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Name: John A Sample Age: 24 Sex: M Referred By: 12/16/78 Interpret Date: 5/9/02 Test Date: 5/9/02 PHONE AND FAX (800) 588-9412 DETAILED ASSESSMENT OF POST TRAUMATIC STRESS - REPORT To aid in diagnosis and treatment planning, Mr. Sample was administered the Detailed Assessment Of Post Traumatic Stress. The following test findings are based on Mr. Sample's responses to a widely used standardized psychological test. As with all such tests, the validity of test results is limited by Mr. Sample's honesty and self-awareness. The report below should be taken as generalized probability statements that are made without benefit of clinical interview or history. Further clinical verification is needed to assist in the interpretation of test findings in light of Mr. Sample's unique history and present circumstances. As psychological tests were designed primarily for diagnosis and treatment planning purposes, the findings below focus on problems, deficits and pathology and de-emphasize Mr. Sample's strengths. Because of this, use without collaboration, other than for the clinical screening purposes, for which they are intended, may be misleading. The following is a CONFIDENTIAL REPORT meant for qualified Mental Health, Correctional and Substance Abuse professionals. While feedback of test findings to clients is highly encouraged and should be an integral part of therapy and treatment planning, clients should not be given copies of this report as they are probable to misunderstand report contents and their tentative nature. PTSD specific testing did not have a "fake good" response set, with Mr. Sample not minimizing his problems and pathology. A mild "fake bad" response set exists in which Mr. Sample may have mildly focused on his problems. The following test findings may be a mild over representation of Mr. Sample's symptoms/problems. Mr. Sample reports having been exposed to a restricted range of traumatic events when compared to those who have been exposed to at least one traumatic incident. This may lead Mr. Sample to have a less complex clinical picture, though this index does not measure the frequency or intensity of the specific types of traumatizing event. Mr. Sample admits to exposure to the following type of traumatizing situations: received serious threats that someone would harm him, was held up, was physically assaulted, witnessed an assault(s) on others, someone attempted to kill Mr. Sample, The last index traumatic event was reported to have occurred between 1 and 3 months ago. At the time of the traumatic event(s), Mr. Sample reports experiencing very severe levels of psychological distress that probably included extensive fear, helplessness, guilt and shame. Such severe reactions are often associated with greater overall later PTSD symptomatology. An above average amount of dissociation, including possible depersonalization and/or derealization, was said to have occurred during the trauma. Mr. Sample's overall present PTSD symptomatology is reported as being in the Severe range. This includes severe reexperiencing/reliving of traumatic experiences via intrusive thoughts, flashbacks, memories, and/or dreams of the event, moderate avoidance of trauma associated stimuli, feelings and thoughts, and severe autonomic over arousal including probable sleep difficulties, irritability, hyper alertness and vigilance, and startle responses. This level of autonomic arousal may result in somatic complaints and substance use to lessen arousal. Mr. Sample described presently experiencing mild dissociation that may include a degree of derealization, depersonalization, and detachment. This may make him somewhat distracted, shutdown, and/or numb. Moderate substance abuse, which may be associated with PTSD, is reported. Mr. Sample does not report significant suicidal thoughts that may be related to PTSD symptoms. Mr. Sample reports very severe present impairments/problems in his daily functioning as a result of his PTSD symptoms. Post Traumatic Stress Disorder RECOMMENDATIONS Mr. Sample's present levels of dissociation needs to be dealt with in therapy. Mr. Sample must be helped to deal with his flashbacks/dreams in positive ways. His avoidance behavior must be gradually challenged, with Mr. Sample being helped dealing with stress provoking stimuli, feelings and thoughts. Stress management procedures and/or medications are indicated to reduce autonomic arousal. Discrete problem solving and skill development, often on a behavioral level, is needed to reduce the effects of Mr. Sample's PTSD symptoms on his level of current functioning. Treatment for substance use may be needed in conjunction with treatment for PTSD/ASD. Variables: Detailed Assessment of Post Traumatic Stress: MVA - 2 DIS - 2 ACC - 2 VIOL - 1 THR - 1 HOM - 1 WAR - 2 ROB - 1 SA - 2 CSA - 2 OTH - 2 WIT - 1 CPA - 2 ONSET - 3 PB - 54 NB - 62 RTE - 24 PDST - 78 PDIS - 62 RELIV - 78 AV - 67 AR - 88 PTST - 82 IMP - 85 TDIS - 62 SUB - 67 SUI - 34 SEX - M |
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