Psychological Report

Assignment Details:
The purpose of this case vignette assignment is to provide an asynchronous format for doctoral students in the PSY8702 course to complete a comprehensive psychological report that should align with all relevant best practices and legal, ethical, and writing standards for a doctoral-level provider of treatment. This assignment provides a platform for doctoral students to showcase their ability to use different assessment instruments to evaluate psychological functioning, integrate informal and formal data within a psychological assessment, establish accurate diagnostic skills, provide tailored recommendations, and write in a professional style for diverse audiences that a psychological report may reach.
Presenting Concerns
• Mr. Z is a Latinx male of Puerto Rican heritage in his late 40s who presents with concerns about increased irritability, persistent nightmares, and feelings of tension and anxiety, especially while driving. These symptoms have progressively worsened over the past year, leading to increased strain in his marital and family life. He reports sleep disturbances, difficulty relaxing, and avoiding previously familiar environments, such as the route he used to take to work.
• Approximately 14 months ago, Mr. Z was involved in a car accident on his way to work, sustaining physical injuries and experiencing severe emotional distress. He has since felt “on edge,” experiencing “flashes of the accident” when driving, which results in feelings of dread. He reports that he took 2 weeks off work to recover but has “never felt the same.” He mentions that his attorney, involved in his personal injury case, may reach out regarding his treatment progress.
• Mr. Z reports muscle tension, particularly in his shoulders and back, along with occasional headaches. He sleeps only 4–5 hours a night due to discomfort and nightmares related to the accident. He describes feeling “down” and frustrated with himself for not feeling “normal,” which has impacted his marriage and interactions with his children.
• He tries to mask his emotional struggles at work by using humor to deflect from instances of forgetfulness or decreased productivity. His primary care physician suggested he attend psychotherapy following the accident due to nightmares and increased alcohol consumption; however, he attended only two sessions. Mr. Z felt that the therapist focused excessively on his identity as an immigrant, rather than addressing his trauma and fears, which led him to stop treatment.
History
• Mr. Z has a history of hypertension and hyperlipidemia, both managed with medication. He reports that he attained developmental milestones as expected and has used alcohol and marijuana since late adolescence. He completed high school with average grades but recalls struggling with focus and activity, wondering if he had undiagnosed ADHD.
• His work history is primarily in construction, where he currently serves as a foreman. Before his accident, he was studying to become a licensed contractor, but he discontinued due to his increased difficulty concentrating and fatigue. He feels regularly exhausted and overwhelmed by his work responsibilities.
• Mr. Z is married with three children, two of whom are still in high school. He notes that he has become more withdrawn, spending his free time watching television at home, which his spouse and children have observed as a change from his previously social nature.
Family History
• Mr. Z’s parents are both of Puerto Rican descent. His mother, residing in Puerto Rico, has experienced orthopedic issues since her 40s, which limited her ability to work. His father passed away in his 60s due to a stroke. He has one younger brother with whom he has limited contact due to a falling out. Mr. Z described his brother as more financially successful, which has contributed to tension between them.
Social History
• Mr. Z was born in Florida, and Spanish was his primary language at home. He identifies strongly with his cultural background and values family and community but feels increasingly isolated due to his symptoms.
Mental Status Examination
• Mr. Z appeared alert and cooperative during the clinical interview. His speech was normal in rate and rhythm, though he exhibited some hesitation when discussing the accident and his emotional experiences. He appeared physically tense, with slower processing when discussing certain topics, particularly his accident and current challenges. Mr. Z’s affect was mood-congruent, and he reported feeling “down” and “disconnected.” He denied suicidal ideation.
You are tasked with writing a comprehensive psychological report based on the case vignette and may add additional information to elaborate on the patient’s presenting issues, context, and mental status, as would be drawn from a clinical interview. Although you will not be presented with test data from a battery of psychological instruments, you will need to discuss the types of information provided by various psychological tests and their strengths and weaknesses.
Please use the following standardized template for a psychological report, which should be at least 10 pages long:
• Bridgepoint Education. (n.d.). PSY640 week four psychological assessment report. https://content.bridgepointeducation.com/curriculum/file/b99fa6dd-a5e4-4ca0-bd87-f57f61aac326/1/PSY640%20Week%20Four%20Psychological%20Assessment%20Report.pdfLinks to an external site.
In the psychological report, include a detailed discussion of the types of clinical information that would be gathered for Mr. Z through a clinical interview, covering the following areas:
• What information each assessment instrument provides
• How combining multiple instruments adds to the clinical picture
• Provide a summary, differential diagnosis, and relevant recommendations based on Mr. Z’s context and history
This report should incorporate the following:
• Cultural considerations
• Scientific literacy to discuss each instrument
• Research literature to inform likely diagnosis
• Legal and ethical considerations
• Mr. Z’s prognosis and future care needs
In your report, address the following for each of the tests:
• Mini Mental State Examination (MMSE): Assessing basic cognitive functioning
• Beck Depression Inventory-II (BDI-II): Measuring depressive symptoms
• Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5): Evaluating PTSD symptoms post-accident
• Wechsler Abbreviated Scale of Intelligence, Second Edition (WASI-II): Assessing cognitive processing abilities
• Minnesota Multiphasic Personality Inventory, Third Edition (MMPI-3): Screening for emotional and personality issues
• Structured Clinical Interview for DSM-5 (SCID-5): A structured interview to confirm PTSD or related diagnostic criteria.