Psychological Assessment Report

Date: 7/26/2018
Examinee: Katharine
DOB: **/**/****
Gender: Female
Ethnicity: Caucasian
Examiner: Katharine
Testing Date: 7/20/2018

Referral
The client came in on her own and has reported symptoms of depression and
anxiety. She is stressed by her graduate workload. She is mainly concerned though
about the psychological disorders and/or choices of her close friends, and now recently,
her sister as well. She would like to quit picking and biting at her nails and cuticles,
which has been a habit of hers since she was in the 2nd grade.

Identifying Information / Relevant History

The client is 23-year-old American graduate student pursuing her degree in
school counseling. She was born healthy and weighed 6 lbs 2 oz at birth. Her biological
mother was 26 years old at this time and her biological father was 24 years old. She
met all her developmental milestones in a timely manner. Significant events in
Katharine’s life include the following:
 Due to her family moving, she transferred from St. John the Baptist school to
Calvary Christian school during 7th grade.
 To pursue more academic opportunities and for personal preferences, Katharine
transferred from Calvary Christian to Scott High School going into 11th grade.
 Katharine’s father lost his job and was out of work for almost a year during 12 th
grade.
 She transferred from Morehead State University to Northern Kentucky University
after her freshman year.
 Her maternal grandfather died tragically and unexpectedly in the fall of 2015.
 She sought university counseling services in the spring of 2016 for depressive
and anxious symptoms.
 She graduated from Northern Kentucky University with a B.A. in psychology in
2017 and began her graduate studies at the University of Cincinnati in 2017.
 Her ill paternal grandfather died in the fall of 2017.

Instruments
The client was administered the following instruments:
  Severity Measure for Social Anxiety Disorder (Social Phobia)-Adult
 Young Schema Questionnaires (YSQ-L3)
 Beck Depression Inventory (BDI-2)
 Beck Anxiety Inventory (BAI)
 Rotter's Locus of Control Scale (LOC)-short scale
 The Myers–Briggs Type Indicator (MBTI)
 Genogram

Initial Interview and Mental Status Examination

Katharine presented for evaluation wearing age appropriate casual clothing.
Notable physical characteristics included height and weight in the lower percentiles
making her look much younger than her stated age. The client’s grooming and hygiene
appeared adequate and she wore her hair fairly long. Her activity level during her
evaluation was normal and her speech was usually clear and unremarkable, except for
the occasional mumbling of her words. No unusual mannerisms were noted besides the
occasional tapping of her leg, which could signal underlying anxiety, nervousness, or
other causes. Her eye contact, mood, and affect appeared typical. She seemed
pleasant and cooperative during the interview. The interview and assessments took
place at my desk in my office where it is typically quiet, excluding the occasional barking
of dogs.

Results
DSM-5 Symptom Specific Measures (Severity Measure for Social Anxiety Disorder)
This assessment was given to the client due to reported anxiety when in social
situations, especially ones that involve larger groups of people. This assessment
measures the client’s physical and psychological symptoms during times of social
interactions. It is a culturally appropriate instrument because she is American and it is
based on the Western standards of anxiety and social situations and what would be
normal and abnormal in these situations. Scores can range from 0 to 40 and her final
score was a 9, suggesting that while she may occasionally have hindering anxious
symptoms in larger social situations, she does not have Social Anxiety Disorder.

Social-Emotional (YSQ-L3)
This assessment was administered to the client to measure the schema, or lens,
in which she view others and the world around her. It gives insight into her emotional
stability and patterns, as well as insight into relationships she has with other people.
This assessment is culturally appropriate because it was founded upon typical
standards and displays of emotions in relationships in Western cultures.
 The two highest rated schemas she scored on were Self-Sacrifice and Emotional
Inhibition. She received a Self-Sacrifice score of 56 out of 102 possible points. Her
Emotional Inhibition score was 35 out of 54 points. These scores suggest that Katharine
may be over-extending herself by taking care of the needs of others before taking care
of her own. This may result in feeling that her own needs are not met by those close to
her and can lead to resentment towards those people. This ties in with her higher score
of Emotional Inhibition because this schema suggests she is holding back many of her
emotions (good or bad) when she is around others in her life. This schema can also
mean she is not communicating her own desire for her needs to be met, which also ties
back into the Self-Sacrifice schema.

Internalizing Problems (BDI-2, BAI)

These two assessments were administered to measure for possible depression
or anxiety disorders. The client stated previously experiencing depressive and anxious
symptoms, so these assessments were especially important to measure if she is
currently experiencing these symptoms.
The client’s BDI score was a 7, out of a maximum score of 63. This score puts
her in the category of “These ups and downs are considered normal”, which suggests
she is experiencing “normal” bouts of depressive symptoms, but they are not overtly
disturbing her life and mostly likely does not currently have clinical depression.
The client’s BAI score was a 14 out of 63. Her score fell into the category of low
anxiety, which is typically viewed as a good thing, although it can sometimes indicate a
person is in denial or has learned to mask their symptoms of anxiety. This could be a
possibility for the client given her previous reports of anxious symptoms and her current
results on the YSQ-L3.

Externalizing Problems (LOC)

This instrument assesses for the client’s view of the amount of control they have
in their life. It is administered to see if she views she has control over her life or if
external factors dictate her life. Out of a maximum score of 13, with scores closer to 1
representing internal locus of control and scores closer to 13 representing external
locus of control, the client’s score was a 7. This suggests that she views her life as
being dictated by a combination of her choices and external influences and factors. She
does not appear to heavily lean to one locus of control over the other.

Personality (MBTI)
 This assessment is used to measure the client’s personality factors, with the
options being Introversion vs Extroversion, Intuition vs Sensing, Feeling vs Thinking,
and Perceiving vs Judging. These traits are on a continuum and are not dichotomous.
This can be used as tool to help the client figure out concrete ideas, like career options
or more abstract ideas, like simply learning more about how they process information.
This was administered to the client because she reported interest in learning more
about her own personality and how to best help herself.
The client’s result was INFP. Her highest or most dichotomous score was
introversion, which she had a strong preference for over extroversion. This treat reflects
how the client interacts in the social world around her. While she can enjoy time with
people, especially with close friends, she gets drained of energy after extended
amounts of time with larger groups of people rather than feeling energized and
rejuvenated after a social gathering. She needs alone time to regain this energy and to
focus and reflect on her internal world. Her next trait, intuition, means that she tends to
pay more attention to the patterns and possibilities when viewing and recalling
information, rather than just focusing on concrete details that have occurred. Her next
trait was a preference for feeling over thinking. This suggests she tends to make
decisions based on values and what she thinks is best for the people involved in the
situation, rather than a preference for making decisions based on objective
technicalities and logic. The client’s final trait was a preference for perceiving over
judging. This trait describes the kind of outer world and lifestyle the client tends to prefer.
Her score suggests she prefers to lead a flexible and adaptable lifestyle and is open to
new experiences and possibilities, rather than preferring to live a more scheduled
concrete lifestyle. This trait also suggests she is less organized and tends to
procrastinate more than people with a preference for judging.

Genogram
The purpose of this genogram (located in Appendix A) was to obtain information
on the mental or physical illnesses that may be in the family. It also displays the
relationships between family members, regardless of if these relationships are directly
with the client or not. All of these factors can in turn affect the client. The genogram
allows for better understanding of the client’s family dynamics. Katharine’s genogram
suggests her parents have a good working relationship, which paints a picture of the
home environment she grew up in. She has two female cousins that are very close in
age with her and this could have affected her development and experiences as a child
or teenager. Her maternal grandmother has a severe mental illness, which could largely
be impacting the family as a whole.

Summary and Conclusions

 Katharine appears to be a well-functioning young adult. The administered
assessments suggest that she does not have social anxiety disorder, generalized
anxiety disorder, or clinical depression. That being said, she may feel distress when she
bottles in her emotions and her own needs aren’t met as she focuses much of her
attention on her loved ones. Over all, Katharine appears to be an introverted, possibility-
seeking, value-oriented, and flexible person.

Recommendations
Based on Katharine’s reported and assessed symptoms (such as fatigue, feeling
“down”, nail-biting, emotional inhibition, extensive focus on problems of loved ones, etc.)
and her own desires, the following items are recommended for Katharine:
 Creation of a self-care plan.
 A more consistent sleep schedule.
 Meeting and spending more time with new friends.
 Talking with or writing a letter to a loved one, discussing her thoughts and
feelings.
 CBT interventions for nail biting/picking.
◦ She can physically or mentally list the reasons why she does not want to
continue to harm her nails and cuticles.
◦ Taking a walk outside or making art (ie using her hands) when anxious, rather
than picking/biting her nails, is suggested.
◦ In a journal, write down her thoughts that cause her to want to bite/pick her
nails. Then, analyze and address these thoughts.
 Meeting with a counselor at least every few months to check in.
 Appendix A

[insert genogram]