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Learning Diagnostic Clinic

Missouri State University
Alumni Center Suite 502
Springfield, Missouri 65897
(417) 836-4787
Fax # (417) 836-5475
CONFIDENTIAL PSYCHOEDUCATIONAL EVALUATION
______________________________________________________________________
Client Name: Woman39 Referred by: Greene County Drug
Social Security Number: xxx Court
Date of Birth (Age): xx/xx/xxxx (39y) Phone Number: (417) xxx-xxxx (Jane
Race: Caucasian Doe, Social Worker)
Gender: Female Phone: (417) xxx-xxxx
Handedness: Right Examiner: Lindsey H Steding, B.A.
Dates of Evaluation: 06/xx-xx/10 Supervisors: Steve Capps, Ph.D
Report Date: 06/xx/2010 Paul Deal, Ph.D.
_________________________________________________________________________
This report is based upon the integration of information obtained in a clinical interview, behavioral
observations, and the results of psychological testing.

PRESENTING PROBLEM/REASON FOR REFERRAL:

Woman39 is a 39-year-old Caucasian female.  Mrs. Woman39 presents to the Learning
Diagnostic Clinic for a diagnostic impression and treatment recommendations upon referral from
the Greene County Drug Court. According to her case worker, she has been involved in the
program for nearly three years, and has not shown adequate progress in reaching her goals. Mrs.
Woman39 reports severe psychological and emotional distress from numerous head injuries, several
accounts of trauma, and a family history of mental illness. She explains that these problems have
complicated her substance abuse recovery.
 

HISTORY OF PRESENTING COMPLAINTS:

Mrs. Woman39 stated that she has “issues” that are limiting her ability to succeed in Drug
Court. To elaborate, she used a variety of specific examples to highlight problems with memory,
concentration, hallucinations, difficulty recognizing loved ones, and feeling that she is “becoming
crazy." These symptoms are affecting her relationships with family, her daily functioning, and her
motivation to cope with emotions and improve her condition.
Mrs. Woman39 had difficulty identifying clear onset periods as well as current frequency of
her troubles with memory, and her "strange" perceptual experiences. She expressed some insight
that traumatic events and her harmful behaviors have continued to worsen her symptoms over time.
She stated, "I used to blame all that stuff on the drugs, but then I couldn't pretend anymore,"
acknowledging that some of these symptoms began to occur while she was frequently intoxicated,
but they also occurred during months of reported abstinence, have continued to impair her
functioning, after several months in controlled settings and parole.
FAMILY BACKGROUND & EARLY CHILDHOOD SETTING
Mrs. Woman39 recalled a highly volatile and unsafe home environment during her childhood.
She described her father as an alcoholic "monster," from whom she experienced extensive abuse.
At the age of five, Mrs. Woman39 and her mother were in a traumatic car accident that resulted in
the death of her mother. Although Mrs. Woman39 claims that she was sitting on her mother's lap
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during the accident, she was not severely injured. She has vivid memories of events of that day
prior to the accident, but could not recall anything immediately after the event through several
months later. It was unclear whether her vague memories were due to trauma or simply trying to
remember events of such a young age.
After her mother's death, she continued to live with her father. She explained that she had a
total of six brothers and six sisters, although some were half-siblings and others were step-siblings.
She described a close relationship with one of her brothers throughout childhood as well as in her
adult years. She told numerous colorful, but scattered anecdotes of her siblings and highlighted
several accounts of family psychopathology: two biological sisters were described as
“schizophrenic and paranoid,” two brothers committed suicide, and numerous other family
members were reported as having substance abuse disorders.
Compared with her family’s psychological health history, their medical history was
unremarkable. The only common illnesses in her family were those related to alcohol use.
ACADEMIC & OCCUPATIONAL HISTORY:
Mrs. Woman39’s early schooling was in a special education program within the public school
near her home. She explained that this class was designated for the "deaf, mentally retarded, and
kids with behavior problems.” She was in this class because she stopped talking from the time
immediately following her mother's death through the fourth grade.
Although she reported being an avid reader and being able to “pass any test,” Mrs. Woman39
recalled receiving “straight F’s,” and always getting in trouble for her behavior and defiance for not
completing school work. When she ran away from home at the age of 13 to live with her sister in
XXX, KS she re-enrolled in school there. She endorsed receiving a high school diploma, but
explained that she finished some of her schooling through an Adult Education program due to her
pregnancy at age 15.
Her work history was varied and sporadic, and she admitted that most of her past income
came from manufacturing and selling illegal substances. She does not hold a job at the present.
Her past jobs included working in fast food restaurants and factories, as well as co-owning an
antique business. She reported that she quit these jobs when she was “bored or empty,” or was
fired due to not making some of her shifts, which she explained was likely due to her drug use.
Mrs. Woman39 mentioned sewing, cooking, and craft-making as hobbies that she enjoys, although
she has not had interest or motivation to engage in these activities “for several years.”
MEDICAL HISTORY:
Mrs. Woman39 endorsed her mother's use of alcohol, cigarettes, and other substances while
pregnant with her.   She denied being a healthy child, primarily due to malnutrition and lack of
resources. The only ongoing health complaint she reported was migraine headaches, which began
after a major car accident at the age of 28 (described below). She does not take any prescription
medication for this condition. In May of 2010, she was prescribed Depakote (t.i.d.; dosage
unknown) while at XXX Recovery Center for Women, which, according to Mrs. Woman39, was to
help her cope with her Bipolar symptoms. She no longer uses this medication.
She has never been hospitalized for any physical illness. However, Mrs. Woman39 discussed
three major accidents for which she was hospitalized. The first incident was when she was five
years old, as discussed earlier, when she was in the car with her mother and her mother was killed.
She could not remember any injuries from that accident. In 1990, she was in a car accident when
her boyfriend crashed the car into a telephone pole, and Mrs. Woman39 reportedly, suffered a
Traumatic Brain Injury (TBI). She did not complete the full term of prescribed rehabilitation
therapy. Another head injury was sustained when Mrs. Woman39 was beaten with a baseball bat by
an ex-boyfriend at the age of 34. She claimed that the physicians at the hospital released her when
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an x-ray showed her skull was not fractured. This was the most recent time she has seen a doctor,
and she recalled her last physical examination to be at least 10 years ago.
Mrs. Woman39 explained that she either sleeps “all the time or hardly at all.” She elaborated
that often times she has trouble falling asleep as well as waking up too early because of racing
thoughts. Her eating habits were also reported to be sporadic and unhealthy.
SUBSTANCE ABUSE HISTORY:
Mrs. Woman39 described some early exposure to alcohol and marijuana, but claimed that she
“really found drugs” when she began to use cocaine at the age of 19. She estimated this use to be
nearly continuous from about 19 to 34 years old. Typical drug usage was detailed as several times a
day and “as much as we could get.” Mrs. Woman39 endorsed that by 28-29 years old, she was
heavily abusing numerous substances, including methamphetamines, cocaine, marijuana, opiates,
and alcohol. She endorsed needing more each time to obtain the previous effect, and she even
described the amount as “near suicidal,” because every time she used she was striving to get a larger
effect than the previous time. Some of the effects she experienced while intoxicated included
shaking, a foaming mouth, passing out, going blind, seeing "shadow people," and feeling
empowered. As she described a period of heavy drug use at approximately 29 years old, she told a
story of staying up for 45 days straight during which her psychotic symptoms were especially
prevalent.
She recalled a few periods where she tried to “get clean” for her daughters, which typically
lasted “a few months to a few years” long. Withdrawal effects included sleeping "all the time,"
feeling severely depressed, having many headaches and seizures, and gaining weight. The only
long-term effect of her use that Mrs. Woman39 identified was a decline in intelligence. During her
time in Drug Court, Mrs. Woman39 declared, she has made a commitment to stop using substances,
which is driven by her motivation to be a better mother and grandmother.

LEGAL HISTORY:
Although she did not appear nervous or unwilling to divulge this information, Mrs.
Woman39’s memories of the dates and charges of her various legal problems were vague and not
very consistent with judicial documentation. She recalled her first incident to be a traffic violation
and arrest around 1996. According to Missouri Court documentation, she received her first
violation as a landlord complaint. These records then indicate that Mrs. Woman39 received a
misdemeanor conviction in August 2008 for operating a motor vehicle while her driver’s license
was revoked, and after she failed to appear for trial she was sentenced to serve 90 days in the county
jail followed by two years of unsupervised probation. In 2009, she was issued a warrant, which was
served satisfactorily. Mrs. Woman39 recalled neither of those accounts. Consistent with
documentation and Mrs. Woman39’s report, in late 2009 she was arrested for manufacturing with
intent to distribute an illegal substance, for which she was sentenced 30 days in jail and 5 years of
supervised probation. This sentence marks the beginning of her involvement in the Drug Court
program.

INTERPERSONAL HISTORY & SOCIAL SUPPORT:

A pervasive pattern of unstable interpersonal relationships was described involving handful of
family members, several abusive boyfriends, and some “business acquaintances.” While living
with one of her sisters in Kansas, Mrs. Woman39 had a relationship with a man whom she
estimated to be in his late 40s, which lasted from the time she was 15 to 18 years old. She recalled
spending a significant amount of her time with this man, and during this time she became pregnant
twice, both times giving the children up for adoption. When this relationship ended, Mrs. Woman39
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moved back to Springfield.

Mrs. Woman39 recounted several intense dating relationships. She also explained the majority
of these to be emotionally and/or physically abusive. Her response to the abuse was to assume that
there was something she needed to change about herself and then she would be loved. Mrs.
Woman39 was married for the first time about 4 months ago. She described her husband as a
“knucklehead” who “really loves me…and perhaps the only person who ever has.” This
relationship began approximately two years ago, while he was “running away from federal parole”
and they lived on a farm “to hide.” Approximately one year ago, they returned to Springfield, and
“got caught.” They stayed in contact while they were “locked up” in separate facilities, and
reunited when they were both released.
Mrs. Woman39 denied difficulties in social situations, and described herself as "a social
butterfly." However, she also expressed that she does not trust people "one-on-one," and explained
that she does not have any true friends. Throughout the evaluation process, she evidenced a low
amount of social support as she continued to describe herself as feeling "empty," and frequently
articulating distrust of others.
CURRENT LIVING SITUATION:
Mrs. Woman39 is presently residing at the XXX residential substance abuse treatment facility,
in XXX, MO. She began her 30-day stay on XXX, 2010, after which she will return to her home in
Springfield, and resume living with her husband.
She reports “good” relationships and frequent contact with her two daughters (ages 16 and 18).
Mrs. Woman39 also reported that she often babysits for her youngest daughter's 2-year-old child.
Several times throughout the evaluation process, she emotionally expressed her daughters and
grandchild as being her motivation to “get better.” She expressed significant guilt that she “missed
a lot” of their childhood due to her drug-related activities.

MENTAL STATUS & BEHAVIORAL OBSERVATIONS:

Mrs. Woman39 was on time or early for most scheduled appointments. She does not drive, so
she gets around by bus or by means of her husband or brother. She cancelled one appointment 10
minutes prior to the scheduled time, claiming that she needed to watch her sick granddaughter.
Mrs. Woman39 was dressed in very casual attire, usually a baggy t-shirt and blue jeans, with
sandals. Her hygiene was adequate, but her hair was unkempt and she did not appear to be wearing
any makeup. She looks her age, without overt signs of aging or exhaustion. She has a tattoo of a
flower (approximately 1 ½ inches) on the inside of her wrist. Mrs. Woman39 presented herself as a
cooperative, easygoing woman throughout the assessment process; however, in her narrative
accounts she described numerous "neurotic" fears and a considerable amount of self-doubt and
feelings of worthlessness. The only manifestation of anxiety was excessive laughing at times when
she seemed hesitant to reveal feelings or beliefs that may appear "crazy." On later testing sessions,
she discussed the laughing as a coping mechanism, revealing insight that she often "laughed off"
events that were traumatic or "too deep" rather than cry about them.
She related to the examiner in a respectful and friendly manner, speaking openly, which
allowed rapport to be easily established. At times, she appeared overly chatty and uninhibited.
Mrs. Woman39 described her mood as "pretty good," most of the time, and then explained that
people call her "crazy" precisely because she is often seen as "happier than most." She claimed her
happy disposition is sometimes a "cover up" for feelings she does not want to acknowledge,
however her affect appeared to vary with the topic of discussion. There was clearly a baseline
buoyant presentation, but her affect would abruptly shift to tearfulness at times when she discussed
current distress and fear of abandonment regarding her daughters or husband.
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Although her baseline speech was of a typical rate, volume, and tone, Mrs. Woman39 spoke in
an animated manner as she relayed information through anecdotes. Her story-telling tended to be
long-winded and tangential, and she often provided indirect responses to the examiner's prompts or
questions. The relevance and sequence of these stories were sometimes difficult to understand. At
times there was evidence of illogical thoughts, such as when she explained that her ex-boyfriend
taught her to stand up for herself, and then she concluded by saying that she would do anything this
boyfriend told her to do. However, she used a high level of vocabulary fluently and appropriately.
Some psychotic symptoms were suggested based on her disclosure of abnormal thoughts and
her endorsement of visual and auditory hallucinations. For example, she recalled hearing her name
when no one else is home, and another time having a face-to-face discussion with her daughter who
was not actually present. She affirmed that the second mentioned example was validated in a phone
call with her daughter after the experience. Bizarre thoughts and paranoid ideation were also
endorsed. At first, Mrs. Woman39 was hesitant to reveal the content of her idiosyncratic beliefs for
which she claims others call her “crazy,” but with slight encouragement, she shared complex,
detailed theories about the AIDS epidemic, terrorists, and the recent oil spill, which she stated are
“based on valid facts.” She also articulated that in the last five years she has become “neurotic,”
providing examples of compulsive behaviors, including checking, straightening, and rituals in her
home. She admitted numerous past suicide attempts, with the most recent account being December
2009. However, she denied currents suicidal ideation or plans as well as homicidal ideation. She
denied ruminations or obsessions.
Mrs. Woman39 was oriented to time, place, person, and purpose. Overall, she appeared alert
and her attention span and concentration was adequate, although she made it clear when she was
becoming fatigued and the examiner varied tasks frequently which was effective in maintaining
effort. She initiated tasks in a confident, almost impulsive manner, by promptly beginning to
respond or work out problems. She remained on task throughout the assessment process and
declined breaks. She demonstrated interest and effort towards most tasks, but with increased
difficulty, she calmly accepted her inability to accomplish tasks. There was some evidence of self-
doubt when the examiner queried to clarify her responses. However, she tended to engage in tasks
with significantly more confidence than was reflected in her negative self-talk during discussions of
her history or ability to function on a daily basis.

RELIABILITY AND VALIDITY:

Mrs. Woman39 was cooperative throughout the evaluation and appeared to put forth her best
effort. Standardization procedures were adhered for all administration procedures. There were
several phone call interruptions during the clinical interview; the phone calls she received during
testing were ignored. No further interruptions were encountered. In light of her scores that
indicate a tendency to over-report distress, as well as her observed dramatic storytelling, the
severity of her problems should be considered with caution when evaluating these results.
However, with the depth and breadth of instruments utilized in this evaluation, an overall picture of
her mental health and cognitive functioning can still be provided with some accuracy. It will be
noted when various assessments are not valid or should be interpreted with caution.
ADMINISTRATION PROCEDURES:
 Beck Anxiety Inventory (BAI)
 Beck Depression Inventory - Second Edition (BDI - II)
 Clinical Interview
 Conners’ Adult ADHD Rating Scale (CAARS)
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 Controlled Oral Word Association Test (COWA)

 Finger Tapping Test
 Green’s Word Memory Test
 Grooved Pegboard Test
 Millon Clinical Multiaxial Inventory- Third Edition (MCMI-III)
 Minnesota Multiphasic Personality Inventory-Second Edition-Restructured Form (MMPI-2-
RF)
 Structured Interview of Reported Symptoms (SIRS)
 Spatial Span in Wechsler Memory Scale-III
 Test of Variable Attention (TOVA)
 Test of Written Language (TOWL)
 Trail Making Test (A & B)
 Wechsler Adult Intelligence Scale- Fourth Edition (WAIS-IV)
 Woodcock-Johnson III Tests of Achievement (WJ-III)

TEST RESULTS:
INTELLECTUAL FUNCTIONING:
WECHSLER ADULT INTELLIGENCE SCALE – IV (WAIS-IV)
Scaled or S/W Scaled or S/W
Verbal Subtests Standard or Performance Subtests Standard or
and INDICES Score %ile and INDICES Score %ile
Similarities 9 37 Block Design 9 37
Vocabulary 12 75 Matrix Reasoning 7
Information 10 50 Visual Puzzles 8 25
Comprehension (12) (75) Figure Weights 8 (25)
Picture Completion 10 (50)
Verbal Comprehension 102 55 Perceptual Reasoning 88 21
Digit Span 7 Symbol Search 9 37
Arithmetic 7 Coding 8 25
Letter Number Sequencing 9 37 Cancellation (9) (37)

Working Memory 83 13 Processing Speed 92 30

*Note: subtests in parentheses are supplemental and not included in FSIQ calculation.

SCALE Score Description %ile

Full Scale IQ 90 Low Average 25

To determine Mrs. Woman39’s overall cognitive abilities she was administered the Wechsler
Adult Intelligence Scale, Fourth Edition (WAIS-IV) from which her composite scores were derived.
Her general cognitive ability is within the Low Average range (FSIQ = 90, 95% confidence interval
= 86-94) of intellectual functioning as measured by the Full Scale IQ (FSIQ).
Intelligence is often considered to be comprised of a combination of verbal functioning (the
ability to think using words) and nonverbal functioning (the ability to reason without words). Mrs.
Woman39’s verbal abilities are in the Average range and significantly exceed her nonverbal
abilities, which are in the Below Average range.
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Mrs. Woman39’s verbal reasoning abilities as measured by the Verbal Comprehension Index are
in the Average range and above those of approximately 55% of her peers (VCI=102; 95%
confidence level = 96-108). The Verbal Comprehension Index is designed to measure verbal
retrieval, verbal reasoning, and concept formation. Her responses tended to be brief, expressed
through a few separated but related words or 3-4 word phrases. When the examiner queried for
more information, this appeared create to self-doubt as evidenced in a hesitant tone and frequent
expressions of "Well, I don't know..." Mrs. Woman39 demonstrated personal strengths on two
activities that relied on her knowledge of vocabulary and general facts. A personal strength
indicates that she scored significantly higher than her average score on each subtest. This strength
likely comes from the extensive amount of reading she recounted, "I was always a really good and
fast reader... I used books as an escape from all the bad stuff going on."
Mrs. Woman39’s nonverbal reasoning abilities, as measured by the Perceptual Reasoning Index,
are in the Low Average range and above approximately 21% of her peers (PRI= 88; 95%
confidence level = 82-95). The Perceptual Reasoning Index is designed to measure nonverbal
concept formation, visual perception and organization, simultaneous processing, visual motor
coordination, learning, and the ability to separate figure and ground in visual stimuli. The client’s
performances on the subtests that contribute to the PRI show these skills to be equally developed.
On the subtest that required her to assemble blocks to re-create a three-dimensional model identical
to a two-dimensional image, Mrs. Woman39 initially approached the task with confidence, but
quickly became frustrated with her inability to complete the task with ease. In this subtest, her
performance demonstrated the ability to analyze and synthesize visual-spatial material to be a
personal weakness, as her scores were lower than her average score for all areas. This also
represents a normative weakness, as she scored lower than the average for the comparison sample
of individuals her age.
Her working memory abilities as measured by the Working Memory Index are in the Low
Average range, and above those of 21% of her peers (WMI = 83; 95% confidence level = 77-91).
The abilities to sustain attention, concentration, and exert mental control make up the WMI, and
Mrs. Woman39's performances indicated that these abilities are equally developed.
Mrs. Woman39’s speed of processing abilities, as measured by the Processing Speed Index,
are in the Average range and above those of approximately 30% of her peers (PSI= 92; 95%
confidence level= 84-101). This index is an indication of the rapidity with which she can mentally
process simple or routine information without making mistakes. Both visual discrimination and
visual motor coordination influence performance in this area, and her skills in these appear to be
equally developed.
Mrs. Woman39 achieved her best among the tasks that relied on her ability to think in words
and reason with verbal information. Her lowest score was on working memory tasks that required
her to sustain attention while listening, and hold numerical information accessible in her memory
long enough to manipulate it and state it aloud.
Mrs. Woman39’s impulsive approach style was clearly helpful in getting her to begin timed tasks
efficiently, and she appeared to enjoy the challenge of completing tasks as fast as possible. As she
attempted to solve tasks that involved recognizing and synthesizing relationships among visual-
spatial stimuli, or hold information in her short-term memory long enough to manipulate it, she
appeared to have difficulty focusing on the immediate goal long enough without mental
distractions. This may be a factor that contributed to her lower scores in these tasks. Furthermore,
these latter tasks depend on a fluid form of knowledge, that requires reasoning and interacting with
information as opposed to the crystallized, fact based knowledge that she demonstrated in her best
performances. Life experiences such as substance abuse, head injuries, illness, and a lack of
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intellectually stimulating environments are common causes for declining abilities with fluid
cognitive skills. This appears to fit with Mrs. Woman39's history.

LANGUAGE AND ACHIEVEMENT:

CONTROLLED ORAL WORD ASSOCIATION
Task # of Words Mean SD z Score
F 12
A 10
S 10
Total 32 40.5 10.7 -0.79
Category 17 21.5 5.5 -0.82
Mrs. Woman39 was administered the Controlled Oral Word Association (COWA) test as a
measure of verbal knowledge and abstract mental operations. Her overall performance was Average
based on normative groups of women her age with her education level. She performed similarly
when given letters or categories as prompts.

TEST of WRITTEN LANGUAGE – 3 (TOWL-3) (informally scored)

Mrs. Woman39 was administered the story portion of the Test of Written Language-Third
Edition (TOWL-3) as an assessment of written expression. An informal analysis of her story is
provided. Mrs. Woman39 constructed a creative, but difficult to follow plot. Her story had 6
sentences, which tended to be complex or even run-ons. The number of sentences is significantly
less than the average of 20 sentences within 15 minutes. The story was difficult to read, due to a
tangential flow. Although all sentences revolved around the same theme and characters, there were
numerous phrases that were awkward to the sequence of the narrative. In addition, there were many
areas in which Mrs. Woman39 had scratched out words, suggesting she was changing her mind
and/or her thoughts were interrupting the flow of her writing process. The story had minimal
punctuation errors, but frequent capitalization errors. Although there were eight spelling errors, they
were phonetically decodable.

ATTENTION, MEMORY, AND CONCENTRATION:

SPATIAL SPAN SUBTEST – WECHSLER MEMORY SCALE-III
Mrs. Woman39 was administered the Spatial Span subtest from the Wechsler Memory Scale –
Third Edition. This subtest requires both attention and working memory skills. Mrs. Woman39’s
scores on this subtest ranged from Low to Average ability level. Her performance appeared to
improve over the course of the tasks. At the beginning she appeared confused about following the
directions, maintaining focus, and remembering the location of the correct sequence of blocks to
tap, and the examiner had to explain directions twice and provide corrective feedback on both
practice trials. This is consistent with the difficulties she demonstrated on other tasks that required
focused attention and working memory.

GREEN’S WORD MEMORY TEST

Mrs. Woman39’s performance on the various memory tasks of Green’s Word Memory Test
indicate that caution is needed in interpreting her scores on this assessment as well as other
measures requiring conscious effort. Test scores may underestimate her abilities.
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TEST OF VARIABLE OF ATTENTION (TOVA)

The Test of Variable of Attention (TOVA) is an individually administered computerized test
developed to assess attention and impulse control in comparison to established norms. Errors are
calculated with respect to both attention and impulse control. Errors of omission occur when one
does not respond to the designated target and are a measure of overall attention. Errors of
commission occur when one fails to inhibit responding and incorrectly responds to a non-target.
Individuals who are administered the TOVA are given an ADHD score that summarizes their
performance on this task. An ADHD score of -1.80 or less (more negative) is suggestive of ADHD
while a score more than -1.80 (more positive) is not. Mrs.Woman39’s ADHD score was -7.24,
which is not within normal limits. These results are suggestive of an attentional disorder. A review
of her performance revealed that omission errors significantly worsened from the first quarter to the
second quarter, suggesting difficulty maintaining attention after 5-6 minutes of a monotonous or
unstimulating task. Then, her performance shifted toward an impulsive approach during the final
subtest. This is typically suggestive of difficulty controlling impulsivity after 15 minutes on task
and /or after 5 minutes of a highly stimulating task. Although Mrs. Woman39’s attentional
difficulties were sometimes observed as problematic during other tests, the extreme severity
suggested by the TOVA score should be viewed with caution, as suggested by scores that reflect a
tendency to overreport symptoms and tendency to undermine full effort.

CONNERS’ ADULT ADHD RATING SCALE (CAARS- S:L)

Subscale T-Score Subscale T-score
A – Inattention/Memory
83 E – DSM-IV Inattention Symptoms 87
Problems
F – DSM-IV Hyperactive-Impulsive
B – Hyperactivity/Restlessness 70 68
Symptoms
C – Impulsivity/Emotional
79 G – DSM-IV Symptoms Total 83
Lability
D – Problems with Self-Concept 68 H – ADHD Index 83

The Conners’ Adult ADHD Rating Scale – Self Report: Long Version (CAARS – S:L) is a self-
report measure designed to assess symptomatology and behaviors in adults which are consistent
with a diagnosis Attention Deficit Hyperactivity Disorder (ADHD). Mrs.Woman39 had several
significant elevations. Her highest elevations suggest trouble with concentrating, often losing
objects necessary for tasks, problems keeping attention focused while working, trouble listening to
others, and making careless mistakes. The DSM-IV Inattentive Symptoms & ADHD Index scale
elevations support a diagnosis of ADHD of the inattentive subtype.

MOTOR ABILITIES:
FINGER TAPPING TEST
Hand Average Mean SD z Score
Left 46 40.6 5.6 0.96
Right 54.4 44.3 5.8 1.74
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Finger tapping is primarily a test of simple motor speed. It also requires the executive functions
of planning and initiation of behavior. Mrs. Woman39’s performance with her left (nondominant)
hand fell within the Average range, and her performance with her right (dominant) hand fell within
the Above Average range of ability (faster tapping than her peers).

GROOVED PEGBOARD
Hand # of Drops Time (Sec.) Mean SD z Score
Left 0 79 66.8 10.7 1.14
Right 0 70 62.8 8.9 .84

The Grooved Pegboard Test measures one’s complex visual-motor-tactile integration and
psychomotor speed, as compared to other tasks which generally assess simple sensory-motor skills.
Mrs. Woman39’s performance was in the Average range for her right hand, and Below Average
(slower than her peers) for her left hand.

EXECUTIVE FUNCTIONING:

BOOKLET CATEGORY TEST

Subtest I II III IV V VI VII Total T score Interpretation
Errors 0 0 31 2 15 4 5 57 41 Below Average
Executive functioning refers to the ability to control one’s own thinking processes and one’s
behavior. It includes being flexible in thinking, being able to sequence, to alternate between ideas,
and to plan ahead. The Booklet Category Test was administered as a test of reasoning, problem
solving, and flexibility.
Mrs. Woman39 performed within the Below Average range based on the number of errors she
committed throughout the test, as compared to other women her age. Her difficulty with planning
was observed several times when she was told that she made an error and then appeared to guess at
the next item rather than using the error to plan a strategy that would help her discover the
underlying theme of the subtest's designs.

TRAIL MAKING TEST

Task # of Errors Time (sec.) Mean SD z Score
Trails A 0 28 30.2 10.4 -.21
Trails B 0 71 64 23.4 .30
The Trail Making Test serves as a measure of mental activities, attention, and speed of
information processing. It requires complex scanning, coordination, visual tracking, speed, and
motivation. In addition, it provides information regarding sustained and altering attention skills
along with sequence and motor skills. Mrs. Woman39’s performance was in the Average range for
both versions of this assessment.

EMOTION AND BEHAVIOR:

MINNESOTA MULTIPHASIC PERSONALITY INVENTORY-2-RESTRUCTURED FORM
(MMPI-2-RF)
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Mrs. Woman39 was administered the MMPI-2-RF, an objective measure of emotional

functioning. A review of the validity scales (TRIN-r: 80T; F-r:120; Fp-r:119; Fs:120; FBS-r: 99)
suggests that Mrs. Woman39 was likely over-reporting psychological dysfunction, thus invalidating
this assessment. Her inconsistent responding, excessive number of infrequent responses, and
assertion of a considerably larger than average number of psychopathological and somatic
symptoms all reflect a strong likelihood of over-reporting.

MILLON CLINICAL MULTIAXIAL INVENTORY - III

Category Base Rate Scores
Disclosure Desirability Debasement
Modifying
Indices 78 25 81

Schizoid Avoidant Depressive Dependent Histrionic Narcissistic

90 70 86 84 17 49
Clinical
Personalit Antisocial Sadistic Compulsive Negativisti Masochistic
y Patterns c

80 66 25 63 84
Severe Schizotypal Borderline Paranoid
Personalit
y 82 91 62
Pathology
Anxiety Somatofor Bipolar: Dysthymia Alcohol Drug Post-
m Manic Dependence Dependenc Traumatic
Clinical e Stress
Syndromes
101 71 98 101 83 103 113

Severe Thought Major Delusional

Clinical Disorder Depression Disorder
Syndromes 83 107 70
The Millon Clinical Multiaxial Inventory – Third Edition (MCMI-III) is a standardized, self-
report questionnaire designed to assess characteristics of a client's personality structure and
emotional adjustment. Ms. Woman39 was administered the MCMI-III to aid in diagnostic
decisions and to gain further insight to her current level of psychological functioning.
An examination of the validity scales suggest that Mrs. Woman39 was overly willing to share
problems, and also that she responded in a manner to highlight and possibly exaggerate her
symptoms. Although this may be a reflection of severe psychopathology, given her scores on other
measures that demonstrate the same bias, it is most likely that Mrs. Woman39’s presentation of
herself is at least slightly skewed in terms of the severity of her symptoms.
Although the overall profile is not an accurate representation of her personality structure, the
elevations on the Borderline and Schizotypal Severe Personality Scales provided support for further
investigating evidence for a personality disorder by means of additional clinical interviewing.
BECK DEPRESSION INVENTORY – Second Edition (BDI-II)
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The BDI-II is a self-report instrument used to measure the severity of depressive symptoms in
adults and adolescents. It provides an assessment of symptoms corresponding to criteria for
diagnosing depressive disorders. Mrs. Woman39 obtained a score of 41, which is indicative of
severe symptoms of depression. The most prominent symptoms she endorsed included loss of
interest, loss of pleasure, loss of energy, indecisiveness, and changes in sleeping. Scores of this
magnitude are above the typical degree of depressive symptoms endorsed by people with Major
Depressive Disorder.
BECK ANXIETY INVENTORY (BAI)
The BAI measures severity of anxiety in adults. Given that anxiety and depression often coexist, the
BAI is constructed to measure symptoms of anxiety which are minimally shared with those of
depression. Mrs. Woman39 obtained a score of 25, indicating that she is experiencing severe
symptoms of anxiety. She specifically endorsed feeling severely bothered by symptoms of having a
"fear of the worst happening," and a "fear of losing control," and feeling "nervous” over the past
week. This is consistent with reported worries and intrusive thoughts, and is likely suggestive of an
Anxiety Disorder.
It should be noted that both the BDI-II and BAI are sensitive to response style on the MMPI-2-
RF. Although mood symptoms are likely to be contributing to Mrs.Woman39's overall distress and
functional impairment, the subjective magnitude of these problems is likely exaggerated.

STRUCTURED INTERVIEW OF REPORTED SYMPTOMS (SIRS)

Primary Scales Scaled Scores Category of Response
Rare Symptoms 6 Probable Feigning
Symptom Combinations 2 Honest
Improbable or Absurd Symptoms 2 Honest
Blatant Symptoms 13 Probable Feigning
Subtle Symptoms 27 Definite Feigning
Selectivity of Symptoms 25 Probable Feigning
Severity of Symptoms 15 Probable Feigning
Reported vs. Observed Symptoms 6 Indeterminate
Supplementary Scales Scaled Scores Category of Response
Direct Appraisal of Honesty 6 Honest
Defensive Symptoms 24 Indeterminate
Overly Specified Symptoms 0 Honest
Symptom Onset 2 Honest
Inconsistency of Symptoms 5 Honest

The Structured Interview of Reported Symptoms (SIRS) is a systematic assessment of

deliberate distortions in self-reports of symptoms. Mrs. Woman39’s dramatic presentation of many
distressing symptoms and a complex history, combined with her perception of legal implications
that may result from the present evaluation, suggested a need to evaluate the likelihood of deliberate
misrepresentation. In addition, her scores on the MMPI-2-RF, which suggest inconsistent
responding and a high likelihood of over-reporting, support the possibility of deliberate distortion of
her symptoms. Mrs. Woman39 was administered the SIRS to gain further information about the
nature of her response style.
Outcomes from the SIRS revealed four scores in the “Probable Feigning” range and one
score in the “Definite Feigning” range. Mrs. Woman39’s markedly elevated score on the Subtle
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Symptoms scale indicates that she has a very atypical presentation and a tendency to endorse
symptoms that untrained individuals would typically associate with everyday problems or minor
maladjustment rather than mental illness. She also showed an elevated score on the Rare
Symptoms, Severity, and Selectivity Subscales, indicating an overall measure of symptom
endorsement utilized to identify an indiscriminate endorsement pattern, even to a severe degree.
Mrs. Woman39’s elevated scores overall denote a need to use caution in interpreting her self-
reports.
An important clinical distinction is whether Mrs. Woman39’s behavior is motivated by an
external incentive (i.e., malingering) or merely to assume a patient role (i.e., Factitious Disorder
with Psychological Symptoms). Mrs. Woman39 spoke frequently about acting “like her sisters”
who she refers to as “crazy” and “Schizophrenic.” It is unclear what she believed may come of this
evaluation, except that it can “help the court understand her problems.” With the variety of
difficulties she reports, and demonstrates at least to some degree, concerning mood, interpersonal
relations, concentration, and psychotic symptoms, it is most likely that she is over-reporting but not
completing malingering.

SUMMARY AND DIFFERENTIAL DIAGNOSIS:

Woman39 is a 39-year-old, married, Caucasian female. She was referred by the Greene
County Drug Court for a psychological evaluation to clarify her level of psychological functioning,
obtain a diagnosis, and receive recommendations for treatment. Mrs. Woman39 is currently
residing at XXX Behavior Healthcare facility for substance abuse rehabilitation.
Mrs. Woman39’s childhood was scattered with abuse, traumatic events, and many acting-out
behaviors. She witnessed the traumatic death of her mother in a car accident at the age of five, and
then continued to live with an alcoholic abusive father who abused her physically and emotionally.
She recalled countless difficulties at school, as well as several attempts to run away and/or commit
suicide. Her interpersonal history also revealed instability, and appeared to revolve around her
substance use. A lack of social support was evidenced in her described mistrust of others and
feelings of being “empty” and unlovable. A family history of mental illness included two accounts
of sisters with symptoms resembling Schizophrenia, another sibling with depression, and several
others with substance-related disorders. All medical conditions endorsed were caused by severe
injuries incurred through car accidents or abusive situations. This included a TBI when she was
about 29 years old, and being hit on the head with a baseball bat when she was 34 years old. She
reported migraines and seizures after these hospitalizations.
Mrs. Woman39 endorsed long-term use of numerous substances, including methamphetamines,
cocaine, cannabis, opiates, and alcohol. She was unable to provide estimate measures, but
considered her use to be “suicidal” in frequency and amount. The maladaptive pattern of
impairment, dependency, and withdrawal effects Mrs. Woman39 depicted on a timeline meet the
criteria for Substance Dependence for cannabis and methamphetamine. Although numerous other
substances were reported to be used on occasion in conjunction with these drugs, these two
substances predominated at particular time periods, and her use clearly meets the criteria for
cannabis and methamphetamine independently rather than as a diagnosis of Polysubstance
Dependence. The reported dates of her last use were used to determine remission specifiers.
Based on this evaluation, Mrs. Woman39’s general cognitive ability is in the Average range of
intellectual functioning (FSIQ: 90) as measured by the Wechsler Adult Intelligence Scale- Fourth
Edition (WAIS-IV). A personal strength was revealed during her performance with tasks that
required verbal reasoning and knowledge of vocabulary.
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Attentional difficulties were assessed using a self-report questionnaire (The Conners’ Adult
ADHD Rating Scale – Self Report: Long Version; CAARS – S:L), and an objective attentional task
(The Test of Variable of Attention, TOVA). Mrs. Woman39’s performance suggests difficulties
with maintaining attention on the task at hand, a limited attention span, and frequent careless
mistakes resulting from poor concentration. Mrs. Woman39’s performance on memory tasks was
similarly poor. On the Working Memory Index of the WAIS-IV, she performed in the Low
Average range. Then on the Wechsler Memory Scale- Fourth Edition (WMS-IV) her performance
ranged from Low to Average. Her performance on The Booklet Categories Test was in the Low
Average range due to difficulties with both short-term memory and planning skills. However, on
the Trail Making test and several other brief motor tasks she performed in the Average range. In
sum, her functional impairments seem to be resulting more from cognitive distractions when she is
not fully engaged in a stimulating activity or needs to perform calculations or manipulate
information in her mind. Based on observations and the client’s reported history, it seems most
likely that these attentional and concentration difficulties do not warrant any additional diagnosis,
but instead are symptoms accounted for by her other diagnoses regarding dysregulated mood
problems and psychotic symptoms.
Mrs. Woman39 was assessed to determine her current social-emotional functioning. Her
responses on the MMPI-2-RF demonstrated a pattern of over-reporting so excessive that the
protocol was considered invalid. Thus, the clinical scales could not be interpreted and additional
measures (especially the BAI and BDI-II) may be overestimates of her current symptoms. Mrs.
Woman39 was also administered the Millon Clinical Multiaxial Inventory – Third Edition (MCMI-
III) as another means to assess emotional adjustment, as well as to detect the presence of a
personality disorder. Her responses again demonstrated a tendency to exaggerate or magnify
symptomatology, thus limiting the accuracy of the profile produced. However, the elevations on the
Borderline and Schizotypal Severe Personality Scales provided support for further investigating
evidence for a personality disorder by means of additional clinical interviewing.
The pattern of intense, yet unstable relationships in Mrs. Woman39’s history was an indicator
of Borderline Personality Disorder. The way she spoke about her husband and their marriage
displayed frequent fluctuations from adoring him to angry statements that revealed fears of his
abandonment or disloyalty. For example, while admiring that he “is all heart,” she reflected, “I
often wonder how valid his love is… I’m like waiting for the ball to drop.” She justified her fear of
him leaving by talking about other lies he has told. Her self-image was similarly labile, shifting
from confidence about not having any fears, to her frequent disappointments at “letting people
down” for “not being good enough.” Accompanying these changes were behaviors and facial
expressions that clearly evidenced a reactive affect. Further supporting a diagnosis for Borderline
Personality disorder was her endorsement of various paranoid ideation and the impulsivity
characterized by her history of acting-out behaviors.
Mrs. Woman39 obtained a score of 41 on the Beck Depression Inventory- Second Edition
(BDI-II), indicating severe symptoms of depression. Although her tendency to over-report distress
indicates caution in interpreting this elevated score, difficulties regulating her mood were evident in
both her presentation and reported accounts. She endorsed experiences that meet the criteria of a
Mixed Episode. Reviewing the timeline she created with the examiner, it was decided that the
presence of her psychotic symptoms described earlier (hallucinations and delusions) were
sometimes concurrent with these Mixed Episodes and other times occurred in the absence of the
mood symptoms. However, the mood symptoms, including loss of pleasure, changes in sleeping, or
increased goal-directed behavior, were reported to be present in various combinations the majority
of the time, thus qualifying a diagnosis of Schizoaffective Disorder, Bipolar Type.
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Ruling out a substance-induced etiology based on Mrs. Woman39’s reported history was
difficult. Substance use can produce symptoms that resemble the mood, anxiety, and perceptual
abnormalities described by Mrs. Woman39. Furthermore, research suggests that long-term use of
substances, particularly methamphetamine, can result in structural changes to the brain that can lead
to psychotic symptoms. However, the DSM-IV-TR specifies that the persistence of symptoms a
month or more after the end of use are more likely to be better accounted for by a primary disorder.
Although Mrs. Woman39 endorsed her psychotic and mood symptoms as beginning during a period
of time when she was using drugs, they have remained at a level of significant impairment much
longer than would be expected by a Substance-Induced Disorder. A similar process was used to
determine whether her symptoms should be attributed to her head injuries, but in the absence of
medical records, evidence is lacking to substantiate a Disorder Due to a General Medical Condition.
However, it is recommended that Mrs. Woman39 consult a physician for a comprehensive
evaluation of her physical condition.
Various expressions of anxiety were endorsed. On the Beck Anxiety Inventory (BAI) she
obtained a score of 25, indicating moderate symptoms of anxiety. In light of the primarily cognitive
nature of her anxiety complaints (i.e., "fear of the worst happening," "fear of losing control”), it is
likely that these are accounted for by the paranoia and delusions within the Schizoaffective
diagnosis, as well as the instability experienced as a result of her Borderline Personality Disorder.
Although a diagnosis of Obsessive-Compulsive Disorder was considered, her reported compulsive
behaviors do not appear to be time consuming or significantly interfering with her daily functioning,
and thus Mrs. Woman39 did not meet the full criteria for this diagnosis.

DIAGNOSTIC IMPRESSION:

Axis I: 295.70 Schizoaffective Disorder, Bipolar Type

304.40 Methamphetamine Dependence, Early Full Remission
304.30 Cannabis Dependence, Early Partial Remission

Axis II: 301.83 Borderline Personality Disorder

Axis III: Migraines

Axis IV: Problems with the legal system, Marital Discord

Axis V: GAF= 50 (current)

TREATMENT RECOMMENDATIONS:
 Due to the accidents she suffered as well as her long-term drug usage, Mrs. Woman39
should visit a medical doctor to have a complete physical examination conducted. An
evaluation will allow a doctor to assist her in developing steps she should take to improve
her health.

 After her inpatient stay, Mrs. Woman39 should continue to participate in substance abuse
treatment. She is experiencing a high level of functional impairment, which suggests a need
for a long duration of treatment. A group setting is recommended to provide an opportunity
for her to experience social support and learn interpersonal skills.
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 The complexity of Mrs. Woman39’s mental health problems is suggested by the recurring
themes of instability in her relationships, identity, and mood. Individual psychotherapy is
recommended, and this treatment should focus on resolving long standing conflicts by
altering the way she relates to others. This can be accomplished with a variety of cognitive-
behavioral and/or dialectical-behavioral techniques.

 Considering the way Mrs. Woman39 tends to relate to others, those involved in her
treatment plan should anticipate problems with compliance. Mrs. Woman39 may interpret
therapist behaviors as indicative of rejection or look for signs of trust betrayal. Effective
efforts to counter her fears of disappointment in therapy or lack of success in treatment will
allow her to build confidence in herself and trust in others.

 Mrs. Woman39 appears to strive to present herself in a positive manner, and desires to be
accepted by others. This may bode well when surrounded by people supporting treatment,
but benefits of treatment will likely fade quickly if she is reintegrated in a social network
with individuals who condone her substance use. She identified family members who may
not believe she is committed to quitting. It may be beneficial for positive role models or
counselor to assist her with articulating boundaries to these people and with creating
distance from past cues for substance use.

 Mrs. Woman39’s strengths in vocabulary and verbal reasoning can be utilized with
bibliotherapy techniques, by encouraging her to read texts related to her treatment goals.

____________________________________________
Lindsey Steding, B.A. Date
Psychological Trainee

___________________________________________
Steve Capps, Ph.D. Date
Licensed Psychologist/ Supervisor

___________________________________________
Paul Deal, Ph.D. Date
Licensed Psychologist/ Supervisor