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PSYCHOLOGICAL EVALUATION

CLIENT:
DOB:
AGE:
Date of Evaluation:
Date of Report:
Referred by:
Examiner:

Mrs. J.R.
06/26/1984
Twenty-eight
December 1, 2012
December 9, 2012
XXXX
David Freeman, Ph.D., Q.M.E. ABPN,
Diplomate, American Board of Professional Neuropsychology
Qualified Medical Evaluator, State of California
Licensed Clinical Psychologist
California State Psychology License Number: PSY11420

ABSTRACT OF FINDINGS
There are multiple circumstances in Mrs. J.R.s life that are consistent with an Extreme and
Exceptional Hardship if her spouse is not granted a waiver. These circumstances include a major
illness in a parent, Mrs. J.R.s major mental disorder and the psychological vulnerability of her
three children to a mood and anxiety disorder.
First, Mrs. J.R.s mother suffers from cancer, a major medical condition. Mrs. J.R. reported that
initially her mothers condition was confined to the ovaries, and following treatment spread to
the abdomen and is now close to other body parts including the kidneys. Due to her mothers
fragile medical condition, Mrs. J.R. provides five hours of care three days per week and about
eight hours of care on a fourth day, assisting her mother with bathing, grooming, shopping,
transportation, medical appointments and other caretaking needs. In my opinion, it is imperative
that her spouse be allowed to return to the United States as Mrs. J.R. has been shouldering a
greater burden of care, which is a psychosocial stressor that has worsened her mental state.
Second, Mrs. J.R. expressed concern about what she believes is a high level of crime in her
spouses home in a small town in Mexico, including crimes involving homicide and home
invasion associated with the drug trade. Consequently, she does not consider living there a
suitable and safe environment for their three children.
Third, Mrs. J.R. has been diagnosed with a major mood disorder by her psychiatrist and placed
on medications for depression (Prozac) and anxiety (Xanax). During my evaluation of Mrs.

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J.R., I also found her to be suffering from a Major Depressive Disorder, Single Episode,
Moderate in Severity on Axis I, per DSM-IV-TR criteria. Recently, her psychological state
deteriorated to the extent that she was placed off work on disability from a psychological
viewpoint. Thus, there has been a progressive deterioration in Mrs. J.R.s mental state over the
course of the past several months, adversely impacting her subjective well-being (mood) as well
as her occupational functioning (ability to work).
This deterioration in Mrs. J.R.s
psychological state is not a normal or typical response to the stressor of being separated from her
husband, but reflects an abnormal or pathological response.
Fourth, the history reflects that Mrs. J.R.s three children have been adversely impacted by the
absence of their father with respect to their psychological and school functioning. Her middle
child reportedly engaged in sexually inappropriate behavior at school, which based on an
investigation, was determined to be a result of her distress secondary to her fathers absence.
There was no evidence of any actual sexual abuse. In addition, two of her three children have
entered into mental health treatment and her youngest child is displaying frequent crying
behavior at night. In my opinion, the separation of the family unit and the significant stress on
Mrs. J.R. has produced significant emotional dysfunction in her children and will likely remain
so indefinitely unless their father is reunited with the family.

END OF ABSTRACT OF FINDINGS


GO TO PAGE THREE FOR REMAINDER OF REPORT

RE: Mrs. J.R.


DOE: 12/1/2012

INTRODUCTION:
On December 1, 2012 Mrs. J.R. underwent a comprehensive psychological evaluation in
Comprehensive Psychological Services Van Nuys office. The purpose of the evaluation was to
examine Mrs. J.R.s psychological state with reference to her spouses request for Application
for Waiver on Grounds of Inadmissibility. Additionally, it was necessary to determine if Mrs.
J.R. is suffering from a mental disorder or of any clinically significant psychological distress
(beyond a normal or typical reaction) secondary to the stressor of being separated from her
spouse.
The interview, mental status examination, psychological testing and review of available records
comprised approximately five and one-half hours and the preparation of the written report
required an additional five hours. In addition to a clinical interview and mental status
examination Mrs. J.R. was administered a battery of psychological tests including the Minnesota
Multiphasic Personality Inventory-2-RF (MMPI-2-RF), Beck Anxiety Inventory (BAI), Beck
Depression Inventory-II (BDI-II) and the Wahler Physical Symptoms Inventory to obtain
objective information on her psychological functioning.
IDENTIFYING INFORMATION:
Mrs. J.R. is a twenty-eight-year old married female who lives in Los Angeles with her three
children, who are eight, six and four. She is employed as a Dish Washer and has worked with
her company from October, 2011 up through the present time period. Previously, she worked for
a different company as a dish washer from June 10, 2007 until September 30, 2011.
Mrs. J.R.s spouse was determined to be ineligible for an immigrant visa due to his
undocumented status while living in the United States.
Mrs. J.R. was informed of the medical-legal purpose of this evaluation, that we did not have a
confidential doctor-patient relationship, and that a report would be filed. She appeared to
understand this admonishment.
PRESENTING PROBLEM PERTAINING TO IMMIGRATION
While Mrs. J.R. denies having a major medical condition that prevents her from traveling abroad
she absolutely needs her husbands help because of his emotional support and assistance
parenting their three children. Additionally, on a typical day, her mother requires hours of
continuous care, which is now divided among her siblings. The care Mrs. J.R. provides to her
mother includes assistance with bathing, traveling, dressing, purchasing groceries, medicines,
and other caretaking needs. Since being released from the hospital, her mother has required an
even greater level of personal care. Mrs. J.R. believes her mother requires all day care, which
is currently divided among the examinee and her siblings. When her spouse was present she had
a different shift, from 8:00 p.m. to 5:00 a.m. which allowed him to care for their children. If he
was with her, she would stop working to be more available for her children and mother.
However, if her spouse was not working he would help her by caring for and feeding their
daughters and mother, which would relieve her depression, lessen her burden and help her lose

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weight. Mrs. J.R. has lost a lot of self-confidence is less concerned with her physical
appearance due to what she is going through and believes she cannot obtain other employment
because of her weight. On the day she is not working, she is at her mothers from 10:00 a.m.
until 7:00 p.m. with her children, caring for them and her mother.
As noted above Mrs. J.R. is providing care for her elderly mother, who requires constant care. To
that extent Mrs. J.R. provides caretaking services for her mother three days a week for five hours
a day, and for eight hours on one of her off work days. Due to her mothers cancer, which is
reportedly spreading, she cannot travel abroad and needs considerable assistance to help her
manage her responsibilities.
Mrs. J.R. also expressed concerns about a lot of home invasion crimes in the town where her
husband lives in Mexico. These crimes include homicide crimes associated with drug trafficking.
Her spouse has spoken to her about what she views as a highly chaotic environment including an
incident when someone was run over by a vehicle and left in the street for an extended period of
time, saying the area is not a suitable place for their family. When thinking of living there, she
described feeling very scary especially because of the effect on her three children.
When asked if she has ever been diagnosed with a mental condition such as clinical depression
by a mental health professional, Mrs. J.R. reported that she was examined by a psychiatrist who
is willing to provide a letter documenting findings regarding the examinees mental state.
In terms of whether or not a parent or any children suffer from conditions such as high blood
pressure, elevated cholesterol, diabetes, asthma, autism, Aspergers or ADD/ADHD, as noted
above her mother was treated for ovarian cancer and now has cancer in the abdominal area which
is spreading near her kidneys. Her mother is undergoing cancer treatment for six months and
may then enter Hospice depending on the treatment outcome. Additionally, the kidney stones
her mother suffers from are not amenable to surgery or other procedures because of the size of
the stones and the cancer treatment.
Although there is no reported family history of Autism, Aspergers ADD or ADHD in her three
children, the eldest child has become very angry; mad easily, is apathetic, refuses to listen
when given directives and talks constantly about missing her daddy and when he will return
so they can attend a father-daughter dance together. The middle child is seeking a lot of
attention and sees a mental health professional because she fights a lot with her sisters, is
uninterested in normal play activities, wants to beat them up and blacks out while crying,
yelling I want my dad; I want my dad; I dont want to be here; I dont want to be here. This
child sees a psychotherapist at the present time. She has seen him every Monday since August of
this year. Mrs. J.R. has noticed the younger daughter cries at night because of the fathers
absence. Mrs. J.R. said a police report was filed because of a thought her middle child was
being sexually mistreated because of her school behavior.
During the course of the
investigation, it was determined that her daughter was not sexually abused and was engaging in
questionable and inappropriate behavior because so much was transpiring in the family due to
the fathers absence. According to Mrs. J.R. her daughter lifted her shirt, began touching her
chest and said this is what her sisters boyfriend did to her, which prompted a child abuse
allegation report and subsequent investigation. It was determined that the child fabricated the

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abuse which she may have learned about from a television show. During the investigation, the
child told the mental health professional she missed her father. The psychiatrist or mental health
professional involved in the investigation concluded that the child is seeking attention by lying
often, inventing stories about herself. Again, this history strongly suggests significant emotional
stress related to the separation of Mrs. J.R.s spouse from the family unit.
Due to the change in her circumstances following the separation from her husband eighteen to
twenty months ago, Mrs. J.R. often feels overwhelmed, and she reports significant frustration.
She stated that she screams a lot, and she feels like a failure. She reported that she is no
longer a good mother. Additionally, she requires financial assistance and has applied for
government assistance such as food stamps, is receiving Medi-Cal and qualified for the Healthy
Family program for which she was paying forty-three dollars a month. Mrs. J.R. believes she
would not be in need of government assistance if her spouse returned home. He formerly worked
as a cook at a local fast food restaurant, earning eleven dollars and fifty cents per hour and often
worked one-hundred or more hours during a two-week pay period.
CURRENT COMPLAINTS:
Physical Complaints
Physically, Mrs. J.R. reported pain in her neck and shoulders which she described as like Im
carrying something heavy beginning about eighteen months ago. Her primary care physician
said it was due to stress which she discussed with him. She rated the pain as 5/10 on a
constant basis with ten representing the highest level of pain severity requiring inpatient
hospitalization. The only treatment she has undergone is psychotropic medications.
Mrs. J.R. also reported tension in the back of her head accompanied by lightheadedness, which is
present five out of seven days, lasting for about two hours, beginning about the same time as the
back and neck pain
Review of Systems:
Mrs. J.R. reported experiencing dizziness when upset emotionally or tearful occurring
maybe twenty times in the last thirty days, lasting for half a day. She also develops leftsided discomfort in her chest like a shot; a needle and on a once weekly basis but has not
paid attention to it.
Because of crying like a baby she has difficulty breathing, which
happens five out of seven days per week, twice a day; lasting for maybe twenty minutes
accompanied by heart pounding.
Along with headaches and when beginning to overthink, her vision becomes blurry,
accompanied by pain and tiredness in her eyes. When asked about her hearing, she mentioned
hearing her daughter calling her at work even though the child was not present. Mrs. J.R.
reported hearing the voice of her daughter a lot due to not being with her when she is at work.
To her, this seems like a voice and she mentioned a work incident when she believed she heard
a coworker yell her name when in fact he verified that he did not call her name. This happened
about six weeks ago and the examinee reported similar occurrences on two other occasions.

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The severity of these psychological symptoms, associated with holding inside her issues over
time has prompted her to seek mental health treatment.
Also, Mrs. J.R. develops nausea when eating and since undergoing gall bladder surgery has an
upset stomach when eating red meat. This does not occur in other situations. Also, she reports
having constipation while having a bowel movement once a day. She denied any change in her
urinary habits.
Mrs. J.R. also reported pain in her right leg due to a car accident when she was fourteen years
old, followed by surgery with instrumentation. She has pain when walking distances and in cold
weather. This has been present all day recently with the onset of colder weather and causes more
difficulty performing her job at her usual pace.
In terms of chronic medical illnesses she was diagnosed with gestational diabetes in addition to
high blood pressure. She denied having any of these conditions currently. Upon direct
questioning, she denied a history of having suffered a stroke, seizure, or head trauma, other
changes in her blood sugars or loss of consciousness. She acknowledged having an episode of
vertigo three to four months ago, in bed, lying down and crying and felt everything spinning
for five to seven seconds. This has not recurred.
Neurovegetative Symptoms:
Upon returning home from work at 1:30 a.m., she goes to sleep at 2:00 a.m. and requires one
hour to fall asleep because of thinking about her mother, husband, daughter and bills.
She
thinks about not seeing her mother alive and often has thoughts about her mother dying because
her father died and she was not present because of having to undergo gall bladder surgery and
could not be near her father due to the possibility of contagion. In terms of her spouse, she
thinks about when he will return, and when it will be the same like before and mentioned her
daughters wanting the presence of their father in their lives and being teased by peers because of
the absence of their father, who is also a big support for her. Upon falling asleep, she
sometimes cant hear the alarm that prompts her to wake up and transport her daughter to school.
Subsequently her four-year old daughter has been missing school at the pre-kindergarten she
attends once a week. Eventually, she wakes up at 12:30-1:00 and said she sometimes will sleep
twelve hours a day and feels more tired upon waking.
In terms of her appetite, Mrs. J.R. tends to consume large quantities of snack foods due to
feelings of anxiety and stress which she believes is responsible for a sixty-pound weight gain in
the past eighteen months.
With respect to sexual urges she said I dont care for it and last saw her spouse in October
2012 to obtain papers for two to three days.
Mrs. J.R. said her spouse has also experienced
sexual performance problems due to all this stress including worry about his daughters and the
separation and not being able to do anything about it.

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Emotional Complaints:
Emotionally, Mrs. J.R. reported feeling angry most of the time, elaborating on becoming very
upset over minor issues, including comments and jokes as she is not in the mood to enjoy
herself or engage in any fun activities because I have enough on my plate. Seeing other couple
playing with their families is extremely upsetting.
Mrs. J.R. acknowledged feeling depressed like four days of the week the entire day
accompanied by urges to sleep a lot and over-promise trips to the park and to the movies for
her daughters because of losing hope; like I dont want to. She elaborated on the lack of any
urge to engage in activity. Her daughters have noticed this and told her that going to the park
does not require money. She wonders about having the strength to go out because of feeling
depressed when she sees other people laughing and happy and when her children will have their
father back in their lives.
Mrs. J.R. rated her depression as like 8/10 on a ten-point scale with ten representing the
highest level of depression severity requiring psychiatric hospitalization, beginning near twenty
months ago when her spouse left.
When asked about other depressive symptoms, Mrs. J.R. reported daily crying episodes, about
ten times per day, elaborating that every little thing causes her to become tearful. Before her
spouse left the country, they enjoyed talking, going out and joking around. Upon direct
questioning, she denied any intent or plan to harm herself but had a thought of not wanting to
live two months ago when she felt as if life was not worth living because of the level of
complexity and stress in her life. She denied any thoughts of wanting to hurt other people.
Socially, she tends to space out, becoming quiet with others, even though she tries to involve
herself in conversations. However, her situation overcomes everything; being separated from
her spouse, which is not like a normal life because she has never been without him at social
functions. One of her nephews has commented that she is no fun because of refusing
invitations and that she needs to stop thinking her spouse will come back quickly. She finds
this discouraging because her spouse has been gone for nearly two years.
Prior to the onset of her depression Mrs. J.R. felt motivated to wake up early, clean her home,
clean for her daughters, focus on her career and return to school to obtain her GED in an effort to
become an Licensed Vocational Nurse, which she now believes is not worth it as she no longer
feels smart because of the number of errors she makes.
BACKGROUND, FAMILY & SCHOOL HISTORY:
Mrs. J.R. reported that she was born in Los Angeles, California and reared by her parents in a
loving and affectionate manner. To that extent she reported Very Close relations with her
parents and felt Mostly Happy throughout childhood. Her father died on July 7, 2009 at the age
of seventy after having suffered several strokes. Currently, Mrs. J.R.s seventy year old mother
is being treated for cancer. Specifically, her mother was previously treated for ovarian cancer,
which was either cured or went into remission for eight months. In March, 2012 the cancer

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returned, this time to the abdomen and is spreading. Her mother also has kidney stones which
cannot be removed due to their size and because of the cancer. Mrs. J.R. mother is undergoing
outpatient chemotherapy every Friday.
Mrs. J.R. is the youngest in a two-child sib-hood, ages thirty and thirty-two respectively. She
completed eleven years of formal education. She earned average grades and denied a history of
school problems such as inattention, comprehension difficulties, issues associated with
hyperactivity and any ongoing emotional difficulties.
MEDICAL & PSYCHIATRIC HISTORY
The births of her three children were accomplished by caesarian section. In 2009, Mrs. J.R.
underwent gallbladder surgery. When she was fourteen years old she sustained an injury to her
tibia bone in a motor vehicle accident, underwent surgery which included instrumentation and
has a rod in her right leg. As noted above, Mrs. J.R. underwent a recent psychiatric evaluation,
was placed off work due to her mood disorder, prescribed anti-depressant and anti-anxiety
medication and has an upcoming appointment with the doctor who placed her off work.
MENTAL STATUS EXAMINATION/BEHAVIORAL OBSERVATIONS:
Appearance: Mrs. J.R. is a 28-year old, right-handed, well-groomed casually clad Hispanic
female who is five feet three inches in height and appears her stated weight of
three-hundred and thirty pounds, which represents a weight gain of about sixty
pounds in the past eighteen months.
Behavior:

Throughout the course of a lengthy (nearly five-hour) evaluation, Mrs. J.R.


interacted in a polite, responsive and entirely cooperative manner. She completely
understood the purpose of the evaluation and was able to provide relevant and
detailed information in response to questions about remote, recent and current life
circumstances. While she reported hearing the voice of her daughter and a
coworker, who were not actually present, there was no evidence she was
responding to internal stimuli or voices over the course of the evaluation.

Cognition:

In terms of her gross cognitive functioning, Mrs. J.R. was alert and well oriented
to time, place, person and circumstances of the current evaluation. Attention and
concentration were mostly intact though she sometimes digressed in response to
questions but was easily redirected. She spoke clearly, articulately and
conversationally with no evidence of expressive or receptive language problems.
Memory for remote, recent and current events was grossly unimpaired. Her
estimated level of intellectual functioning, based on her verbal presentation,
background and education is in the Low Average to average range. She was able
to complete the psychological testing well within normal time limits.

Mood:

Mrs. J.R. was moderately distressed for most of the evaluation and displayed a
limited range of emotional response. While she easily established and maintained
eye contact, she never smiled or departed from her constricted emotional tone.

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Specifically, she exhibited multiple depressive symptoms included recurrent


crying spells throughout the interview escalating to uncontrollable sobbing for up
to one minute when discussing the separation from her spouse and the possibility
of living without him in the United States and of moving to Mexico to be with
him. While denying any active suicide intent or plan, Mrs. J.R. admitted to having
thoughts of not wanting to live as recently as two months ago. She also admitted
to less overall stamina and increased fatigue due to the weight gain.
PSYCHOLOGICAL TESTING
The services of an interpreter were not required for administration of the psychological testing.
In order to further assess Mrs. J.R.s psychological status and to obtain objective information on
her symptoms, complaints and problems she was administered the following psychological tests:
Minnesota Multiphasic Personality Inventory-2-RF (MMPI-2-RF), Beck Anxiety Inventory
(BAI), Beck Depression Inventory-II (BDI-II) and Wahler Physical Symptoms Inventory
(WPSI).
MMPI-2-RF
The examinee was given the Minnesota Multiphasic Personality Inventory-2-RF and answered
all but eleven of the 338 items in this lengthy psychological test, taking an average amount of
time for its completion. The computer-generated profile was scored with software provided by
NCS Assessments and a computer-generated interpretation of the MMPI-2-RF was created with
software from Psychological Assessment Resources.
The following represents my analysis and conclusions drawn from the results of the claimants
psychological testing, which includes my review of the computer-generated interpretation as well
as the profile produced by the test results.
Validity: (T Scores)
VRIN-r TRIN-r L-r F-r K-r Fp-r Fs FBS-r RBS
48
57T
71 115 35 94 107
89
21
On a measure of consistency Mrs. J.R. endorsed the items in a reliable manner (VRIN-r = 48T).
There were no indications of a fixed inconsistent response set (TRIN-r = 57T). The examinees
score on a measure of infrequent responses (F-r = 113T) is markedly elevated compared to the
normative sample and suggests the possibility of over-reporting of a broad range of
psychological, somatic and cognitive symptoms. There were also indications of over-reporting
of unusual psychological symptoms (Fp-r = 94T) and of a wide range of cognitive and somatic
complaints (Fs = 107T; FBS-r = 89T; RBS Raw = 21). Thus, the scores on the substantive
scales cannot be interpreted due to invalidity. However, it must be noted that elevated scores can
be obtained by individuals with actual, legitimate psychological complaints. Thus, an elevation
cannot be considered completely due to over-reporting as extra-test considerations must be
evaluated, particularly when there is a documented history of marked psychological dysfunction.

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10

Beck Anxiety Inventory (BAI):


On this self-report measure of anxiety, she obtained a raw score of 38 which corresponds to the
classification severe on this self-report measure of anxiety.
Beck Depression Inventory-II (BDI-II):
The examinee scored in the range of severe depression (Raw score = 49) on on this self-report
measure of depression.
Wahler Physical Symptoms Inventory:
On this task, a self-report measure that assesses physical symptoms, she obtained a WPSI score
corresponding to the 9th decile, which indicates she is reporting a marked level of physical
distress when compared to an outpatient female sample.
DSM-IV-TR DIAGNOSIS
Presented psychiatric diagnoses based upon the history provided, review of records,
psychological testing and clinical examination are:
Axis I: Clinical Disorders (and Other Conditions That May Be a Focus of Clinical Attention)
Major Depressive Disorder with Anxiety, Single Episode
Moderate in Severity
Axis II: Personality Disorders and Developmental Disorders
Dependent Personality Traits
Axis III: General Medical Conditions
Deferred to Physicians
Axis IV: Psychosocial and Environmental Problems
1. Health concerns
2. Spouses immigration issues
Axis V: Global Assessment of Functioning
Current GAF = 53 (Current)

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DISCUSSION OF DIAGNOSIS
On Axis I, Mrs. J.R. meets DSM-IV-TR criteria for a Major Depressive Disorder, Single
Episode, which is presently at a moderate level of severity and chronic. This diagnosis involves
the presence of persistent depressed mood or loss of interest or pleasure for at least a two-week
period and representing a change from a previous level of functioning. There may also be
significant weight loss when not dieting or weight gain, insomnia or hypersomnia nearly every
day, psychomotor agitation or retardation nearly every day, fatigue or loss of energy, feelings of
worthlessness or excessive or inappropriate guilt, diminished ability to think or concentrate,
recurrent thoughts of death or recurrent suicidal ideation. The symptoms cause clinically
significant distress or impairment in social, occupational or other important areas of functioning
and are not due to the direct physiological effects of a substance. Major Depressive Disorder,
single episode, indicates there has only been one Major Depressive Episode whereas Major
Depressive Disorder, recurrent, indicates the presence of two or more Major Depressive
Episodes.
In Mrs. J.R.s case, she reported a major change in her mood when her spouse was unable to
return to the United States and continues to display prominent depressive symptoms consistent
with a Major Depressive Disorder, Single Episode, Moderate in Severity on Axis I. To that
extent she acknowledged a moderate level of depression (8/10) which is present a majority of the
time, accompanied by recurrent crying spells during the day, excessive guilt, problems focusing
her attention and loss of interest in many of her usual activities. Moreover, the evidence for a
major mood disorder was also evident in her mental status, when she exhibited a persistently sad
and forlorn facial expression, recurrent crying spells with a pronounced helplessness and
pessimism regarding her current circumstances. While Mrs. J.R. acknowledged an above
average number of unusual complaints on the MMPI-2-RF, this is commonly seen among
individuals with actual mental disorders with a corroborating mental health history. Recently,
Mrs. J.R. underwent a psychiatric evaluation, was prescribed anti-depressant and anti-anxiety
medication and placed on disability for two to three months due to the extent of her
psychological deterioration. In my opinion, her emotional state clearly reaches the level of a
clinically significant and diagnosable mental disorder and cannot be considered a normal or
typical emotional reaction to the separation from a spouse.
On Axis II, there is no indication of a formal personality disorder. However, there are
Dependent Personality Traits, based on the history, information in the records, and psychological
testing. The history reflects that Mrs. J.R. has relied on her spouse to a marked extent to assist her
with normative demands. For example, she emphasized that she absolutely needs her spouses
assistance because he was always there for her emotionally, helped her to cope with stress in
order to avoid becoming upset (how to ignore stuff) and helped provide assistance for their three
children as well as helping with her very ill mother. Many of her spontaneous comments suggested
ongoing themes of helplessness and psychological discomfort when alone due to fears of being
unable to function at her usual level of ability. There are no signs of other dependent traits such as
volunteering to engage in tasks that are unpleasant and of going to excessive lengths to obtain
nurturance and support.

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CURRENT IMPAIRMENT: GLOBAL ASSESSMENT OF FUNCTIONING


The Global Assessment of Functioning scale (GAF) is a 100-point scale that is divided into 10
categories from the most severe impairment (1-10) to superior functioning (91-100). The GAF is
determined by examining two main sources of information (1) psychiatric symptoms, and (2) social
and occupational functioning. According to the DSM-IV-TR (2000), in cases where the
individuals symptom severity and level of functioning are discordant, the final GAF rating always
reflects the worst of the two (pg. 32-33).
In determining the claimants GAF score, I first examined the examinees current psychological
symptoms. In summary, the psychological symptom-rating portion of the GAF is rated as 53. A
rating in the lower portion of the moderate range of impairment was assigned when considering the
totality of information including symptom presentation, based on her mental status, interview
behavior and the psychological testing. Mrs. J.R. reported a level of depression in the moderate
range (8/10) approaching severe and the psychological test results documented moderate to severe
levels of depression, anxiety and a preoccupation with physical symptoms (Beck Depression
Inventory-II = 38, Beck Anxiety Inventory = 49).
Additionally, Mrs. J.R. is often preoccupied with her physical health, presenting with numerous
physical complaints that involve a strong psychological component. The severity of these symptoms
is marked, as noted in her score on the Wahler Physical Symptoms Inventory, which indicates she
has a level of physical distress greater than 90% of outpatient females. Consequently, based on a
careful review of her symptoms based on her mental status, self-report, interview behavior,
psychological testing and the available records, Mrs. J.R. has a level of psychological impairment in
the low end of the moderate range.
The next step of the analysis for the GAF concerns social and occupational functioning.
The
claimants GAF, as it pertains to her social and occupational functioning, is approximately 53.
While Mrs. J.R. has been gainfully employed for the past five years, her depression began adversely
impacting her work performance to the extent that the psychiatrist who recently examined her
placed her off work due to the deterioration in her psychological functioning. Additionally, she
reports that it is more difficult to become motivated and involved in her childrens activities,
including minimally expensive activities such as going to a local park. Thus, her mood disorder
has negatively impacted her capacity to function in two areas, employment and parenting capacity.
Notwithstanding the mild difficulties above, Mrs. J.R. has meaningful relationships and despite
lesser motivation is actively involved in the lives of her three children. Despite the level of
psychosocial stress in her life, she related in a pleasant and cooperative manner during the interview
portion of the evaluation and complied with everything expected of her.
As noted above, to derive the final GAF score that should be used for the permanent impairment
rating, the DSM-IV-TR requires that the examiner select the lower of the two ratings between
psychological symptoms and social and occupational functioning. Consequently, the final GAF
score would be a GAF = 53 (current). That is because the psychological symptoms portion of
the rating was 53 and equal to her social and occupational score which was also 53.

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RECOMMENDATIONS
Due to the severity of her psychological distress, with prominent and clinically significant levels
of depression and anxiety, alterations in her sleep and appetite, energy level and libido, as well as
declines in her coping capacity it is strongly recommended that Mrs. J.R. be referred for twentyfour to thirty-six sessions of individual psychotherapy to help her manage her mood, improve her
stress tolerance and learn effective coping skills. In view of significant neurovegetative
symptoms impacting her sleep, appetite and libido it is also recommended that she continued to
receive psychiatric treatment consisting of monitoring and adjustments of her psychotropic
medications. Estimated length of treatment would be six to twelve months initially on a twice
weekly basis, with gradual reduction in the frequency of visits depending on treatment response.
This treatment should be considered medically necessary, in view of the symptom severity.
REVIEW OF RECORDS:
02/01/2012

Ms. XXXX MSW/County of XXXX Human Services

In this correspondence, it is recommended that the examinees daughter undergo counseling for
separation anxiety regarding the deportation of her father to Mexico. There was a reported history
of negative behavior at school, which resulted in agency involvement.
SUMMARY OF OPINIONS
After interviewing Mrs. J.R., conducting a mental status examination, reviewing available records
and administering and interpreting a battery of psychological tests, it is my opinion that she suffers
from a Major Depressive Disorder, Single Episode, Moderate in Severity accompanied by
prominent anxiety and psychophysiological symptoms secondary to the separation from her
spouse. It is my further opinion that her condition has not stabilized, is in fact worsening rendering
her in need of immediate psychological and psychiatric treatment.
In addition to suffering from a major mental disorder, Mrs. J.R. is providing medically necessary
care to her mother in excess of twenty hours per week. Her mother has been treated for ovarian
cancer and the condition has spread to the abdominal area and other body parts. In addition, two
of her three children have entered psychological treatment due to fathers absence and the
youngest child, according to Mrs. J.R. is usually tearful at night. Mrs. J.R. also expressed concerns
about her capacity to earn income in Mexico if she joined her spouse there and is concerned about
the level of crime in the town where her husband currently lives. Moreover, if she moved to
Mexico to be with her spouse, Mrs. J.R. does not believe she will earn adequate income to repay
the six-thousand dollars she owes to numerous relatives.
As noted in multiple sections in this report, the deterioration in Mrs. J.R.s psychological state does
not represent a normal reaction to the stressor of being separated from her spouse but the
emergence of a major mental condition, Major Depressive Disorder, Single Episode, Moderate in
Severity and Chronic, according to DSM-IV-TR criteria.

RE: Mrs. J.R.


DOE: 12/1/2012

14

Although determination of Extreme and Exceptional Hardship is ultimately deferred to a Trier of


Fact, in my opinion, these factors are consistent with an Extreme and Exceptional Hardship to a
Qualifying Family Member, in this case, Mrs. J.R., the spouse of Mr. A.R., if he is denied entry
into the United States.
Thank you for allowing me to participate in the evaluation of this individual. Feel free to contact
me if further information or clarification is needed

Respectfully submitted:

_________________________________________
David Freeman, Ph.D., Q.M.E. ABPN,
Diplomate, American Board of Professional Neuropsychology
Qualified Medical Evaluator, State of California
Licensed Clinical Psychologist
California State Psychology License Number: PSY11420
Date: December 9, 2012