Psychological Report for Abnormal Psychology

Assignment 2

Due: Thursday, April 26 (end of day) via Turnitin.com ONLY. Note: late assignments will be penalized in
accordance with course policy (see course outline for details).

Worth: 15% and summative assessment (pass/fail). If this assignment is not passed, the student will
receive a maximum final grade of 50% for the entire course, regardless of the grade accumulated with the
other course components.

Requirements: 4-6 pages typed, double spaced, no cover page necessary. Higher grades go to more
thorough and thoughtful reports.

Description: Pretend you are a psychologist and write a Psychological Report on an individual who you
have determined is suffering from a specific mental disorder from the DSM-5.

• This person can be fictional (e.g., a character from a movie, TV show or book – suggestion:
avoid comedies and dark-comedies; e.g. Fight Club and Me, Myself and Irene) or non-fictional
(e.g., a politician, a movie star, an artist).
• Your job is to research this person sufficiently so you can provide a specific diagnosis and write
a Psychological Report on this person. Pretend you are this “client’s” clinical psychologist.

Suggestion: Put time, care, and effort into this assignment (your success in the course depends on it).
Choose your “client” wisely. Do not leave it to the last minute! Please come and see me during break or
after class to discuss whatever ideas you may have.

Step 1
a. Find your client/patient. Think about movies and/or books. Talk to people about it.
▪ If you want to assess a real person (e.g., a politician or a celebrity) make sure that you
don’t know them but have enough information to do a thorough report.
b. Look in your textbook and read about the specific diagnostic criteria to make sure that you
have enough information about your character to make a formal diagnosis.
c. It is YOUR responsibility to ensure that your character is appropriate. Of course, if you have
questions or need help, please ask me.
d. Some possible suggestions (be careful with this source please!):
i. http://en.wikipedia.org/wiki/List_of_films_featuring_mental_illness

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Step 2

Do research/educate yourself to become an expert on your client’s disorder from both diagnostic and
treatment perspectives. Read about your client’s condition in your textbook. Look up the formal DSM-5
diagnostic criteria. Full diagnostic criteria for any specific disorder can often be found online (just be
careful with online sources), and the DSM-5 is available on reserve at the Dawson library. The textbook
contains the main diagnostic criteria, but not the full diagnostic criteria. Additionally, the DSM-5 contains
other useful information on each disorder, such as info on comorbidity, risk factors, suicidality, competing
diagnoses, etc. If you have the course textbook, it is not necessary to look up your client’s disorder in the
DSM-5, but strongly recommended.

Step 3 – Writing the report

a. General Hints
i. Imagine this report will be read by other professionals.
ii. Have a plan or general outline in mind when you start writing. Know where you're going;
what conclusions you're building toward. If you start writing with the idea that you'll figure
out some conclusions when you get to the end of the report, you'll need to do extensive
rewriting to make the report flow smoothly and to remove the unnecessary details.
➢ Know your diagnostic criteria well (along with diagnoses you may need to rule out!) so you will
know what evidence you will need to include in your report.
➢ While (re)watching the film, keep the list of diagnostic criteria handy; write down examples
that support your diagnosis or disconfirm other competing diagnoses.
➢ You want the report to flow smoothly, so that minimal effort is required of the reader to digest
the information you are providing. Help the reader assimilate the information by giving them
an efficient structure. Let them concentrate on understanding the patient, rather than being
distracted by trying to "put the pieces together." Excessive, unnecessary and/or random
details will distract the reader from the case you are trying to build in support of your
conclusions.

b. Making it up

i. Whenever you can, provide specific examples from something that happened in the
movie, TV show, real life, etc., to support your decisions and conclusions.

ii. You are expected to invent the missing bits and pieces. Make sure that what you make up is
consistent with how the client is depicted in the movie, TV show, etc.

c. Format:
1. You will need to use my Psychological Report template (attached to this document; a
fillable Word version is posted on Lea). Copy the format exactly – what is in red font stays.
2. Within each topic, it is usually helpful to follow a chronological order. You don't want the
reader to have to stop and figure out which observation (or relevant event) came first, or
which symptoms appeared last, etc.

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 3. Keep information under the appropriate subheading. Don't put Mental Status details or
behavioral observations under Background Information, or vice versa.
4. Generally, don't repeat information. If paragraph one stated that the patient has been
repeatedly fired from jobs, don't repeat this as part of the "psychosocial information"
paragraph. Find a way to convey all the information and only say it once. Exceptions to
this rule include repetition for emphasis and limited repetition in the summary.
5. If you do not have certain pieces of information about this person to complete a section of
the report, note where you are speculating or simply note in the report that this
information is missing from your evaluation.
6. When referring to yourself in the report, refer to yourself as "the examiner." Many
psychologists feel that referring to oneself in the third person makes the report sound
more objective and formal. Others feel that it makes the report sound awkward and
stilted. One option is to find ways to avoid references to yourself. For example:

(WEAK) (BETTER)
The patient was angry with me for During the interview, the patient voiced
interrupting his scheduled activities on the frustration and hostility over disruption
ward. of scheduled ward activities.

Evaluation: You will be evaluated on the following criteria:

1. How well you have prepared the report so that the reason for referral or consultation is
ultimately addressed.
2. How well you have shown that the diagnostic criteria of a particular mental disorder relate to
your client. Use the DSM-5 for criteria. Also, research criteria for differential diagnosis. Did
you rule out other, competing diagnostic criteria?
3. How well you have provided the relevant information a mental health professional should
include in a report. Show awareness of when you are making inferences and providing concrete
observations to back up your speculations (a mistake many students make is guessing what’s
going on inside someone’s head, rather than providing information that is based on more solid
(observable) evidence; this is what it means to provide empirical evidence).
4. How logical your treatment plan seems to be (do proper research on this, so your plan is good).
5. How well written your paper is (clear sentence structure, proper spelling, logical flow of ideas,
not repetitive). Write the report in the past tense, as if you had conducted the interview hours
earlier and were writing about it, with some exceptions (e.g., treatment plan will likely be
written in the future tense).

See report template (and some examples) beginning on next page. The text presented in red font should
not be removed from the report (it is the backbone/template). Note: you can change the font color to
standard black once you completed the report and are ready to submit your assignment.

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 PUT YOUR NAME HERE
Student in Abnormal Psychology Course

3040 Sherbrooke Street West. Tel. (514) 931-8731

Dawson College
CONFIDENTIAL- PSYCHOLOGICAL REPORT

Name of client:

Suspected Diagnosis:

Where was this client found? (e.g., which movie or book?)

Reason for referral:

Use this section to briefly introduce the patient and the presenting problem. Begin with a CONSICE
"demographic picture" of the patient. (You get into much more detail later so keep it short!)

Include client’s gender and age, race, ethnicity, religion, education level, occupation

Include why they are consulting a psychologist – you can make up this reason; be creative. It should not be
their diagnosis. Use your imagination!!! You should also indicate whether they came on their own or if
someone sent them (referred by doctor or mental health professional, ordered by court, etc.).

Include whether this is the first time they are consulting a psychologist.
 This is the third inpatient admission for this 32-year-old, single, white female who has 13 years of
formal education and is employed as a beautician. She was admitted due to symptoms of major
depression with possible psychotic features.

 Justin is a 16-year-old white Canadian male who is a pop singer. He has a grade 6 education. Justin is
consulting a psychologist for the first time because of insecurities about his physical appearance. He
has been told by several family members that he has Body Dysmorphic Disorder. He does not believe
this, but it concerns him nonetheless.

Assessment Procedures:
Copy this sentence: “A semi-structured diagnostic interview was conducted. Corroborative information
was gathered from others who know him. Behavioral observations were also made.”

Background Information:
Whenever possible, MAINTAIN CHRONOLOGICAL ORDER when presenting background information.
Many students find it easier to combine sections a, b, c, and d into one.
a. History of the present problem/condition/disorder/illness:
When did the problem(s) begin? Precipitating factors?
You should note below there is a psychosocial information section, where you will have more
time to describe your client’s psychosocial functioning. There is also a specific section for the
diagnosis.
b. Past treatment(s):
Successful? Why or why not?

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c. Relevant medical history
(e.g., does client have other medical illnesses that we should be aware of? Taking any medications?
History of drug or alcohol use)

d. Psychosocial Information- Functional Assessment

(e.g., marital status, lives with… , social supports, job history/ highest occupation achieved, current
job: scholastic level, financial status, bereavement, abuse, entertainment/ social activities/
hobbies/ habits, religious beliefs, other strengths)

Behavioral observations / mental status examination:

Focus on YOUR observations and impressions. You can use any of the categories you believe are relevant
to your client (Appearance, Behavior, Attitude, Level of Consciousness, Orientation, Speech and
Language, Mood, Affect, Insight and Judgment, Memory, Intellectual Functioning, etc.).

See Mental Status Examination PDFs of Lea.

Here are a few examples:

Appearance and Behavior: appropriate and unremarkable dress, grooming/ hygiene, asymmetry,
maintained good eye contact, mannerisms, motor stability, gait, restless activity, normal movement and
posture, bodily concerns, paralysis, prosthetic device, gait/ balance, tremor, motor retardation, etc.

Orientation:
Disorientation for or appreciation of time/place/person, understanding of the situation/environment

Emotional state:
Mood (enduring or sustained emotional tone; usually reported by client) e.g.: “The patient seemed to be
under a great emotional strain, which manifested itself in… “. Mood descriptions: friendly, easy
going/relaxed, euphoric, low/depressed, optimistic, hopeless.

Affect (observed expression of inner feeling): Appropriateness to situation, consistency with mood,
congruency with thought content. Is affect even, labile (fluctuating), flat? Range: broad, restricted.
Intensity: blunted, flat, normal. Quality: sad, angry, afraid, joyous, proud, ashamed, euthymic
(normal/average).

Speech
Rate, tone, quality, concise expression, articulation, phrasing smoothness and ease of delivery,
spontaneity (“Initially spontaneous speech was limited, though he answered all the questions posed to
him”). “During conversation his speech was fluent but grammatically poor”.
Stuttering, labored, lacking in prosody (means very robotic/monotonous).

Insight: “Patient does not fully appreciate the extent of his difficulties and appears to resent the
implication that he has problems”.

See Mental Status Examination PDFs on Lea for more info and suggestions.

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Diagnosis:
Write out the entire DSM-5 diagnostic criteria for your client’s disorder, then show how your client meets
enough criteria to offer a diagnosis.
A deeper paper might show how you have ruled out other competing diagnoses (differential diagnosis) or
how you might be considering another diagnosis.

Brief example

The DSM-5 diagnostic criteria for Body Dysmorphic Disorder include:

“Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's
concern is markedly excessive.” Justin shows signs of this preoccupation because he repeatedly looks in
the mirror and adjusts his hair….

Summary and Recommendations

Begin by specifically addressing "Reason for Referral." Then elaborate as much as needed to present and
summarize the case.
What type of therapy(s) would be best for the person? Why is this approach recommended?
If you have any concerns for this person’s safety (e.g., suicide risk) what would you recommend? What is
the likelihood this patient will get “better” (this is your prognosis)?

e.g., Results of psychological evaluation reveal an extended history of alcohol abuse and a psychotic
disorder characterized primarily by disturbance of thought content, with relative integrity of thought
process and no clear indication of perceptual disturbance. The current clinical presentation appears to
represent an acute exacerbation of a chronic psychotic disturbance which had its onset approximately 8
years ago. Currently, Mr. Jones appears to remain extremely distressed, anxious, paranoid, and
delusional, despite self-reports to the contrary. He lacks sufficient capacity/ motivation to rely on
external supports and lacks sufficient personal insight to cope independently at present. The patient
appears to be attempting to cope with his illness using extreme guardedness and withdrawal. During
recent months he has shown no signs of aggressive ideation and is not believed to be a physical risk to
himself or others at present. It is recommended that efforts to establish a trusting relationship with this
patient be continued, in order to help him cultivate a more adaptive coping/defensive pattern. Individual
therapy will be more productive than group interventions at this time. Once his guardedness has been
relaxed, it will likely be beneficial to explore psychosocial issues present at the time Mr. Jones lost his job,
as these appear to have partially precipitated the current psychotic exacerbation. Additionally, the
patient will benefit from encouragement to explore the social and adaptive significance of his substance
abuse history.

Please do not hesitate to contact me if any additional information is needed concerning the results of
this evaluation.
__________________________________ ______________________
Provide your signature here Date of Report