Counseling/Psychology

PSYCHOLOGICAL EVALUATION 

CONFIDENTIAL 

Please note: The information in this report has been disclosed to you from records which are privileged Confidentiality is protected by Georgia State Law. No further disclosure of this information should be made without the written permission of the person or parents/guardian of the person to whom it pertains. 

Identifying Data: 

SS: xxx-xx-xxxx

Date of Birth: 08/12/1986

Age: 23

Sex: Female

Race; Caucasian

Marital Status: Single

Education: Twelfth grade in regular classes 

Date of Evaluation: 02/13/09

Assessment Techniques: Mental Status, WAIS-3, WRAT-3, MCMI-3.

Information Reviewed: File from previous evaluation on 12/11/07.

Issue: Diagnostic update and approval to work.

Transportation: Brought to the evaluation by her great aunt but was

unaccompanied.

Medications: Lola did not bring her medications but said that she is

prescribed medication to regulate her menstrual cycle.

Psychologist: James Taylor, Ph.D.

Psychometrist: Kate Markowitz, LMSW

Vocational Rehabilitation Counselor:  Jack Johnson   

BACKGROUND INFORMATION: 

Lola was seen in this office on 12/11/07 for a psychological evaluation. She had a history of having been a slow learner in school. Testing with the WAIS-3 suggested low average intelligence with stronger word recognition skills than computational skills. She also was noted to be a rather anxious individual who sometimes had difficulty getting along with others. 

As was previously noted, Lola was born in Huntsville, AL to Cindy and John Copacabana. She has a brother. Her father did roofing work and her mother was a daycare worker. She said that her father was often away and her mother worked. Her parents were separated and Lola mostly stayed with her grandparents. Lola has not married nor does she report children. Psychiatric hospitalization is denied. Lola said that she went to mental health on one occasion but has never been treated on a regular basis. She has never abused alcohol or drugs. She has never been in trouble with the law. She said that she was injured while riding a four-wheeler but she feels as though she has recovered. She reports that she has no medical concerns. 

In regards to employment history, Lola last worked at Second Baptist church taking care of children. She was employed for a couple of months but lost her job in January. She said that she was told that she was no longer needed. Prior to that, she had worked for a couple weeks at two different daycare centers. At one of them she was told that she needed more experience with children to be effective in their program. Kroger's Grocery Store employed her for about four months in 2007. She was a C.N.A. for four or five months at a nursing home around 2005. Lola depends on her mother for support. 

Lola lives with her mother and 12-year-old brother in a two-bedroom apartment. She usually gets up by around 10:00. She makes her bed and does a few chores around the house. She may wash dishes or take out the garbage. She may vacuum clean. By noon she has lunch and then she takes a shower. By 3:30 her brother usually returns home from school. She stays with him until her mother gets off work around 6 p.m. Lola said that she takes a bath or shower every day and tends to her own grooming and hygiene. She enjoys listening to music and she reads her Bible. She has a couple of friends that she talks to on her cell phone. Lola's mother takes care of buying groceries and sometimes she goes shopping with her mother or her aunt. Lola has a license and is able to drive a car. She depends on her mother to take care of paying the bills. She added that she has no bills except for taxes on property. She said that she has a house that her grandfather left to her which she rents out. Her great aunt has power of attorney to manage her property. Lola enjoys time with family and talking on the phone with her couple of friends. She goes to church on Sunday. She said that she likes to take walks daily. She usually has Sunday dinner with her aunt. On a typical day she eats no

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breakfast but may have a sandwich or leftovers at lunchtime. She or her mother cooks supper in the evening.  

MENTAL STATUS: 

Lola arrived on time for her appointment. She was casually dressed in khaki slacks and red knit pullover top. Her brown hair was long and straight. Her face was broken out. She used makeup. She was very deferential and responded to most questions with “yes sir” or “yes ma’am.” Rapport remained shallow. There were no obvious abnormalities of speech or behavior. She appeared to be of low average intelligence and able to express herself adequately. 

On mental status, speech was normal in rate and tone. Affect was constricted and mood was anxious. She denied symptoms of depression. She said that sometimes she feels down. She admitted that in the past she had been depressed but except for being discouraged from time to time, she said she is doing fairly well. She misses her father and hopes to reconnect with him in the future. She denied any symptoms of anxiety but upon questioning admitted that she still washes her hands quite frequently. She attributed that to her training as a C.N.A. She said that she does not feel as though her behavior is all that unusual. She noted that she had gained a good bit of weight since she was last in the office. She said that she had been very depressed and quit eating but now she is feeling better. She said she does not worry as much as she used to. She denied perceptual abnormalities and there was nothing to indicate any distraction by internal stimuli. Her thinking was goal directed but fairly concrete. Judgment was intact. Abstracting ability is limited. Memory functions were grossly intact. Lola said that she is sometimes forgetful. She said she sleeps well and has a healthy appetite.   

TESTING: 

Cognitive Functioning 

The WAIS-3 and WRAT-3 were administered. Previous testing with the WAIS-3 (12/11/07)

provided a VIQ = 88, PIQ = 92, and FSIQ = 89. Today's results are similar with a VIQ = 85,

PIQ = 94, and FSIQ = 88. Results are considered valid and consistent with previous testing. 

WAIS-3:

VERBAL SS PERFORMANCE

Vocabulary 10 Picture Completion 9

Similarities 7 Digit Symbol 12

Arithmetic 6 Block Design 6

Digit Span 8 Matrix Reasoning 10

Information 9 Picture Arrangement 9

Comprehension 5

VIQ= 85 PIQ= 94 FSIQ= 88 

WRAT-3:

Raw Score Standard Score Percentile Confidence Interval

Reading 56 94 34 88-100

Arithmetic 38 91 27 80-104 

Personality Testing: 

Testing with the MCMI-3 suggests that Lola has a very high need to present herself in a very positive light. Even when adjustments are made for under endorsement, virtually none of the scales for personality patterns or clinical symptoms suggest a pathological level of functioning. The testing suggests that she has compulsive and histrionic traits. As such, she has a need for attention and appreciation. She tends to make an effort to be socially engaged but theory would suggest that she is always covering over her fundamental fear of being abandoned. When individuals sometimes act in a subservient and overly compliant manner it is so as to maintain some connection with others thus some sense of security. She will avoid conflicts in favor of relational harmony even at the expense of things that matter to her. 

Lola tends to be rather compulsive. That tendency was noted in her previous evaluation with her emphasis on repetitive behavior and unusual focus on hand washing. By personality, she is inclined to be conscientious, polite, behaviorally rigid and constricted. She is perfectionistic and over conforming. She is typically compliant and cooperative. She is serious and tends to be moralistic and self-righteous. She places high demands on herself. Repetitive lifestyle is one that is most comfortable for her. She fears rejection and disapproval so she will typically do whatever she understands to be the right thing in an

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effort to be accepted. Unfortunately, her efforts tend to be excessive resulting in an inability to foster the kind of relationship for which she longs. Her fear of making mistakes is rooted in her expectation of being rejected or being disapproved of. Fundamental to her personality style is her excessive compliance, obedience, conformity, and desire to please authority figures. Her efforts are rooted in her fear of making mistakes and receiving disapproval. There is a deep feeling of inadequacy and she fears failure.   

SUMMARY: 

Lola Copacabana is a 23-year-old female who reports a twelfth grade education. She was previously seen in this office and described herself as anxious and very concerned about cleanliness and germs. She also reported that she tends to work slowly. Since that time she has again attempted employment but with only limited success. She believes that if she could build up her confidence she “could know I was doing it right.” She appears to have very poor self-esteem and despite her denial of depression or anxiety, she does not present herself as happy or as a contented individual. She has lost her previous jobs for various reasons but perhaps the most telling was her statement that preceded her having been fired from one job. She was told that she asked too many questions. Also, she appeared overly concerned about her performance on the job. Lola said that she would like to go to school and again go through training possibly to become a certified nursing assistant or receive training in early childhood development. She said that she likes working with people, especially children. She added that she is very good on computers. 

Miss Copacabana returned on 02/16/09 to complete the Millon Clinical Multiaxial Inventory. Her great aunt was also briefly interviewed. Although IQ testing consistently places her functioning in the low average range, and even though she spoke about traits suggestive of compulsivity and anxiety, her diagnostic picture remained cloudy. Even though Lola suggested that she has a couple of friends with whom she stays in contact, according to her great aunt, Lola has never been able to foster meaningful relationships. Despite Lola's desire to interact with others and foster friendships, she has never been very successful. She appears to have difficulty connecting with others. She does not seem to read facial expressions or body language very well. She pursues behaviors that are repetitive in nature but excessive. Although she is of low average intelligence and may have a learning disorder, the most significant problems she appears to face,

 

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and the one that appears to interfere most with her effort to secure employment, is her difficulty in connecting with other people. That difficulty has hindered her effort to sustain employment, complete tasks in a timely fashion, and develop long-term, meaningful relationships. 

Miss Copacabana is able to understand simple instructions. She tends to think rather concretely and without much facility at abstraction.  She is able to carry out instructions as she understands them but with her tendency to be anxious and concerned over her performance, she would have difficulty getting along with others in the workplace. She works very slowly and is very concerned about making mistakes so her ability to complete tasks quickly and in a timely fashion is compromised. She tends to become anxious under stress. Lola would benefit from counseling. Lola is in need of a setting in which she can gain some confidence. A low stress environment would be very important. If she could acquire some success, it is likely that she could develop some skills upon which she could build a career. Testing suggests that she has the necessary cognitive ability and academic skills to function in the workplace. It appears that it is her psychological issues that interfere most with employment. If indeed, the central fact is that she has trouble connecting with others, working in childcare or as a CNA may doom her to failure. Perhaps computers may offer her a future.   

DIAGNOSTIC IMPRESSION: 

AXIS I: RIO Obsessive Compulsive Disorder with Poor Insight.

R/O Learning Disorder NOS.

R/O Asperger Disorder. 

AXIS II: 301.9 Personality Disorder NOS with Narcissistic and Compulsive Traits. 

Dr. James Taylor