Abnormal Psychology Clinical Diagnosis

REPORT OF PSYCHOLOGICAL ASSESSMENT

This material is an example created to represent symptoms and does not represent actual patient information.

NAME: Jane Doe

DATE OF BIRTH: 01/17/2001

CHRONOLOGICAL AGE: 16 years 1 month

PARENTS: Jim & Janet Doe

GRADE: Completed tenth grade

DATES OF ASSESSMENT: 12/20, 12/23

IDENTIFYING DATA AND REASON FOR REFERRAL: Jane is a 16 year and 1 month old Asian American adolescent, referred for psychological evaluation due to concerns related to academic and social function. Although Jane has a history of strong academic performance, she has recently struggled in her classes, receiving failing grades.

SOURCES OF INFORMATION: Information was gathered from Jane’s mother, Jane, Jane’s teacher Ms. Strudel, and Jane’s educational and medical records. Further data was obtained from behavioral observation and standardized psychological testing.

Medical and Developmental History:

Janet Doe was interviewed regarding Jane’s developmental and medical history. Janet related that she was 25 years old at the time of Jane’s birth and that neither the pregnancy nor birth involved complications. Jane’s birth weight was within normal limits, per Ms. Doe’s report.

Ms. Doe denied developmental difficulties for Jane. She reported that Jane reached appropriate developmental milestones related to toilet training, speech, and gross and fine motor development.

Ms. Doe related that Jane has experienced influenza while growing up. She denied other medical conditions or regularly administered medications.

Family History: Jane is the only child of Mr. and Ms. Doe. Janet Doe denied that anyone in her family had been formally diagnosed with mental disorder; however, she reported that her father had struggled with “stress”, having difficulty sleeping, spending all of his time worrying, and sometimes feeling too nervous to leave the house. Janet Doe described herself as a constant worrywart and related that she struggled with insomnia and “anxiety attacks.” Symptoms of “anxiety attacks” described by Janet Doe were consistent with experience of a panic attack. Janet Doe denied knowledge of mental health difficulty on Mr. Doe’s side of the family, although she related that she knew he had “struggled with drinking” during his early 20’s. Ms. Doe stated that she did not believe Mr. Doe was currently experiencing difficulties with substance use or other mental health symptoms.

Both Jane and Janet Doe described Jane’s relationship with family members in positive terms. Jane reported that she felt close to her mother and father and comfortable discussing difficulties with them. Janet related that she felt close to Jane. She described Jane as a somewhat shy, but easy to get along with child. Ms. Doe denied that Jane experienced difficulties or conflict in her interactions with the family.

Social History:

Janet and Jane Doe, and Jane’s social studies teacher, Ms. Strudel, reported on Jane’s social function. Janet reported that Jane has been a shy and cautious child growing up. She related that, as a child, Jane enjoyed playing with other children if they initiated the interaction, but did not approach them to make acquaintance. Despite this, Janet related that Jane seemed generally content, if somewhat inhibited as a child.

Ms. Strudel described Jane as “bookish,” but “generally well adjusted.” She reported that Jane appeared to have a small group of close friends, although she seemed shy. Ms. Strudel reported that, although she was a bit quiet, most students appeared to like Jane and that she was often among the first chosen for group activities. Ms. Strudel related that Jane did not volunteer to ask or answer questions in class, to her recollection, although she believed that Jane knew the material. Ms. Strudel reported that she believes Jane is uncomfortable speaking in front of others. Ms. Strudel described an instance in which Jane had to give a brief presentation in front of her classmates. She related that Jane appeared extremely nervous during this presentation, as evidenced by Jane’s hands trembling visibly, Jane blushing, and limited eye contact Jane made with the audience.

When asked about her social interactions with peers, Jane became tearful. She related that, outside of a small group of friends, she felt that no one really liked her. Jane related that she had always felt somewhat shy around people she didn’t know well, but that this feeling became stronger after she was bullied at the end of 9th grade. Jane described an incident during which a popular girl made fun of her Harry Potter t-shirt. Jane reported that the girl called her a “weirdo nerd” in front of her peers in the school cafeteria and made inappropriate comments about Jane and the Harry Potter character. Jane related that it seemed to her as if everyone was laughing along with the girl. She described several other more minor incidents when the girl or her friends would make Harry Potter related jokes when Jane was around. Jane related that the jokes stopped after a few weeks, but that the experience continued to be fresh in her mind. When queried, Jane related that she had not been teased prior to this incident and that her interactions with peers were generally good, although she stated that she had always been shy.

Behavioral Observation: Jane was appropriately dressed and groomed when she attended the assessment interview. She made limited eye contact and spoke quietly.

Academic Achievement: Jane is currently finishing the 10th grade. Her grades in school have typically consisted of A’s and B’s, although this has changed over the past year. Jane’s grades for the past year have primarily consisted of D’s and F’s. Jane has never received special education services or tutoring.

Psychological Symptoms and History:

Janet Doe described Jane as hesitant to try new activities and play with new toys when she was growing up. She related that she believed Jane was nervous when doing something unfamiliar or new. Janet Doe reported that a part of her was happy that Jane was less willing to explore and that she believed Jane was safer as a result. Janet related that she was very worried that something would happen to Jane, while Jane was growing up, and that she made sure to warn Jane of any possible dangers and to do her best to protect Jane from potential harm. When queried for examples, Ms. Doe described not allowing Jane to climb onto anything taller than one foot until she was around 8 or 9 years old, telling Jane about potential for rabies when seeing pet dogs in the park, and telling Jane that she could contract a sexually transmitted disease from public restrooms. Janet related that she knew some of her fears were excessive, but that she wanted to ensure that Jane was kept from harm.

Jane reported that she “felt like a freak” and described distress associated with interacting with others. She related that she felt extremely nauseous if she knew she would have to give a presentation in class. Jane reported that she would blush and that her hands would tremble when she became nervous. She related extreme discomfort with these visible expressions of her anxiety and reported a great deal of concern related to trying to hide these symptoms. Jane reported worry that if people could see how anxious she was, everyone would know that she was a “freak.” Jane reported that she always felt extremely uncomfortable around people she did not know well. Jane related that she avoided speaking with new people or giving presentations whenever possible, and sometimes feigned illness or other plans to get out of these situations. When she had to interact with people she didn’t know well or speak, Jane reported that she felt like she was “dying,” that her thoughts were racing, and that she was terrified. Jane related that, while she had always been somewhat shy, being upset to this extent only began after the bullying incident. When queried about her grades, Jane related that she was felt very uncomfortable in class and worried that she might be called on. Jane reported that it was difficult to concentrate on the material due to her worries. She additionally related struggling with completing assignments, due to concern that her teachers would judge her work negatively.