NEUROPSYCHOLOGICAL
EVALUATION
CONFIDENTIAL
PRINCIPAL DIAGNOSES:
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296.33
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Major Depressive Disorder, Recurrent,
Severe
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300.02
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Generalized Anxiety Disorder
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300.23
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Social Anxiety Disorder
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301.89
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Other Specified Personality Disorder with mixed
avoidant, dependent, and borderline features.
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|
|
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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
