Personal Information

Name: Mr. Pikachu

Sex: Male
Age/Civil Status: 22 years old/Single
Birthdate: September 9, ****
Birthplace: Quezon City
Educational Attainment: Senior High School

Source of Referral: Dr. Caterpie

Reasons for Referral: Neuropsychological evaluation to rule-out or confirm the presence of
Major Depressive Disorder

Case History

Mr. Pikachu is a 22-year-old Filipino who was born on September 9, ****. He is currently
residing at Matapang Street, Quezon City and is living with his family. He is a third-year
engineering student at CEU merge class.

Mr. Pikachu was referred by Dr. Caterpie for a neuropsychological evaluation in order to rule-out
or confirm the presence of Major Depressive Disorder.

It must be noted that all background information in this evaluation is based on the information
given by Mr. Pikachu and his mother during the assessment.

Mr. Pikachu was born via caesarean section on the year ****. He reported to have been
described by his parents as a curious baby as he reached the different developmental milestones
of his life. Also, he considers himself to have grown normally with no physical defects from birth
till present. His academic performance was described as above average; he was a consistent
honor student during his elementary and high school years. However, during college, his
performance decreased from above average to average ratings. On the other hand, his
relationship with his peers, classmates, and teachers were reported to be generally fine as no
significant disruptive experiences were reported by Mr. Pikachu during the interview.

Currently, he described himself as someone who is in need of exercise to improve his physical
health. Additionally, his mental health was reported to be healthy at times but he is afraid that he
might experience the same depressive episodes again. In relation to this, he is taking Arcalion
and Brintellix to address the symptoms of depression; these medications were prescribed by his
attending physician Dr. Wazowski from Monster University Medical Hospital since the first
week of October, 2017.

With regard to Mr. Pikachu’s family history, an existing medical history of asthma from his
mother’s side was reported. Also, he stated that his mother, older brother, and older sister
experienced depressive episodes at certain stages of their lives which were similar to the stage
Mr. Pikachu is currently in. Both parents are still alive. However, he only speaks to his mother as
he received a lot of verbal punishment from his father growing up. He was the youngest child
with two older brothers and an older sister. In relation to this, his relationships with his siblings
were described to be generally fine by Mr. Pikachu.

Mr. Pikachu is currently in a relationship with a girl he met from an online game. She was his
first girlfriend and their relationship started last September 2016. Their relationship was
described to have a lot of romance and was very sweet in the beginning, during the honeymoon
stage. However, Mr. Pikachu’s sweetness was described to become more relaxed after a few
months. This resulted to their break-up last August 2017 which triggered Mr. Pikachu’s recent
depressive symptoms until they got back together by the month of October within the same year.
These events prompted Mr. Pikachu to seek professional help as he is afraid that he might
experience the same depressive symptoms again.

Mr. Pikachu initially experienced depressive symptoms in the month of September last 2016.
According to his reports, it was originally experienced during a summer semester where he
suddenly felt separated from his classmates. Additionally, he described that his academic
performance declined and that he felt overshadowed by his other classmates. As a response to the
given circumstances, he then began to go on his own, spending time in a nearby computer shop
during break times and would directly go home after his last class.

Eventually, a concerned classmate referred him to a professor for help. Then, a staff from their
school guidance office also conducted an interview. These referrals lead to an appointment with
the guidance office and a doctor from their school clinic who suggested that he needs to see a
psychiatrist. On September 2016, he met a psychiatrist from the Walt Disney Medical where he
had an interview session. In addition to this, his classmate also referred him to a psychologist
within their school. He failed to report the details related to the said referrals and interviews as he
claimed to have forgotten them all. After the appointment with a psychiatrist where he allegedly
wasn’t able to receive assessment results or interventions the reported symptoms eventually
waned down until a relapse occurred between the months of June and July 2017.

Mr. Pikachu reports to have experienced severe forms of depressive symptomatology in June or
July 2017. However, he failed to identify a specific trigger for such experiences. Nonetheless, he
confirmed that he recently felt sad most of the day. Also, his interest in previously enjoyable
activities was also affected. In relation to this, he slept a lot and had a hard time getting up from
bed. Furthermore, he reports to have experienced feelings of worthlessness, diminished ability to
concentrate, and had contemplated on committing suicide within the past month. Conversely, no
attempts of suicide or any forms of self-harm were reported during this time.

On the other hand, the mother of Mr. Pikachu supported his reports about the first time he
experienced the said depressive symptomatology last September 2016. This time, Mrs. Ash
identified an event that could’ve triggered her son’s depression; Mr. Pikachu was transferred
from Management Engineering course to an Engineering course within the same university but
this transfer separated him from the rest of his friends. Mrs. Ash also noticed that these
depressive symptoms eventually waned down, the reason why they weren’t able to do a follow-
up on the interview he had with his psychiatrist last September 2016.
However, by August 2017 she noticed that Mr. Pikachu had constant fights with his girlfriend
almost every night. She added that they decided to end their relationship within the same month
and by the month of September 2017, Mr. Pikachu began to again overtly manifest symptoms of
depression. Additionally, he posted that he satisfied five out of nine symptoms of depression at
Facebook. Also, upon immediate confrontation, Mr. Pikachu talked about suicidal ideation and
other causes he identified to have triggered the depression which includes her mother’s strict
requirements for academic performance, existing family dynamics which was described as less
expressive, and his resentment towards his father.

Behavioural Observation
Mr. Pikachu went to the evaluation appointment wearing casual clothing. He was accompanied
by his mother. He was very cooperative all throughout the entire assessment procedure and was
able to perform and accomplish different tasks without losing focus or interest. No irrelevant
behaviours and gestures were observed during the entire assessment. However, he expressed
fatigue during the final phase of the intelligence test but eventually agreed to continue the
assessment after a short break. Lastly, expressive and receptive language ability were intact
during the entire assessment procedure.

Tests Results
A. General Intellectual Ability

WAIS-IV

Composite 95% Confidence Percentile Qualitative

Index
Scores Interval Rank Description
Verbal
105 99-110 63rd Average
Comprehension
Perceptual
105 99-111 63rd Average
Organization
Working
111 104-117 77th High Average
Memory
Processing
124 113-130 95th Superior
Speed
Full Scale IQ 112 108-116 79th High Average

Summative interpretation of General Intellectual Ability

Results

Mr. Pikachu was tested to be able to analyze his Verbal Comprehension, Perceptual Organi-
zation, Working Memory, Processing Speed, and Full-Scale IQ. Results showed that Mr.
Pikachu scored average to comprehend the spoken language. As for the client's perceptual or-
ganization, he also acquired an average score. In terms of working memory, the client's abil-
ity to memorize new information is higher than average. On the other hand, the score of
 client's processing speed was classified as superior ranking. Lastly, his full-scale IQ was seen
to be high average.

Mr. Pikachu’s score shows that he is at a higher level regarding processing speed than others.
His verbal comprehension and perceptual organization scores are in line with the average
level, with the same total scores and percentile rank. However, his cognitive processing abil-
ity is high on average. In general, his full-scale IQ suggests that he has a higher intellectual
ability than the usual person.

Interpretation

Mr. Pikachu's WAIS-IV evaluation results suggest that he is within the normal range for Ver-
bal Comprehension and Perceptual Organization. It implies that he can easily use, under-
stand, and think with spoken language for Verbal Comprehension. Mr. Pikachu’s Perceptual
Organization index average score indicates that he is capable of accurately interpreting, sys-
tematizing, and thinking with visual information.

In terms of Working Memory, Processing Speed, and Full IQ Scale, he performed admirably.
He received High Average and Superior scores on these indices. In the High Average range,
he can maintain attention, focus, and exert mental control. This is also reflected in the fact
that he was a consistent honor student throughout his elementary and high school years.

B. Affective and Personality Domains

PAI – Personal Activity Intelligence

Scale Raw (T) Description Score Interpretation

Score Score
Validity Scales:
Inconsistency (INC) Measures the subject’s The score implies that he
8 58 consistency in answering did respond consistently
and attended appropriately
to PAI item content.
Infrequency (INF) Measures random Interpretation
responding, indifference, The score indicates that the
3 51 carelessness, confusion, or client understood and
reading difficulties answered each item
correctly.
Negative Impression Measures possible Interpretation
(NIM) malingering The score indicates that he
11 84 may have exaggerated his
responses.

Positive Impression (PIM) Measures possible Interpretation

presentation of a very The score suggests that he
5 27 favorable impression has little to no interest in
presenting himself
favourably.
Clinical Scales:
Somatic Complaints 33 72 Measures preoccupation Interpretation
(SOM) w/health matters & somatic
complaints
Anxiety (ANX) Measures phenomenology
39 71 & observable signs of
anxiety
Anxiety-Related Disorders Measures symptoms &
(ARD) behaviors specific to
46 81 anxiety disorders
Depression (DEP) Measures symptoms &
52 90 phenomenology of
depressive disorders
(unipolar)
Mania (MAN) Measures the affective,
32 60 cognitive, & behavioral
symptoms of mania &
hypomania
Paranoia (PAR) Measures symptoms of
46 82 paranoid disorders & more
enduring characteristics of
paranoid personality
Schizophrenia (SCZ) Measures symptoms
relevant to the broad
36 78
spectrum of schizophrenic
disorders
Borderline Features Measures attributes related
(BOR) to borderline level of
personality functioning,
indicating unstable &
57 89
fluctuating interpersonal
relations, impulsivity,
affective lability &
instability, & uncontrolled
anger
Antisocial Features (ANT) Measures history of illegal
acts & authority problems,
24 62 egocentrism, lack of
empathy/loyalty, instability
& excitement-seeking
behavior/s
Alcohol Problems (ALC) Measures problematic
4 49 consequences of alcohol-use
& features of alcohol-
dependence
Drug Problems (DRG) 6 54 Measures problematic
consequences of drug use
(prescription & illicit) &
His score indicates that he
is likely to accept that his
health is worse than that of
his peers, and that his
medical problems are more
challenging and
distressing.
Interpretation
His score suggests that he
may show signs of anxiety
and tension.
Interpretation
His score indicates that he
may be viewed as insecure
and uncomfortable in
social situations.
Interpretation
He may appear to be
unhappy, pessimistic, and
self-conscious.
Interpretation
This indicates that he may
be irritable and impatient.
Interpretation
His score indicates that he
has the potential to be
doubtful and violent.
Interpretation
He is likely to be
withdrawn, isolated, and
alienated, based on his
score.
Interpretation
He is prone to being
impulsive, openly angry,
moody, and emotionally
unstable.
Interpretation
This suggests that he may
have a history of antisocial
behavior.
Interpretation
This indicates that he is
not showing any signs of
alcoholism.
Interpretation
This shows that he has few
signs of drug dependence.
 features of drug
dependence.
Treatment Consideration Scales:
Aggression (AGG) Measures characteristics & Interpretation
attitudes related to anger, His score indicates that he
hostility & aggression; this has the potential to be
43 83 includes a history of aggressive, angry, and
aggression (verbal or hostile.
physical)& attitudes
conducive to aggressive
behavior
Suicidal Ideation (SUI) Measures suicidal thoughts- Interpretation
ranging from hopelessness His score indicates that he
through general & vague has suicidal thoughts.
31 107
thoughts of suicide, to
thoughts representing
distinct plans for the
suicidal act
Stress (STR) Measures the impact of Interpretation
current or recent stressors in He may be under moderate
10 59
the areas of family, health, stress, according to this
employment, finances, & symptom.
other major life areas
Non-support (NON) Measures a lack of Interpretation
perceived social support According to his score, his
16 80 (considering both the level social and personal
& quality of available relationships provide him
support) with little support.
Treatment Rejection Measures attributes Interpretation
(RXR) theoretically predictive of The score indicates that he
interest & motivation to may be prone to rejecting
make changes of a or ignoring changes in his
psychological/ emotional life.
nature: feelings of distress
1 20 & dissatisfaction,
willingness to participate,
recognition of need for
change, openness to new
ideas & a willingness to
accept responsibility for
actions
Interpersonal Scales:
Dominance (DOM) Measures the extent to Interpretation
which a person is The result indicates that he
controlling and independent lacks confidence and may
in personal relationships. struggle to meet his needs
18 45 Conceptualized as a bi-polar in his personal
dimension, with a dominant relationships.
interpersonal style at the
high end and a submissive
style at the low end.
Warmth (WRM) 10 26 Measures the extent to Interpretation
which a person is supportive The score indicates that he
& empathetic in personal has little investment in his
relationships; social interactions, which
 conceptualized as a bi-polar can make him seem
dimension w/ a warm, unfeeling of others.
outgoing interpersonal style
at the high end & a cold,
rejecting interpersonal style
at the low end

Summative interpretation of Affective and Personality Domains

Clinical Scales

Results

Mr. Pikachu's clinical scale results show that he has Somatic Complaints (SOM), Anxiety
(ANX), Anxiety Related Disorders (ARD), Depression (DEP), Paranoia (PAR),
Schizophrenia (SCZ), and Borderline (BOR). This is because he scored above the per-
centile. He is within the average percentile on Antisocial Features (ANT), Alcohol Prob-
lems (ALC), Drug Problems (DRG), and Mania (MAN).

Interpretation

Mr. Pikachu's scores indicate evidence of clinical problems, based on the results of the
Personality Activity Intelligence (PAI) Examination and when compared to the T-Scores
listed in the PAI Reference Guide.

Mr. Pikachu appears to be concerned about his health problems, which could indicate that
he has Somatic Complaints, according to the interpretation. His anxiety (ANX) and anxi-
ety related disorders (ARD) scores are high, indicating that he is afraid of his surround-
ings and is tense. When his scores are interpreted, it is shown that he is impulsive and a
risk-taker, that he might be perceived as unfriendly, and that he is isolated from others.
Mania, Schizophrenia, and Borderline Features are all clinical diseases that can be linked
to this. He can also be perceived as sad, depressed, suspicious, and aggressive toward
others, resulting in a high Depression, Paranoia, and Antisocial Features score. Both alco-
hol and drug problems have a low score, making them insufficient to be recognized as
one of his disorders.

Treatment Considerations Scales

Results

Mr. Pikachu's scores revealed that, although having modest treatment rejection scores, he
had higher than average responses in Aggression (AGG), Suicidal Ideation (SUI), and
Non-Support (NON). His Stress (STR) and Treatment Rejection (RXR) responses indi-
cate that he is within the normal response range.
 Interpretation

Mr. Pikachu's scores indicated that, while he had low treatment rejection scores, his
scores in Aggression, Suicidal Ideation, and Non-support were higher than average and if
not given notice it could indicate potential complications within the treatment.

Interpersonal Scales

Results

Mr. Pikachu's Dominance (DOM) scores on the Interpersonal Scales were average, indi-
cating that he has neither a submissive nor a dominating style in interpersonal relation-
ships. His Warmth (WRM) score was at the low end.

Interpretation

Mr. Pikachu's DOM scores on the Interpersonal Scales indicate that he has a submissive
personality. It suggests that he will have some difficulty meeting his needs in his personal
relationships. His WRM score indicates that he is uninterested in social interactions. He
has a tendency to appear cold and unfeeling toward others.

Summative interpretation of Affective and Personality Domains

BDI-II (43)
Results
Mr. Pikachu received a total score of 43 on the BDI-II, indicating that he is suffering
from severe depression.

Interpretation
The client's BDI-II scores of 43 indicates that he may be suffering from severe
depression. This is consistent with his symptoms, which include feeling weak almost
every day due to fatigue, having recurring thoughts about death, losing interest in
activities he previously enjoyed, having a lesser ability to focus, and being in a depressive
state often.

BAI (27)
Results
His score on this test is 27, which, according to the BAI scale, puts him in the range of
severe anxiety.

Interpretation
His BAI test resulted in a score of 27, indicating that he is suffering from severe anxiety.
This was demonstrated when he stated that he had been experiencing anxiety symptoms
while suffering from depression. He was reported to have significant distress in social
and academic functioning, as well as fears of losing control of himself.
 DASS (D – 38, A – 24, S – 27)
Results:

In this test, however, he received a 38 on depression, which is on the extremely severe

scale, a 24 on anxiety, which is also on the extremely severe scale, and a 27 on stress,
which is on the severe intensity scale.

Interpretation:

Mr. Pikachu DASS score is consistent with his BDI-II and BAI test results. His
depression (D) score of 38 places him in the extremely severe category. His anxiety (A)
score of 24 indicates that he is experiencing extremely severe anxiety. On the stress (S)
scale, his score of 27 indicates that he may be severely stressed. This can be attributed to
the symptoms of depression and anxiety that he is experiencing. He reported being sad on
most days, sleeping more than usual, having suicidal thoughts, distress, and being afraid
of the worst.

Structured Clinical Interview

Mr. Pikachu reported to be in a depressed mood most of the day. Also, he exhibits diminished
interest on previously interesting activities. Likewise, he tends to sleep a lot as compared before.
Similarly, he felt weak almost every day due to loss of energy and fatigue. Furthermore, he felt
worthless and is experiencing recurrent thoughts about death. Moreover, his ability to think
clearly and concentrate has diminished over the past weeks. These symptoms were reported to
have significant distress on social and scholastic functioning. In relation to this, such experiences
are not attributable to physiological effects of substance or other medical condition.

In addition to this, he is also experiencing symptoms of anxiety during the course of depression
as he fears the worst and is experiencing fear of losing control over himself. Also, there would be
times where he felt unusually restless and unsteady.

On the other hand, no forms of manic and psychotic episodes or symptoms were reported by Mr.
Pikachu. Additionally, the signs and symptoms currently manifested by Mr. Pikachu does not
satisfy any form of personality disorder from different clusters. In relation, observation and
reports of Mrs. Ash (Mr. Pikachu’s mother) complemented such reports provided by Mr. Pikachu
about the absence of manic and psychotic symptoms.

Summary

Mr. Pikachu's WAIS-IV results show that he is in the High Average range and can thrive in an
academic setting. He scored exceptionally well on three indices which are the Working Memory,
Processing Speed, and Full-Scale IQ, but only average on the other two which are the Verbal
Comprehension and Perceptual Organization. This indicates that he has a higher intellectual
capacity than others. It was notable how high his t-scores were for Somatic Complaints, Anxiety,
Anxiety-Related Disorders, Depression, Paranoia, Schizophrenia, Borderline Features,
Aggression, Suicidal Ideation, and Non-Support in his affective and personality domains.

This could be related to the symptoms he has been showing, such as sleeping more, having
difficulty getting out of bed, feeling overshadowed by his classmates, suicidal ideations, and a
constant sense of worthlessness. His relationships with his siblings and mother were fine, he
said, but he rarely spoke to his father because of the verbal punishment he received from him as
a child. Examining his test results for PAI, BDI-II, BAI, and DASS, as well as his reports about
the symptoms that he has been experiencing, we found that they were all consistent. This could
be evidence of the presence of Major Depressive Disorder.

Diagnostic Impression

Mr. Pikachu reported that he experienced depressive episodes just like his family members, hav-
ing anxieties that he might experience those depressive episodes again, lost interest in activities
he previously enjoyed, envisioned on committing suicide but does not show of self-harm, though
he felt insignificance, mostly sad every day, and he has weakened his concentration ability. Of
all the symptoms that are indicated, Mr. Pikachu appeared to have 5 over 9 symptoms that are
consistent with the DSM-5 analysis for depression.

Recommendations

Mr. Pikachu may be suffering from Major Depressive Disorder, based on his symptoms and test
results. One of his major concerns prior to undergoing a neuropsychological assessment was that
he would relapse into depressive symptoms. He needs to learn and recognize his triggers in order
to gain a better understanding of it. He should develop healthy coping mechanisms after spotting
warning flags. He identified himself as someone who relies on physical activities to keep his
physical and mental health in balance. Exercising can be a beneficial activity for him;
nevertheless, he must remember to set realistic goals and take adequate rest afterward in order to
recover. Mr. Pikachu is also advised to undergo Psychodynamic Therapy in order to address his
negative feelings and repressed emotions. This may also guide to his self-esteem and how well
he can work on improving his relationships.

Thank you for giving us the opportunity to work with Mr. Pikachu. Should you have any
questions regarding this report or if we can be of further assistance, please do not hesitate to
contact us at the ****** *******, at cell phone number, (632) ***-****.

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