PSYCHOLOGICAL EVALUATION

Jonathan Rich, Ph.D.

Psychologist PSY 10259

7545 Irvine Center Drive, Suite 200         (949) 623-9824

Irvine, CA 92618                                 jrich@PsychologicalTesting.com

PSYCHOLOGICAL EVALUATION

Client’s Name: Mary Smith

Date of Birth: 3/15/63

Date of Assessment: 9/2/2014

Home Street Address: 1234 Main St.

Costa Mesa, CA 92626

Telephone #: 714-555-2345

Service Coordinator: Sally Ride

Referred By: Dept. of Rehabilitation

Anaheim Branch

IDENTIFICATION AND REFERRAL:

Mary is a 51-year-old woman. She drove herself to the examiner’s office. She reported that she previously received Department of Rehabilitation services to assist her in obtaining a teaching credential. She is being reassessed because her school is asking her to obtain additional needed coursework. She has a history of anxiety and depression. She is being assessed to determine her current mental status and her ability to remain stable and complete additional coursework.

HISTORY:

This history was provided by Mary.

Family History 

Mary is married. She lives with her husband and her two children age 21 and 25. She reported that her husband has a history of alcoholism, and that at one point in 2005 she insisted that he leave the home because of this. He is presently recovering. 

Mary was raised by both parents until her father died in 1970. Her mother died three years ago. Mary was born in Los Angeles and has always lived in Southern California. 

Educational and Vocational History

Mary obtained a Bachelor’s Degree in English and Speech. Seven years ago she obtained her teaching credential. Prior to her teaching credential she worked in a flower shop and as a receptionist. She currently is teaching 9th and 10th grades. She indicated that she needs to go back to school to obtain two courses in order to continue teaching. These courses involve teaching English as a Second Language.  

Medical and Mental Health History

Mary reported that she has been diagnosed with fibromyalgia, high cholesterol, and a slight heart valve problem. She currently takes the medication Vivactal (a tricyclic anti-depressant), Buspar, and Alprazolam as needed. Her only surgeries were C-sections to deliver her children and surgery for carpal tunnel syndrome and trigger thumb. 

With regard to mental health treatment, she was first started on psychotropic medications in 1990 by her general physician. In 2005 she voluntarily went to a psychiatric hospital for one week for treatment of depression and medication stabilization. After 2005 she saw various mental health clinicians including a marriage and family therapist, psychologist, and a psychiatrist. She has never attempted suicide. 

Antisocial Behaviors/Substance Abuse

Mary has never been arrested or charged with a crime. She reported that 28 years ago she drank “recreationally” and drank a lot on occasion but alcohol has never caused problems for her. She has been abstinent from alcohol for 28 years. She has no history of illicit drug use. 

Daily Functioning

Mary drives a car. She has had no recent tickets or accidents. She is able to shower, bathe, groom, dress and manage money independently. Describing her activities in a typical day she said that she teaches full time. She noted that she is active in her church and choir and has an active social life. 

MENTAL STATUS:

General Appearance

Mary’s grooming and hygiene were good. She walked with a normal gait. She was well dressed. She appeared her stated age. 

Attitude and General Behavior

Mary was pleasant and cooperative throughout the assessment. She responded well to instructions and appeared to try her hardest on the tasks presented. 

Mood and Affect

Mary demonstrated a broad range of affect. When asked to describe her mood she said that she has felt a little upset dealing with the Department of Rehabilitation. She occasionally wakes up early in the morning. She stated that her appetite is normal. She stated that she has interest and pleasure in daily activities. She denied feelings of worthlessness. She denied concentration difficulties. She denied any suicidal thoughts or intent.   She reported that she last felt markedly depressed about two years ago.

Stream of Mental Activity

Mary responded in a coherent and relevant fashion. The rate and rhythm of her speech was normal. Her speech was clear and 100% intelligible. 

Sensorium and Orientation

Mary was alert and aware of her surroundings. She correctly stated the current date, the current day of the week and the city of her residence. 

Memory

Mary correctly recalled her birth date, the name of the current president and the name of the previous president. She registered three objects after one trial and recalled two of the three objects after a delay of 30 minutes. She repeated eight digits forward and six digits reversed. 

Fund of Information

Mary’s fund of information was within normal limits. For instance, she was able to name the capital of Italy. 

Concentration and Attention

Mary demonstrated adequate ability to attend to instructions and adequate task persistence. She counted backwards from 20 to 1 in 8 seconds with no errors. 

Perceptual Distortions

Mary did not appear to be responding to internal stimuli. She denied any history of auditory or visual hallucinations. 

Judgment/Insight

Mary’s judgment and understanding of social conventions was intact. When asked how she would respond if her neighbor’s house were on fire she said, “Make sure no one is in there, call the fire department.” She has adequate insight into her current condition. She realizes the need for psychotropic medication. 

TESTS ADMINISTERED:

Wechsler Adult Intelligence Scale, 4rd Edition (WAIS-IV)

Wide Range Achievement Test, Revision 4 (WRAT-4)

Minnesota Multiphasic Personality Inventory, II (MMPI-II)

TEST RESULTS:

WAIS-IV

Verbal Comp.Perceptual Reas.
SimilaritiesBlock Design11
Vocabulary11 Matrix Reasoning15
Information12 Visual Puzzles11
Comprehension(8)
Working MemoryProcessing Speed
Digit Span12Symbol Search10
Arithmetic13Coding9
Index%ile
Verbal Comp.10255
Perceptual Reasoning11482
Working Memory11482
Processing Speed9742
Full Scale IQ10870

On the WAIS-IV, Mary obtained a Full Scale IQ of 108. This score is near the high end of the Average Range of Intelligence and exceeds 70 out of 100 persons her age. Her Perceptual Reasoning Index was significantly higher than her Verbal Comprehension Index, reflecting greater facility with tasks requiring nonverbal reasoning and performance than with tasks requiring words. 

Mary’s Verbal Comprehension Index of 102 exceeds 55 out of 100 persons her age and is in the Average range.  This reflects word knowledge, fund of general information, understanding of social conventions, and abstract verbal reasoning within an average range.  

Mary’s Perceptual Reasoning Index of 114 exceeds 82 out of 100 persons her age and is in the High Average range.  This reflects relatively strong nonverbal reasoning abilities.

Mary’s Working Memory Index is in the High Average range and is a relative strength.  This reflects strong auditory attention and concentration.  Mary’s processing speed is consistent with her generally average level of functioning.

WRAT-4

Subtest Standard Score       Percentile Grade Equivalent

Word Reading 101 53 12.7

Sentence Comprehension 81 10 8.1

Spelling 102 55 >12.9

Math Computation 124 95 >12.9

Reading Composite 89 23 ——

On the WRAT-4, Mary demonstrated sight-reading and spelling abilities that were average and consistent with what would be expected given her general level of intelligence. Her reading comprehension abilities were a relative weakness. Her reading comprehension is in a low average range. While she is able to read orally at a 12th grade level, her reading comprehension is markedly weaker, at an 8th grade level.  

The discrepancy between her general level of intelligence and her reading comprehension is sufficient to be considered a reading disorder.  Her Math Computation skills were in a superior range and above a high school level. Mary was able to add, subtract, multiply and divide whole numbers, decimals, and fractions. She was able to solve algebraic equations. She was able to work with percentages.

MMPI-2

ScaleT-Score
L(Lie)-Scale68
F(Infrequency)-Scale45
K(Correction)-Scale56
1-Hs70
2-D55
3-Hy65
4-Pd40
5-Mf53
6-Pa48
7-Pt59
8-Sc54
9-Ma48
0-Si50

On the MMPI-2, Mary’s responses to the items indicated that, on this test administration, she might have felt the need to present as having strong moral character or to deny having any weaknesses. Despite this tendency to present herself in a positive light, her responses can be considered a good reflection of her current state and the current protocol can be considered valid.

Significant elevations were seen on MMPI-II scale 1 and 3.  Scale 1 reflects concern about bodily function.  Individuals with elevations on this scale tend to have multiple vague physical complaints and tend to convert emotional distress into physical symptoms.  Elevations on scale 3 are seen in individuals who are interpersonally demanding and tend to maintain shallow relationships.

The combined elevation on scale 1 and 3 generally reflects an individual who is conforming and conventional.  Such individuals value being seen positively by others.  Mary may be emotionally over controlled and express anger and other negative feelings in indirect ways.

Scale 2 measures depression.  This scale was within the normal range, suggesting that Mary’s depressive symptoms are currently well controlled.

DIAGNOSTIC IMPRESSIONS:

296.35 (F33.41) Major Depression, recurrent, in partial remission due to medication

315.00 (F81.0) Specific Learning Disorder, with impairment in reading: Reading comprehension

SUMMARY AND RECOMMENDATIONS:

Mary is a 51-year-old woman. She has a history of major depression, including one psychiatric hospitalization. At present, her depression appears to be well controlled by medication. She reports functioning well at her job and maintaining an active social life. She currently appears to maintain good emotional stability with the assistance of medication. This testing reflected intelligence near the high end of the average range and strong math skills, but low average reading comprehension.  Considering that she successfully completed college and is currently emotionally stable, it is likely that she could successfully complete the remaining study needed.  However, the present testing suggested that she struggles with reading comprehension, and may need accommodations to compensate for a reading disorder.

Thank you for referring this very interesting woman for assessment.

________________

Jonathan Rich, Ph.D.

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