Sample Psychological Report

Topics: Anxiety, Posttraumatic stress disorder, Tram accident Pages: 10 (3048 words) Published: May 21, 2013
Sample Psychological Report




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Personal Injury Division Sample Psychological Report
NAME: DATE OF BIRTH: ADDRESS: Mrs Jones 6 June 1969 The Rookery High Street Midloe Cambridgeshire Not as yet known Not as yet known Clay More 123456789/jones 987654321 25/JONES/CP 25 October 2003



I am Mr Brown. I am a Chartered Clinical Psychologist. My specialist field is psychological trauma an area within which I have worked over the past seven years. Full details of my qualifications entitling me to give expert opinion and evidence are set out at the end of this report. (1.2) INSTRUCTIONS The case concerns an accident dated 3 November 2002 in which the claimant allegedly suffered personal injury. I have been jointly instructed by Clay More Solicitors and Pailess Insurance to investigate for the court whether the claimant has suffered a formal psychological/psychiatric condition as a result, and the effects and prognosis of this if appropriate. I have been provided with the claimant’s general practice notes and records.

(2) INVESTIGATION (2.1) INTERVIEW DATE OF INTERVIEW: 6 October 2003 ALSO INTERVIEWED: Mr Jones (Husband) (2.1.1) ON EXAMINATION Mrs Jones presented entirely appropriately and gave a clear and consistent account of the accident and its impact upon her. She was clearly distressed by her level of anxiety in relation to the driving situation. (2.1.2) THE INCIDENT AND SUBSEQUENT DEVELOPMENTS On the 3 November 2002 Mrs Jones was returning home from work and travelling through the village of Mulsoe. She described how a car in front suddenly braked to turn into a driveway and as she came to a halt she was hit from behind by a lorry. Her immediate reaction was, “Oh no, I can’t cope with this”. She “disintegrated into tears” and was surprised by the extent of her reaction. Feelings of distress persisted in the aftermath of the accident and a woman from a nearby house came to her assistance. She remained in the car and contacted her husband on her mobile phone, to inform him of the accident. At the scene she recalled feeling “totally

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Sample Psychological Report

pathetic”, and unable to control her emotions. The police were called and dealt with the aftermath of the accident and she later returned home with her husband. She remained very tearful when she arrived home and went to bed saying, “I felt I wanted to be out of it”. Generally felt that she was unable to cope with the extent of her reaction. She was aware of an overwhelming sense of vulnerability in that accidents could occur at any time. She did not want to talk about the accident but described vivid intrusive images of the accident that would repeatedly come into her mind. The following day Mrs Jones awoke in great pain from her neck and made an appointment to see her doctor. He diagnosed a whiplash injury and recommended that she rest for a few days. Mrs Jones was off work for a week or so, during which time the pain was severe. However, she noted that this has improved since and the pain generally recovered within a period of several months. On interview she did not report any ongoing pain related problems. Mrs Jones gained a replacement vehicle from her insurance, which she needed to attend work. She reflected that she lives in a rural area and was dependent upon a car for transportation. However, when the car arrived she described feeling “terrified of driving” and that the trip to work became “a...
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