PSYCHOLOGICAL EVALUATION REPORT

Patient Name: Piglet

DOB: 12/28/1976

Date of Evaluation: 12/15/2016

Assessment Completed by: Avery Matowik

Identifying Information: Piglet was referred to our facility today by a close friend Pooh. Piglet,

a 40-year-old male pink pig, lives in the Hundred Acre Woods in a beech tree with Pooh. Piglet

is not married, does not have any children or family, but has a strong support system at home

built up of friends he considers to be his family. Piglet did not finish high school, however he is

able to read and can write well enough to create short notes. Piglet is unemployed. Piglet is being

admitted as an outpatient to our facility due to symptoms relating to Generalized Anxiety

Disorder (GAD). Piglet has no prior history of any mental health related admissions or

diagnosis’. Other than symptoms of anxiety, Piglet is in good overall health.

Chief Complaint: “I do not want to come out from under my chair… the world is too dangerous

for small animals like myself”

History of Presenting Problem: It is apparent through discussion with this individual that his

anxious behavior and excessive nervousness has been long term. Piglet states he becomes very

panicked when he goes into the forest with Pooh to get honey because he is afraid of Woozles

and Heffalumps. His fear of Woozles and Heffalumps is chronic; he gets severe panic attacks
when thinking of them. There was no indication of any type of conflict or even actually seeing

Woozles or Heffalumps before, so it is unknown why Piglet is so afraid of them. This individual

also fears he is too small to be in the forest so he often runs back home and hides under his chair.

His friends are the only ones who can rationalize his thinking and get him to come out from

under it. Piglet is constantly fearing what could go wrong in any situation which attributes to him

staying indoors and being afraid to go outside. Piglet often gets overwhelmed by excitement; for

example, when his friend Tiger bounces on his tail, Piglet becomes very panicked. Physical

symptoms of Piglet’s anxiety include compressing his hands together, shuttering, stomach upset,

shaking, and twitching of the ears.

Family History: As previously stated, Piglet has no known family members, however at one

point his grandfather was in his life and it is believed there was no history of any mental health

disorders.

Personal and Developmental History: Growing up, Piglet did not know his parents or any

possible siblings he may have had. Piglet was raised by his grandfather who took good care of

him. Piglet always had a lot of friends. Piglet did not complete school because it was very

difficult for him; he was always too afraid to leave the house so he eventually stopped attending.

Piglet believes he was eight years old when he began experiencing symptoms relating to anxiety.

When Piglet was 25, his grandfather passed away. Piglet had been living in his grandfather’s old

home until recently when he moved in with Pooh for support with his fears.

Assessment Procedures: During the interview with Piglet I had the opportunity to present the

individual with the GAD-7 Assessment. This is a self-administered patient questionnaire which

screens and measures the severity for generalized anxiety disorder. When scoring this

assessment, it is advised that scores 10 or above require further evaluation. On this seven item
scale, Piglet scored 19. In accordance to this scale, it is quiet apparent Piglet meets the criteria

for this disorder. In proceeding with completing a diagnosis, the DSM-5 was used as an

additional reference. According to the DSM-5, the patient must meet three of six symptoms

listed within the manual. Of the six, Piglet is in agreement that he meets at least five of these six

symptoms. During our time assessing these resources, it took a total of thirty minutes.

Mental Status Evaluation: Individual appears alert and oriented. He becomes rather distracted

when anxiety is triggered, however during regular conversation he responds well and can focus

on the discussion. Patient is dressed very casually and is well groomed. Individual makes

appropriate eye contact. Vocabulary and grammar skills were appropriate and within average

intellectual range. Piglet’s attitude was a bit passive however cooperative. It was apparent he was

feeling skittish and desperate for help. His memory appeared to be fully in tact. There was no

evidence of suicidal or homicidal ideation. There was some evidence of paranoia when

discussing Woozles and Heffalumps, however this very well likely plays a role in GAD. Aside

from his fears, his social judgment seemed appropriate.

Results of Evaluation: It is my clinical impression that after assessing Piglet we will be treating

him as an outpatient for Generalized Anxiety Disorder.

Summary/Recommendations: After assessing Piglet for symptoms relating to anxiety and

nervousness we will be treating him with Cognitive Behavioral Therapy (CBT). CBT has a

strong reliable history of assisting patients with GAD. CBT allows patients to become trained in

detecting internal and external anxiety cues and respond with a strategy to manage the

psychological symptoms. It is recommended that efforts are made to establish a trusting

relationship with Piglet to successfully help him nurture a better coping pattern. Individual

therapy will be much more successful than group therapy for Piglet so we will meet privately for
a set twelve sessions, then reassess his needs. It is always a fear that the individual will not

comply with therapy, or that CBT will be ineffective for this patient due to the fact that GAD is

the most difficult form of anxiety to treat. If the patient choses not to participate in therapy due to

fear or an issue trusting his clinician, it is likely he will go untreated for an even longer period of

time.
 References

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Diagnostic and statistical manual of mental disorders: DSM-5. (2013). Washington, D.C.:

American Psychiatric Association.

Evans, S., Ferrando, S., Findler, M., Stowell, C., Smart, C., & Haglin, D. (2008). Mindfulness-

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Spitzer, Robert L., et al. "A brief measure for assessing generalized anxiety disorder: the GAD-

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