Psychological Evaluation

Kamakura-Kita Psychiatric Hospital

Kanzaki Hitomi

Date of Evaluation: 9/24/96

Case No.: 69,115,99

Building No.: 7

Date of Report: 9/25/96

PURPOSE FOR EVALUATION: The patient is a 15-year-old, single, female Japanese high-school student. The evaluation was made due to alterations in her behavior after a temporoparietal stroke, as noted by her friends and family. Her BMI of 17.2 indicates a possible case of anorexia nervosa, and her parents fear that she is experiencing depression with possible psychotic delusions.

ASSESSMENT PROCEDURES:
Minnesota Multiphasic Personality Inventory (MMPI-A)
Holmes and Rahe Stress Scale (SRRS)
Mental Status Examination
Stanford Hypnotic Susceptibility Scale (SHSS)
Fantasy-prone Personality Scale (Wilson & Barber)
Review of Prior Psychological Assessment
Review of Prior Medical Records
Clinical Interview

The patient participated in 4 hours of testing and a 1 hour diagnostic interview. Tests were administrated by the presiding psychiatrist.

BACKGROUND INFORMATION: The patient has no prior history of depression or other major psychological disorders. Her family indicated that the first signs of depression came after the death of her grandmother, who was very close to her. After experiencing a temporoparietal stroke and being hospitalized for four days, she apparently became very quiet and often seemed "lost in her own world."

Family reports indicate that around this time, she abandoned two of her valued hobbies, Tarot fortune-telling and sprinting. She would occasionally talk of dreaming of another world she calls 'Gaea,' perhaps a form of paracosmic fantasy.

MENTAL STATUS EXAMINATION: The patient appeared quiet and introverted, preferring to contemplate or fantasize rather than responding to my inquiries. Nonetheless, she was casually dressed and seemed to be oriented in reality. The patient avoided eye contact, but there was no abnormality of gait or deportment. Speech functions were normal. Vocabulary and grammar suggested intellectual functioning at an above average range.

Memory and thought functions appeared to be intact. Thought content revealed no evidence of paranoia or suicidal ideation. However, she gave the impression of a fantasy prone personality, and, after hesitation, admitted to believing in a paracosm called 'Gaea.' Whether this fantasy pre- or postdated the stroke is unclear. No other evidence of mental disorder presented itself.

RESULTS OF EVALUATION: See pages 2-4.

SUMMARY AND RECOMMENDATIONS: Results of psychological evaluation reveal a fantasy prone personality with some schizotypal beliefs and a deeply developed, internally coherent secondary world. While her personality has become more introverted after the stroke, there is no evidence of depression as such.

As the patient's daydreams do not appear maladaptive, it is recommended that the efforts to establish a trusting relationship be continued in individual therapy sessions. The patient will benefit from gaining a more grounded, realistic perspective on her fantasies.

Please let me know if there are any questions concerning this evaluation.

xxxx xxxxxxx, Ph.D

Psychiatrist