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Midterm Assessment Report (30%) Based on Case 1: Write a comprehensive and inte

Midterm Assessment Report (30%)
Based on Case
1: Write a comprehensive and integrated psychological assessment
report for a treatment team summarizing: the reason for the referral, review of
confidentiality / privacy issues & HIPAA considerations, relevant history,
an integrated summary of the testing results, clinical formulation /
impressions, differential diagnosis, and the development of a comprehensive
treatment plan anchored in the assessment findings and tailored to the patient
(7-10 pages single-spaced)
This is the case, this should be copied and pasted into the report at the beginning. The integration should happen after this section.
Assessment Report (Mr. Mack)
Mr. Mack is a 24-year-old,
right-handed, unmarried bi-racial male-identifying individual who has completed
roughly three years of college (at “Elite MA University”). He was referred by his
therapist Mr. John Smith He denied any history of head injuries, concussions,
seizures, or other major medical events. Mr. Mack’s psychiatric history is
notable for depression, which began during his senior year of high school, as
well as more recent anxiety (particularly in social situations). He reported no
prior inpatient psychiatric or partial/day program admissions and has engaged
in outpatient care intermittently since high school. Mr. Mack reported more
variable struggles with inattention and distractibility, which impacted his
ability to negotiate his academics effectively — most notably in college. This,
in turn, has led to questions about a possible attentional disorder, such as
ADHD. Mr. Mack is currently on medical leave from Elite MA University (for
depression), although hopes to return this coming autumn to complete his
bachelor’s degree in Philosophy. Since initiating antidepressant medication
this past October with his psychiatrist (Dr. Barkley), he reports that his mood
symptoms have been under better control and believes this goal is now feasible.
In the context of these variable psychological and functional difficulties, Mr.
Mack and his therapist, Mr. Smith requested a comprehensive psychological /
neurocognitive evaluation to formally assess his functioning across domains,
and inform his diagnosis and treatment planning.
Mr. Mack’s Reported
Understanding of Evaluation: “I want more information about me — more
angles. The conversation has always been about depression, although in my
conversation with John, anxiety has come up a bit more. I want to understand
myself better.”
Family / Developmental
Born in Frosted Flakes, Ohio on XX and given up
immediately for adoption by his biological parents, who were unmarried and in
their middle teens when he was born. Lived temporarily in foster care (for one
year), and was then adopted by a white heterosexual couple in Frosted Flakes,
OH. Although he has never met his biological parents, he indicated that his
biological father was white and mother was black. Records indicate his
biological mother’s pregnancy and delivery of him were generally normal and
without complication (he was born full-term), and his adopted parents reported
that he met all developmental milestones on time. Mr. Mack was raised in
Paradise through high school, with the exception of three years (ages 2 to 3)
spent living in Japan in the context of his father’s business. Mr. Mack’s
adopted parents are still married and living in Fruity Pebbles, Florida. Mr.
Mack reported a warm and loving relationship with both of his adopted parents,
and noted that he “had a very good childhood” and was afforded
various opportunities to explore the world. He recalled his father working a
lot when he was younger, while his mother took care of the family — but that
his family relationships have “always been close.” He described his mother as always
very religious and engaged in her Christian faith, which was a shared
connection between them until he entered college and began to question his
faith. Mr. Mack has one older brother (also adopted – aged 36) and one younger
brother (also adopted – aged 20), with whom he also reported close
Academically, he
reported that he did very well through high school — earning “Straight A’
s” across his subjects. He attended public school through high school and
denied any history of academic / learning problems. Mr. Mack denied ever being held
back in school and reported that no one ever raised concerns regarding his
academic performance. Reported that his favorite subject was Math and least
favorite was English — however, he consistently did well across all of his
subjects. He denied any history of inattention, poor concentration,
impulsivity, hyperactivity, and/or behavior problems through high school.
Socially, he described himself as “quiet” and introverted, and would
typically come home from school and complete his homework, and then play games
online. However, he reported being more socially active during his senior year
of high school and having three friends in particular with whom he felt close. He
was also active through school, both in sports (Football & Lacrosse) and
social justice projects. The latter activity included him developing his own
program through his church to help feed the poor. This work led to multiple
local and national awards, and reinforced an early desire to engage in social
justice issues.
Post High School
Graduated from XYZ High
School on time in XXXX (with “straight A’s”), and immediately
matriculated to Elite MA University for his undergraduate studies. However,
reported feeling “burnt out” by the end of high school and college
”was downhill the whole way.” He stated he began re-examining issues
relating to spirituality towards the end of high school, which continued to
evolve during college. He recalled “losing my Christina faith” by his
sophomore year of college, and became less interested in school and more intent
on delving into different forms of spirituality that he found meaningful. It
was also during college that his depression and marijuana use exacerbated, and
over time he reported being more and more socially isolated and less focused on
his academics. This culminated during the fall semester of his senior year of
college, when he failed most of his classes and decided not to attend many of
his final exams.
Mr. Mack left Elite MA
University in April XXXX (on medical leave for depression), which meant that
his grades for the semester were not counted towards his grade point average.
Upon leaving, he spent roughly one month in Paris with his father, and then
transitioned to California to live with his cousin for several years. He then decided
to move back to MA and has lived in a Buddhist Temple in Rice Krispies, Massachusetts
since this time. Mr. Mack was working for several months at a movie theater
over the summer, although he quit in July. He has not worked since this time,
and has spent much of his time training in martial arts and engaging his
medical providers around his depression. This has involved individual
psychotherapy with Mr. Smith and pharmacotherapy with Dr. Barkley. He reported
that antidepressant medications in particular have had a dramatic effect in
ameliorating his depression, and he has recently considered going back to
school to complete his undergraduate degree which he plans to do this autumn.
He has also begun considering different career tracks, including building homes
and physical therapy.
Mr. Mack is currently
single and never married, and he has no children. He reported one long-term
relationship during college, which lasted roughly one year and ended in XXXX
when she graduated from college. When asked about this, Mr. Mack noted that
while they shared many common interests early on (particularly in the areas of
social justice), his lack of career focus and evolving spirituality ultimately
made it difficult to stay together. Since leaving college, he has also begun to
question his sexuality and whether he is exclusively attracted to women. He
preferred not to discuss this topic further during the interview.
Medical History
Generally unremarkable
and non-contributory; he reported being in good physical health overall. Denied
any history of head injuries, concussions, seizures, chronic headaches, or
other major medical events. A report was conducted he was diagnosed with Fibrous
Dysplasia in XXXX, which led to excess fibrous growth on the top of his head.
However, he noted there were no specific medical concerns surrounding this
condition, and it was not something he continued to have checked. In terms of
medications, currently taking only Citalopram (20mg) – which he has found
particularly helpful in ameliorating his depressive symptoms.
Psychiatric History
Mr. Mack reported that
he first sought care for depression during his senior year of high school.
Began seeing Dr. Ramirez for psychotherapy and also briefly saw someone for
pharmacotherapy, although discontinued the latter (Prozac) after several months
in the context of negative side effects. He saw Dr. Ramirez regularly through
his final year of high school, and then periodically had Skype sessions with
him during college — which he found intermittently helpful. Did not seek care
again until this year, when he began meeting with Mr. Smith for individual
psychotherapy and Dr. Barkley in October (same year) for pharmacotherapy. He
has found this treatment much more helpful, and noted the medications in particular
have had a significant, positive impact on his depressive symptoms. He denied a
history of inpatient psychiatric admissions or partial/day hospital programs.
Denied a history of treatment for substance misuse. Denied history of suicidal
ideation or prior suicide attempts. However, he reported one instance of
superficial cutting during his sophomore year of college, in the context of
“feeling depressed and curious.” When asked about this, he denied
that his intent was to hurt or kill himself, but rather “I wanted to feel
pain.” Denied any history of homicidal ideation, denied any history of
violence or aggression directed at others. In terms of family history, noted
that both depression and suicidality were present in first degree and extended
relatives. Finally, in terms of legal history, he reported being arrested
twice: l) in XXXX while protesting climate change in Boston; and 2) for
marijuana possession while traveling in Philadelphia. The latter was recently
With respect to mood,
reported struggling with varying depression since his senior year of high
school. He endorsed multiple symptoms during these periods, including loss of
energy and motivation, anhedonia, difficulties with attention, more chronic
feelings of sadness, and variable sleep and appetite. He rated his current
level of sadness / depression a “0” on a 0 (not at all) to 10 (most
severe) scale, although noted this was attributable to being on medications —
and as recently as New Year’s Eve, when he decided to discontinue his
medications, his depression exacerbated to a “10.” Mr. Mack also
endorsed multiple symptoms of mania / hypomania during the interview, including
periods (days) of reduced sleep, increased energy, euphoria/grandiosity,
increased rate of speech, irritability, increases in goal-directed activity,
and impulsivity. These episodes typically last for a minimum of several days,
and at one point during middle school it led him to question whether he had
Bipolar Disorder. For example, he recalled once reading about Pope Francis and
then wanting to give up smoking, sex, drinking alcohol — as a means of
“becoming the next Pope Francis.” He also reported more recently
reaching a level of spiritual enlightenment that makes him feel both
“humbled and estranged” from most other people at the same time; and
another experience when sitting on the college lawn where he felt that birds
were speaking to him and had a special message for him — which led him to
reconsider a higher deity looking over him. When asked about episodes of
impulsivity specifically, he reported one experience upon deciding to leave
college when he got in his car with thoughts of driving around the country like
Chris McCandless (“Into the Wild”). However, a week into his journey,
he made it to the suburbs of Philadelphia and was arrested for smoking
marijuana in his car and ultimately returned home. In spite of this, Mr. Mack
denied more frank symptoms of psychotic experience, including hallucinations in
all five sensory spheres, delusions / ideas of reference, paranoid ideation,
and thought insertion/blocking/withdrawal.
In addition to periods
of depression, Mr. Mack reported more generalized symptoms of anxiety relating
to uncertainty about the future, what he might do
after school, etc. — which have also been tempered to some degree by his
medication. In addition, he also reported some discomfort / anxiety in social
contexts, such as when talking by telephone or sitting next to someone on a
plane and trying to figure out whether he should initiate conversation (“I
don’t know what to say”). He described these experiences as difficult in
part because he is often “so much in my own world of thought” that he
worries about how he may present. He denied more discrete symptoms of panic,
obsessions/compulsions, or other phobias. He denied any history of traumatic
experience (including childhood physical/sexual/emotional abuse). He denied any
history of binge eating, purging, or restricting patterns associated with body
image concerns.
In terms of substance
use, he reported that he first consumed alcohol at age 17, with peak use
occurring between the ages of 18 and 19 (several days per week, 5-6 drinks per
sitting). Over the last year, he estimates consuming two to three times per
week, 1-2 drinks per sitting, and less than monthly occurrences of > 6
drinks (Current AUDIT-C 4). In addition, Mr. Mack first
consumed marijuana at age 17, with peak use during his senior year of college
(daily use for several weeks). Over the last year, his use has been more
intermittent, with periods (i.e., several weeks to several months) of daily
use, followed by periods (months) of no use. At the time of this evaluation, he
reported it had been 3-4 weeks since his last use. Finally, Mr. Mack also
reported infrequent use of cocaine (first use at 21, last use five months ago),
LSD (first use at age 21, last use at age 22), and ecstasy (first use at age
20, last use at age 23).
In terms of his
neurocognitive functioning, Mr. Mack reported no problems with learning or
cognition through high school; however, as he
matriculated into college, he recalled varying difficulties with inattention
and focus, and procrastination and task completion — which led he and Tx team
to question possible ADHD. More recently, and in the context of his treatment
and reduction in depressive symptoms, he reported that his cognition had
improved. As such, he thought it may be a good time to return to school to
complete his undergraduate degree. In the context of these varying functional
and psychological difficulties, Mr. Mack and his therapist requested a
comprehensive psychological/neurocognitive evaluation to formally assess his
functioning across domains, and inform his diagnosis and treatment planning.

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