dependency, schizoid features, and a high level of avoidance.    
  
Since Ms. ______ has not developed any measure of confidence in her ability to overcome challenges, to learn to deal more effectively with every day challenges, or take small steps to expand her ability to experience positive mood states, her depressive symptoms have increased significantly to the point in which she has contemplated and/or attempted suicide at least 4 times.  Her suicide attempts appear to be more likely cries for help and a manifestation of the terribly hopeless state that she is unable to deal with at those times.  When talking with Ms. ______ , she reported that even during the times she made actual suicide attempts, her attempts have not really reflected a clear desire to die.  Instead, she explained that during these times, she has felt so terrible and hopeless that she has basically “not wanted to feel anymore” and to find relief from her emotional pain and suffering.  
  
The results of this evaluation clearly support the fact that Ms. ______ exhibits serious mental health disorders, and the combination of her own temperament and personality development, significant shyness and social deficits have contributed to her inability to function.  
  
Ms. ______ is now to the point that without significant family and therapeutic support and a strong desire on her part to make changes, she could be headed in a direction of a permanent disability that will continue to affect all areas of her life, including the inability to be successful in a vocational or educational setting. In addition, her severe and chronic depression, as well as her severe anxiety need to be better controlled, reflecting a significant reduction in symptoms, or she will not have the capacity to make some of the permanent changes that need to occur in her life. If these things are not available to her, she will continue to experience feelings of hopelessness that lead to both suicidal thinking as well as the potential for suicide as a final way of escaping the extreme depression and hopeless thinking that have now become a part of her daily experience.  
  
RECOMMENDATIONS  
Ms. ______ has already been prescribed several medications to help reduce severe depressive symptoms, moderate symptoms of anxiety. She is also prescribed medication to aid with regulation of moods and stabilize sleep. However, she continues to exhibit severe depression with suicidal thinking. It is recommended that Ms. ______ and her parents talk with her psychiatrist to discuss the possibility of ECT since her response to medications thus far suggests limited efficacy.   
  
One of the most helpful areas of focus in a therapeutic setting should be aimed at teaching Ms. ______ more about the mind/body connection and how powerfully the mind and one’s thinking can impact physical functioning and physical well-being. She needs help in understanding that even gentle exercise such as walking can make a significant difference in her mood and help to reduce physical symptoms of anxiety by up to 20 percent. Engaging in daily exercise can be framed in a very positive way, as it opens the door to changes in cognition, and an understanding that she can begin to feel better and less pessimistic about her current and future mental and medical health.   
  
Due to her other mental health issues, it appears that Ms. ______ ’s binge eating disorder has not been addressed successfully. Once the depression and anxiety are under better control, getting her the appropriate help for her eating disorder should also be a focus of therapy since it is another manifestation of her self-loathing and inability to manage her strong negative emotions properly.   
  
Since Ms. ______ is a very concrete thinker, insight oriented therapy may not be particularly helpful. The majority of therapy should focus on learning and applying concrete strategies for emotional regulation and distress tolerance as well as building social relationship skills. According to Ms. ______ , dialectical behavioral therapy  (DBT) is the approach being used by her current therapist and should continue to be an excellent approach for these problems regardless of which therapist she is working with. She also needs to work with a therapist who can help her to understand thinking errors and distortions that lead to self-hate, poor self image, anxiety and depression (i.e. cognitive-behavioral approach), developing better coping strategies, and providing a supportive environment as she faces ongoing challenges.  
  
Another important aspect of treating Ms. ______ would be to help her parents gain additional education and insight regarding the development of personality disorders so that understanding and progress can be made in this area as well. While Ms. ______ is legally and adult, her developmental level is much closer to that of a young adolescent. Her parents might be interesting reading the book, Treating Personality Disorders in Children and Adolescents: A Relational Approach by Efrain Bleiberg MD, a book that approaches the development of personality disorders from a perspective of interpersonal relationships combined with temperament and environment.  
  
Ms. ______ will very likely require medication for anxiety and depression on a long-term basis. While she may not require a mood stabilizer at this time, the combination of mental health problems she displays means that it will be important for her to maintain an ongoing relationship with a psychiatrist who is aware of her history and who can prescribe the appropriate medications.  
  
Due to Ms. ______ ’s constellation of disorders, she would very likely qualify for vocational rehabilitation services and she may wish to consider contacting the State Department of Vocational Rehabilitation for further evaluation and/or support regarding work or financial support for continued education to help with her educational or vocational goals. Ms. ______ ’s diagnoses, along with this evaluation should assist in qualifying her for services. Information regarding these services in the state of Utah can be accessed through the website: www.usor.state.ut.us.  
  
If Ms. ______ decides to return to Salt Lake Community College or another college or vocational center, it will be very important for her to contact the Disability Resource Center at the college or university in which she is planning to attend.  Support from the center can include such things as directing her towards more appropriate instructors, making accommodations so that tests can be taken within the testing center rather than the classroom, and being given extra time to complete assignments or to take tests.  
  
With the help of her support system, Ms. ______ should look very hard to find social opportunities for one-on-one or small group interactions. Becoming involved in church groups that include activities and social outings would be very helpful for her, particularly as she improves in her ability to interact and feel more comfortable talking with people she does not already have strong ties with. An excellent book that deals with learn to understand and respond to others in more socially appropriate ways is titled, Socially Curious and Curiously Social: A Social Thinking Guidebook for Bright Teens and Young Adults by Michelle Garcia Winner and Pamela Crooke  
  
Additional Books  
Living Fully with Shyness and Social Anxiety: A Comprehensive Guide to Gaining Social Confidence by Erika Hilliard.  
  
Beyond Shyness: How to Conquer Social Anxieties by Jonathan Berent and Amy Lemley.    
  
When Perfect Isn't Good Enough: Strategies for Coping with Perfectionism  by Martin Antony PhD  and Richard Swinson MD   
  
The Gifts of Imperfection: Let Go of Who You Think You're Supposed to Be and Embrace Who You Are by Brene Brown  
  
If I can provide any additional information or more specific recommendations, please do not hesitate to contact me.  
  
  
NEUROPSYCHOLOGICAL TEST RESULTS  
  

Patient: ______ ______  Date of Testing: 7/11/2014 Neuropsychometrician:   Alivia Irwin, LCSW  WECHSLER ADULT INTELLIGENCE SCALE-FOURTH EDITION (WAIS-IV)  
(mean = 10; s.d. = 3)   
    
Verbal Comprehension  
Perceptual Reasoning  




Similarities  
10  
Block Design  
6  
Verbal Comprehension:  
96  
(39th percentile)  
Vocabulary  
10  
Matrix Reasoning  
13  
Perceptual Reasoning:  
92  
(30th percentile)  
Information  
8  
Visual Puzzles  
7  
Working Memory:  
71  
(3rd percentile)  
(Comprehension)  
10  
(Figure Weights)  
(-)  
Processing Speed:  
65  
(1st percentile)  
   
  
  
(Picture Completion)  
(-)  
Full Scale I.Q.:  
80  
(9th percentile)  
Working Memory        
  
Processing Speed  
  



Digit Span  
4  
Symbol Search  
3  



Arithmetic  
6  
Coding  
4  



(Number/Letter Seq.)  
(-)  
(Cancellation)  
(-)  





WIDE RANGE ASSESSMENT OF MEMORY AND LEARNING-SECOND EDITION (WRAML2)  
(mean = 10; s.d. = 3)   
  
Core Subtests  
  
  

Index  
  
Story Memory  
12  

Verbal Memory:  
94  
(34th  percentile)  
Design Memory  
9  

Visual Memory:  
94  
(34th percentile)  
Verbal Learning  
6  

Attention/Concentration:  
85  
(16th percentile)  
Picture Memory  
9  

General Memory:  
87  
(19th  percentile)  
Finger Windows  
8  

Working Memory:  
83  
(13th percentile)  
Number/Letter  
7  

Verbal Recognition:   
99  
(47th  percentile)   
Optional Subtests  
  
  

  
  
Verbal Working Memory  
9  
  

  
  
Symbolic Working Memory  
5  
  

  
  
Sentence Memory  
10  
  

  
  
Story Memory Recall  
11  
  

  
  
Verbal Learning Recall  
8  
  

  
  
Story Recognition   
11  
  

  
  
Verbal Learning Recognition  
9  
  

  
  
Sound-Symbol  
-  
  

  
  
Sound-Symbol Recall  
  
  
-  
  

  
  
HALSTEAD-REITAN NEUROPSYCHOLOGICAL TEST BATTERY  
  Name Writing:  
Dominant hand (R): 9 seconds (mean = 7.5)  
Non-dominant hand (L): 20 seconds (mean = 21.6)  
    
  Finger Tapping Test:  
Dominant hand (R): 41.6 (mean = 44.3)  
Non-dominant hand (L): 39.8 (mean = 40.6)  
    
 GROOVED PEGBOARD TEST   
  
Dominant (R): 94 seconds, 0 errors  
(mean = 61; age-appropriate range = 0 errors)  
Non-dominant (L):  115 seconds, 1 errors  
(mean= 66; age-appropriate range = 0 errors)  
  
  
CONTROLLED ORAL WORD ASSOCIATION TEST (COWAT)  
F: 7   
A: 5   
S: 9   
Total FAS: 21 Mean = 39.3 Animals:   
  
WIDE RANGE ACHIEVEMENT TEST-REVISION 3 (WRAT3)  
  
  
Raw  
Score  
Standard Score  
  
Percentile  
Grade Equivalent  
Reading  
41  
86  
18th   
HS  
Spelling  
37  
89  
23rd   
8th   
Arithmetic   
35  
83  
13th   
6th   

PEABODY PICTURE VOCABULARY TEST-FOURTH EDITION (FORM B)  
  
Raw Score: 194  
Percentile: 27th  Grade Equivalent:   11.3  
Standard Score: 91  
  
   
  
WISCONSIN CARD SORTING TEST  
  
Age Equivalent: 17:11   
Trials Administered  
93  
  
Total Correct  
67  
  
Total Percent Error  
28%  
(standard score = 91; 27th percentile)  
Total Percent Perseverative Error  
14%  
(standard score = 90; 25th percentile)  
Total Percent Non-Perseverative Errors   
14%  
(standard score = 92; 30th percentile)  
Conceptual Level Responses  
68%  
(standard score = 94; 34th percentile)  
Categories Completed  
6  
>16th   
Trials to Complete Category I  
27  
=<1st   
Failure to Maintain Set  
0  
>16th   
Learning to Learn   
8.55  
>16th   
  
MILLON CLINICAL MULTIAXIAL INVENTORY III (MCMI-III)   
  
Raw BR*  
Score  
Modifying Indices Disclosure 116 72  
Desirability 2 10  
Debasement  
22  
79  
  
Clinical Personality Patterns  
  
  
Schizoid  
17  
93  
Avoidant  
19  
96  
Depressive  
16  
86  
Dependent  
19  
100  
Histrionic  
2  
8  
Narcissistic  
5  
25  
Antisocial  
6  
62  
Sadistic  
7  
64  
Compulsive  
12  
45  
Negativistic  
8  
64  
Masochistic  
7  
66  
Severe Personality Patterns  
  
  
Schizotypal  
12  
68  
Borderline  
11  
71  
Paranoid  
5  
61  
Clinical Syndromes  
  
  
Anxiety  
15  
100  
Somatoform  
12  
74  
Bipolar: Manic  
1  
12  
Dysthymia  
14  
82  
Alcohol Dependence  
3  
60  
Drug Dependence  
2  
40  
Post-Traumatic Stress  
10  
69  
Severe Clinical Syndromes  
  
  
Thought Disorder  
15  
74  
Major Depression  
19  
13  
Delusional Disorder  
0  
0  
   
* Base rate > 75 are clinically significant  


No comments:

Post a Comment