Psychological Assessment Report

PSYCHOLOGICALEVALUATION
October 14, 2024
Date
Name: Niña Paula Tuan

Age: 20 years old
Civil Status: Single
Home Address: Barangay Tejero, Cebu City
REASON FOR REFERRAL

This 20-year-old client came on her own accord for psychological evaluation as basis for
treatment and intervention, to address ongoing feelings of anxiousness because of a sexual assault
incident she experienced two years ago.
EVALUATION PROCEDURES:
1. Biopsychosocial Interview
2. Personality Assessment Inventory - Adult (PAI-A)
3. Revised NEO Personality Inventory (NEOPI-R)
MENTAL STATUS EXAM

She appeared presentable and in age-appropriate clothing . Client maintained proper eye
contact during the whole duration of the interview and affect was moderate. She was cooperative.
Language and vocabulary use were good. During testing, client was fairly focus answering the tests
given the minimal extraneous variables present (noise, small talk with seatmates), but she took time to
understand and answer the test items. During interview, she was observed to be generally cooperative,
genuine and articulate. No perceptual disturbances were observed. Speech intelligibility was
comprehensible. Client reported to have attempted committing suicide and to still having suicidal
thoughts and ideations now. Also, judgment was appropriate and insight was fair.
BACKGROUND HISTORY
Niña, a 20-year old female, presented with feelings of ongoing anxiety with onset since two
years ago. She is the eldest child of the family. Her biological parents separated when she was younger
and her mother is currently working as an OFW. She currently lives with her grandparents along with
her siblings. She disclosed having encountered other two incidents of sexual assault prior to what she
experienced two years ago. She likewise reported being unable to form intimate relationship with the
opposite sex because of her trust issues rooting from her parent’s infidelity. Academically, she is
currently a 3rd year student taking up Bachelor of Psychology.
TEST RESULTS AND CLINICAL IMPRESSION
1. Somatic Complaints
The client does not present any symptoms of somatic complaints.
2. Overall Functioning
Cognitive Functioning
She is inferred to have average cognitive abilities. Her perceptions, thoughts and feelings of
others is considerably good. She believes that certain people are hostile and are trying to make life
difficult and unpleasant and should be held accountable for it. She is seen as overtly suspicious and
hostile (PAR). Her negative experiences growing up led her to hold negative beliefs about others.
However, she is deliberate when making decisions.
Emotional Functioning
She experiences negative emotions. She is prone to feelings of guilt, hopelessness, and
loneliness. She may also be easily discouraged and often dejected (DEP). Further, she is apprehensive,
fearful, prone to worry, nervous, and tense (ANX). These may be influenced by factors such as
personality trait, inability to connect with significant others (e.g. biological parents, stepmother,
siblings, peers) due to separation, past bullying, and current interpersonal dynamics at home.
Interpersonal Functioning
In terms of relationships, she keeps her circle small generally, has few friends, seems to be
uncomfortable when around others and prefers asocial activities (SoI). She tends to be reserved and
distant (WRM). She assumes that others may be dishonest or dangerous. However, she is competitive.
She tries to fit in a group, not really stick out and just go with whatever happens, but she also doesn’t
mind telling people what she thinks whenever she feels necessary. As per interview, she has a normal
relationship with her mother, she reported that there may have been times that they would fight if
differences arise but they can also share happy moments together, she feels more closer to her
grandparents and sister as they were the one she is with most of the time.
Self-Concept
She tends to have poor self-image. She has several negative self-appraisals manifested in her
negative attitude about herself and the uncertainty of the future. Also she is uncomfortable around
others, sensitive to ridicule, and prone to feelings of inferiority. She tends to have a lower opinion of
her abilities and admits that she is often unprepared and inept. On a positive light, she has high
aspiration levels and is eager to work hard to achieve her goals. She is purposeful and has a sense of
direction in life.
Ability to Cope
She perceives that her life is sometimes stressful because of the overwhelming crisis given to
her sometimes all at once. Even though, she feels that the world is against her, she always strives to
find a way to get by and continue. She may often see herself as inept but that does not stop her to push
through and find a way out of her problems. Despite everything that she has been through, she is still
choosing to continue on life.
RECOMMENDATIONS:
Based on the overall assessment results, the following actions are recommended:
Somatic Problems:
1. Not applicable
Interpersonal Problems:
2. Engage in counselling and gradual exposure.
Other Problems
3. Go through individual counseling to increase coping strategies and address depressive and anxious
emotions, low self esteem and negative beliefs about herself and others.
Respectfully submitted,
Czarhina Angel Yu
APPENDIX
Personality Assessment Inventory - Adult (PAI-A)

The Personality Assessment Inventory-Adolescence (PAI-A) is a self-administered, objective
test of personality designed to provide information on critical client variables in professional settings.
The PAI contains 264 items, which comprise 22 non-overlapping scales: 4 validity scales, 11 clinical
scales, 5 treatment scales, and 2 interpersonal scales. Ten of the scales contain conceptually derived
subscales designed to facilitate interpretation and coverage of the full breadth of complex clinical
constructs.
PAI MAIN SCALE
SCALES Score
Inconsistency (ICN) Average
Infrequency (INF) Low
Negative Impression (NIM) Elevated
Positive Impression (PIM) Average
Somatic Complaints (SOM) Elevated
Anxiety (ANX) Elevated

Anxiety-Related Disorders (ARD) Average
Depression (DEP) Elevated
Mania (MAN) Average
Paranoia (PAR) Elevated
Schizophrenia (SCZ) Elevated
Borderline Features (BOR) Elevated
Antisocial Features (ANT) Average
Alcohol Problems (ALC) Low
Drug Problems (DRG) Low
Aggression (AGG) Average
Suicidal Ideation (SUI) Elevated
Stress (STR) Elevated
Non-Support (NON) Average
Treatment Rejection (RXR) Low
Dominance (DOM) Low
Warmth (WRM) Average
Revised NEO Personality Inventory (NEO-PI-R)
The Revised NEO Personality Inventory measures five broad domains or factors of
personality namely; Neuroticism, Extraversion, Openness to Experience, Agreeableness,
Conscientiousness, and other six more specific traits within each domain. This test identifies how she
describes himself, how she thinks, what she feels and how she interacts with other people.
5 Domains Interpretation
Neuroticism Very High
Extraversion Low
Openness to Experience High
Agreeableness Low
Conscientiousness Low

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PSYCHOLOGICALEVALUATION

October 14, 2024

Name: Niña Paula Tuan

REASON FOR REFERRAL

MENTAL STATUS EXAM

Personality Assessment Inventory - Adult (PAI-A)

Anxiety (ANX) Elevated

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