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Review the brief Alzheimer’s Association, Florida (2018) video demonstrating the administration of a mental status examination.

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Prior to beginning work on this discussion, read the assigned chapters from the text. It is highly recommended that you review the brief Alzheimer’s Association, Florida (Links to an external site.) (2018) video demonstrating the administration of a mental status examination. This video is linked above and is also listed in the recommended resources. Although not required, this video shows the administration of a mental status exam and may prove helpful in this discussion.

Access the Barnhill (2014) DSM-5 Clinical Cases e-book in the DSM-5 library, and select one of the case studies. The case study you select must be one in which the client could be assessed using one or more of the assessment instruments discussed in this week’s reading on testing special populations and neuropsychological testing.
For this discussion, you will take on the role of a psychology intern at a mental health facility working under the supervision of a licensed psychologist. In this role, you will conduct a psychological evaluation of a client referred to you for a second opinion using valid psychological tests and assessment procedures. The case study you select from the textbook will serve as the information provided to you from the professional who previously evaluated the client (e.g., the psychologist or psychiatrist).
In your initial post, begin with a paragraph briefly summarizing the main information about the case you selected. Evaluate and describe the ethical and professional interpretation of any assessment information presented in the case study. Devise an assessment battery for a psychological evaluation that minimally includes a clinical interview, mental status exam, intelligence test, observations of the client, and at least two psychological tests specific to the diagnostic impressions (e.g., attention deficit/hyperactivity disorder, post-traumatic stress disorder, autism spectrum disorder, etc.). The assessment plan must be presented as a list of recommended psychological tests and assessment procedures with a brief sentence explaining the purpose of each test or procedure. Following the list of tests and assessment procedures you recommend for your client, compare the assessment instruments that fall within the same categories (e.g., intelligence test or achievement test), and debate the pros and cons of the tests and procedures you selected versus the test and procedures reported by the referring professional. If no psychological tests or specific assessment procedures are mentioned in the case study, minimally assume a diagnostic interview was conducted and debate the pros and cons of the tests and procedures you selected versus making a diagnosis based only on a diagnostic interview.
Case 8.1 Sad and Alone
Richard J. Loewenstein, M.D.
Irene Upton was a 29-year-old special education teacher who sought a psychiatric consultation because “I’m tired of always being sad and alone.”
The patient reported chronic, severe depression that had not responded to multiple trials of antidepressants and mood stabilizer augmentation. She reported greater benefit from psychotherapies based on cognitive-behavioral therapy and dialectical behavior therapy. Electroconvulsive therapy had been suggested, but she had refused. She had been hospitalized twice for suicidal ideation and severe self-cutting that required stitches.
Ms. Upton reported that previous therapists had focused on the likelihood of trauma, but she casually dismissed the possibility that she had ever been abused. It had been her younger sister who had reported “weird sexual touching” by their father when Ms. Upton was 13. There had never been a police investigation, but her father had apologized to the patient and her sister as part of a resultant church intervention and an inpatient treatment for alcoholism and “sex addiction.” She denied any feelings about these events and said, “He took care of the problem. I have no reason to be mad at him.”
Ms. Upton reported little memory for her life between about ages 7 and 13 years. Her siblings would joke with her about her inability to recall family holidays, school events, and vacation trips. She explained her amnesia by saying, “Maybe nothing important happened, and that’s why I don’t remember.”
She reported a “good” relationship with both parents. Her father remained “controlling” toward her mother and still had “anger issues,” but had been abstinent from alcohol for 16 years. On closer questioning, Ms. Upton reported that her self-injurious and suicidal behavior primarily occurred after visits to see her family or when her parents surprised her by visiting.
Ms. Upton described being “socially withdrawn” until high school, at which point she became academically successful and a member of numerous teams and clubs. She did well in college. She excelled at her job and was regarded as a gifted teacher of autistic children. She described several friendships of many years. She reported difficulty with intimacy with men, experiencing intense fear and disgust at any attempted sexual advances. Whenever she did get at all involved with a man, she felt intense shame and a sense of her own “badness,” although she felt worthless at other times as well. She tended to sleep poorly and often felt tired.
She denied use of alcohol or drugs, and described intense nausea and stomach pain at even the smell of alcohol.
On mental status examination, the patient was well groomed and cooperative. Her responses were coherent and goal directed, but often devoid of emotional content. She appeared sad and constricted. She described herself as “numb.” She denied hallucinations, confusion, and a current intention to kill herself. Thoughts of suicide were, however, “always around.”
More specific questions led Ms. Upton to deny that she had ongoing amnesia for daily life, particularly denying ever being told of behavior she could not recall, unexplained possessions, subjective time loss, fugue episodes, or inexplicable fluctuations in skills, habits, and/or knowledge. She denied a sense of subjective self-division, hallucinations, inner voices, or passive influence symptoms. She denied flashbacks or intrusive memories, but reported recurrent nightmares of being chased by “a dangerous man” from whom she could not escape. She reported difficulty concentrating, although she was “hyperfocused” at work. She reported an intense startle reaction. She reported repeated counting and singing in her mind, repeated checking to ensure that doors were locked, and compulsive arranging to “prevent harm from befalling me.”
Dissociative amnesia
Major depressive disorder, chronic, with suicidal ideation
Posttraumatic stress disorder
Ms. Upton reports persistently depressed mood, insomnia, fatigue, feelings of worthlessness, and suicidality. It is not surprising that she has received serial treatments for major depression. These treatments, however, have been unsuccessful, although psychotherapy has provided some benefit.
In addition to her depressive symptoms, Ms. Upton describes a cluster of symptoms that are central to conceptualizing her problems and her treatment. Although her younger sister is the one who reported him for “weird sexual touching,” the father also apologized to the patient. Ms. Upton has a history of severe self-cutting that occurs when she sees her family. Sexual intimacy disgusts her and intensely exacerbates her chronic sense of shame and worthlessness, so she avoids men. She has recurrent nightmares of being chased by “a dangerous man.” Although the patient casually denies having been abused, she describes a 6-year autobiographical memory gap that seems to have ended at the exact time that her father was sent away for inpatient treatment of alcoholism and “sex addiction.” Even the smell of alcohol induces severe nausea and “stomach pain.” Given these facts, it is not surprising that previous therapists have “focused on the likelihood of trauma.”
The apparent child sexual abuse in conjunction with a 6-year memory deficit conforms well to a DSM-5 diagnosis of dissociative amnesia (DA).
In contrast to the memory failures associated with intoxications and neurocognitive disorders, DA involves problems with autobiographical memory: what I did, where I went, what I thought or felt, and so forth. The most common presentation of DA is localized DA, an inability to remember a specific period of time or event, such as all of second grade. In selective DA, memory is preserved for some of the events during a circumscribed period of time, such as some retained memories from second grade, but with amnesia for all or part of the actual trauma.
DA is associated with physical and sexual abuse, and its extent seems to increase with increased severity, frequency, and violence of the abuse.
DA can be difficult to distinguish from other trauma-related diagnoses because such disorders as posttraumatic stress disorder (PTSD) also feature memory loss in the context of trauma. If the memory loss is the core symptom and involves a period that extends well beyond the actual trauma, then DA should be coded separately from a PTSD diagnosis. Ms. Upton’s memory loss extended over 6 years, which conforms to the period of presumed sexual abuse. In addition, she describes intrusive thoughts (nightmares), avoidance (of dating and sex), negative alterations in cognitions and moods (belief in her “badness”), and hyperarousal/hyperreactivity (startle reaction). In other words, she also meets criteria for PTSD and so warrants a comorbid diagnosis.
A subgroup of DA patients will also have significant obsessive-compulsive disorder symptoms, and Ms. Upton describes recurrently counting, singing, checking, and arranging, all in an effort to “prevent harm from befalling me.”
Another subgroup of patients will have far broader amnesia, called generalized dissociative amnesia (GDA). The loss of memory can expand to include an entire life, including personal identity, fund of knowledge, and memory for skills. Longitudinal observation of people with GDA shows that many will meet diagnostic criteria for DSM-5 dissociative identity disorder (DID).
DID is notable for a disruption of identity characterized by two or more distinct personality states. These states involve a marked discontinuity in the sense of self as well as clinically relevant memory gaps. Although Ms. Upton does not recall much of elementary school, she denies experiencing typical DID symptoms such as suddenly finding herself somewhere without recalling having gotten there (dissociative fugue); unexplained appearance or disappearance of possessions; being told of unrecalled behavior; and inexplicable fluctuations in skills, capacities, and knowledge (e.g., being able to play music at one time but being unable to access this skill at another). In addition, individuals with DID tend to experience symptoms such as hearing inner voices, depersonalization/derealization, a subjective sense of self-division, behaviors related to switching or shifting of identity states, and symptoms related to overlap or interference between identity states. Although these symptoms warrant longitudinal investigation, Ms. Upton specifically denied them and is unlikely to have DID.
The diagnostic interview with people with DA is unusual. They rarely volunteer information about memory problems. They commonly minimize the amnesia and its connection to traumatic events. Perhaps most important, discussion of even the possibility of trauma can induce intense anxiety, flashbacks, nightmares, and somatic memories of the abuse. Tact, pacing, and timing are critical, and a zealous pursuit of “truth” can inflict psychological harm on a person who is still suffering from abuse endured many years earlier.

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