INTERNATIONAL MENTAL HEALTH NETWORK, LTD.
P.O. Box 578
Poway, CA 92074-0578
Phone: (858) 486-9745
Fax: (858) 486-9760
E-mail: nac01@juno.com
A package of 10 test booklets and 50 answer sheets
available for $25 from IMH-Network: (858) 486-9745
Test Description
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S A M P L E P R O F I L E
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TRAUMATIC EVENT SEQUELAE INVENTORY
International Mental Health Network, Ltd.
TC: 111
FACILITY ID: 123
PATIENT ID: 1231234
SOCIAL SECURITY NUMBER: 123-45-6879
LAST NAME: Doe
FIRST NAME: John
GENDER: Male
AGE: 33
RACE: White
HIGHEST GRADE COMPLETED: 12
MARITAL STATUS: Separated
OCCUPATION: Mechanic
CURRENT EMPLOYMENT STATUS: Unemployed
INPATIENT/OUTPATIENT: Outpatient
NUMBER OF INPATIENT ADMISSIONS: 1
NUMBER OF OUTPATIENT ADMISSIONS: 1
DATE OF LAST DISCHARGE: 08/01/1008
YEARS OF ALCOHOL USE: 12
YEARS OF DRUG USE: 12
SUBSTANCES USED LAST 2 YEARS: Marijuana
Speed
Amphetamines
SOURCE OF REFERRAL: Other Facility
FINANCIAL CLASS: Private Insurance
DATE OF LAST PHYSICAL EXAM: 08/01/1998
ADMISSION DATE: 08/01/1998
DATE OF TESTING: 08/11/1998
TOTAL RAW SCORE: 20
T-SCORE: 56.86
____________________________________________________________________________
This clinical profile is a confidential assessment report intended for use
by professional staff only. Its purpose is to provide clinicians with a
comprehensive clinical picture of each patient under their care, and to help
maximize therapeutic effectiveness through careful assessment, treatment
planning, relapse prevention, and aftercare. Recommendations made in this
profile do not imply that existing clinical approaches should be replaced or
modified. Their intent is to further promote individualization of patient
treatment planning, multidisciplinary approach to treatment of each patient,
patient's participation in own recovery process, and continuous monitoring
and reassessment of the therapeutic process for mutual benefit of both the
patient and clinical staff. Statements in this profile are hypotheses for
further consideration in combination with other clinical factors utilized
in therapy. This profile is intended for use by a multidisciplinary clinical
team.
____________________________________________________________________________
________________________________ _______________ ______________
Reviewing Professional Title Date
COPYRIGHT (C) 1997 IMH-NETWORK ISBN: 1-58028-050-1
_______________________________________________________________________________
Patient: Doe, John 08/11/1998
TESI SUMMARY TABLE
Raw Score T-Score Range
PRIMARY DISTURBANCES:
PDI-01 SOMATIC DISTURBANCES 4 Low
PDI-02 MOOD DISTURBANCES 8 Mild
PDI-03 COGNITIVE DISTURBANCES 6 High
PDI-04 BEHAVIORAL DISTURBANCES 6 Mild
PDI-05 MARITAL DISTURBANCES 13 Mild
PDI-06 OCCUPATIONAL DISTURBANCES 12 Mild
PDI-07 GENERAL FUNCTIONALITY DISTURBANCES 14 Mild
PDI-08 PSYCHOMOTOR ACCELERATION 10 Mild
PDI-09 PSYCHOMOTOR RETARDATION 12 Moderate
PDI-10 FEAR 12 Mild
PDI-11 DISASSOCIATION 6 Moderate
PDI-12 HYPERACTIVITY 8 Mild
Total Score 111 56.21
SYSTEMIC DISTURBANCES:
SDI-01 CARDIOLOGICAL 1 Low
SDI-02 MUSCULOSKELETAL 3 Mild
SDI-03 HEMATOLOGICAL 1 Low
SDI-04 METABOLIC 11 Mild
SDI-05 ENDOCRINE 6 Mild
SDI-06 GASTROINTESTINAL 1 Low
SDI-07 NEUROLOGICAL 5 Mild
Total Score 28 50.52
CLINICAL IMPAIRMENTS:
CI-01 SOCIAL WITHDRAWAL 3 Low
CI-02 LACK OF COMMUNICATION 3 Mild
CI-03 SOCIAL IMPERTURBABILITY 14 Moderate
CI-04 OPPOSITIONALISM 6 High
CI-05 MANIPULATIVENESS 7 Moderate
CI-06 DEFENSIVENESS / LYING 0 None
CI-07 SELF DISCLOSURE 0 None
CI-08 EGOCENTRICITY 4 Mild
CI-09 ASSAULTIVENESS 5 Mild
CI-10 TANTRUMS 5 Mild
CI-11 COGNITIVE DEFICIT 7 Severe
CI-12 LEARNING DISABILITY 3 Moderate
CI-13 HOPELESSNESS 13 Mild
CI-14 INADEQUATE SELF-CARE SKILLS 6 Mild
CI-15 CONCOMITANT MEDICAL CONDITION(S) 6 Low
CI-16 DISSOCIATIVE STATES 3 High
CI-17 DYSPHORIC MOOD 7 Moderate
CI-18 EATING DISORDER 1 Low
CI-19 AUTO-DESTRUCTIVE POTENTIAL 10 Mild
CI-20 MOOD LABILITY 9 Mild
CI-21 OBSESSIONALITY 6 High
CI-22 RAGE REACTIONS 7 Mild
CI-23 INEFFICACY OF REST 8 Mild
CI-24 CONCENTRATION DEFICIT 5 Moderate
CI-25 DEFICIT IN FRUSTRATION THRESHOLD 4 Mild
CI-26 GENDER DYSPHORIA 8 Moderate
_______________________________________________________________________________
Patient: Doe, John 08/11/1998
CI-27 EXTERNALIZATION OF LOCUS OF CONTROL 8 Mild
CI-28 PERCEPTION OF SELF-INEFFICACY 8 Mild
CI-29 HYPERACTIVITY 6 Mild
CI-30 ATTENTION DEFICIT 3 Moderate
CI-31 MEDICAL RISK FACTOR 8 Low
CI-32 SOMATIZATION 4 Low
CI-33 PHYSICAL MALFUNCTIONING 6 Low
CI-34 MARITAL DYSFUNCTION 13 Mild
CI-35 MARITAL DYSFUNCTION W/BEHAVIORAL DYSCONTROL 6 Moderate
CI-36 MARITAL DYSFUNCTION W/EMOTIONAL LABILITY 13 Mild
CI-37 MARITAL DYSFUNCTION W/ECONOMIC LABILITY 10 Moderate
CI-38 SUBJECTIVITY OF APPRAISAL 11 Mild
CI-39 EGO IMPLOSION 13 Mild
CI-40 DEPLETION OF INTERNAL RESOURCES 8 Mild
CI-41 SIGNIFICANT REHABILITATIVE LIMITATIONS 15 Mild
Total Score 282 63.94
AREAS OF DYSFUNCTIONALITY:
DYS-01 SOMATIC 4 Low
DYS-02 EMOTIONAL 12 High
DYS-03 COGNITIVE 4 Severe
DYS-04 BEHAVIORAL 3 Mild
DYS-05 MARITAL 15 High
DYS-06 OCCUPATIONAL 11 Mild
DYS-07 INTERPERSONAL 13 Moderate
DYS-08 AVERAGE DAILY LIVING SKILLS 8 Moderate
DYS-09 GENERAL 15 Mild
Total Score 85 58.05
DEGREE OF CONGRUENCE WITH DSM-IV DIAGNOSTIC CRITERIA:
CRITERION B: 7 PERSISTENT REEXPERIENCE OF TRAUMATIC EVENT Mild
CRITERION C: 12 PERSISTENT AVOIDANCE OF TRAUMA-ASSOCIATED STIMULI Moderate
CRITERION D: 9 PERSISTENT SYMPTOMS OF INCREASED AROUSAL High
CRITERION F: 9 IMPAIRMENT IN SIGNIFICANT AREAS OF FUNCTIONING High
_______________________________________________________________________________
Patient: Doe, John 08/11/1998
PROFILE CHARACTERISTICS
Clinical picture presented by this patient indicates a possibility of
recent exacerbation of psychiatric condition which may have existed prior
to the occurrence of the traumatic event(s) in question.
It is likely that the traumatic event experienced by this patient acted
as a trigger for such exacerbation. Clinical research also indicates that
traumatic events do not necessarily represent the primary cause of a typical
stress response. Therefore, premature assumptions about a traumatic event
being a sole factor of elevation of psychiatric disturbances should be
avoided with this type of a patient profile. Consideration should be given
to possibility of multiple causes with, or without common etiology.
When examining this patient's clinical picture, attention should be paid
to the nature and complexity of the symptom spectrum. Often, a symptom
pattern may indicate overlapping and migratory nature of different conditions
whose origins and course have become diffuse and difficult to trace. Symptoms
presented by the patient should be assessed in terms of onset, chronology,
temporal associations, precipitating factors, single or multiple exacerbating
and ameliorating factors, degree of symptom acuity and severity, symptom
consistency and coincidence with extrinsic factors, and associated symptoms.
History should be taken of previous episodes during which the patient
experienced similar worsening of condition, including surrounding
circumstances and a degree and nature of patient's current and past clinical
impairment. An assessment of patient's functionality before and after the
occurrence of a trauma should also be performed.
Substance abuse and physiological comorbidity should not be ruled out.
Many of patients with this type of profile show patterns of substance
use/abuse originating prior to the occurrence of a trauma, and extending
after the ceasing of symptoms attributable to PTSD.
Initial treatment strategy should focus on the amelioration of
psychiatric disturbance(s) and a degree of predictable stabilization.
Relapse prevention, and prevention of retraumatization should be given
special clinical consideration when formulating aftercare and long term
rehabilitative plans and goals. Plans for recovery should be realistic, and
within patient's domain of abilities.
Monitoring patient's spectrum of symptoms on regular basis is highly
recommended. A list of additional applicable psychometric measures is
included with this profile, all of which have minimal test saturation effects
with repeated administrations.
_______________________________________________________________________________
Patient: Doe, John 08/11/1998
CLINICAL CHARACTERISTICS
The test findings suggest moderate level of clinical depression.
Patients with this type of profile are often worriers who upset
themselves over many things. Frequently, their outlook is pessimistic and
their self-concept poor. This may represent a chronic pattern or a reaction
to a specific environmental stressor, such as loss of love or loss of a
caring relationship.
Tearfulness, guilt feelings, anxiety, and somatic complaints are often
part of this clinical picture. It is clinically advisable to explore for
suicidal ideation.
Expressing physical complaints, crying, feeling guilty, dejected and
anxious are all part of the clinical picture. These may represent a chronic
pattern or be a situational reaction to a specific event.
Frequently, these clients will discuss past losses and present feelings
of hopelessness about ever being happy, and they ignore any positive feelings
or events that happen to them in the present.
Often, they may have experienced fear of irretrievable loss of some
highly valued physical or emotional object. They respond to this real or
imaginary loss by blocking of further needing or "wanting."
They may become blocked in the "despair" phase of the mourning process
and are afraid to cry and feel angry. Depression and introjection are common
mechanisms of defense. They need to express anger and "rage at fate" in order
to finish the grieving process. Explore also for low energy, sleep
difficulty, problems at school or work, difficulty making decisions, and
losses in relationships marked reduction in efficacy of interpersonal
functioning.
While there is no single or preferred method of working with these
patients, a more structured and direct approach should be more effective
than an unstructured, permissive, or supportive one.
The main focus on therapy should be to encourage the patient to express
anger and sadness about past losses without blaming themselves or others.
Explore for losses in relationships and thoughts of self-destruction and
consider pharmacologic consultation.
Trust is invariably an issue for these patients and securing their
confidence through empathy is critical to developing rapport. Explore for
losses in relationships and suicidal thoughts and threats.
The prospect of a schizophrenic disorder will often require further
assessment and should include the weighing of risks and benefits of one
treatment against those of others. For patients in whom depression is a
primary diagnosis, either interpersonal psychotherapy or cognitive and/or
behavioral therapy will often provide the best results.
Some of the prominent clinical characteristics which may be exhibited
by the patient experiencing this level od depression may be:
- learned helplessness,
environment,
- externalization of locus of control,
- distractibility,
- anxiety without apparent etiology,
- pattern of decreased energy level and fatigability,
_______________________________________________________________________________
Patient: Doe, John 08/11/1998
- life-role dissatisfaction,
- apathy toward self and others, failure to assert oneself in
order to meet needs, frequently allowing others to make
decision regarding personal welfare, living accommodations,
nutrition,
- self-criticism and dissatisfaction over inability to perform
previous tasks, skills, or activities,
- history of neglectful, domineering and overprotective
relationships,
- perceived negative body image,
- preoccupation(s) with depressive moods,
- physiologic symptoms of anxiety such as tachycardia,
tachypnea,
- increase in quantity but decrease in quality of sleep,
- decreased involvement or interest in significant others
such as immediate family, long-term friends, etc.,
- doubts about self-worth and abilities and expressions of
failure or inability to deal with tasks and situations,
- increased shyness,
- increased indecisiveness,
- anxiety about new situations and people,
- unresolved actual or perceived losses,
- situational crises,
- goal obstacles,
- identifiable psychosocial stressors,
- loss of appetite,
- withdrawal from interpersonal relationships,
- decline in appearance and self-care,
- emotional and cognitive ambivalence,
- interest in unrealistic belief systems, astrology,
superstition, etc.
- decrease in self-efficacy,
- failure of problem-solving strategies,
- decrease in effectiveness of coping skills,
- difficulty in managing external stressors,
- perception of ineffectiveness of the available support
system(s),
- recent body weight issues such as weight gain or loss,
- possibility of substance use/abuse,
- resistance to engage in therapeutic alliance.
MOOD AND AFFECT SYMPTOMS
The following is a spectrum of mood and affect symptoms specific
to this profile type. Clinicians should also document and monitor any
additional mood and affect symptoms which may arise during the course of
treatment.
- Anxiety, worry, fear ............................................ ____
- Blunted affect .................................................. ____
- Emotional reactivity ............................................ ____
- Episodes of moderate depression and apathy ...................... ____
- Vegetative depressive features .................................. ____
- Low emotional adjustment ........................................ ____
- Emotional inertness ............................................. ____
- Range of vulnerabilities ........................................ ____
- Emotional fragility ............................................. ____
- Poor psychological health ....................................... ____
- Self-alienation ................................................. ____
- Naivete ......................................................... ____
- Sensitivity ..................................................... ____
_______________________________________________________________________________
Patient: Doe, John 08/11/1998
- Brooding ........................................................ ____
- Frequency of painful affect states .............................. ____
- Highly subjective experience of the disease process ............. ____
- Poor ego strength ............................................... ____
- Ego constriction ................................................ ____
- Pseudomaturity .................................................. ____
- Obsessionality .................................................. ____
- Neuroticism ..................................................... ____
- Occasional feelings of derealization ............................ ____
- Diminished interest in daily activities ......................... ____
- Lack of positive moods .......................................... ____
- Patterns of comorbidity between Axis I and Axis II disorders .... ____
- Long term course of disorder and comorbidity .................... ____
- Event-environment induced morbidity ............................. ____
- Low energy and increased fatigability ........................... ____
- Lassitude, malaise .............................................. ____
- Absence of adiurnal variation in mood and energy ................ ____
- Lack of assertiveness, indecisiveness ........................... ____
- Lack of ability to relax ........................................ ____
- Loss of reactivity to pleasant stimuli .......................... ____
- Diminished self-esteem .......................................... ____
- Feelings of worthlessness and hopelessness ...................... ____
- Introversion, shyness, social phobia ............................ ____
- Feelings of alienation and isolation ............................ ____
- Reliance on introspective cues .................................. ____
- Augmentation of perception of environmental stressors ........... ____
- Somatization of anxiety ......................................... ____
- Lack of permanent relief from somatic symptoms .................. ____
- Depressive episodes as a reaction to pain exarcebation .......... ____
- Psychological adaptation to pain via mood disorders ............. ____
- Psychological adaptation to pain ................................ ____
- Degree of discomfort expected ................................... ____
- Temporal contiguity referenced through process of illness/pain .. ____
- External locus of control ....................................... ____
- Sense of self-worth extrinsically contingent .................... ____
- Lack of specific symptoms as precipitating factors .............. ____
- Low need to succeed at the time of admission .................... ____
- Precipitation of relapse ........................................ ____
- Emotional augmentation during early recovery .................... ____
- Strong need for affection ....................................... ____
- Increased sensitivity to disapproval and criticism by others .... ____
- Overconcern with acceptance of authenticity
of own symptoms by others ....................................... ____
- Persistent need for excessive advice
and reassurance from others ..................................... ____
- Lack of immediate relief from distress even when stressors
are neutralized ................................................. ____
- Disturbance in sleep patterns ................................... ____
- Insomnia, hypersomnia, sleep inefficacy ......................... ____
- Exarcebation of psychiatric and somatic symptoms
with substance withdrawal ....................................... ____
- Lack of long range improvement in well-being .................... ____
- Poor psychological health ....................................... ____
- Persistent lack of sexual excitement ............................ ____
- No erotic sensations ............................................ ____
- Impotence ....................................................... ____
- Lack of positive external emotional stimulation ................. ____
- Reduced ability to speak of emotions (alexithymia) .............. ____
- Chronic stress from environment, family, vocation ............... ____
- Inability to tolerate negative affect ........................... ____
- Sense of internal conflict ...................................... ____
- Alexithymia ..................................................... ____
_______________________________________________________________________________
Patient: Doe, John 08/11/1998
- Resistance to adopting a psychological view
of the somatic symptoms ......................................... ____
- Emotion-focused wishful thinking ................................ ____
OTHER:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
BEHAVIOR SYMPTOMS
The following is a spectrum of behavior symptoms specific to this
profile type. All symptoms which are reported and observed should be
documented and monitored at regular intervals. Additional behavioral
symptoms which may arise during the course of treatment should also be
documented.
- Procrastination ................................................. ____
- Tendency toward indecisiveness and avoidance of responsibilities ____
- Difficulty initiating projects & independent actions ............ ____
- Stressful interpersonal relationship(s).......................... ____
- Avoidance of focused treatment and confrontation modalities ..... ____
- Possibility of substance use/ abuse ............................. ____
- Seeking reassurance, acceptance by others ....................... ____
- Occasional avoidance and displacement of responsibility ......... ____
- Diffusion of personal goals and self-imposed limitations ........ ____
- Dissatisfaction or change in role or relationship ............... ____
- Recent loss/dissolution of intimate relationships ............... ____
- Occasional preference for isolation and solitude,
- Claims that social interactions bring unsatisfactory results .... ____
- Social introversion and drifting ................................ ____
- Preference for passive participation in conversations
- Expressed and noticed discomfort in social interactions ......... ____
- Noticeable decrease in recreational orientation and skills ...... ____
- Patterns of somatization ........................................ ____
- Lack of diversionary activities ................................. ____
- History of unsatisfactory relationships ......................... ____
- Emotional-focused coping and avoidance .......................... ____
- Mild deregulation of food intake ................................ ____
- Neglect of health practices ..................................... ____
OTHER:
_________________________________________________________________ ____
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___________________________ ________________________________
DATE CLINICAL STAFF
_______________________________________________________________________________
Patient: Doe, John 08/11/1998
PRIMARY DISTURBANCES
SYSTEMS |RSC| | RANGE |FLAG
------------------+---+--------+-------+-------+-------+--------+--------+----
PDI-01| 4| ******* |Low |
| | | |
PDI-02| 8| *************** |Mild |
| | | |
PDI-03| 6| ******************************* |High |<===
| | | |
PDI-04| 6| *************** |Mild |
| | | |
PDI-05| 13| *************** |Mild |
| | | |
PDI-06| 12| *************** |Mild |
| | | |
PDI-07| 14| *************** |Mild |
| | | |
PDI-08| 10| *************** |Mild |
| | | |
PDI-09| 12| *********************** |Moderate|
| | | |
PDI-10| 12| *************** |Mild |
| | | |
PDI-11| 6| *********************** |Moderate|
| | | |
PDI-12| 8| *************** |Mild |
------------------+---+--------+-------+-------+-------+--------+--------+----
Total raw score: 111 T-score: 56.21
_______________________________________________________________________________
Patient: Doe, John 08/11/1998
SYSTEMIC DISTURBANCES
SYSTEMS |RSC| | RANGE |FLAG
------------------+---+--------+-------+-------+-------+--------+--------+----
SDI-01| 1| ******* |Low |
| | | |
SDI-02| 3| *************** |Mild |
| | | |
SDI-03| 1| ******* |Low |
| | | |
SDI-04| 11| *************** |Mild |
| | | |
SDI-05| 6| *************** |Mild |
| | | |
SDI-06| 1| ******* |Low |
| | | |
SDI-07| 5| *************** |Mild |
------------------+---+--------+-------+-------+-------+--------+--------+----
Total raw score: 28 T-score: 50.52
_______________________________________________________________________________
Patient: Doe, John 08/11/1998
CLINICAL IMPAIRMENTS
SYSTEMS |RSC| | RANGE |FLAG
------------------+---+--------+-------+-------+-------+--------+--------+----
CI-01| 3| ******* |Low |
CI-02| 3| *************** |Mild |
CI-03| 14| *********************** |Moderate|
CI-04| 6| ******************************* |High |<===
CI-05| 7| *********************** |Moderate|
CI-06| 0| |None |
CI-07| 0| |None |
CI-08| 4| *************** |Mild |
CI-09| 5| *************** |Mild |
CI-10| 5| *************** |Mild |
CI-11| 7| *************************************** |Severe |<===
CI-12| 3| *********************** |Moderate|
CI-13| 13| *************** |Mild |
CI-14| 6| *************** |Mild |
CI-15| 6| ******* |Low |
CI-16| 3| ******************************* |High |<===
CI-17| 7| *********************** |Moderate|
CI-18| 1| ******* |Low |
CI-19| 10| *************** |Mild |
CI-20| 9| *************** |Mild |
CI-21| 6| ******************************* |High |<===
CI-22| 7| *************** |Mild |
CI-23| 8| *************** |Mild |
CI-24| 5| *********************** |Moderate|
CI-25| 4| *************** |Mild |
CI-26| 8| *********************** |Moderate|
CI-27| 8| *************** |Mild |
CI-28| 8| *************** |Mild |
CI-29| 6| *************** |Mild |
CI-30| 3| *********************** |Moderate|
CI-31| 8| ******* |Low |
CI-32| 4| ******* |Low |
CI-33| 6| ******* |Low |
CI-34| 13| *************** |Mild |
CI-35| 6| *********************** |Moderate|
CI-36| 13| *************** |Mild |
CI-37| 10| *********************** |Moderate|
CI-38| 11| *************** |Mild |
CI-39| 13| *************** |Mild |
CI-40| 8| *************** |Mild |
CI-41| 15| *************** |Mild |
------------------+---+--------+-------+-------+-------+--------+--------+----
Total raw score: 282 T-score: 63.94
_______________________________________________________________________________
Patient: Doe, John 08/11/1998
DYSFUNCTIONALITY
SYSTEMS |RSC| | RANGE |FLAG
------------------+---+--------+-------+-------+-------+--------+--------+----
DYS-01| 4| ******* |Low |
| | | |
DYS-02| 12| ******************************* |High |<===
| | | |
DYS-03| 4| *************************************** |Severe |<===
| | | |
DYS-04| 3| *************** |Mild |
| | | |
DYS-05| 15| ******************************* |High |<===
| | | |
DYS-06| 11| *************** |Mild |
| | | |
DYS-07| 13| *********************** |Moderate|
| | | |
DYS-08| 8| *********************** |Moderate|
| | | |
DYS-09| 15| *************** |Mild |
------------------+---+--------+-------+-------+-------+--------+--------+----
Total raw score: 85 T-score: 58.05
______________________________________________________________________________
Patient: Doe, John 08/11/1998
DSM-4 CRITERIA CONGRUENCE
SYSTEMS |RSC| | RANGE |FLAG
------------------+---+--------+-------+-------+-------+--------+--------+----
DSM-4 CRITERION B| 7| *************** |Mild |
| | | |
DSM-4 CRITERION C| 12| *********************** |Moderate|
| | | |
DSM-4 CRITERION D| 9| ******************************* |High |<===
| | | |
DSM-4 CRITERION F| 9| ******************************* |High |<===
------------------+---+--------+-------+-------+-------+--------+--------+----