PSYCHOLOGICAL ASSESSMENT REPORT

PSYCHIATRY DIAGNOSTIC ASSESSMENT REPORT

CASE FORMULATION, DIAGNOSIS AND TREATMENT PLAN

Private and Confidential: For Clinical Purpose Only

NOT VALID FOR MEDICOLEGAL ISSUES

Dr Tina Gupta Dr Tina Gupta

MD (AIIMS, NEW DELHI) MD (AIIMS, NEW DELHI)
Consultant Psychiatrist Consultant Psychiatrist
DMC Regd No. 603 DMC Regd No. 603

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Disclaimer: The contents of this document are strictly confidential. Results provided are based on current examination and
the assumption that information collected from the sources are reliable. However psychiatric assessments may have inter
rater variability and discrepancies in interpretation may arise with different examiners.

*The report is valid purely for clinical, diagnostic and management purpose, for deciding treatment and prognosis.
*Not valid for medicolegal opinions.
*Client is advised to avoid indiscriminate sharing of the contents of this assessment report as confidential information is
documented.
*This document is solely intended for clinical case record. It may contain privileged or confidential information shared by
client and should not be circulated or used for any purpose other than for what it is intended.

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PSYCHOLOGICAL ASSESSMENT REPORT

Name:

Age/ Sex:

Contact No.s:

EMAIL:

Date of Testing:

Purpose of Assessment: DIAGNOSTIC CLARIFICATION AND TREATMENT PLANNING

Referred by: SELF

Assessment conducted by: Dr Tina Gupta (MD AIIMS)

Tests Used:

● Clinical History

● Mental State Examination

Assessment done over sessions on .

**………….. has been interviewed on Video conferencing in view of the physical restrictions during
Covid lockdown. She was capable to handle very effectively without assistance the online interviews
and assessment system. Her mental state has been evaluated on multiple interviews. The
Observations are reliable to make a provisional diagnosis.**

Informants:

General appearance and Behavior during interview:

Cooperation: Satisfactory
Attention: Present
Concentration: Ill sustained in lengthy tasks like TAT stories
Interest/ Motivation: Present
Comprehension: Adequate
Psychomotor Activity: Slow
Behavior Problem: None
Vision: Normal
Hearing: Normal

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PATIENT IDENTIFICATION

To clarify diagnosis and plan treatment a detailed diagnostic psychiatric assessment was initiated.

……….. has been interviewed on Video conferencing in view of the physical restrictions during Covid
lockdown. …….. presented with complaints suggestive of ………… , hence an evaluation was planned
to carefully identify underlying……….. Her mental state has been evaluated on multiple interviews.
The observations are reliable to make a diagnosis.

RELEVANT CLINICAL & PERSONAL HISTORY

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MSE

She appears as a young lady of stated age, well kempt and groomed. Rapport was established and
psychomotor activity appeared slow. No abnormal movements, hallucinatory behavior, mannerisms
etc were noted. At the time of assessment she reported mood was low with a lack of initiative,
motivation. Speech tone / volume were wnl. She has a good command on language and is very
expressive of her issues. She is not very expressive of her thoughts, rating scales and self reports
helped her to write and express her problems. During assessments she was also started on
medication, improvement was noted in subsequent interactions in her responses. On emotionally
sensitive discussions, she maintains a fair emotional control. No delusions. No obsessions /
compulsions. Higher mental functions are intact.

TEST FINDINGS

● TAT

Formative Analysis: stories are lengthy elaborative descriptions of the stimulus cards and
pointwise enlisting of the instructions given to her. The analysis of the content of stories
indicates that the plots of the stories are real, structured, complete, well organised,
appropriate to stimulus cards and original. Good logical development of the theme,
coherence is present in all stories giving all the three basic parts of the story. Ideas
expressed possess internal consistency. They are generally reasonable in the light of the
stimulus presented. The stories had clear beginning, middle and end. Imagination is varied
yet original. Overall her imaginations are reality oriented and rationale. Quality of her
imaginations are descriptive and philosophical in nature. As regards to grammatical
structure of language there is no disjunction anywhere. The language used by her is rich in
vocabulary and well expressive of her thoughts. She has closely observed the details in the
cards. Many action words as well as words that modify and qualify and words that describe
emotions have been used. She has introduced new events, characters, relationships and
given them titles, thus enriching her content. She has observed all the essential gross details
in the picture. Her mental approach has generally been from whole to parts. The main

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characters in her stories are seen gripped with conflicts of achievement, affection, ambition,
prosperity, abundance etc. the conflicts are described as minor daily life challenges and
solutions are also simple, easily attainable. The hero addresses problems actively and
resolution of most problems is also described. In her stories hero resolves problems by
restriving, counteracting and obliterating fear and failure by resumed independent action.

The above analysis indicates that the subject is definitely endowed with superior intellectual
powers and her V and W abilities are of higher order. Her self-esteem appears to be intact.
Ego structure is intact to face conflicts.

Thematic Analysis: The content on various cards is descriptive.

Significant needs: Thematic analysis indicates that her dominant need are > achievement ( to
accomplish or master, to excel, to overcome obstacles and attain a high standard, to excel in
talents ), > affiliation (to please and win affection of a cathected O, to adhere and remain
loyal to a friend), > autonomy ( to get free, shake off restraint and get out of restrictions, to
be independent, to resist coercion and restriction) , > inf avoidance ( to avoid humiliation,
inferiority, derision, indifference of other), > harm avoidance, > succourance ( to be nurtured
supported , sustained, protected, loved , advised, guided , indulged by the sympathetic aid
of an allied O, to always have a supporter, to remain close to a devoted protector, ), >
recognition ( to be known, valued).

Emotional adjustment: seem satisfactory.

Ego structure: ego functioning is intact as evident from the complete identification with the
hero in the stories, happy and realistic outcomes, plots of stories being realistic, adequate
control of drives and impulses, thought processes as revealed by being appropriate, mature,
complete, original, & intact judgement.

Super ego structure: adequate

Basic Personality traits: emotionality, anxiety ridden, introversion.

Final summary: the trend of the TAT shows good perceptual organization and perceptual
range but personalization of stories is limited. The dynamic personality that emerges from
TAT is that she is basically dominated by sentiments and emotions. The purpose of the test
was to identify and explore underlying depressive cognitions beneath her somatic
presentations. The test reveals presence of mild level of depression.

● RORSCHACH

INTERPRETATION

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A comprehensive analysis of ……….clinical history, mental state examination and findings on

projective tests and rating scales suggest that The evaluation is done on multiple discussions
via video conferencing but are complete and reliable to make a provisional diagnosis and
start her treatment.

SUMMARY AND TREATMENT PLAN

Provisional Diagnosis:

Pharmacotherapy :
Anti -Depressants and Anti Anxiety medication for 8 to 12 weeks followed by
a maintenance phase. Medication will be closely monitored and later tapered and stopped
as the child recovers.
Weekly monitoring of progress of symptoms on standard scales for anxiety
and depression to monitor improvement with therapy.

Psychotherapy:

Wishing her recovery

Dr Tina Gupta MD AIIMS

Senior Consultant Psychiatrist at:
✔ WEE CARE CLINIC, Hauz Khas , Delhi 16

✔ Max Hospital Panchsheel Park

✔ NIPCCD Ministry of Women and Child Development Child & Adolescent Clinic