Practice Assessment Clinical Case

¶ … Gender: Female

Birthdate: 01/16/1985

Age: 30 years, 11 months

Dates of Evaluation: 10/25/15 -10/30/2015

Reason for Referral

This is a 30-year-old right-handed woman referred by Dr. Smith for a psychological evaluation to determine any lingering psychological and cognitive effects as a result of a mild head injury that she suffered on October 15, 2015 as a result of an automobile accident. The client has complained of severe memory problems, being disoriented at times, feeling depressed and anxious, and having nightmares the accident. Her physical complaints consist of headaches, back aches, poor sleep, nausea, and vomiting.

Identifying Information

The client is a 30-year-old, divorced, Hispanic woman who lives with her children in a home that she rents in XXX (client please insert city). She has been married three times and has three children from two of the marriages.

Developmental History

The client grew up in XXXX (insert). She reported that her mother had no issues with her pregnancy and that she was born at full term. She is the third child in a sibship of seven. All developmental milestones were met at appropriate times and did experience any developmental delays or issues with motor tasks, language acquisition, or toilet training. Her primary language was Spanish and she told me that she learned English when she went to formal school.

Medical History and Psychiatric History

According to her self-report and to medical records, the client was a restrained driver who was driving after stopping at a four-way stop when her car was struck on the driver's side front quarter panel by another car. Her airbag deployed. The other driver fled the scene and has not been found. She reported that she experienced a brief loss of consciousness of unknown duration and she was taken to Fredrciks Hospital Emergency Department (referred to as ED in this report) where she obtained a Glascow Coma Scale score (GCS) of 14. She was able to vividly recall the accident, her ride in the ambulance, and speaking with medical personal. Her orientation was reportedly intact for person and place, but temporal her orientation was slightly off according to time of day according to the medical record. Reports also indicate that she was anxious and had a very mild left scalp abrasion; however, CT scan of the brain was negative for acute changes and a CT scan of the spine was also negative. She was admitted to the hospital where she claims she remained for three days; however, the records provided to me indicated that she was discharged the next day on 10-16-2015. She was discharged home.

The client has complaints of pain, confusion, depersonalization (feeling that her legs were not part of her body), and other vague ailments. There are reports of six ED visits before her MVA and three shortly after the accident. Her complaints before the MVA that led to her ED visits consisted of anxiety related to financial concerns, difficulties with ulcerative colitis, stroke-like symptoms which were thought to be related to her anxiety, and paralysis related to deep vein thrombosis (DVT) in her right arm. The patient discussed these admissions and was offended that there was an insinuation in the reports that she was medication seeking. Nonetheless, three subsequent CT scans of the brain obtained in response to the patient's complaints of cognitive problems and headaches failed to reveal any evolving acute cerebral changes. I also note mention of two EEG's (10/18/2015; 10/20/2015) ordered by her physician. Results of these tests have also been reported as unremarkable. Her physical complaints at these visits consisted of her having headaches, back aches, poor sleep, nausea, and problems with memory.

Psychiatric History

The client's psychiatric history is remarkable for depressive symptoms during an admission in January of 2014 for treatment of her DVT. She also reported being physically and sexually abused by her three ex-husbands, but denied significant emotional distress as a result of that experience. I am not able to find mention of this prior abuse in any other of the medical reports provided to me by her case manager. The patient was diagnosed with an adjustment disorder and a history of post-traumatic stress syndrome (which is equivocal given the information in the reports).

According to the information presented in medical records the patient received significant assistance and supervision from her family following her accident, but over time this has apparently decreased. She received PT, OT, Speech Therapy, as well as psychiatric support following her discharge from the hospital. According to the records I have been provided with she made good progress in her therapies; however, based on the results of her most recent evaluations her insurance has stopped funding further rehabilitation. She was not driving, going to school, or working at the time of this evaluation.

The client's current medications are reviewed based on a list of medications provided by her. The client's current active medical regimen according to this list consists of Tylenol, Lunesta, Ultram, Cymbalta, Xanax, and Ambien. She does not smoke and denied a history of drug or alcohol abuse.

Academic and Employment History

The client he reported that she graduated from high school on her history form, but records indicated she obtained a GED. When confronted with this discrepancy she admitted that she dropped out of high school as a junior in order to work full-time and obtained a GED. She reported that her grades in high school were "above average" even though she was held back in the tenth grade. She was never identified as having a learning disability or was involved in special education classes.

The client reported that she was preparing to go to school to be a nursing assistant at the time of her accident. She has completed one year of college and just began classes again shortly before her accident. She did not return to school following her accident and reported that she does not retain material that she reads now, whereas this was not a problem for her prior to her accident. She discussed trying to read and recall information from an anatomy book she was reading and how this was very difficult for her. As a result the patient is concerned about returning to school in the future. Regarding her grades, the patient reported her college GPA as a 3.40 on the history intake form she completed during her lunch break during the first evaluation which is somewhat lower than her previous report to me during the initial interview of a grade point average of 2.20.

With respect to her employment, the client was an interviewer for a research project at a local university. She apparently took a leave from her position following her accident, as would be expected. According to her self-report she attempted to return to work "too soon" after her accident leading to some difficulties interviewing clients and she subsequently was let go. She has also worked as a waitress at several restaurants. She was not working at the time of this evaluation.

Tests Administered

Mini Mental Status Examination

Wechsler Adult Intelligence Scale-III (WAIS-III)

Minnesota Multiphasic Personality Inventory-II (MMPI-II)

Millon Clinical Multiaxial Inventory-III (MCMI-III)

Mental Status and Behavioral Observations

The client was accompanied to the evaluation by her case manager, Martha Stewart and her personal friend Natasha Bardernoff. The initial interview was completed with both present. The client did not fully fill out the consent form or release forms, but instead had her case manager or friend completed much of the information on the forms and then the client signed them.

During the evaluation the patient was cooperative and friendly. Affect was depressed at times and eye contact was intermittent. Expressive language was fluent but with occasional word finding difficulties. She displayed frustration with several tests, especially tests that appeared to challenge her. Several times during the evaluation she openly expressed frustration when she perceived she was not doing well or during tests when she received feedback about her performance. The patient also became tearful when we discussed her mood and reaction to her current state of affairs (not working, etc.). Otherwise, the evaluation was completed without incident. Performance on several measures often used to assess motivation and effort was variable and observations during several measures indicate that the patient may not have been putting forth a full effort at all times. However, I do not believe that there is an overt intentional effort on this patient's part to present as frankly impaired and I will discuss this further in this report. The present evaluation addressed orientation, general intellectual ability, and personality and emotional functioning

Mental Status Evaluation

MMSE: 25/30 (Problems with Immediate recall and attention)

1. Appearance

A. Neatness: dirty, disheveled, meticulous appropriate.

B. Clothing: unusual, bizarre, inappropriate, age appropriate.

2. Behavior

A. Posture: slumped, rigid, inappropriate, appropriate.

B. Body movements: accelerated, slowed, restless, agitated, peculiar, appropriate.

C. Attitude: submissive, domineering, hostile, appropriate, suspicious, provocative, guarded, cooperative.

D. Gait: unusual, shuffling, staggering, unremarkable.

E. Eye contact: present, absent, intermittent.

F. Speech: rapid, slow, atypical, slurred, stammer, circumstantial, tangential, rambling, preseverating, appropriate.

3. Affect/Mood Projected

Blunted, unvarying, euphoric, angry, hostile, fearful, anxious, alert, depressed, lethargic, labile, appropriate.

4. Intellectual Status

A. Intelligence: below average, average, above average.

B. Attention/Thinking Processing: impaired attention span, impaired, abstract thinking, concrete thinking, adequate in all areas.

5. Orientation

Time (yes, no), Place (yes, no), Person (yes, no).

6. Judgment

Impaired decision making, adequate decision making, impaired impulse control, adequate impulse control.

7. Memory

Impaired immediate recall, impaired recent memory, impaired remote memory, WNL in all areas.

8. Insight

Good, fair, poor, blames others, does not acknowledge problems.

9. Thought Process

A Obsessions Yes No

B. Compulsions Yes No

C. Phobias Yes No

D. Inordinate fears Yes No

E. Depersonalization Yes No

F. Suicidal ideation, gestures Yes No

G. Homicidal ideation, gestures Yes No

H. Delusions Yes No

I. Hallucinations -- auditory, visual Yes No

10. Mental Status within normal limits Yes No

Test Results

Cognitive Functioning

The client was administered the Wechsler Adult Intelligence Scale --Third Edition (WAIS-III) to assess her intellectual functioning. The WAIS-III produces three major IQ indices, a Full Scale IQ index (an estimate of overall intellectual functioning), a Verbal IQ scale (overall verbal performance skills), and a Performance IQ index (overall nonverbal skills; Groth-Marnat, 2009). In addition for additional composite indices are calculated: Verbal Comprehension, Perceptual Processing, Working Memory, and Processing Speed that make up the Full Scale IQ score (Tulsky, 2003). The client's performance on these four indices ranged from the Borderline range to Average range.

WAIS-III Results (Mean = 100; Standard Deviation = 15)

Index

IQ

Percentile Rank

Classification

Verbal IQ

50

Average

Performance IQ

92

27

Low Average

Verbal Comprehension

63

Average

Perceptual Organization

97

42

Average

Working Memory

79

8

Borderline

Processing Speed

76

5

Borderline

Full Scale

97

42

Average

WAIS-III Subtest Scores (Mean = 10; Standard Deviation = 3)

Subtest

Scaled Score

Percentile Rank

Classification

Verbal Comprehension

63

Average

Vocabulary

13

86

High Average

Similarities

11

66

Average

Information

15

93

Superior

Comprehension

10

50

Average

Perceptual Organization

97

42

Average

Picture Completion

8

16

Low Average

Block Design

9

37

Average

Matrix Reasoning

10

50

Average

Picture Arrangement

8

Low Average

Working Memory

79

8

Borderline

Arithmetic

5

2

Mildly Deficient

Digit Span

6

5

Borderline

Letter Number Sequencing

5

2

Mildly Deficient

Processing Speed

76

5

Borderline

Digit Symbol

6

5

Mildly Deficient

Symbol Search

5

2

Mildly Deficient

Significant discrepancies (Black, Wallace, Sokoloff, & Kenworthy, 2009) were observed between the client's Working Memory (Standard Score = 79) and Processing Speed (Standard Score = 76) indices and her Verbal Comprehension (Standard Score = 105) and Perceptual Organization ((Standard Score = 97). There is a 26 point difference between her Verbal Comprehension and Working Memory indices; a 29 point difference between her Verbal Comprehension and Processing Speed indices; an 18 point difference between her Verbal Comprehension and Processing Speed indices; and a 15 point difference between her Perceptual Organization and Processing Speed indices. Therefore the client's Full Scale IQ does not accurately represent the variability in her overall functioning and the differences in her index scores need to be taken into consideration (Hogan, 2015).

The client's Verbal Comprehension Index, a measure of general her verbal skills including verbal fluency, her ability to understand and use verbal reasoning skills, and general verbally mediated knowledge abilities was in Average Range (Verbal Comprehension = 105). She demonstrated a relative strength regarding her overall fund of general information (Information subtest 93rd percentile). However, her ability to attend to new information, hold new information in short-term memory and mentally manipulate this material was significantly poorer than one would predict given her overall verbal reasoning skills (Working Memory = 79). Moreover, her ability to focus her attention, quickly scan and discriminate or sequentially order visual information was also significantly poorer than expected given her verbal reasoning ability (Processing Speed = 76). Thus, while the client has an adequate fund of stored general information and adequate verbal reasoning abilities she may be easily overwhelmed when challenged to process new information quickly or when there is a significant amount of new material or unfamiliar material to process (Baddeley, 1992).

In addition, the client's non-verbal reasoning abilities such her ability to examine a visually mediated problems, recruit her visual-motor and/or visual-spatial skills, and then create solutions to the problem at hand (Lange, 2011) was in the Average Range (Perceptual Organization = 95) and significantly better expressed than her Working Memory and Processing Speed indices (Working Memory = 79; Processing Speed = 76 respectively). Thus, while the client expresses adequate non-verbal reasoning potential there may be a serious restriction on this ability when she is challenged to work with and manipulate visually-mediated information quickly or when there is a significant amount of material presented to her at once.

The results of intellectual testing suggest overall adequate verbal and non-verbal intellectual abilities; however, the client may exhibit limitations in her ability to process and use information if she is required to work quickly or perceives that there is too much information for her to handle.

Socio-Emotional Functioning

The client was administered two measures to assess her level of socio-emotional functioning: the MMPI-2 (a self-report true-false questionnaire that assesses emotional functioning and potential psychopathology) and the MMCI-III (a self-report true-false questionnaire that assess personality style and socio-emotional functioning).

MMPI-II Results

Scale

T-Score

L (Lie)-Scale

45

F (Infrequency)-Scale

K (Correction)-Scale

33

Hysteria Scale

90

Depression Scale

93

Hypochondriasis Scale

92

Psychopathic Deviant Scale

80

Masculine-Feminine Scale

70

Paranoia Scale

Psychasthenia Scale

89

Schizophrenia Scale

Mania Scale

60

Social Introversion

88

The client produced a classic "fake bad" profile on the validity scales of the MMPI-II. People who produce similar validity scale profiles may be attempting to illicit assistance for severe perceived psychological stress as opposed to attempting to overtly presently themselves as being impaired in an effort to achieve some form of secondary gain. The client's validity scale profile suggest that she may indeed be producing a "cry for help" regarding her overall perceived psychological distress (Walters & Clopton, 2000). As the profile is deemed invalid the clinical scales cannot be interpreted.

MMCI-II Results

X Disclosure

Y Desirability

Z Debasement

V Validity

1 Schizoid

2A Avoidant

2B Depressive

3 Dependent

4 Histrionic

5 Narcissistic

6A Antisocial (Aggressive)

6B Sadistic

7 Compulsive

8A Negativistic (Passive-Aggressive)

8B Masochistic (Self-Defeating)

S Schizotypal

C Borderline

P Paranoid

A Anxiety

H Somatoform

N Bipolar: Manic

D Dysthymia

B Alcohol Dependence

T Drug Dependence