Psychological Report Writing

**Adapted from UP-PGH format

Psychological Assessment is similar to psychological
testing but usually involves a more comprehensive
assessment of the individual.

Psychological assessment is a process that involves the

integration of information from multiple sources, such
as tests of normal and abnormal personality, tests of
ability or intelligence, tests of interests or attitudes, as
well as information from personal interviews.

Collateral information is also collected about personal,

occupational, or medical history, such as from records or
from interviews with parents, spouses, teachers, or
previous therapists or physicians.
. IDENTIFYING INFORMATION
I
State the name, age, marital status, sex, occupation, race, nationality, and
religion if applicable; previous admissions for the same or a different condition; with
whom the patient lives

II. REASON FOR REFERRAL/ CHIEF COMPLAINT

State the client’s chief complaint; why the client came to the psychologist,
preferably in the patient’s own words or the referral’s.

III. HISTORY OF PRESENT ILLNESS

Development of symptoms or behavioral changes that a precipitate in the
client’s asking for assistance; how illness has affected the client’s life activities and
personal relations.

IV. PAST PSYCHIATRIC AND MEDICAL HISTORY

Past medical condition: name of hospital, type of treatment, length of illness,
effect of treatment

V. FAMILY HISTORY * genogram

VI. PERSONAL HISTORY (ANAMNESIS)

History of patient’s life from infancy to the present; emotions experienced with
different life periods (painful, stressful, conflictual)
VII. BEHAVIORAL OBSERVATIONS/
MENTAL STATUS EXAMINATION
Summary of the examiner’s observations &
impressions derived from the interview
A.) APPEARANCE/ORIENTATION
Patient’s appearance & behavior during the interview;
attitude towards the examiner – cooperative,
attentive, evasive, guarded, etc
General description: posture, clothes, grooming,
healthy, sickly, old looking, young looking, hair, nails,
signs of anxiety – restless, moist hands, perspiring
hand, etc.

B. ) SPEECH
Rapid, slow, slurred, loud, whispered, echolalia, etc.
 C.) MOOD AND AFFECT
MOOD (a pervasive & sustained emotion that colors
the person’s perception of the world) How does the
patient say s/he feels – depressed, anxious, angry,
irritable, euphoric, empty, guilty, anhedonic, etc.

AFFECT (the outward expression of the patient’s

inner experiences) How does the examiner evaluates
patient’s affect: broad, restricted, blunted or flat; is
the emotional expression appropriate to the thought
content; give examples if emotional expression is
inappropriate
 D.) THINKING AND PERCEPTION
FORM OF THINKING: overabundance of ideas, flight
of ideas, slow thinking, stream of thought,
quotations from patient; loose associations, lack of
causal relations in patient’s explanations; incoherent
speech (word salad), neologisms (development of
new words)
CONTENT OF THINKING: Preoccupations about the
illness, obsessions, compulsions, phobias, suicidal
ideation, antisocial urges or impulses
THOUGHT DISTURBANCES: delusions(thought
insertion, withdrawal, broadcasting, etc) ideas of
reference, persecutory delusions
Formal Thought Disorders
Circumstantiality. Overinclusion of trivial or irrelevant details
that impede the sense of getting to the point.

Clang associations. Thoughts are associated by the sound of

words rather than by their meaning (e.g., through rhyming or
assonance).

Derailment. (Synonymous with loose associations.) A

breakdown in both the logical connection between ideas and
the overall sense of goal-directedness. The words make
sentences, but the sentences do not make sense.

Flight of ideas. A succession of multiple associations so that

thoughts seem to move abruptly from idea to idea; often
(but not invariably) expressed through rapid, pressured
speech.
Neologism. The invention of new words or phrases or the
use of conventional words in idiosyncratic ways.

Perseveration. Repetition of out of context of words,

phrases, or ideas.

Tangentiality. In response to a question, the patient gives a

reply that is appropriate to the general topic without actually
answering the question.
Example:
Doctor: Have you had any trouble sleeping lately?
Patient: usually sleep in my bed, but now I'm sleeping on the
sofa.

Thought blocking. A sudden disruption of thought or a break

in the flow of ideas.
PERCEPTUAL DISTURBANCES
Hallucinations & illusions: does patient hears
voices or sees visions
Depersonalization and derealization: extreme
feelings of detachment from self or from the
environment
 E.) SENSORIUM
1.) ALERTNESS: observation
2) ORIENTATION: What is your name? Who am I? Where are
you now? Where is it located?
3) CONCENTRATION: Starting at 100, count backward by 5.
Name the months of year starting with December
4) MEMORY
IMMEDIATE- Repeat these numbers after me: 10 5 7 1 8
RECENT – What did you have for breakfast?
I want you to remember these things: yellow pencil,
Iphone, laptop. After a few minutes, I’ll ask you to repeat
them.
LONG TERM – What was your address when you were in the
6th grade? Who was your teacher? What did you do during
the summer between high school & college?
5) CALCULATIONS: If you buy an apple that
costs Php10.00 and you pay with a Php50.00
bill, how much change should you get?
6) FUND OF KNOWLEDGE: What is the capital
of the Philippines?
7) ABSTRACT REASONING: Which one does
not belong in this group: a dog, a lion, a
dolphin, a carabao? How is an apple and an
orange alike?
 F.) INSIGHT
Degree of personal awareness & understanding of
illness
Complete denial of illness
Slight awareness of being sick but denying it at the
same time
Awareness of being sick but blaming it on others

G.) JUDGMENT
Social judgment: Does the patient understand the
likely outcome of his or her behavior, and is s/he
influenced by this understanding?
A summary of six levels of insight follows:
1. Complete denial of illness

2. Slight awareness of being sick and needing help, but

denying it at the same time

3. Awareness of being sick but blaming it on others, on

external factors, or on organic factors

4. Awareness that illness is caused by something unknown in

the patient
5. Intellectual insight: admission that the patient is ill
and that symptoms or failures in social adjustment are
caused by the patient's own particular irrational feelings
or disturbances without applying this knowledge to
future experiences

6. True emotional insight: emotional awareness of the

motives and feelings within the patient and the
important persons in his or her life, which can lead to
basic changes in behavior.
 2 kinds of Judgment
1. Social judgment: Subtle manifestations of behavior that are
harmful to the patient and contrary to acceptable behavior in the
culture; does the patient understand the likely outcome of
personal behavior and is patient influenced by that
understanding; examples of impairment

2. Test judgment: Patient's prediction of what he or she would do in

imaginary situations (e.g., what patient would do with a stamped,
addressed letter found in the street)
VIII. DIAGNOSIS
AXIS I: Clinical syndromes (Schizophrenia, generalized
anxiety disorder, mood disorder)

AXIS II: Personality disorders

AXIS III: Any general medical conditions

AXIS IV: Psychosocial & environmental problems

relevant to illness

AXIS V: Global assessment functioning exhibited by

the client during the interview
 Differential Diagnosis
A differential diagnosis is a systematic diagnostic
method used to identify the presence of an entity
where multiple alternatives are and may also refer
to any of the included candidate alternatives
(which may also be termed candidate condition).
This method is essentially a process of elimination,
or at least, rendering of the probabilities of
candidate conditions to negligible levels.
Differential Diagnosis

The method of differential diagnosis was first

suggested for use in the diagnosis of mental
disorders by Emil Kraepelin

At least 5 or more differential diagnosis.

Key words : deferred, rule-out

Prognosis

Opinion about the probable future course,

extent, and outcome of the disorder; good and
bad prognostic factors; specific goals of
therapy
 Biopsychosocial Model
BIOLOGICAL PSYCHOLOGICAL SOCIAL

PREDISPOSING

PRECIPITATING

PERPETUATING
Comprehensive Treatment
Plan/Recommendation

SHORT TERM AND LONG TERM GOALS

-includes Pharmacotherapy, Psychotherapy

Hospitalization, Psychosocial Skills Training
and out-patient treatments.
 Remember:
The number one principle as future
psychologist in assessing your patients/clients:
YOU, YOURSELVES ARE THE
TOOL.