Psychological Assessment Report

Identifying Information / Relevant History

Demographic Information
- Name: [Name Redacted]
- Age: 45 years
- Gender: Male
- Nationality: Pakistani
- Marital Status: Married

Family History
The client comes from a family with a significant history of psychological issues. The
client is the fourth child in a family with five siblings. His mother has been on
psychiatric medication for the past 35 years due to an undiagnosed psychological
illness, which has affected the family dynamics. His maternal grandmother also
suffered from a similar condition but was never diagnosed nor received medication.
Both displayed symptoms of anxiety and depression. Mother currently takes ALP 1.o
mg 3x alongside His father suffered from Parkinson’s disorder during the last 10
years of his life passing away 8 years ago. Siblings including 3 sisters and 1 brother
are all married and are not diagnosed with any mental health condition so far.

Medical History:
Client reports no significant medical concerns in the past. Currently he reports
discomfort in his chest at times of heightened anxiety or stress.

Developmental Milestones
The client is the fourth child in a family with five siblings. He reports faint memories
of his childhood, particularly a strong aversion towards his younger sibling, who was
born just 1.2 years after him. Father and mother had perfectionist tendencies and
preferred an older brother who was more organized and responsible. Client reports
being belittled in childhood by older siblings and reports lack of respect for his views
or presence.
He completed primary and secondary education from a local school completing
Engineering degree from a government university. Got married 15 years ago and has
2 young children 7 and 8 years. His marital relationship had been stable until
recently and reports no major issues with the spouse who recommended him in the
first place. He is currently employed in the government sector.
 Significant Events
The client reports a strained relationship with siblings where he experiences
disregard for his opinions. He reports a surface connection with extended family
members. There is also a lack of bonding between the mother and client and reports
feeling of abandonment with the mother as the reason for lack of warmth in the
relationship. Recently, the client experienced a sudden loss of emotional and
physical connection with his spouse. This change coincided with an immense
increase in his workload at the office, causing him to enter a freeze state,
characterized by emotional numbness and disconnection. The client was assigned a
new post and suddenly after shifting to the duties he felt stunned, unable to
communicate his stress to his manager nor to his wife. He recalls a few details after
shifting and says his wife reports that he had become completely silent and
withdrawn. He does not possess clear memories of this period except an awareness
that something happened to him which he is not sure of. The symptoms however are
now reported to be improved with reduced dissociation at present. Currently he
reports heightened anxiety, and increased anger outbursts even during minor
stressful circumstances which he says were not so triggering before. He also reports
a demeaning or dismissing behavior of wife. He also says wife is very talkative and
does not listen to him properly, often making jokes about him which make him angry.

Observations
The session was conducted online and due to poor internet connection at the client's
end the video had to remain turned off. During the few glimpses caught, the client
appeared relaxed, having a composed demeanor.

Behavior
The client demonstrates a tendency to withdraw when discussing emotional topics,
indicating discomfort with vulnerability. He appears hesitant to express his needs and
reports anxiety before communicating with others. He expresses slowly hesitating
often after long pauses.

Mood and Affect

He reports mood fluctuations between sadness and frustration, with moments of
anger surfacing, at minor things. He also mentions feeling intensely anxious worrying
about the future finances of the family . He reported considering sucide but did not
make any attempts so far. Affect was not observed clearly. Client reports over
sleeping and over eating however anhedonia was not observed.
Cooperation
The client was cooperative during the assessment but appeared guarded. He shared
information about his experiences but was hesitant to delve deeply into emotional
topics.

Emotional Functioning
The client exhibited signs of emotional dysregulation, including anxiety, anger, fear
of future, frustration, guilt and loneliness. He reported struggles to articulate his
emotions and needs at office and work, often feeling overwhelmed by anxiety and
anger. He reports prolonged period of silence and withdrawing at home ending in out
of proportion anger outbursts on wife followed by guilt and suicidal thoughts.

Self-Concept
The client displays low self-esteem, poor self image, lack of belief and confidence
in his abilities. He also has fear that things will never improve and he will be unable
to make things better.

Interpersonal Functioning
He lacks interpersonal skills particularly inability to communicate his concerns at
work and at home. He mentions inability to explain his situation to spouse and
inability to report the impact of heightened stressful situations at work to his Senior
Manager.
These strained relationships with his spouse are exacerbated by his emotional
disconnection and inability to communicate his needs effectively. Increased anger
outbursts suggest unresolved conflicts that impact his ability to maintain healthy
relationships. Strained relationships with siblings and mother are also highlighted.
Also lack of the ability to engage in assertive communication is evident. Unproved
fear of abandonment is also expressed in relevance to wife.

Social Functioning
Current level of social functioning is of sufficient level. Client continues to go to
work and manages to deliver work needs mostly on time. He also attends necessary
family events and engages sufficiently with the family. Yet the client experiences
heightened anxiety before engaging in communication during conflict, leading to
avoidance of resolution. This pattern contributes to feelings of isolation, emotional
distress and growing unresolved issues .

Cognitive functioning
He reports increased forgetfulness and dissociation during stressful times, impacting
his ability to engage effectively in relationships and daily activities. One major
dissociative episode is mentioned after shifting duties at work.
Summary and Conclusions

The client is a 45-year-old male experiencing an episode of a sudden loss of

expression and communication with immediate family. Onset being increased
work-related stress and leading to a dissociative response. His family history reveals
a pattern of psychological illness, with both his mother and maternal grandmother
experiencing undiagnosed mental health issues. The client reports increased
forgetfulness, dissociation during stress, and physical symptoms such as chest
discomfort. Anger outbursts linked to unresolved past issues further complicate his
emotional state.

Diagnosis

The client displays symptoms consistent with Adjustment Disorder with Mixed
Anxiety and Depressed Mood due to the recent emotional disconnection and
increased work stress. Additionally, Dissociative Symptoms may be relevant, given
dissociation episodes (not experienced before) during stress.

Treatment Recommendations

1. Interpersonal Therapy:
- Engage in individual therapy, such as Cognitive Behavioral Therapy (CBT) , to
address emotional dysregulation, anxiety, and past trauma. The therapy will focus on
helping the client process unresolved anger and improve emotional expression.

2. Stress Management Techniques:

- Learn and practice stress management techniques, including mindfulness,
relaxation exercises, and grounding techniques to reduce anxiety and enhance
emotional regulation.

4. Psychoeducation:
- Provide psychoeducation regarding the impact of familial mental health issues
and how these may influence his own experiences. Understanding these patterns
can help the client gain insight into his behaviors and emotional responses.

5. Conflict Resolution Skills:

- Work on developing conflict resolution skills to enhance his ability to
communicate needs effectively and manage interpersonal relationships without
avoidance or aggression.

Regular follow-up sessions will be essential to monitor progress and adjust the
treatment plan as needed.