Psychological History Case Study: Summary of Clinical Interviews & Testing Results

Psychosocial History

Fred is a patient who is married to a wife that he had met in his days in college. Together, they have been blessed with five children, all female, aged between 12 and 20. Although they have been having a successful and peaceful relationship, his wife has been often complaining of the emotional distance. Some of these relational challenges have made Fred to be overwhelmed with life challenges. This has made him doubt his commitment to family especially regarding support for their fourth daughter who has been experiencing chronic cardiac problems, thereby implying that she needs more attention and care.

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Besides his family background, Fred had generally a good upbringing and mostly healthy, according to reports shared by his mother. Most of his developmental milestones were achieved as expected. When growing, Fred was a social child, who often played with other children although their relationships could not last for long. He also demonstrated good academic background, with most of his scores being grade B, thereby indicating that he was always above average. He was largely not a bother at school regarding discipline. However, he started experiencing depression feeling at junior college, which made him avoid his friends.

Despite his emotional challenges in college, he still managed to finish and take a management job. However, he often felt tension and nervousness when promoted to senior positions. At the management job, he depicted that he had problems with concentration, which contributed to challenges when doing his work. Fred has not been into psychoactive drugs and other forms of substance abuse, only occasional use of alcohol, mostly in social functions. It is also important to note that Fred and his wife are active church members, where they have volunteered in various activities. He also did not serve in the military.

Test Findings

Fred has often complained of disturbances at work that made him resign at workplace. He has been evaluated for multiple somatic problems such as gastrointestinal problems and headache which tested negative. However, he has been taken through Minnesota Multiphasic Personality Inventory-2 which showed a result of "27'8+-30164/5:9# 'F+-L/K.

The client was also evaluated using the Outcome Questionnaire, that was administered at 8/5/2014. In this analysis, the OQ-45 was administered by receptionist prior to each visit. The findings are illustrated in the appendix. The back-depression inventory was also evaluated as part of the post-treatment as illustrated in the appendix. Also, BDI was administered x2 at UH-PES, and last treatment session at MHS. This was for the DSM-5 Level 1 Cross-Cutting Symptom Measure, that was conducted at 8/4/2014, and the comprehensive report is indicated in the appendix.

The other test that was conducted was the DSM- 5 Level 2 Cross-Cutting Symptom Measure for Depression that was administered at 8/42014. The details for the pretreatment phase are availed in the data provided. Through the analysis of the tests conducted, the client was diagnosed with various conditions. The primary diagnosis is 296.31 (F33.0) Major Depressive Disorder which has been recurrent. Also, Fred was diagnosed with low self-esteem, anxiety, and also demonstrated vocational and financial stress.

From the test findings, the MMPI-2 results show validity as the client was able to mark both the true and the false gaps. Besides, all the questions were answered for evaluation. The analysis demonstrates that some of the scores were above 65, and others were below 50. In this regard, it can be deduced that the T-score met and even exceeded the T65 threshold to illustrate clinical significance. Regarding the System Distress (SD) score of the client, all the scores obtained were above 36, which is the RCI cut off. With the client changes indicating more than 10 points (11), the OQ-45 shows that the symptoms are relevant for the clinical significance. The overall quality of life was also examined by the analysis of the test by the patient over time.

The analysis depicts that all the evaluations met the 63-point cut off for clinical relevance and significance. Some of the scores were above 80, with the highest being 82, thereby depicting a very disturbed patient. However, the highest score (82) was noted at the beginning of the evaluation on 5/8/2014, with the lowest score (66) being noted at the end of the assessment of 4/11/2014, hence indicating that the therapies helped the patient regarding emotional disturbances. At the end of the treatment, the score is above 63, the cut-off which shows that the client is still facing psychological difficulties that affect his quality of life. At the end of the evaluation, the T-Score for the DSM-5 assessment was 69.3. This score is above the T-65 cut off point, which demonstrates the clinical significance. The high sore shows that the client (Fred) is being adversely affected by the psychological symptoms that manifested themselves during the clinical and psychological treatment.

From the test findings, it was noted that Fred is an intelligent man who has great support for his family and has developed an excellent social network through the church engagements. He has been considering that his mood problems are psychological. However, the test findings indicate that he needs serious mental management.

Treatment History

After the diagnosis, Fred was subjected to various modalities of treatment, mainly the Individual Psychotherapy (90837), at the outpatient level of patient care. Both cognitive therapy and psychopharmacological therapy have been implemented. Effexor was administered to Fred with a dosage of 75mg for a period of 3 months. The treatments were administered with strategies that engaged the client regarding the cognitive techniques that aimed at controlling the self-depreciation and worry.

The treatment goal entailed an evaluation of the history of the depression, and the response to antidepressant medication, to check whether the therapy is alleviating the depressed moods and restore the level of functioning. Besides, the treatment aimed at ensuring the client developed strong cognitive beliefs and patterns. Finally, the treatment aimed at facilitating development of a consistently positive image and resolving the major conflicts that led to anxiety.

Treatment Outcomes

Despite the treatment approaches conducted, Fred indicated that he was not able to solve his emotional challenges. However, he demonstrates the willingness to try mental health counselling. Besides, he is ready to take all his psychotropic medications as required by the doctor to stabilize his life, and he also hopes he will start to feel better. His wife has also been insisting that Fred takes part in the treatment, which he has not objected. However, Fred is still worried that he might not be saved, although his wife is determined to save him and help him to recover at whatever cost.

Summary and Conclusions

Fred is a white male aged 44 years, who presented symptoms of depression and later diagnosed with Major Depressive Disorder. Some of the prevalent symptoms that facilitated the diagnosis included the anhedonia, depressed mood, low self-esteem, anxiety, and suicidal thoughts that impaired his occupational functioning. Through his treatment for cognitive therapies, Fred demonstrated some improvement based on the changes in behavior. Besides, the results demonstrated reduced scores for impairment based on the OQ-45 and the BDI tests.

Recommendations

Based on the findings, it is still evident that Fred is experiencing psychological challenges. Although the therapies have improved his condition, he still faces problems that should be solved. Therefore, it is recommended that he continues with new medication and psychotherapy. To relieve some of the symptoms, prescription medications may be administered, such as atypical antidepressants, SSRIs, and other antidepressants deemed effective. The psychotherapy should also aim at solving the personal crises and evaluating new methods of solving problems. If the symptoms persist, alternative forms of therapy and treatment should be considered including in-patient care.