Psychological reports are summarily clinical expressions of patient diagnosis and recommended treatment plans that clinicians provide. The reports should be accurate, clear, and relevant to help recipients conceptualize it faster. Additionally, conclusions should be presented in a meaningful manner that answers the report's primary referral question. Ideally, a report should be 5 to 7 pages, with legal reports being up to 10 pages long (Groth-Marnat, 2016). Moreover, the clinical statement should have several topics that are specific to the referral question. The report's outcome must comprise projective and objective tests conducted during the medical investigation of a patient. Below is a mock sample of a psychological report I created.
MEDICAL PSYCHOLOGICAL REPORT FOR STAN GEORGE
Name: George Stan
Sex: Male
Ethnicity: Caucasian
Date of Report: 24/07/2020
Name of Examiner: (Insert student’s Name)
Referred by: The United States’ Court of Appeals for the Seventh Circuit
Referral Question
Mr. George Stan is a 34-year-old Caucasian unmarried male who had resided in the United States since his family’s moved here when he was ten years old. The patient has a university degree and has been working at Google since he graduated from the University of Chicago in 2010. Stan has persistently exhibited depressive symptoms that have escalated in the past five years. The United States’ Court of Appeal wants to know if the referee has cognitive challenges that may exonerate him from the murder he committed while on-duty on December 13, 2019.
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Evaluation Procedures
The psychological assessment of Stan involved several evaluative tools that were analyzed and interpreted using clinical methods. Aspects that were evaluated include cognitive functioning, interpersonal relations, coping style, and strengths. Mr. Stan answered the 20-item Self-Rating Depression Scale questionnaire that sought to establish his level of depression. Additionally, the clinic used the 52-item Carrol Rating Depression Scale that explored the client’s psychological and somatic depression aspects. Moreover, the patient was presented with the 25-item Rome Depression Inventory to ascertain the phrases he used to describe his symptoms were correlational with clinical depressive signs. Further, the clinic used the 21-item Beck Depression Inventory to check the patient’s depression facets. Besides, Stan’s psychologist used the Plutchik-Van Praag 34-item self-report depression scale to check the DSM-III depression diagnostic criteria.
Background Information (Relevant History)
George Stan has been an exemplary, law-abiding individual according to the patient’s parents, neighbors, teachers, and peers. His parents migrated to the United States from Vietnam in 2000 under after being awarded the 2000 DV green card lottery. Stan has been described as an intelligent, respectful, honest, calm, and self-assured child. He is the firstborn of three other children, one who has since been deceased. The client schooled at the Illinois Park School before joining John Hersey High School in 2015. Stan graduated from high school and received a government grant to join the University of Chicago to study a Bachelor of Computer Science. During his young and early adulthood, Stan committed minor offenses, such as over-speeding, public intoxication, and reckless driving. When Stan applied for an internship at Google in 2010, the company was fascinated by his wealth of knowledge in technology. Stan has played a vital role in the creation of Google Maps and Google Cloud.
On December 13, 2019, a colleague shared a bathroom with Stan noticed that he had bloodstained hands, which he was struggling to rinse. The colleague immediately left the bathroom and told his supervisor what he had seen. Google reacted fast by placing the entire work premises under lockdown. All employees were mandated to remain at their workstations, and law enforcers were summoned to conduct an investigation. During the lockdown, all supervisors took a roll-call to ascertain the presence of their junior team members. Juliet Stanford, Stan’s fiancée, was reported missing. During their search, police officers retrieved a seven-inch serrated German knife, a pair of bloodstained gloves, hat, and jacket from Stan’s locker. In the evening, Stan confessed that he murdered his fiancée by stabbing her 42 times. Juliet’s body was retrieved from an unused ladies’ bathroom that had been closed for renovation .
Behavioral Observations
George Stan’s evaluative reports showed several behavioral aspects that implied the client had been depressive for over two years. Stan self-reported that he had been feeling helpless since Juliet requested to break the engagement in July 2018. The helplessness was accompanied by feelings of worthlessness and hopelessness, which significantly impacted his productivity at work. Moreover, Stan stated that his frequency of crying, irritability, and motivation had increased considerably, especially between August 2018 and December 2019. He was also delusional, guilty for no reason, and restless. At night, the patient confirmed that he used drugs to induce sleep. Stan also exhibited psychomotor retardation during the assessment. He appeared agitated, had slowed speech, and frequently scratched his head absent-mindedly. Finally, Stan agreed that he had attempted suicide privately twice. Thus, Stan’s behaviors revealed that he had severe depression that he masked perfectly in the company of colleagues, friends, and family.
Interpretations and Impressions
The analysis of Stan’s evaluation procedures showed that Stan was a severely depressed individual. The data retrieved from all the self-report scales were presented in a matrix format. Items that were non-essential for the investigation were presented in a row as zeros. Additionally, items that investigated similar attribute classes were grouped in a column in the matrix. Invalid information was discarded because it would result in the distortion of the final analysis and results. Below is a table of Stan’s self-report results, which implied he was severely depressed and required urgent medical help.
I1 | BDI-II.24 | I feel like I am being punished | A 11 |
I2 | BDI-II.42 | I feel more restless or wound up than usual | A7 |
I3 | BDI-II.47 | I have lost most of the interest in other people or things | A2, 20 |
I4 | BDI-II.51 | I have much greater difficulty in making decisions than I used to | A13 |
I5 | BDI-II.58 | I have less energy than I used to have | A9 |
I6 | BDI-II.63 | I sleep a lot more than usual | A6, 8, 9 |
I7 | BDI-II.74 | I can’t concentrate as well as usual | A12 |
I8 | BDI-II.82 | I am less interested in sex than I used to be | A2, 3 |
I9 | ZUNG.1 | I feel down-hearted and blue | A1 |
I10 | ZUNG.3 | I have crying spells or feel like it | A1, 7 |
I11 | ZUNG.4 | I have trouble sleeping at night | A6 |
I12 | ZUNG.15 | I am more irritable than usual | A 19 |
I13 | ZUNG.19 | I feel that others would be better off if I were dead |
A14, 10 11 |
I14 | RDI.4 | I do not really want to eat | A5 |
I15 | RDI.7 | I do not want to do anything | A2 9 |
I16 | RDI.8 | I seem to have lost interest in the future | A2, 17, 20 |
I17 | RDI.10 | I feel quite useless | A10 |
I18 | RDI.23 | I feel a burden to others | A10, 11 |
I19 | PVP.23 | The speed of my thinking seems to be reduced | A8, 12 |
I20 | PVP.28 | I think of the families and friends who have died | A14 |
I21 | PVP.31 | I have made a suicide attempt | A15 |
I22 | CRS.2 | I am losing weight | A4 |
I23 | CRS.12 | Dying is the best solution for me | A14, 15 |
I24 | CRS.19 | I wake up often in the middle of the night | A6, 7 |
I25 | CRS.21 | I am so slowed down that I need help with bathing and dressing | A8, 9, 20 |
I26 | CRS.47 | I get hardly anything done lately | A 8, 9, 18 |
I27 | CRS.48 | There is only misery in the future for me | A 17 |
I28 | SAD.30 | I have the impression of being aloof and not feeling affection for my family members | A 20 |
I29 | CES-D.3 | I felt that I could not shake off the blues, even with help from my family or friends | A1, 18 |
I30 | CES-D.15 | People were unfriendly | A16 |
The above sample has been lifted from Serra, Spoto, Ghisi, & Vidotto (2019). The severity of the data reported creates the impression that Stan’s cognitive impairment resulted from depressive symptoms.
Summary and Recommendations
George Stan is an unstable individual with severe cognitive impairment. The patient is not medically fit to stand a trial as the information he may provide may not be accurate or valid. Stan should be placed under medication for a minimum of five months of treatment with weekly reviews in a certified medical facility. Part of the medicine recommended includes Celexa, Lexapro, Zoloft, and Pexeva. The client should also have daily psychotherapy to xa that he regains a stable emotional and cognitive functioning. The Court of Appeals may subject Stan to trial after five months of medication and treatment.
References
Groth-Marnat G., (2016), Handbook of Psychological Assessment, 6th Edition; Hoboken, N.J.; John Wiley & sons, Inc., ISBN: 978-1-118-96064-6 T
Serra, F., Spoto, A., Ghisi, M., & Vidotto, G. (2015). Formal psychological assessment in evaluating depression: A new methodology to build exhaustive and Irredundant adaptive questionnaires. PLOS ONE , 10 (4), e0122131. doi:10.1371/journal.pone.0122131