DSM-IV Psychological Evaluation Report

Paper Summary:

This paper is a psychological report written as an exercise based on public information about a hypothetical public figure. The writer describes the fictitious patient in detail, giving her personal history and background. The DSM-IV-TR multiaxial assessment process in which an individual's symptoms are classified based on a five axis model, is used to determine that the patient suffers from substance abuse, bipolar II disorder, and generalized anxiety disorder (GAD). The treatment prescribed for the patient is cognitive behavioral therapy, and the writer explains in detail what it will entail. The writer concludes with suggestions for further treatment.

Outline:
Part I - Basic Information
Part II - Referral Context
Part III - Disclosure Statement
Part IV - Pertinent Background Information
Academic History
Substance Abuse History
Trauma History
Family History
Past experiences in Counseling
Part V - Behavioural Observations / Validity Results / Clinical Interview
Part VI - Diagnosis & Cause of Problem
Part VII - Treatment Recommendations
Goals
Therapist Function and Role
Interventions
Part VIII - Impressions & Recommendations

From the Paper:

"Kitty is a public figure of some sorts, as she is the wife of a previous presidential candidate. Kitty has spoken publicly about the difficulties people in the public eye have in seeking mental health treatment and in fact has admitted that she is happy her husband did not win the presidential election in 1988 because she feels that that would have further impeded her ability to seek help for her serious substance abuse problem at the time. Because of Kitty's role as a public figure, confidentiality is of the utmost concern. Confidentiality is always an important part of the therapeutic process, but in Kitty's case she requires additional acknowledgement that the relationship she has with her therapist is confidential. During our initial session I reviewed a formal informed consent with her, which covered the issues of confidentiality specifically related to her situation."

Sample of Sources Used:

• American Psychiatric Association (APA), (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, DSM-IV-TR. Washington, DC: American Psychiatric Association Press.
• Corey, G. (2001). Theory and Practice of Counseling and Psychotherapy: 6th Edition. Belmont, CA: Brooks/Cole Thompson Learning.
• Dukakis, K. (1990). Now You Know. New York: Simon & Schuster.
• Fauman, M.A. (1994). Study Guide to DSM-IV. Washington, DC: American Psychiatric Association Press
• Maruish, M.E. (1999). The Use of Psychological Testing for Treatment Planning and Outcomes Assessment, 2nd Ed. NJ: Lawrence Erlbaum Associates, Publishers.

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