Love Elf ...: November 2007

We use real cases in class to practice on. While names and dates have been changed, the indintifying information is real. This is the kind of stuff I've been doing lately!

Psychological Evaluation

Name: Al Hambra Occupation: Unemployed
Age: 37 Marital Status: Single
Evaluator:
Date of Evaluation: 10/3/07 Date of Report: 10/17/07

Identifying Data and Reason for Referral:
Al Hambra is a 37year-old Caucasion gay male recently admitted for inpatient psychiatric and chemical dependency treatment. He was referred for psychological testing by his psychiatrist to assist in diagnostic clarification (re: mood disorder, psychosis and substance abuse/dependence), treatment planning and aftercare recommendations.

Evaluation Instruments and Sources of Information:
Minnesota Multiphasic Personality Inventory-Second Edition (MMPI-2)
Clinical Interview

Background Information:

Developmental History:
The client, Al Hambra, reports that to his knowledge he had an uncomplicated birth and early development. His childhood was typical, and he hit milestones seemingly at a normal rate. There were no early behavior problems or psychiatric difficulties reported by Al.

Family History and Significant Relationships:
At the time of interview, Mr. Hambra presented as very guarded, irritable, and non-forthcoming, especially when asked about his family. For example, he states that his father was deceased 8 years ago, but when queried on the cause, he merely responds, “It doesn’t matter, does it?” He has been estranged from his mother for several years. When asked why, he again refuses to discuss the topic, and answers with “I don’t feel like discussing it now”. He has one younger sister, with whom he has no contact. According to Mr. Hambra, “we just don’t see eye to eye”. Furthermore, his romantic relationship history has been poor, described by the client as frequently conflicted and riddled with excessive breakups, which were usually complicated by his drinking. Al reports that he tends to hold onto grudges and resentments and presents as bitter about “love”. His most recent partner left last year, after 2 years in the relationship.

Education and Employment History:
Mr. Hambra denies knowledge of any early learning or behavior problems. He is a High school graduate and attended trade school in cosmetology. In fact, he taught cosmetology for several years. Al is currently on disability, and has been for the last four years due to mental illness (“mania and depression”).

Medical and Psychiatric and Alcohol/Drug History:
There have been nine previous inpatient psychiatric treatment attempts, including hospitalization three years ago in a state facility for “drug induced psychosis”. The client is quoted as admitting, “I get severely depressed, then I drink to medicate” and “I get detoxed, then I leave depressed, then I drink again”. He has a history of “chronic lower level” depression and has had suicidal ideations “for years”, however, denies any suicide attempts although he did overdose on Klonopin (benzodiazapine – anti-anxiety) and whisky once several years ago. Al Hambra states that his depression is exacerbated by “a lot of deaths” - seven in last two years. He moved to California last year, “because I didn’t want to be depressed anymore”. Upon arriving in California, he was diagnosed as HIV positive.

Al admits to a history of heavy alcohol abuse, amphetamine abuse, and abuse of miscellanies Rx meds. He was treated in past with Wellbutrin (Antidepressant), Tegretol (Mood Stabilizer), Vistaril (Anti-Anxiety), Mellaril, and Zyprexa (Antipsychotics). He also admits to alcohol and amphetamine induced/exacerbated hallucinations (“I feel bugs crawling on me” “I hear nurses and others talking to me and about me about how to persecute me.” “They’re trying to drive me crazy, I know it”.

Factors Prompting Referral:
Client presented for treatment with paranoia, hallucinations, severe depression, suicidal thoughts, irritability, agitation, and an extremely poor response to multiple prior treatments and medications. He had been sober 5 days when tested. Diagnostic clarification is needed in regards to mood disorder, psychosis, and substance abuse/dependence and recommendations for treatment planning.

Behavioral Observations:
Al was cooperative and expressive, yet suspicious, in the assessment process. He demonstrated no overt defensive behaviors or attitudes towards the testing itself. There was no evidence that he was responding to any internal stimuli and no presence of disorganized thinking beyond self reported DT’s and paranoia (i.e not floridly psychotic). There is no behavior evidence of threats to validity of these current assessment results.

Assessment Results:

Cognitive Functioning:
The highest level of education achieved by Al is a high school diploma, attained at a trade school where he studied cosmetology. He has been able to maintain employment in the past, as a cosmetology teacher. However, he has been on disability for the last four years for mental illness (“mania and depression”). Al seems to be of a least average overall intelligence.

Personality Functioning:
Al’s overall response pattern to the MMPI-2 questions suggests an average score range and scores at this level suggest a valid protocol {L Scale}. However, based on Al’s specific responses, there is evidence of possible exaggeration of symptoms and problems {F Scale}. This exaggeration could perhaps serve as a “cry for help.” However, this test-score range may also be indicative of serious psychological problems {F Scale}, perhaps including severe depression and/or paranoia. Also, the response pattern examined herein is likely to represent a balanced self-view {K Scale}. Both positive and negative behaviors and personality characteristics are likely to have been acknowledged in responding to the MMPI-2 items {K Scale}. Overall, based on the pattern of responses and general indication of a need for help, the following personality profile is likely to present a valid description of Al’s current psychological functioning.

Based on similar test score interpretation, Mr. Hambra’s profile indicates probable moderate to severe impairment/turmoil {7} in daily functioning, significant symptoms of paranoia, signs of disturbed thinking, and prominent delusions of persecution {6}. Among psychiatric patients with this personality type, diagnoses of schizophrenia or paranoid disorder are most frequent and they often have long histories of inpatient and/or outpatient psychiatric treatment {6}. This is evident in Mr. Hambra’s history of nine previous inpatient treatments, including being admitted for “drug induced psychosis”. Mr. Hambra may be seen by others as suspicious and guarded and may commonly exhibit hostility, resentment, and an argumentative manner {6}. Furthermore, these individuals may appear to be sarcastic (“It doesn’t matter, does it?”) argumentative, sullen, irritable and hostile {6/4}. Persons of this personality type commonly have felt like leaving their home situations (Harris-Lingoes PD1). Depression, when present, tends to be externalized {6/4} and they may feel depressed, hopeless and pessimistic {2} much of the time (Harris-Lingoes PD1). For example, Mr. Hambra moved to California “because I didn’t want to be depressed anymore”, and thereby seemingly externalized his depression and stressors, attempting to “escape” them by moving to California. Individuals of shared personality types tend to be quick tempered; they may demand much of others but resent reciprocal demands on them {6/4}. They are often quick to see themselves as criticized, provoked, maltreated, or victimized by others (projections) and blamed unfairly (Harris-Lingoes PA1), but are reluctant to admit to their own exploitation, manipulativeness, and mistreatment of others {6}, and tend to blame others (Harris-Lingoes PA1). They are often stubborn, unforgiving, resentful, oversensitive, and fearful of vulnerability. Men tend to be sullen and vengeful {6/4}. Also, overt paranoid trends often will manifest well-organized and elaborate delusions of persecution, control, or both {Spike 6}. For example, Al admits that he “hears the nurses and others talking to me and about me about how to persecute me” and “they’re trying to drive me crazy, I know it.” Furthermore, Al may tend to be rigid, resentful, and often could deny his suspiciousness, personal problems, and distress unrelated to the primary delusion {Spike 6}. Mr. Hambra does deny suicide attempts, however, overdosed on Klonopin and whisky several years ago. He could most often severely lack insight {Spike 6}.

Excessive use of alcohol is typically a problem with this personality type {4}. Oftentimes, family problems arise and interpersonal relationships become damaged, directly effected by the individual’s alcohol abuse. Al reports that this is the case for many of his past relationships. He retreats into the bottle, and has little impulse control, and this is additionally evidenced by his chronic drug use. Other roadblocks to positive intrapsychic functioning may include the use of projection as a defense mechanism {6}, limited frustration tolerance {4}, repressed hostility and anger {6/4} and poor judgment and considerable risk taking {4}.

Al may be prone to experience a chronic resentment of family and authority, and may feel mistreated and picked on, angry and resentful and he may harbor grudges {6}. Also, persons with similar personality types often crave affection but will likely alienate those who would provide that affection {6/4}. There is evidence of this based on the report that Al has no contact with his only sibling, his younger sister, because they “just don’t see eye to eye.” He has also been estranged from his mother for several years for undisclosed reasons, and refuses to discuss it. Similarly, personal history typically would include stormy relationships with family, in which the family members tend to be blamed for personal difficulties {4}. Furthermore, Al reports a long history of poor intimate relationships, characterized by several conflicts/breakups, which may have caused him to hold onto grudges and resentments and become “bitter about love”. Persons of similar personality type also are suspicious of the motivations of others, feeling that they are getting a raw deal from life and avoiding deep emotional involvement {6/4}.

Diagnostic Impression:
Axis I: 291.5 Alcohol Induced Psychotic Disorder, with Delusions
R/O 291.89 Alcohol Induced Mood Disorder, With Depressive
Features
305 Alcohol Abuse
305.70 Amphetamine Abuse
305.90 Other (or Unknown) Substance Abuse (Rx meds)
Axis II: 301.0 Paranoid Personality Disorder
Axis III: Disease of the Blood (HIV+)
Axis IV: Death of Family Member, Discord with Sibling,
Unemployment, Impaired Familial Support System
Axis V: GAF = 30 (current)

Summary:
Al Hambra is a 37year-old Caucasion gay male recently admitted for inpatient psychiatric and chemical dependency treatment. He was referred for psychological testing by his psychiatrist to assist in diagnostic clarification (re: mood disorder, psychosis and substance abuse/dependence), treatment planning and aftercare recommendations.
The testing results suggest that Mr. Hambra is currently experiencing Alcohol Induced Psychotic Disorder, with Delusions. However, Mood Disorder, with Depressive Features should be ruled out. Symptoms include prominent delusions and hallucinations, severe depression, suicidal thoughts and irritability. These symptoms tend to occur within a month of substance withdrawal. He also reports heavy Alcohol Abuse, Amphetamine Abuse and Abuse of miscellaneous other Unknown substance(s). Results also suggest an Axis II diagnosis of Paranoid Personality Disorder. Suggestions from both testing and history reveal that he suspects, without sufficient basis, that others are exploiting him or deceiving him, he is reluctant to confide in others, he reads hidden demeaning and/or threatening meanings into benign remarks or events and he persistently bears grudges. Somatization of stress and the compulsive use of alcohol or other substances may have been used periodically as ineffective coping mechanisms.

Prognosis for psychotherapy is generally poor because individuals of similar personality types typically do not like to talk about emotional problems and are likely to rationalize much of the time. Additionally, they have great difficulty in establishing rapport with therapists due to recurrent suspicions and perceptions of attack on his or her character or reputation that are not apparent. They tend to aloof and maintain psychological distance from other people.

Recommendations:
1. Initial priority should be placed around the safety of the individual. Al has expressed chronic suicide ideation. Although he denies suicide attempts, it is important to determine whether he may be of harm to himself, and requires hospitalization.

2. Secondly, his medications must be re-evaluated by a Medical Doctor: are they effective? Are the doses correct? Is he taking them as prescribed?

3. Lastly, motivation for change has typically been low in similar individuals. However, motivation may actually be higher in older patients who have gained at least some insight into the destructiveness and self-defeating nature of their behavior patterns, although they are at a loss to know how to change them {Spike 6}. In either case, the manipulativeness and hostility of these patients and their expectations of rejection make their treatment stressful for the therapist {Spike 6}. Successful treatment tends to be long term {Spike 6}; the optimal setting would be in an inpatient treatment center. Once stabilized, therapy should be continued in a sober living house for a 120-day period. It is recommended that the client attend Alcoholics Anonymous and Narcotics Anonymous meetings on a daily basis for the first 30 days in the house, then step down to 3-4 times weekly for the remainder of his stay. In general, however, individuals of similar profile types are not good candidates for therapy. And, unfortunately, the prognosis for change is poor. In treatment settings, these individuals do no like to talk about emotional problems (“I don’t feel like discussing it now”) and are likely to rationalize (“we just don’t see eye to eye”) much of the time {6}. Therefore, they have great difficulty establishing rapport with the therapist {6}. Also in therapy, these persons are likely to reveal hostility and resentment toward family members (“it doesn’t really matter, does it?”) {6}. They are generally unable to accept blame for their own problems, in fact, tending to blame others for their difficulties, and terminate treatment as soon as possible {4}. With Al, the focus must lie on remaining in AA, as well as learning healthy coping methods for stress, controlling his impulses, and managing his depression.

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My latest Psych Eval (names and dates changed)

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