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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 father’s 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, can’t 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 didn’t 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

mother’s 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 can’t 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 don’t 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. Decena’s 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 client’s 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 client’s 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.