Date of Birth: April 2,1994
Date of Evaluation: February 8, 2013
The client was referred because by her family because of continuous disturbance after 3 months of the rape incident.
Maria was interviewed for two hours and administered the Impact of Event Scale – Revised (IES-R) Administered Beck Depression Inventory (BDI)
The client was wearing pants, T-shirt and jacket, she is 5’2’’ tall and has a brown eyes and fair complexion. During the interview Maria was very aloof and distant. She is always looking down, maybe because she is shy or ashamed to what had happen to her. Although she was remained seated on her chair you would notice that there is something wrong to her. During the IES and BDI test, she was thinking carefully on what she will answer at some point she really stops to think or skip onto the next item. After the testing you would notice the sadness in her facial expression.
Maria stated that she was raped by a tricycle driver three months ago she said that she was screaming and no one can hear her she was hit for several times due to screaming and she was very helpless. After the incident, she was very quiet and distant to men also to her father and brother they said that most of the time she was only staying inside her room, doesn’t eat much and sometimes doesn’t eat at all. Her family reported that she hardly sleeps she stays awake until dawn and when she falls asleep they hear her talking while sleeping saying “tulong, tulungan ninyo ako” while crying and they’ll wake her up and after she will just scream thinking that her family members is the one that raped her. From the day after the incident happened she never acted normal or the way she was before, jolly and very happy person.
Maria was born and raised in Angeles city and her biological parents remained married. Her father is approximately 45 years old, working on their own water refilling station. She described her father as a “very loving and caring father”. She said that she was very close to her father before the incident happened. Her mother is approximately 44 years old and living as a plain housewife since they were married. She is the third of four siblings, older brother 23, older sister 21 and younger brother 10. She was very close to her family until the incident happened she started being distant to her parents especially to her father and brothers she always want to be alone and she just cries she is also very agitated whenever she rides tricycle even with her family she explains that everything is coming back to me whenever I ride tricycle she noted. She also doesn’t want to talk about what had happened to her also in school where she is studying as a second year tourism student her parents said that her professor’s are very concerned about what’s happening to Maria because she cannot be able to participate well in her classes and it has already affecting her grades.
Interpretations and Impressions
On Beck Depression Inventory, she scored 32 which if it scaled from 31-40 you have a severe depression. And on Impact of Event Scale-Revised she scored 10 this scores has an impact on her daily living, attitude, performance and thinking.
DIAGNOSTIC IMPRESSIONS DSM-IV
AXIS I: Post Traumatic Stress Disorder, Chronic
AXIS II: V71.09 No Developmental or Personality Disorder Diagnosed
AXIS III: No Physical Condition or Disorder Diagnosed
Axis IV: recurrent distressing of the event
Axis V: GAF 52
Summary and Recommendations
Maria is suffering from Post Traumatic Stress Disorder, chronic due to continuous disturbance in dreams, perception, being distant to family especially to men because of the traumatic event that had happened. The client is recommended to seek further assistance for the treatment of her disorder, including her family to overcome...