RORSCHACH PROTOCOL REPORT

Client: Smith Age: 60 Gender: Female

Test Date: 1/28/18
Examiner: James P Choca PhD

Test Responses:
01: Card I Orientation: v Rx Time: 7
Score: W o FMa - (2) FAB2.ALOG
v 2 little birds carrying something, it looks like a chicken but that's
impossible, but that's what it looks like, they r carrying this up
INQUIRY: bird {D2} chicken {Dd21}, I didnt know what else to make it.
It's an impossibility but...the beaks {outside small d}, the eyes
{inside shading d}, the crop of feathers at the top, and the wings
{projection toward bottom)
ANYTHING ELSE? this is the shape of the chicken {Dd24}, but it has
shoes {top of Dd21)on [laughs]

02: Card I Orientation: ^ Rx Time: 10

Score: D o F o A
^ putting it this way it's a frog (D4)
INQUIRY: the eyes {Dd22}, the shape of the frog
ANYTHING ELSE? no

03: Card II Orientation: ^ Rx Time: 17

Score: W o FC u A.Cg FAB1
2 little elephants with clown hats on [laughs]
INQUIRY: 1st thing I saw r the clown hats {D2}, the trunks {D4}, 3 legs
showg on each elephant {bm projections}. It dt show the ears
ANYTHING ELSE? no
RED BM? that's one of their legs. They r sitting down
CLOWN HAT? the shape of it and maybe the color. Clown hats wd have
more color than that
ANYTHING ELSE? no

04: Card III Orientation: ^ Rx Time: 12

Score: W o Ma o H.Hh (2) P
[i know i am always horrible at this kd of thing] 2 waiters at a table
INQUIRY: maybe they r moving the table
ANYTHING ELSE? no. Now I c these as decorations that r in the
restaurant [red]
ANYTHING ELSE? no
DECORATIONS? well, mostly if u wanted to include everything in the card
05: Card III Orientation: v Rx Time: 13
Score: D o Ma - H (2)
2 children walking away from each other
INQUIRY: foot on the ground {Dd32}, heads with noses {Dd31}, leg moving
forward {Dd21}, hair {top of Dd31}, trees or something in the
background {bm of Dd31}. The leg could be this also, but that's a very
long leg {D5}, I just saw it here {top of Dd31}
ANYTHING ELSE? no

06: Card IV Orientation: ^ Rx Time: 10

Score: W o Mp u (H).Hh (2)
huge shoes, these wd b jesters, they r leang up against a pole
INQUIRY: pole {D5}, here is their shoe {d}, the heel of the shoe {D2},
this is the hat {D4} drooping down, it shd have a little bell at the
end [laughs]
ANYTHING ELSE? no

07: Card IV Orientation: v Rx Time: 9

Score: W o Mp u (H).Hh
v this way wd b a king, this wd be the crown {Dd28}, he's holding up
papers with both hands {D2}
INQUIRY: he's sitting on something {bm of D5}, there r 2 dogs there and
these are the dog tails coming up {D4}
ANYTHING ELSE? no. His eyes {small d in outside mid D1}, sort of
misplaced
ANYTHING ELSE? no

08: Card V Orientation: ^ Rx Time: 6

Score: W o F o A P CON
a butterfly, his wings r down, it shd have them open, butterfly or bat!
INQUIRY: antenna, that wd b the feet on the bat but for the butterfly,
that dt really go in {D9}. It wd b more the shape of a bat
ANYTHING ELSE? the wings r more that of a bat, but this made me think
of a butterfly {D6}. It could be a bat with a butterfly antenna
[laughs]
ANYTHING ELSE? no

09: Card VI Orientation: > Rx Time: 16

Score: W v m.rF u Bt
v> the trees and a tree stump reflected in the water
INQUIRY: stump {D3}, or some kd of flower growg
ANYTHING ELSE? no>

10: Card VI Orientation: v Rx Time: 8

Score: D o FMa o A.Hh (2) DV1.FAB1
v 2 bears playing flutes {D1} [laughs]. I like the one of the reflected
in the water better
INQUIRY: bear ears and the nose {top cn}, top legs {Dd24}, bm legs
{Dd25}, this part here is the flute {small projection above Dd24}, or
it could be a violin, just playing an instrument
ANYTHING ELSE? no

11: Card VII Orientation: ^ Rx Time: 8

Score: W o Mp u H.Hh (2)
2 ladies lookg at each other
INQUIRY: this could be where they r sittg {D4}, this could be their
torsos & their hands, the main thg is their faces
ANYTHING ELSE? there is a feather in their hair {D5}
ANYTHING ELSE? no
12: Card VII Orientation: v Rx Time: 9
Score: W o FMp - (2)
v 2 Scottie dogs
INQUIRY: their bodies {D9}, the tail {D6}, the head {D3}, the eyes, the
ears. I dk what they wd b hanging on to, if they wanted to include the
whole thing {D4}, something pulling them up
ANYTHING ELSE? no

13: Card VIII Orientation: ^ Rx Time: 9

Score: W FMa o A.Na (2) P
v^ the pink things on the side jump out as leopards or some kind of cat
INQUIRY: they r climbg rocks or something
ANYTHING ELSE? no

14: Card VIII Orientation: ^ Rx Time: 20

Score: Dd o F u (A).An
the skeleton of a fish
INQUIRY: this is the head {D4}, & the skeleton {D3}. Some of the meat
is still in there
ANYTHING ELSE? no

15: Card VIII Orientation: v Rx Time: 17

Score: W v CF o Bt
v this way it makes me think of a flower
INQUIRY: mainly this part, is the blossom {D2}, these could be leaves
{D4}, & this could be some other flowers
ANYTHING ELSE? the colors
ANYTHING ELSE? no

16: Card IX Orientation: v Rx Time: 9

Score: W v C'F u Fd INC2
v carrots, lettuce, and tomatoes. Going under the ground, on the ground
and above the ground. They wd not be on the same stem, but that's what
I c
INQUIRY: [points to the parts]
ANYTHING ELSE? the colors
ANYTHING ELSE? no

17: Card IX Orientation: < Rx Time: 3

Score: W v CF.rF - Ls
< beautiful autumn scene reflected in the water
INQUIRY: here is the water and here is the diff colored trees. Actually
I like that one a lot
ANYTHING ELSE? no

18: Card X Orientation: ^ Rx Time: 8

Score: D o Ma o H.Fd (2)
>v<^ 2 ppl drinking from straws
INQUIRY: ppl {D2}, drink & straws {D6}

19: Card X Orientation: v Rx Time: 9

Score: W v C'F u Art
>v goes with the painting bit we had the other day. I am not too
imaginative
INQUIRY: the colors, splotches of paint
PAINTING BIT? Oh, nothing, it looks like an abstract painting of some
kind, just colors
ae? no
20: Card X Orientation: ^ Rx Time: 6
Score: WS o FC - H.(H).Cg ALOG
a sumo wrestler, with red robes, he's holding feathery things on both
arms {D1}, head and body {DdS29}, legs {DdS30}, something on his knees
{Dd33} g-string {D6}, something around his neck {D3}, some kd of hat on
{D11},
the black part wd b his hair, those could be his attendants {D15}
[laughs]
ANYTHING ELSE? no
ATTENDANTS? Well, these things r there, what else cd they b?> ^
 RORSCHACH SEQUENCE REPORT

Client: Smith Age: 60 Gender: Female

Test Date: 1/28/18
Examiner: James P Choca PhD

Test Responses:

Response Card Orientation Rx Time Score

01 I v 7 W o FMa - (2) FAB2.ALOG
02 I ^ 10 D o F o A
03 II ^ 17 W o FC u A.Cg FAB1
04 III ^ 12 W o Ma o H.Hh (2) P
05 III v 13 D o Ma - H (2)
06 IV ^ 10 W o Mp u (H).Hh (2)
07 IV v 9 W o Mp u (H).Hh
08 V ^ 6 W o F o A P CON
09 VI > 16 W v m.rF u Bt
10 VI v 8 D o FMa o A.Hh (2) DV1.FAB1
11 VII ^ 8 W o Mp u H.Hh (2)
12 VII v 9 W o FMp - (2)
13 VIII ^ 9 W FMa o A.Na (2) P
14 VIII ^ 20 Dd o F u (A).An
15 VIII v 17 W v CF o Bt
16 IX v 9 W v C'F u Fd INC2
17 IX < 3 W v CF.rF - Ls
18 X ^ 8 D o Ma o H.Fd (2)
19 X v 9 W v C'F u Art
20 X ^ 6 WS o FC - H.(H).Cg ALOG
 RORSCHACH STRUCTURAL REPORT

Client: Smith Age: 60 Gender: Female

Test Date: 1/28/18
Examiner: James P Choca PhD

GLOBAL INDICES:
n % Exner Intl Psyc

R 20
Rejected 0
P 3 15 Low
(2) 9 45
3r+(2) 15
RT Achr 9.2
RT Chr 11.2
AFR 0.67

LOCATION SCORES:
n % Exner Intl Psyc

W 15 75 High
D 4 20 Low
Dd 1 5
d 0 0

S 1 5
SR 0 0
SI 0 0
Sum S 1 5

RATIOS INVOLVING LOCATION:

n Exner Intl Psyc
W:M 15:6
W:D 15:4

PLATE ORIENTATION:
n % Exner Intl Psyc

^ 10 50
> 1 5
v 8 40
< 1 5
DEVELOPMENTAL QUALITY:
n % Exner Intl Psyc

+ 0 0
o 14 70
v/+ 0 0
v 5 25 High High

ALTERNATE DEVELOPMENTAL QUALITY:

n % Exner Intl Psyc

Sy 0 0
Vg 0 0

DETERMINANTS:
n % Exner Intl Psyc

M 0 0
Ma 3 15
Mp 3 15 High
Sum M 6 30
FM 0 0
FMa 3 15
FMp 1 5
Sum FM 4 20
m 1 5
ma 0 0
mp 0 0
Sum m 1 5
FT 0 0
TF 0 0
T 0 0
Sum T 0 0
FY 0 0
YF 0 0
Y 0 0
Sum Y 0 0
FV 0 0
VF 0 0
V 0 0
Sum V 0 0
FC' 0 0
C'F 0 0
C' 0 0
Sum C' 0 0
FC 2 10
CF 2 10
C 0 0
DETERMINANTS (cont.):
n % Exner Intl Psyc

Sum C 4 20
Cn 0 0
FD 0 0
Fr 0 0
rF 2 10
Fr+rF 2 10 High High High
F 3 15 Low

INDICES & RATIOS INVOLVING DETERMINANTS:

n % Exner Intl Psyc

Lambda 0.18 Low

Blends 2 10
a:p 6:4
WSumC 3
M:WSumC 6:3
M+WSumC 9
FM+m 5
YTVC' 0
FM+m+YTVC' 5
FC:CF+C 2:2

CONTENT SCORES:
n % Exner Intl Psyc

H 0 0 Low Low Low

(H) 0 0
Hd 0 0
(Hd) 0 0
Hx 0 0
A 0 0 Low Low Low
(A) 0 0
Ad 0 0 Low
(Ad) 0 0
Ab 0 0
Al 0 0
An 0 0
Art 0 0
Ay 0 0
Bl 0 0
Bt 0 0
Cg 0 0
Cl 0 0
Ex 0 0
CONTENT SCORES (cont.):
n % Exner Intl Psyc

Fd 0 0
Fi 0 0
Ge 0 0
Hh 0 0
Ls 0 0
Na 0 0
Obj 0 0
Sc 0 0
Sx 0 0
Voc 0 0
Xy 0 0
Idio 0 0
Nc 0 0

INDICES & RATIOS INVOLVING CONTENT:

n % Exner Intl Psyc

CONT 0 0
H+Hd:A+Ad 0:0
H+A:Hd+Ad 0:0

FORM QUALITY:

OVERALL n % Exner Intl Psyc

+ 0 0
o 7 35 Low
u 8 40 High
- 5 25 High
n 0 0
F ONLY

+ 0 0
o 2 10 Low Low Low
u 1 5
- 0 0
n 0 0
M ONLY

+ 0 0
o 2 10
u 3 15 High High High
- 1 5
n 0 0
S ONLY

+ 0 0
o 0 0
u 0 0
- 0 0
n 0 0

SPECIAL SCORES:
n % Exner Intl Psyc

DV1 1 5
DV2 0 0
INC1 0 0
INC2 1 5 High High High
DR1 0 0
DR2 0 0
FAB1 2 10 High High High
FAB2 1 5 High High High
ALOG 2 10 High High High
CON 1 5 High High
AB 0 0
CP 0 0
AG 0 0
MOR 0 0
PER 0 0
COP 0 0
PSV 0 0
AGM 0 0
AGC 0 0
MAH 0 0
MAP 0 0
ODL 0 0
PV 0 0
NB 0 0

SPECIAL SCORE INDICES:

n Exner Intl Psyc

Sum6 8 High High

WSum6 37 High High High
 REPORT OF PSYCHOLOGICAL EVALUATION

REPORT IN BRIEF: Ms. Smith (not her real name) is a 60-year-old White single woman
who was admitted into the psychiatric ward in a depressed and psychotic state. The
patient had been experiencing a great deal of distress associated with her attempts to
take care of her terminally ill brother. The depression had practically lifted by the time of
the testing. The Rorschach clearly showed a disturbed thought process. Although there
were some signs of hypomanic behavior, the evidence for bipolar affective instability was
not impressive.

PRESENTING COMPLAINTS: In addition to dysphoria, other signs of depression had

included the patient feeling useless, having crying spells, experiencing sleep difficulties,
and losing ten pounds. She was religiously preoccupied and obsessed with the thought
of death. She had become socially isolated. The hospitalization was precipitated by her
taking Darvon, alcohol, and Nyquil at the same time, apparently in an attempt to fall
asleep.

Ms. Smith had been expressing very peculiar ideas in the recent past. She was
concerned that “either” she or her brother had been molested by their father, and that
she had killed her father. At the time of admission she felt that Mother Theresa needed
another miracle in order to become a saint, and that the miracle would be the cure of her
brother who is dying of cancer. In order to make that cure possible, however, she
thought that either she or her other brother would have to die. She dreamed that her
healthy brother would kill himself.

At times Ms. Smith appeared to have lost control of her own behavior. She had assumed
responsibility for taking care of her brother but had become so inappropriate at the
hospice where the brother stays that she presented a problem at that setting. At one
point she started crying hysterically, reportedly repeatedly asserting that the brother will
have to “die.”

PSYCHOSOCIAL STRESS: The patient has been very close to her 69-year-old brother,
the brother who is now terminally ill. Since Ms. Smith’s retirement last year, she has
been feeling less needed and important.

PSYCHIATRIC HISTORY: The patient had an untreated episode of depression 20 years

ago. She denied ever having any manic or hypomanic symptoms. Zyprexa had been
prescribed to her by her physician prior to the hospitalization, but the patient had not
taken this medication.

Ms. Smith has never had any difficulties with substance abuse. The family history of
psychiatric illness is contributory for depression in the case of her father and her older
brother. The older brother suicided. Alcoholism has been a problem for a brother and a
nephew. Her father suffered from major cognitive deficits in his later years.
MEDICAL HISTORY: Ms. Smith is moderately obese. She smokes 2 packs of cigarettes
a day. The patient had a colostomy for a ruptured colon in 1990, with reversal of the
operation in 1991. She suffers from arthritis and hypertension, and is medicated for both
of these problems.

SOCIAL HISTORY: Ms. Smith was born and raised in ---, to a family of French-
Canadian ancestry. Her mother suffered from a heart condition associated with the
rheumatic fever she had as a child, and died many years ago. A “loving” person, the
mother never presented any problems for the patient. The father was the dominant
figure in the home since he was strong-willed and strict. After retiring from his years as a
salesman, the father worked as a security guard. He had become demented and
depressed by the time he died of renal failure.

The patient was the youngest of 4 siblings. She lost one of her 3 brothers when the
brother suicided. This brother had 2 daughters from his second marriage but the patient
has not had any contact with that side of the family for years. She feels close to her 71-
year-old brother. A priest, this brother is now retired. The patient plans to stay with him in
California after she leaves the hospital. She usually spends the Christmas holidays with
him and going earlier will allow her to take a needed break from the situation with her
terminally ill brother.

The person in the family to whom Ms. Smith has been the closest is her second brother.
This brother moved into an apartment in the same building the patient occupies after his
divorce many years ago. He is terminally ill with lung cancer, which has metastasized to
other organs. It had been the patient who had taken responsibility for her brother’s care
in the past.

Ms. Smith has many good friends, and has never had any social problems. She is
typically in contact with the many friends she made during the years she taught grade
school. She has one particularly good friend, the person who brought her into the
hospital and visits her frequently.

EDUCATIONAL HISTORY: Ms. Smith has a Bachelor’s degree. She was an

outstanding student and graduated with honors. She also completed 36 hours of
postgraduate work in the field of special education.

OCCUPATIONAL HISTORY: Ms. Smith retired last year after teaching grade school for
38 years. Although she did not want to continue working full-time, she noted that her job
put some meaning into her life that she has been missing since her retirement. She
plans to eventually sign up as a substitute teacher in order to meet some of those needs.

MENTAL STATUS EXAMINATION: At the time of the examination the patient was alert,
oriented, verbal and coherent. The speech, language, calculations, construction ability,
abstractions and memory were all intact. The thought process was orderly and effective.
The thought content was unremarkable. The affective response was appropriate to the
content of the conversation. The mood was occasionally dysphoric, but demonstrated a
good range of emotions. There was one occasion when the patient became tearful.
Suicidal or homicidal ideation was denied. Ms. Smith stated that she was feeling
anxious, especially at the beginning of the evaluation. The psychomotor activity was
within the normal range. The patient was very cooperative.

TEST RESULTS:
Shipley Institute of Living Scale (SILS)

Estimated Intelligence Quotient (IQ) = 119

Emotional Assessment System (EAS)

Av T-Score Graph ¦ O
Scale Sec Raw 0-1-2-3-4-5-6-7-8-9-0 TN TP
---------------------- --- ---- --------------------- --- ---
Tier A: Validity Indicators
Aa Attention 23 1 ¦¦¦¦¦¦|¦¦¦|¦¦ | 62 51
Ac Comprehension 6 2 ¦¦¦¦¦¦|¦¦¦| | 46 50
Ad Disclosure 23 0 ¦¦¦¦¦¦|¦¦¦| | 44 49
Ai Inconsistency 13 0 ¦¦¦¦¦¦|¦¦¦| o | 44 58

Tier B: Basic Scales - Personality

B01 Introversive/Schizoid 6 13 ¦¦¦¦¦¦|¦¦¦|¦o | 55 59
B02 Sensitive/Avoidant 6 18 ¦¦¦¦¦¦|¦¦¦|¦¤ | 60 61
B03 Cooperative/Dependent 6 29 ¦¦¦¦¦¦|¦¦¦|o¦¦|¦ 73 57
B04 Dramatic/Histrionic 5 14 ¦¦¦¦¦¦|¦¦¦|o | 43 53
B05 Self-assured/Narcissistic 6 7 ¦¦¦¦¦¦|¦o | | 37 38
B06 Competitive/Antisocial 6 3 ¦¦¦¦¦¦|¦ | | 33 50
B07 Disciplined/Compulsive 6 28 ¦¦¦¦¦¦|o¦¦|¦¦¦| 65 34
B08 Schizotypal 5 14 ¦¦¦¦¦¦|¦¦¦|¦o | 54 59
B09 Borderline 6 6 ¦¦¦¦¦¦|¦¦¦|o | 43 53

Tier B: Basic Scales - Mood

B10 Anxiety/Anxiety Disturbance 7 14 ¦¦¦¦¦¦|¦¦¦|¦¦o| 58 63
B11 Anger/Explosive Disturbance 9 0 ¦¦¦¦¦¦|¦ | o | 35 59
B12 Pessimism/Depression 4 14 ¦¦¦¦¦¦|¦¦¦|¦ o| 54 67
B13 Optimism/Mania 7 9 ¦¦¦¦¦¦|¦¦¦|o | 47 55

Tier B: Basic Scales - Pathological Defenses

B14 Somatic Concerns 6 6 ¦¦¦¦¦¦|¦¦¦| | 48 68
B15 Eating Disturbance 8 11 ¦¦¦¦¦¦|¦¦¦|¦ | 55 52
B16 Substance Abuse 7 2 ¦¦¦¦¦¦|¦¦ | o| 40 66
B17 Distrust/Paranoia 6 9 ¦¦¦¦¦¦|¦¦¦| o | 45 60
B18 Thought Disturbance 8 6 ¦¦¦¦¦¦|¦¦¦| o | 50 59

Tier B: Environmental
B19 Current Stress 8 12 ¦¦¦¦¦¦|¦¦¦|¦¦o| 60 64
B20 Posttraumatic Stress 5 8 ¦¦¦¦¦¦|¦¦¦| o| 47 65

Tier B: Level of Functioning

B21 Global Functioning 9 11 ¦¦¦¦¦¦|¦¦¦|¦¦¦| 67 70

| Indicates average and average range for the non-psychiatric sample

O Indicates average for the psychiatric group (T score given on left column)
¦ Indicates examinee's T Score
¤ Indicates examinee's T score when it is similar to the psychiatric group score
The Millon Clinical Multiaxial Inventory - III

Personality Style Scales: Scores=> Raw Base Rate

1 - Introversive (Schizoid).....................= 10 71
2A - Inhibited (Avoidant)........................= 9 65
3 - Cooperative (Dependent).....................= 16 88 **
4 - Dramatic (Histrionic).......................= 9 42
5 - Confident (Narcissistic)....................= 9 49
6A - Competitive (Antisocial)....................= 5 60
7 - Disciplined (Compulsive)....................= 24 86 **
8A - Negativistic (Passive-Aggressive/Explosive).= 1 7

Severe Personality Scales:

2B - Depressive..................................= 5 32
6B - Aggressive/Sadistic.........................= 3 36
8B - Self-Defeating..............................= 2 23
S - Schizotypal.................................= 7 63
C - Borderline..................................= 2 14
P - Paraphrenic.................................= 1 15

Clinical Symptom Scales:

A - Anxiety.....................................= 8 78 *
H - Somatic Preoccupations......................= 5 43
N - Hypomania...................................= 2 24
D - Dysthymia...................................= 5 33
B - Alcohol Abuse...............................= 1 25
T - Drug Abuse..................................= 2 60
R - Post Traumatic Stress Disorder..............= 0 0
SS - Psychotic Thinking..........................= 9 63
CC - Psychotic Depression........................= 9 63
PP - Psychotic Delusion..........................= 3 65

Modifier Indices:
X - Disclosure..................................= 90 58
Y - Desirability................................= 16 74
Z - Debasement..................................= 9 61
V - Validity....................................= 0

Beck Depression Inventory – Second edition (BDI-II)

Score = 12 (Minimal depression)

Rorschach Inkblot Test

The results of this test will be incorporated into the discussion section below.

Thematic Apperception Test (TAT)

The results of this test will be incorporated into the discussion section below.

INTELLECTUAL ASSESSMENT: The mental status examination gave no indication of

cognitive or memory deficits. The score from the SILS suggested that Ms. Smith is a
bright individual. This finding was consistent with the level of education the patient
achieved, and her performance both in school and work. This is an area of significant
strength for her.

PERSONALITY ASSESSMENT: The patient appeared to have a dependent personality

with compulsive elements. Although her dependency may have been exacerbated by
her state of mind at the time of the testing, this personality appeared to reflect life-long
characteristics. She has seemingly functioned well throughout her life and does not have
a personality disorder. Nevertheless, this dependent-compulsive personality undoubtedly
played a role in the events leading to her hospitalization as will be discussed below.

The testing indicated that Ms. Smith has a low self-esteem and an orderly and
compulsive nature. Individuals with similar dependent-compulsive personalities hold the
life assumption that other people are more capable, interesting or valuable than they are.
They are unconceited and personable and are often capable of forming strong
interpersonal relationships with others. They aim to be as congenial as possible to those
around them in order to secure the support they need. As a result, similar people tend to
be fairly submissive or, at least, compliant. They shy away from competitive situations
because such situations make them feel unsupported and vulnerable. When they feel
protected, however, they tend to be quite at ease and conflict-free.

One way in which Ms. Smith defends against the insecurity that her low self-esteem may
bring is by counting on the guidance and protection of others. The second defense
mechanism that she uses is thinking that if she manages to avoid ‘making a mistake,’
she can always expect the outcome to be a positive one. Individuals with a similar
‘compulsive’ bent are orderly and plan for the future. They prepare in a conscientious
manner and do the work on schedule. They try to be efficient, dependable, industrious
and persistent. Often these individuals relate in an overly respectful and ingratiating
manner. However, they may be somewhat perfectionistic and demanding. Similar people
believe in discipline. They may tend to be indecisive and have significant problems
making a decision by themselves. The compulsive inclination may also serve to
strengthen the feelings of inadequacy that are beneath it in that, whenever bad events
take place, Ms. Smith will be inclined to look for what mistakes she made that led to the
undesirable outcome.

EMOTIONAL ASSESSMENT: Although Ms. Smith was reportedly very depressed on

admission, she had improved a great deal by the time of the testing. She was animated
and jovial, and only occasionally showed any signs of depression. It appeared that this
depression had lifted too rapidly to represent a major affective disorder. Judging from
the Rorschach, the patient was energized and productive, was emotive, could
experience positive emotions, and was capable of being involved and motivated.

The patient complained of anxiety and showed a moderate level of anxiety on the
psychiatric questionnaires.

The Rorschach unfortunately showed very serious distortions of the reality testing. Ms.
Smith was manifesting substantial and marked perceptual distortions consistent with the
presence of a serious thought disorder. Judging from this test, she has been functioning
with poor boundaries, and tends to put ideas together that do not belong together.
Although her thinking process was of very poor quality, her level of functioning tended to
be pulled up by her capacity for insight. Ms. Smith was often aware of her distortions,
and would qualify them or become tentative in the expression of these ideas.

The patient was animated but her energy level was not excessive. Judging from the
projectives, her level of productivity was not out of the ordinary. Consequently, the
evidence in support of a bipolar disorder was not impressive.

The testing also revealed a great deal of stress. Judging by the number of times that the
issue of death reoccurred in the TAT stories, the brother’s illness has been very hard for
Ms. Smith to deal with.

DISCUSSION: Given her dependent-compulsive personality, it seemed that Ms. Smith

had become very close and emotionally dependent on her brother prior to his illness.
This, and the debt she felt she owed him for his taking care of her when she was ill, put
her under a great deal of pressure.
It seemed that Ms. Smith developed peculiar ideas and went completely out of control
prior to her hospitalization. By the time of the testing she had been able to reintegrate,
even though signs of psychosis were still present. The depression she showed on
admission had also lifted. Perhaps both of these problem areas are best conceptualized
as an acute reaction to the impending death of her brother.

DIAGNOSTIC IMPRESSIONS:
Brief psychotic disorder with marked stressor
Adjustment disorder with mixed anxiety and depressed mood
Dependent personality style with no personality disorder
Status post colostomy and reversal
Hypertension
Arthritis
External Stress: Impending brother’s death
Level of Functioning: Serious symptoms at the time of admission

RECOMMENDATIONS: Continued evaluation for the use of psychotropic medications in

reducing the symptomatology was indicated.

Ms. Smith would also benefit from counseling or psychotherapy. Given the personality
style described above, would experience as supportive a relationship where the other
person has a benevolent and protective attitude towards her. Feeling that the therapist is
a powerful expert who will advise and guide her appropriately will be reassuring for Ms.
Smith. The patient would be expected to establish a strong therapeutic alliance without
much difficulty, and to find such a relationship helpful.

At the time of the testing the patient was planning to visit her brother in California for a
period of time. This plan would have the effect of taking her out of the stressful situation
with her terminally ill brother. Since she seems to need a break at this time, this plan
should be supported.

James P. Choca, PhD