Psychological-Report Full

PSYCHOLOGICAL REPORT
I.
IDENTIFYING INFORMATION
Name: Aaron Decena
Sex: Male
Age: 18 years old
Social Status: Single
Address: Malolos, Bulacan
Nationality: Filipino
Religion: Catholic
Date of Consultation: December 29, 2014, January 18, 2015
II.
REFERRAL QUESTION
Aaron Decena was referred by his friend for psychological assessment for his low energy and
unusual gloom following the death of his parents.
III.
CASE BACKGROUND
Aaron Decena is an 18 year-old first year college student taking up BS Biology at Bulacan
State University in Malolos, Bulacan. He is the eldest among four siblings and currently staying
with his relatives in Maunlad, Malolos, Bulacan. His Aunt took care of them and became his
guardian, after the death of both his parents.
The interviewers asked about the incident and he told them that he became different after the
death of his father. He described himself as a rebellious introvert. When asked about it, he shared
to us that it was due to the difficult adjustment he was going through because was very close
with his father for he was the only son. He shared to us their father-son moments that
strengthened their relationship. They would often have family day during Sundays and his father
taught him how to play chess.
Mr. Decena narrated that when he was in grade 5 his father was diagnosed of nasopharyngeal
cancer when he was still in elementary. He was not aware of his fathers illness until it became
worse. He was told that his father was sick but he never thought that his father was dying, so he
felt shocked when he heard the news that his father died.
After the event, he said that he was so affected he often just stayed in his room, cant eat and
stopped mingling with other people. He said that he buried himself in playing video games and
his social life was also affected. He got into fights and when gone to high school, became a total
introvert. He didnt talk to other people unless they talk to him first. He walked slower than
before and always had a handkerchief to hide his face.
When asked about his mother, he shared that it was also difficult for him. He was 16 years
old when his mother died from breast cancer. His mother was a nurse and so she was busy all the
time, but though they were not that close to each other, he said that it was still not easy. After her
mothers death, they needed to live with their relatives and he said that it actually did him better
for the new family he had was a happy family.
He also shared that he is taking up BS Biology because he wants to become an
oncologist, and help cancer patients. But he added that sometimes he feels like he cant finish
what he started and that he has not done anything right in his whole 18 years of life. It came from
him that he feels like he dont have a future and is scared of what might happen in the future.
He told us about all the changes that occurred in their lives and how they cope up with
this event. When asked about his relationship with his girlfriend his face suddenly lightened up
and he smiled and laughed occasionally.
IV. PHYSICAL AND BEHAVIORAL OBSERVATION

Aaron Decena is a young boy with petite body and dark complexion. He stands about 5 feet 7
inches tall, with short black, straight hair. During the sessions he wore black shirt and shorts. On
an initial glance, he looks very timid but he responded very well.
During the interview, he spoke in a very soft voice. He always has handkerchief in his hand
and used it to cover his mouth or wipe his face. He seems very anxious because he kept on
fidgeting while talking about his parents and cannot maintain eye contact also . When asked
about the incident he did not open up readily. He said that he does not want to remember
anymore the death of his parents and talking about it brings back a bitter memory that is why he
is not comfortable in telling us about it.
V. TESTS ADMINISTERED
Hamilton Depression Rating Scale (HAM-D) , Hamilton Anxiety Scale (HAM-A), Major
(ICD-10) Depression Inventory and Generalized Anxiety Disorder 7-item (GAD-7) scale. These
tests were administered on December 29, 2014. Hopkins Symptoms Checklist, Harvard T
Scale and Kinetic Family Drawing were administered on January 18, 2015.
VI. TESTING BEHAVIOUR
During the test administration, Mr. Decena was quiet and calm. He was cooperative and
asked questions when he was unsure of the instructions. He readily answered the tests
administered and finished it without consuming much of the time. It was only during the KFD
that he took his time, and was a bit hesitant to draw.
VII. TEST RESULTS AND INTERPRETATION

Mr. Decenas test results in the Hamilton Anxiety Scale (HAM-A) and in Generalized
Anxiety Disorder 7-item (GAD-7) was Mild Anxiety alongside is his Hopkins A Symptoms
Checklist which shown that he has clinically significant anxiety.
His test results in the Hamilton Depression Rating Scale and Major (ICD-10) Depression
Inventory was Mild Depression alongside is his Hopkins D Symptoms Checklist which shown
that he has clinically significant depression.
His Kinetic Family Drawing suggested that he is trying to move on from his past and is
trying to appreciate the new family he has.
VIII. SUMMARY FORMULATIONS
Aaron Decena is a person who suffers from mild anxiety and depression after he experienced
two significant traumatic events. In effect, he became rebellious, introvert and has low selfesteem. Because of these, he thinks of himself as weak thus, he is not comfortable in talking
about those incidents anymore. He also avoids engaging or participating significant events.
IX. DIAGNOSTIC IMPRESSION
Aaron Decena has experienced mild depression, anxiety and a lowered self-esteem after the
events.
PREPARED BY:
Camalig, Krismer Abigael
Caparas, Angela
Lacaba, Mary Rose
Manalaysay, Jackelyn
Sumala, Sharmaine
BS Psychology 3A
SUBMITTED TO:
Mr. CHRISTIAN V. CRUZ
Instructor, Crisis Intervention
TREATMENT PLAN
OBJECTIVES
1. To reduce the
anxiety that the client
is experiencing
PROCEDURE
EMDR (Eye
Movement
Desensitization
Reprocessing)
DURATION
EXPECTED
OUTPUT
3-6 sessions/weeks
77-100% total
remission of anxiety
TFT(Thought Field
Therapy)
Lasts up to 15
minutes and is not
repeated
The anxiety will

disappear
2. To prevent the
clients mild
depression from
developing into major
depression and
alleviate his negative
thoughts and feelings
toward himself
Logotherapy sessions
10-20 sessions
New found meaning of

life for the client
Cognitive Behavioral
Therapy
*10-20 sessions
Negative thoughts will

be altered to more
productive thoughts
and more productive
behaviours
3. To improve the
clients self esteem
The client should

continue engaging in
activities where he is
socializing with other
people.
The client will go

back to his old self
where he felt
productive and
confident.

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PSYCHOLOGICAL REPORT

IV. PHYSICAL AND BEHAVIORAL OBSERVATION

VII. TEST RESULTS AND INTERPRETATION

The anxiety will

New found meaning of

Negative thoughts will

The client should

The client will go

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