Psychological Evaluation
Confidential
Community Mental Health and Psychiatry19 Jeanette Street,
Brackenfell, Cape Town 7560
021 981 9850
Name:
_________Aleena Andriele
__________Dates of Evaluation: 0067.11.02
Case No.:
______2234915
_ -___________-___________________0067.11.03
Admission Date:
_0067.11.01
________- ____Date of Report:
____ 0067.11.04
DOB:
_______ __ 0052.05.16
Age:
__________ 15
Gender:
___ _ ___Female
Education:
___ __8th grade
PURPOSE FOR EVALUATIONThis is the fourth inpatient admission for this 15 year old Caucasian female who is in the 8th grade at Deutsche Internationale Schule Kapstadt in an English speaking class after completing her education at Weizmann Primary School. She was admitted due to symptoms of major depression, anti-social behavior, learning disability, and possible psychotic features.
This evaluation is to screen for possible evidence of psychosis, depressive disorder, and the source of these problem. As well as an assessment of possible learning disabilities and the results of previous treatment methods.
ASSESSMENT PROCEDURESMCMI-III
MMPI-2
DES
Mental Status Examination
Review of Prior Psychological Assessments
Review of Prior Medical Records
Structured Clinical Interview
This patient participated in 4 hours of testing and 2 hour of diagnostic interview. Tests were administered by Jacques Saris, M.S. and interpreted by Teresa Dalton-Morgan, M.A..
BACKGROUND INFORMATIONBiological parents are unknown. Patient was discovered as a small child outside of the Velvet Nail in Clifton, Cape Town by purveyor Siamel Andriele in the year 0053. Medical records show there was no sign of malnutrition or abuse and the patient was in good health at the time that Mr. Andriele filed official papers for adoption later in that year. In 0055 she began attending Weizmann Primary School. The following year records indicate a difficulty socializing with the other students and an assessment conducted. Contact with primary instructor indicates the patient was the target of bullying, distant from her peers, and a very quiet child that exceeded the standard material covered in class. Patient received a series of counselings from Weizmann Primary School counselor David Schwiez until his termination from the school in 0057. School records indicate a continuation of stressors for the patient. In 0064.08.24 patient was admitted to Somerset Hospital after being found unconscious near her home. Medical records indicate the patient was sexually assaulted, raped, her right humerus and clavicle were fractured in the incident, and minor trauma to the head. The patient's adoptive father was immediately arrested and indicted as the primary suspect, but charges were dropped after DNA evidence cleared him of any wrong doing. Corpse of suspected perpetrator was discovered on 0064.08.26 laying on the shore of Robben Island. Patient was released from Somerset Hospital on 0064.08.27. Patient received counseling at Kenilworth Clinic following the incident. Evaluation received from Kenilworth indicates Post-Traumatic Stress Disorder, Dissociative Amnesia, and Conversion Disorder. Identified symptoms included self-alienation from society, inability to remember the events that took place on 0064.08.24, loss of speech and facial expression, complaints of headaches, and severe nightmares. Treatment at Kenilworth Clinic reflected a reduction in the severity of symptoms and renewed stability in the patients mental and motor functions. Treatment ceased in 0066 after medical officials could provide no further benefit to the patient. Patient transferred from Weizmann Primary School to Deutsche Internationale Schule Kapstadt on 0067.09.12 due to continued mistreatment from fellow students that created additional stressors. Patient was apprehended on 0067.10.08 after repeatedly stabbing another student with a fork.
MENTAL STATUS EXAMINATIONResults of mental status examination revealed the patient to be alert and able to track conversation, but distracted at the same time. The patient was casually dressed and well groomed. Orientation was intact for person, time, and place. Eye contact was focused on a single point straight ahead and did not deviate. There was no abnormality of gait, posture, or deportment. Speech functions were clear and concise with appropriate volume, rate, prosody, and fluency with no evidence of paraphasic errors. Vocabulary and grammar skills suggested average intellectual functioning. Facial emotion and response were severely limited.
The patient acted aloof and hesitant to cooperate. Her mood was despondent. Memory functions were intact with respect to immediate and remote recall of events and factual information including previously forgotten memories from the traumatic incident. Thought content revealed a sense of detachment, apathy, and hallucinations. The last of which was communicated by the patient as being a song and a need to see the ocean to understand it. She showed a moderate level of personal insight in her ability to recognize her disconnect with the world around her, but was unable to provide reasons why or what may precipitate the feeling.
SUMMARYThe patient is a 15 year old Caucasian female who suffered a traumatic incident three years ago causing the onset of Dissociative Amnesia, Conversion Disorder, and Post-Traumatic Stress Disorder in an attempt to cope. Shame over what supposedly took place combined with her inability to ever properly adapt to social interaction with peer groups brought about a Major Depressive Disorder and Antisocial Personality Disorder which forced her even farther away. In the recent event at Deutsche Internationale Schule Kapstadt it is believed the patient's memory of the incident returned resulting in a violent reaction. In an attempt to cope once more the patient became detached from reality leading a Depersonalization Disorder. Patient shows no remorse for her actions or care for the well being of the victim; this reaffirms the diagnosis of Antisocial Personality Disorder. Upon inquiry the patient revealed hallucinations characterized by Schizophrenia in relation to a song and view of the ocean. The patient also appears to have a preexisting Schizoid Personality Disorder not diagnosed in previous evaluations and the onset of which can not be determined. No learning disabilities were evidenced and believe the underlying issue is an unwillingness to respond due to preoccupations of the mind. There is no evidence of improvement from previous treatments.
DIAGNOSTIC IMPRESSIONSAXIS I:
---- - --- 309.81
----POST TRAUMATIC STRESS DISORDER, ACUTE
-----------------296.32
----MAJOR DEPRESSIVE DISORDER
-----------------300.12
----DISSOCIATIVE AMNESIA
-----------------300.11
----CONVERSION DISORDER
-----------------295.9
-----SCHIZOPHRENIA
AXIS II:
---- ---- 301.20
----SCHIZOID PERSONALITY DISORDER
-----------------301.7
-----ANTISOCIAL PERSONALITY DISORDER
-----------------300.06
----DEPERSONALIZATION DISORDER
AXIS III:
AXIS IV:
---------RESIDES NEAR SCENE OF TRAUMATIC INCIDENT, RESIDES NEAR COAST, LACK OF FRIENDS
AXIS V:
------- --CGAS
--- - 47
RECOMMENDATIONSThe patient would benefit from an anti-depressant and group therapy to socially reintegrate with a peer group. This method should ease the effects of social withdrawal to make interaction with patient easier. Reevaluation following six months of therapy will be needed to assess the progress of treatment.
-
-------------------------------
Teresa Dalton-Morgan, M.A.
--- --------------- ------James Raineke, Ph.D.
Psychology Associate
------------ ---------------- --Psychologist II
Adopted Father: Siamel Andriele
