Department of Psychology, Counselling and Therapy of Psychology Clinic Assignment

Assignment Task

Background Information

The following information and documents were available to the clinician as background information:

• Intake Form, La Trobe University Psychology Clinic
• Clinical Interview complete with Mr Jack Black
• Clinical Interview completed with Mrs Jane Black (mother)
• Discharge Summary, The Alfred Hospital

Presenting Problem

Jack reported that since his accident his memory has been “terrible”. He reported that he often needs information to be repeated or written down in order to remember them, which contrasts with before his accident, when he could be given numerous instructions all at once and be able to remember and complete all tasks. He said that he often finds his attention drifting and now has difficulty, for example, sustaining attention throughout a whole movie. Jack felt that his cognitive difficulties were worsening, particularly over the past 6-12 months.

When asked about his mood, Jack rated it as 5/10 (with 10 being best). He described feeling guilty for not working but at the same time lacking motivation to find employment. He reported often feeling fatigued, despite maintaining a reasonable bedtime (around 11pm) and often sleeping in (to at least 9am). He described feeling lonely, but also having little desire to socialise. He said that he plans to go and watch his team play football most weekends but rarely goes. He felt that many of his friends had moved on with their lives and were getting married and buying houses and that he felt “stuck”. Jack hoped that the current assessment would help establish whether his accident had caused any permanent brain damage and provide him recommendations as to how to get his life back on track.

Medical and Psychiatric History

Jack was involved in a motorcycle accident on 22/03/2020. He had been trailbike riding with three friends in regional Victoria when he ran into a fallen tree branch and was thrown off his bike. He struck his head (he was wearing his helmet) and lost consciousness immediately. His friends called 000, although it took paramedics one-hour to reach the scene due to the dense forest they were in. His friends told paramedics that he was unconscious at the scene for approximately 40 minutes. His Glasgow Coma Scale (GCS) was 12/15 when the paramedics arrived. He was stretchered out and driven by ambulance to the Alfred Hospital. CT Brain on 22/03/2020 revealed no skull fracture and no intra or extra axial mass, collection or haematoma. Post-traumatic amnesia was reported to have resolved by 25/03/2020 (i.e., 3 days post injury) and he was discharged home on 26/03/2020, with discharge notes indicating that he had suffered a moderately severe traumatic brain injury (TBI) but had made a good recovery. He was to attend an outpatient neurology assessment in six-weeks. According to Jack, this appointment was never organised, and he has not attended any follow-up neurology appointments. Jack also broke his collarbone in the accident, and he reported that he had to wear a sling for approximately six weeks. He reported that the injury had healed well, and he has full strength and range of movement back in his arm. Jack’s medical history is otherwise unremarkable. He has never received any psychiatric diagnoses. His mother, Jane Black, reported that Jack was born two weeks early with no complications and that he met all developmental milestones at appropriate times.

Psychosocial History

Jack currently lives with his mother, father, and two younger brothers (aged 18 and 20). He reported that he has a good relationship with his family and that they are very supportive of him. Jack had one serious 18-month relationship prior to accident and has not dated since his accident. Prior to his accident Jack played for a local football club, however missed the 2020 season due to his broken collarbone and has not returned to playing football since. He also previously enjoyed trailbike riding but had not been back on a motorcycle since his accident. Jack reported that he has a wide circle of friends, largely from his football club. Before the accident he would see his friends regularly both at the football club and outside the club. He now catches up with friends approximately once per month.

Educational and Occupational History

Jack reported no difficulties with literacy or numeracy prior to the injury and described himself as an “average” student. He enjoyed secondary school and said that his favourite subjects were geography and maths. He decided to leave school at the end of Year 11 to take up a carpentry apprenticeship with his uncle. He successfully completed his apprenticeship before the accident, although his uncle was unable to keep him on once he was fully qualified. At the time of the accident, he had been regularly contracting for a large homebuilding company for six months. He returned to this job six weeks after the accident, however after approximately two months he found he was being engaged for substantially less hours. He has since worked for four smaller building firms, the longest duration being for four months. At the time of the assessment Jack had been unemployed for five months and was receiving Newstart Allowance.

Jack acknowledged that his difficulty securing and maintaining employment over the last couple of years is likely due to poor performance. He said that he had been frequently late to work and was slow to complete jobs. He would often forget to do important things like ordering materials for jobs. When given large jobs, he would become overwhelmed and have difficulty working out where to start. He is worried that his worsening cognitive complaints (i.e., attention and memory) mean he may not be able to return to this kind of work.

Drug and Alcohol History

Jack reported that prior to the accident he had never been a big drinker, largely due to his commitment to remaining fit to play competitive football. During the football season he would limit himself to two stubbies of beer after the weekend game. During Summer he would also drink more on weekends (although rarely more than six beers) and on two to three weekdays per week (usually only two beers). Approximately two months after his accident, Jack began to consume more alcohol, drinking six stubbies of beer on most days. When he was working this would reduce to two beers per day on average. For the past five months he had been drinking an average of six to eight beers every evening. On occasions when catching up with friends he reported that he might drink as much as 18 beers (approximately once per month). Jack reported that he smoked cannabis approximately a dozen times during late high school but has not used since leaving school. He denied any other illicit drug use.

Informant History

In a telephone conversation with Jack’s mother, Jane Black, Jane described her son as “different” since the accident. She felt she had lost part of her previous “care-free, hilarious, generous” son. She reported that things had gotten worse over the last six months or so and that he appeared to have “given up”. She described a lack of drive and excessive sleep. She was also quite concerned about Jack’s alcohol consumption. She said that she frequently encourages Jack to visit his friends, but he always seems to have an excuse. Apart from mowing the lawns, Jack does not contribute to any household chores, which is in contrast to previous behaviour, whereby he would help with cooking and cleaning, even when working full-time. Jane had noticed changes in Jack’s memory since the accident and she finds that she now has to remind him of events and tasks numerous times. She did wonder whether this was due to him forgetting information, or whether he just doesn’t take it in in the first place.

Presentation

Jack attended 30-minutes late for his assessment session at the La Trobe University Psychology Clinic. He reported that he had forgotten to set his alarm and had slept in. He was dressed casually and appropriately. Jack presented as quiet and frequently looked down at his hands during the clinical interview; however, he seemed to become more engaged and relaxed as time went on. He was able to answer all questions directly asked of him. Jack maintained appropriate eye contact and his speed and intonation in speech was normal. He responded well to humour and was able to engage in reciprocal conversation. He did not present with any perceptual or motor disturbances. Jack did not demonstrate any overt difficulties maintaining his attention or in his ability to concentrate. He occasionally demonstrated a lack of confidence in his abilities, particularly during memory tasks. Jack appeared to give his best effort on all tasks and the results of the current assessment are considered to be a valid indication of his current level of cognitive functioning.

Summary

Jack is a 22-year-old male referred by his GP for neuropsychological assessment to determine his current level of cognitive functioning, in the context of a moderately-severe TBI sustained in a motorcycle accident approximately three years ago. Whilst Jack made a good recovery immediately following the accident, he now reports difficulties with attention and memory that have worsened over the past 6-12-months. Additionally, Jack reported low mood, amotivation, fatigue, loneliness, and increased alcohol consumption over this same time-period. He has been unemployed for the past five months. During assessment, Jack appeared to give his best effort but occasionally demonstrated reduced confidence, particularly during memory tasks. The results are a valid representation of his current cognitive functioning.

Assessment revealed a varied cognitive profile. Jack’s overall level of intellectual functioning (general ability index) was at the age-expected level ( Average ). His verbal comprehension skills were also at the age-expected level ( Average ), with a strength in his vocabulary knowledge ( High Average ). Jack’s perceptual (visual) reasoning and visuoconstructional skills where variable ( Low Average to Average ). Jack displayed weaknesses in processing speed ( Extremely Low ), as well as auditory and visual short-term and working memory ( Low Average ). In particular, his auditory working memory span (4 pieces of information) was significantly lower than his auditory short-term memory span (8 pieces of information).

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