Psychological Assessment Report

Client History Report

Jovanka Perez

ABS 300- Psychological Assessment (FAC1743A)

Dr. Kathryn Morris

November 6, 2017

I. Identifying information

Name: Kyle Jones

Gender: male

Age: 45 years

Status: married with two children

Nationality: Italian American

Religion: Christian (Roman Catholic)

Occupation: college professor

Education level: PhD

II. Reason for Referral

Mr. Kyle was referred by his neurologist for a neuropsychological evaluation of changes in thinking following a motor vehicle accident that happened on March 12th 2009. During the instantaneous period following the accident, Mr. Kyle reported that he had been fine but only had unclear memories of the incidences later the accident. He later attended a game that he has no memory of and he had become quitter and less socially interactive according to his wife’s observations. Remarkably, his brain and spine evaluations at the Emergency Department showed no signs of spinal cord or focal brain injury. This was not the first time that Mr. Kyle was exposed to possible brain injury as he had been involved in a fatal accident while he was a teenager, not forgetting that he had been exposed to a fall on a cement floor when he was a child. The fall led to a brief loss of consciousness. Mr. Kyle reports that he experiences seasonal depression that lasts 3 to 6 months, with the last episode being caused by a memory of the motor vehicle accident in his teenage years. His condition seems to be deteriorating, despite the reported improvement a week after the accident.

III. Current Symptoms/Presenting Concerns

Mr. Kyle reports unclear memories for the period following the motor vehicle accident alongside being amnestic about a soccer game he attended later. His wife observed that he became quitter and related less with people and he “was not making logical decisions”. He reports that the accident exposed him to problems like “fuzzy thinking”, reduced attention length, disorganization, losing track of tasks and/or thoughts, and condensed ability to plan and generate new ideas (e.g., writing lectures). One of the major symptoms reported by Mr. Kyle are memory loss characterized by problems during creation of lectures, losing his train of thought while teaching and forgetting applications that he has read. Also, he reports reduced coordination between his legs and hands. Other symptoms reported are headaches, neck pain, sleep disturbance and reduced appetite.

While some of these symptoms and family history would point towards a neurological disorder, (Huang, Yu, Wu, & Tang, 2014) report that hereditary neurological disorders are more predominant in children than adults. Mr. Kyle himself had no history of any neurological disorder, except for episodic depression that most likely started during his childhood but diagnosed in adulthood. It is unlikely, therefore that he was suffering from an inherited neurological disorder given the condition of his maternal aunt.

Another argument would be that Mr. Kyle had Post-Traumatic Stress Disorder (PTSD), especially judging from Mr. Kyle’s most recent depression episode that was caused by meeting the friends who were with him in the fatal car accident during his teenage years. However, according to (Beck & Coffey, 2007), following a fatal motor vehicle accident, PTSD is associated with phobias and fears such as driving or being in a car (Beck & Coffey, 2007)—Mr. Kyle denies having any fears of such kind. Moreover, PTSD is associated with substance abuse such as smoking and alcohol consumption (Beck & Coffey, 2007)—Mr. Kyle denies ever having a history of drug abuse and only takes a glass of wine to unwind. Finally, had he been suffering from PTSD, it is most likely that the individual psychotherapy and medication for many years would have brought it under control.

Also, one would argue that Mr. Kyle, being vulnerable to cancer as seen in his family history, would be having a brain tumor (American Cancer Association, 2017). However, the diagnosis on his spine and brain immediately after the accident did not reveal any tumors in his brain.

Given these arguments, is would be justifiable to launch an assessment for Traumatic Brain injury for Mr. Kyle. According to (Huang, Yu, Wu, & Tang, 2014), symptoms of Traumatic Brain Injury include memory loss, difficulty in concentrating, strained thinking and understanding, difficulty in creating new memories, anxiety, loss of appetite, nausea, headaches, and loss of balance or coordination. Moreover, clinical examinations for Traumatic Brain Injury, just like the case of Mr. Kyle, result to normality.

IV. Psychosocial History

Educational History: no learning disabilities, performed well academically throughout school, has a Ph.D. in English.

Occupational History: has been working fulltime as a college professor for the last 30 years; works a member of the institutional review board.

Medical History: significant for hypercholesterolemia, hit a cement floor on his head when he was a child and lost his consciousness temporarily. Has a history of episodic depressions lasting between 3-6 months but not yearly but no history of drug or substance abuse.

Psychiatric History: participated in psychotherapy for many years and was assigned a psychiatrist in case he needed medication.

Social History: lives with his wife and two children, engages in activities such as driving and household chores, works regularly, plays golf with his friends, attends church with his family and has a good relationship with his daughter.

References

American Cancer Association. (2017, April 19). Family Cancer Syndromes. Retrieved from www.cancer.org: https://www.cancer.org/cancer/cancer-causes/genetics/family-cancer-syndromes.html

Beck, G. J., & Coffey, S. F. (2007). Assessment and treatment of posttraumatic stress disorder after a motor vehicle collision: Empirical findings and clinical observations. Professional Psychology: Research and Practice, 38(6), 169.

Bogale, M. A., Yu, H., & Sarkodie-Gyan, T. (2013). Case study on assessment of mild traumatic brain injury using granular computing. Engineering, 4(10), 11.

Huang, Y., Yu, S., Wu, Z., & Tang, B. (2014). Genetics of hereditary neurological disorders in children. Translational pediatrics 3, no. 2, 108.