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Dr. Michael E. Shery, Clinical Psychologist

2615 Three Oaks Rd, Cary, IL 60013, Ph: 847 275 8236

 

Psychological Assessment

 

Re Subject: Mr. John Doe

Date of Birth: 07-03-61

 

Situation Leading to Referral: In late November of 2009, the subject's ex-wife called to inform him that his son had over-dosed and died. The wake was held on December 6, 2009 and that evening, shortly after his son's services, he discovered that his mother who was residing in Las Vegas had had an accident and was in the hospital intensive care unit, (ICU); his mother passed-away on March 24, 2010. Exacerbating the situation, his long-term live-in girlfriend had moved out of his house the weekend after Mother's Day, 2010 because the subject had evicted him from his house in Oct, 2009.

S.N., one of his deceased son's friends, would call him intermittently and finally in June, 2010, asked the subject if he could move in with him because of personal problems. The subject acceded to the request, provided his stay would only be short term. In mid-July he permitted a female friend who was living in a bad environment to also move in and in mid-August, S. N's girlfriend was also given permission to move in because of problems at home.

The subject reports having multiple conversations with them about several problems regarding day-to-day maintenance, cleaning etc. At one point, SN was taking too long in the bathroom when the subject was in a hurry to leave the house and an altercation broke out: The subject reported that when he finally started going into the bathroom, SN grabbed him around the neck in a choke hold and the both fell to the floor.

SN called the police and the subject reported hearing him screaming that he had guns. The subject ordered SN to get out of his house and then further reported that SN then charged at him; the subject then reported pushing him away.

After the police arrived and while the subject waited outside, they interviewed SN inside the house. Upon concluding the interview they returned outside and asked the subject if he had indeed, pushed SN. The subject had admitted that he had and the police subsequently arrested him.

This report is the culmination of his complying with the court's order that he receive a psychological exam containing assessments of grief and anger issues and comply with its recommendations.

Overview of the assessment: The assessment process consisted of interviews with the subject, a review of the situations causing the evaluation to be mandated and the review of psychological testing data and other relevant information.

Subject’s Presentation during the Interviews: The subject was punctual in keeping his appointments. His initial appointment was on June 9, 2011 and a subsequent one took place on 7-26-11. He arrived alone and was appropriately and casually attired for both. He was respectful, cooperative and at the initial appointment, appeared mildly frustrated with the legal process.

 

Caveat: The interview data is valid only insofar as the subject was not prevaricating or deceptive during the interviews.

 

Social History:

The client is a 49-year-old white male. He reports that he has no religious preference.  He lives in a house and has lived there for more than five years. He lives alone.

When asked about his dietary habits, he indicated that his diet is nutritious.  He says he eats breakfast, lunch, and dinner. In his spare time the client enjoys outdoor, mechanical, technical, and domestic activities and television.

 

Developmental History

While pregnant with him, his mother smoked tobacco. As a child the client was somewhat happy and recalls that he was ill no more often than his peers. As a teenager he was somewhat unhappy but remembers being healthy.

Before age 18 he had close friends with whom he could discuss nearly anything. He has more than one such friend now. The client is not aware of childhood problems with toilet training or with learning to sit up, crawl, stand, walk, talk, feed himself, or dress himself.

He does, however, report a childhood problem with enuresis. He recalls being very afraid of dying. He does not report having any difficulties with coordination, excitability, or overactivity before age 13. He does recall getting into many fights.

The client does not report a history of running away from home, having suicidal preoccupations, or attempting suicide as a child or teenager and he reports no unusual eating habits as an adolescent.

He recalls physically maturing at roughly the same time as most of the boys he knew. He felt that he could discuss only certain aspects of sex with his parents and began dating before the age of 18. He usually dated every week, one person at a time and remembers that his parents objected to the individuals he dated but did not interfere.

After the first time he had heterosexual intercourse he reportedly felt happy and satisfied. Currently, he enjoys sexual intercourse. He reports not having a homosexual experience.

 

FAMILY OF ORIGIN

The client was raised by his natural parents and having brothers and sisters.

He reports that his mother loved him too much and gave him more than enough time and attention. He recalls that he could always talk to his mother about problems and claims that his mother accepted him but criticized him when necessary.

He reports that she always praised him for his accomplishments, though she was reasonably strict and always wanted to know where he was going and what

he would be doing. She usually psychologically punished him when he misbehaved by yelling at him or making him feel that he had hurt her.

The client reports that his father gave him very little time and attention and that he was never able to talk to him about problems. He claims that his father criticized everything he did, though occasionally praising him for his accomplishments.

His father was an extremely strict disciplinarian who always wanted to know where he was going and what he would be doing. Punishment always resulted when his father discovered that he had misbehaved.

To punish the client psychologically, he would yell at him, take away privileges, embarrass him, or put him in "time-out". Corporal punishment usually included spanking or slapping. At least once, his father hit him with an object as a form of punishment

 

EDUCATIONAL HISTORY

He reports that his elementary school performance was usually good. In general, he liked elementary school and describes himself as being neither popular nor unpopular with most schoolmates. In high school he received mostly B's and his extracurricular activities included athletics.

He reports no major antisocial behaviors in high school and described himself as being neither popular nor unpopular with other students and as being neither happy nor unhappy in high school. The client reports graduating from high school and trade/vocational school. He reports attending but not finishing junior college.

MARITAL HISTORY

The client reports his primary sexual orientation to be heterosexual. He is currently divorced and is living alone. He reports being married only once and having one natural child as well as stepchildren. He does not have a spouse or spousal figure at this time.

OCCUPATIONAL HISTORY/FINANCIAL STATUS

 

Current Job:

Length of Employment: 3 years

Job Description- Chief Mechanic

Job Disciplinary History: Unremarkable

Performance Reviews: He reports they have been satisfactory.

Absenteeism: Unremarkable

 

The client is employed full-time, is paid in hourly wages and holds a skilled labor position in the service industry. He has had his present job for more than eight years and reports being somewhat satisfied with his work. He reports thinking about changing jobs and is currently looking for one.

He has quit and been laid off from jobs in the past. He reports resigning from a previous job because of an opportunity for a better one and dissatisfaction with his job. Over the past year his household income has increased somewhat and is more than sufficient to pay for basic necessities

LEGAL HISTORY

The client reports having been charged with criminal offenses, though, there are no charges currently pending.

MILITARY HISTORY

The client has never served in the United States military.

SYMPTOM SCREEN

The last physical examination the client had was more than a year ago; he recalls having no problems at that time. His last dental exam was within the last month, as he is currently having problems with his teeth.

He has never had surgery and believes that he is currently in excellent health; he also reports that he is allergic to certain drugs. His family history includes diabetes and heart trouble or stroke. His own history includes an ulcer; he has never had prostate problems.

Lately he has experienced leg cramps that wake him up. He also complains of recent constipation and reports that he has recently been troubled by back pain.

He reports drinking alcohol several times a year and usually drinks beer or hard liquor. He does not report any usual diagnostic signs of current pathological alcohol use, and he has not experienced an increase in tolerance over time.

No usual diagnostic signs of psychosocial impairment caused by alcohol use were reported. He has used cannabis but he does not do so now and no usual diagnostic signs of current pathological drug use were reported. No usual diagnostic signs of psychosocial impairment caused by drug use were reported either.

No episodes of depressed mood, diminished energy, loss of appetite, sleep disturbance, or suicidal ideation lasting two or more weeks were reported and no periods of elated mood or hyperactivity lasting one week or more were reported either.

He does not report having experienced thought broadcasting, thought insertion, thought withdrawal, auditory distortions and hallucinations, grandiose beliefs, persecutory beliefs, or feelings of being controlled and no phobias were mentioned. He denies having had unwanted, repetitive thoughts or having performed repetitive acts. However, he does have trouble falling asleep at times.

Mental Status: During my interviews with the subject he was alert, oriented to person, place, time and situation. His levels of judgment and insight were normal, as was his ability to remember and concentrate. He showed no signs of disordered thought processes and his manifested affect was appropriate to the content of his verbalizations. Intellectually, he appears to function in the average to high average range.

Behavioral observations: Initially, he appeared aware of the process of psychological dynamics and the purposes of testing. He provided detailed responses, using many words. He was always compliant, accepting and respectful and he believes he is able to function normally in the absence of any psychotherapeutic treatment.

During his interviews, he provided complete and detailed information with little prodding by the examiner. He had no difficulty discussing his internal feeling states and possible problematic behaviors.

 

Tests Administered and their Results:

 

Millon Clinical Multiaxial Inventory III (MCMI III)

The major complaints expressed by the client's MCMI-III responses do not take the form of distinct Axis I symptoms.

This patient strives to be seen as proper and conventional in spite of the ambivalent feelings that exist under his controlled surface. He has a strong sense of duty, and it takes prolonged stress for him to display upsetting or angry feelings. He may have difficulty sharing personal information.

This subject appears to be an essentially well-functioning (i.e., "normal") individual with no major personality disturbances who has been undergoing disturbing psychosocial stressors and is now exhibiting troublesome symptoms that are largely situational.

He is likely concerned with appearances, that is, with being seen by others as composed, virtuous, and conventional in his behavior. He likely attempts to downplay or minimize distressing emotions.

The MCMI-III profile of this man often indicates a fear of public humiliation, a rigid and tense compliance with social conventions and propriety, and a receptivity to the beliefs and values of institutional authorities (e.g., church, business).

He appears self-effacing, noncompetitive, and nonassertive. A strong sense of duty to others may typify his social relationships. He strives to be a considerate and cooperative person, one who is, at times, even subservient and unambitious; he may even tend to downplay his attributes and abilities.

Condemnation and disapproval from others upset him and he avoids negativism by appearing to be accommodating and respectful, especially with those in authority. This man's efforts to appear unassertive and quite proper lead him to seek institutions and persons with considerable power and control. By following their rules and guidelines, he hopes to hide the rebellious feelings that occasionally slip through his front of respectability and restraint.

Fearing the exposure of these feelings and seeking to check them, he has had to learn to lead a life of tense and disciplined self-control. Certain forms of self-assertion would endanger the security and respect he seeks.

It is possible that this man lacks appreciable psychological insight into himself and others. Therefore, he may be quite indecisive and easily upset. Deviations from his routine often produce anxiety. He strongly desires to appear favorably to others.

Furthermore, he dreads making mistakes or taking risks, lest they provoke disapproval and punishment. Contributing to these fears is a conscience that serves to counter his negative urges and embarrassing thoughts.

He tends to constrain his feelings and deny any significant emotional conflicts.

Most notable is his inclination to exhibit an unusual adherence to social conventions and propriety, leading to a preference for polite, formal, dutiful, and "correct" personal relationships. He is deferential, ingratiating, and even obsequious at times, going out of his way to impress them with his kindness and serious-mindedness. He seeks the reassurance and approval of others, experiencing considerable anxiety when he is unsure of their wishes or expectations.

This contrasts markedly with his treatment of subordinates, with whom he can be quite autocratic and condemnatory, often appearing self-righteous. Also salient is his habit of constructing the world in terms of rules, regulations, time schedules, and social hierarchies, which results in his being upset by unexpected changes in routine and the sudden appearance of certain inconveniences.

He tends to be rigid and stubborn about adhering to convention which is associated with the ease with which he can become upset by having to deal with novel customs and ideas. In these circumstances, he feels unsure of what course of action he should take and thereby often ends up immobilized and frustrated.

 

Quality of Life Inventory (QOLI)

OVERALL QUALITY OF LIFE CLASSIFICATION

This individual's satisfaction with life is average. This person is basically happy, content, and satisfied with life. People scoring in this range are generally successful at getting what they want out of life, are able to get their basic needs met, and achieve their goals in most important areas of life.

If they have a list of goals they want to achieve in their lifetime, their overall success in doing so is good. They believe that their lives have meaning and purpose, and they usually feel energized about fulfilling their personal goals.

They set realistic goals for themselves and are optimistic about their chances for eventually achieving them. In fact, people scoring in this range have generally found positive and rewarding environments or circumstances in the areas of love, work, and play.

They also have useful skills and strategies for fulfilling their most cherished needs, goals, and wishes. In particular, they have rewarding relationships, satisfying leisure activities, and meaningful work or retirement pursuits.

People with scores in this range usually have good physical and mental health. They also tend to live longer than people who are chronically unhappy. When health problems or disabilities do arise, people with scores in the average range tend to adapt. They usually accept their limitations and find new sources of joy, meaning, and satisfaction in their lives.

The Aggression Questionnaire (AQ)

The results suggest that the subject is average in his overall tendency to be abnormally aggressive. He also scored in the average range on the Physical Aggression Scale, which would suggest that he reports about the same tendency as others his age to use physical force when expressing anger.

He scored in the high range on the Verbal Aggression Scale, suggesting that, when faced with conflicts, he is likely to be more verbally argumentative than others his age when confronted with frustration and stress. He should be encouraged to learn and use stress-reduction methods..

He scores in the average range on the Anger scale suggests that he does not experience an unusual amount of anger, but his high averagerange on the Hostility scale, suggests he may experience anger, suspicion, resentment and alienation in somewhat higher ranges as others in his chronological peer group; oppositional tendencies may exist when confronted with stressors.

The Indirect Aggression score is also in the average range, suggesting that he has about the same tendency to express aggressive feelings in ways other than direct confrontation, such as passive-aggressiveness, as others his age.

Symptom Severity

On the basis of the test data (assuming denial is not present), it may be reasonable to assume that the patient is exhibiting psychological dysfunction of mild to moderate severity.

Diagnostic Impression:

Axis I: Clinical Syndrome

The major complaints expressed by the patient do not take the form of distinct or isolated symptoms but rather appear to reflect pervasive difficulties.

Axis II: Personality Disorders: 301.40 Obsessive Compulsive Personality

Axis IV: Psychosocial and Environmental Problems

This individual has the following problems which complicate or exacerbate his present emotional state:  fustration; bereavement; grief

Recommendations: Therapy for this subject does not reach the threshold of being absolutely necessary. Whereas he may benefit from psychotherapy to raise his frustration tolerance, he does not appear to be sufficiently motivated and, therefore, would not benefit from psychological treatment at this time.

Also, therapy is not necessary to resolve his grief or bereavement issues.

Is any treatment or further evaluation needed? No

 


Respectfully Submitted,_________________________;________

Dr. Michael Shery, Psychologist Date

Illinois Psychologist, 71-1937

 

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