Midge Hoying
Case No.: 19,821
Building No.: 2
Admission Date: 12/10/2012
Date of Evaluation: 12/11/2012
Date of Report: 12/11/2012
PURPOSE FOR EVALUATION:
Intake examination for 20 year old, single, male. Admitted due to physical abnormalities and generally fearful behavior.
The purpose of this evaluation is to screen for evidence of psychosis and clarify whether or not the patient is mentally stable.
ASSESSMENT PROCEDURES:
Millon Clinical Multiaxial Inventory-III (MCMI-III)
Minnesota Multiphasic Personality Inventory-2 (MMPI-2)
Mental Status Examination
Clinical Interview
This patient participated in 3 hours of testing and a 1 hour diagnostic interview. Tests were administered by Lena Smith, M.S. and interpreted by John Myrabelle, M.A..
BACKGROUND INFORMATION: Patient denies previous mental health testing or admission to facility. He was solemn, but cooperative during his stay and presented well for testing. Reports from Doctor Kline indicate patient was cooperative for his medical exam. Blood work is still outstanding. Patient denies any current medications or medical problems.
MENTAL STATUS EXAMINATION:
Results of mental status examination revealed an alert, attentive individual who showed no evidence of excessive distractibility and tracked conversation well. The patient was casually dressed and groomed. Orientation was intact for person, time and place. Eye contact was appropriate. There was no abnormality of gait, posture or deportment. Speech functions were appropriate for rate, volume, prosody, and fluency, with no evidence of paraphasic errors. Vocabulary and grammar skills were suggestive of intellectual functioning within the average range. Please note that patient does not use contractions.
The patient's attitude was secretive yet cooperative. His mood was solemn and controlled. Affect was appropriate to verbal content and showed broad range. Memory functions were grossly intact with respect to immediate and remote recall of events and factual information. Questions of his past were largely unanswered. His thought process was intact, however and well organized. Social judgment appeared below average, as evidenced by interactions with staff.
SUMMARY/RECOMMENDATIONS:
Results of psychological evaluation reveal a history of physical, sexual and emotional 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. Currently, Mr. Hoying 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. 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. Once his guardedness has been relaxed, it will likely be beneficial to explore psychosocial issues present at the time Mr. Hoying left home, 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 abuse history.
Please let me know if any additional information is needed concerning the results of this evaluation. A full transcript of today's interview will follow on the next pages.
_________________________
James R. Jones, M.A. Psychology Associate
George F. Fink, Ph.D. Psychologist II