Stephanie Nelson, Ph.D.

, ABPdN, ABPP-CN
Board Certified Pediatric/Clinical Neuropsychologist
2800 E. Madison Street, Suite 304
Seattle WA 98005
Phone: (360) 334-6156
Fax: (425) 242-5121
[email protected]

CONFIDENTIAL NEUROPSYCHOLOGICAL EVALUTION

Dear Terry –

You took part in a neuropsychological evaluation in October 20XX. You were concerned about your long history of
sensory problems and social sensitivity. In the past, you’ve been diagnosed with depression. More recently, you
were diagnosed with Generalized Anxiety Disorder (GAD). At the time you came to see me, you’d been in therapy
since 20XX, focusing on anxiety. You sought out this evaluation to see if there is something underlying your
anxiety, such as an attention problem or an autism spectrum disorder.

EVALUATION QUESTIONS
Together, we developed the following questions for this evaluation:
1. What are your cognitive strengths and weaknesses? Do you have an attention problem?
2. What is your social interaction style? Do you have autism?
3. What can we learn about your temperament, personality traits, and coping style that will support you?
4. Are there other things you can do to improve your emotional well-being?

MAIN SUMMARY
Your test results show you are an exceptionally gifted individual who experiences a great deal of anxiety,
especially in social situations. You also experience high levels of discomfort and depression. Your emotional
distress affects you socially and physically. Your distress also affects how you process sensory information and your
perception of how well you can attend in your daily life. There are many options available that will support you,
including medication, therapy, occupational therapy, and changes you can make to your daily routine.

SOURCES OF INFORMATION
After we discussed the results of the evaluation, we agreed I would write this report in the second person (“you”)
rather than the third person, as you sometimes find pronouns (both gendered and gender-neutral) uncomfortable.
You said this report would primarily be for your own personal use. However, you also said you would share it with
your therapist. Because you are very familiar with your history, I will only briefly summarize that history below. The
rest of this report discusses your test results in narrative form and includes suggestions for treatment. The tests we
did are listed in the tables at the end. Normally, I gather a lot of information from a person’s family about their
history. However, you are not currently close with your family, so you asked me not to speak with them. You
signed consent for me to speak with your therapist and one of your close friends to get more information about
you. All the other information in this report came directly from you and from the tests we completed together.

YOUR HISTORY

Your Main Concerns

You are 32 years old. You said your main concern is being bothered by hypersensitivity to clothing, touch, noises,
light, temperature, and other sensory sensations. Your second major concern is problems interpreting implicit
communication and expressing yourself in casual conversation. You also said you have problems understanding
speech in background noise. You told me you have had your sensory problems for as long as you can remember.
You said your problems interacting with people have been an increasing challenge since high school, although you
have always been, in your words, “introverted, shy, and awkward.” You are especially uncomfortable with your
office’s open floor plan All the noise and movement affect your sensory sensitivities and social comfort level.
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Your Educational and Work History

You did very well in school, and graduated from Local State College early, with a bachelor’s degree (with Honors) in
computer science. You achieved an exceptional GPA and won several awards for your scholarship. You currently
work as a researcher in computer programming. You said you chose this career path to try to minimize social
interaction. At work, you prefer well-defined tasks you can work on independently. You also do well with ample
time to complete tasks in advance of the deadline, as you experience stress if you feel rushed. You reported your
job performance is “acceptable.” You are regularly promoted and given impressive performance reviews. Your
supervisor has singled out your teamwork and leadership skills as a particular area of strength. Yet, you are
concerned you are “held back” professionally by the issues you describe. You are not sure your teammates
appreciate working with you. You said supervisors seem “annoyed” when you ask for more clarity around tasks or
more time to complete assignments. You have wondered if you should tell your supervisors that you have anxiety
or autism, so they better understand your needs.

Your Social History

You were born in Portland, OR, and moved to Seattle, WA three years ago when you received a job offer at the
company you currently work for. You live alone. You reported you have two very close friends, as well as a small
circle of more casual acquaintances. You originally met most of your friends through a close friend at work, which
allowed you to quickly expand your social circle. However, you feel you have trouble meeting new people and
starting conversations. You worry that without that close friend from work, you would not have met all the friends
you have, and you would be “lonely and alone.” Outside of work, you have many hobbies. You like playing
videogames, writing poetry, learning foreign languages, and doing crossword puzzles. You also enjoy murder
mystery re-enactments. You often organize murder mystery events with other people who also enjoy this hobby.
You take part in many intramural and independent sports. You volunteer at your local community agency. You did
not report any current or past restricted interests or repetitive behaviors, though you think you read much more
than most people. You also “like to keep an orderly schedule” and feel stressed if you must change plans. You
identify as aromantic and non-binary. You are not in a romantic relationship and are not sure you want to be in
one because you think it would be “stressful and scary.”

Your Medical History

You were generally physically healthy as a child, and you did not experience any major injuries, accidents, or
illnesses before age 16. At age 16 you experienced seizure-like episodes. You were diagnosed with non-epileptic
seizures after considerable medical work-up. At age 17, during your senior year of high school, you were
hospitalized for a suicide attempt. You realized you were transgender when you were 20 years old. You
transitioned in 20XX, with surgeries in 20XX and 20XX. You have not experienced any active suicidal ideation since
your last surgery. Right now, you have sleep problems, fatigue, muscle aches and pains, and ongoing non-epileptic
seizures. Your family history is notable for anxiety and depression.

YOUR TEST RESULTS

Your Cognitive Test Results

Your cognitive skills are very strong. Your overall problem-solving skills, as assessed by the Wechsler Adult
Intelligence Scale, Fourth Edition (WAIS-V), are in the very superior range (Full Scale IQ = 155, 99th percentile). You
have a good understanding of statistics, and we talked in our feedback session about how your overall IQ score is
more than 3 standard deviations above the mean. In colloquial terms, you are exceptionally gifted.

Your cognitive skills are certainly a wonderful strength that have allowed you to achieve professional success. On
the other hand, your cognitive strengths may serve to isolate you from your peers. You are likely to have different
interests, richer ways of perceiving the world, and a deeper thought process than many other people. This might
be true even in environments that attract individuals with strong cognitive skills, like your professional field. In any
environment, you might find it difficult to find others whom you truly ‘connect’ with and who understand you. This
may leave you feeling frustrated, lonely, or confused. I recommend you seek out resources that specifically address
the needs and interests of highly gifted individuals. These resources will provide you with more understanding of
the unique strengths and weaknesses that giftedness confers. These communities will also connect you with
similarly-capable peers.

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Another potential pitfall for you is that your strong cognitive skills may lead you to ‘overthink’ things. You might
see flaws in things that others do not notice or expect problems in situations that are not actually problematic.
This may occur without your conscious awareness, simply because you have a lot of cognitive resources for
anticipating, finding, and solving problems. You said this has been your experience at work, where you see
problems that no one else on your team even notice. Yet, you also see many potential problems that turn out not
to be a concern, and you worry your team sees you as “too critical.” I wonder if it would be helpful to think of
yourself as someone who has a “critical eye” rather than as someone who is innately critical. You are exceptional
at refining things. You know exactly how to perfect tasks, products, or systems. You also easily see potential weak
points and can prevent problems before they happen.

You told me you especially liked the cognitive tasks that felt like “straightforward intellectual puzzles.” Because
you find these kinds of problems easy and fun, you will be most comfortable with this type of problem. You are
especially oriented towards problems where there is a clear definition of the problem and a clear right-or-wrong
answer. However, you feel confused and uncomfortable with problems that are fuzzily-defined. You have seen this
in your work, where you get overwhelmed by assignments that are not perfectly clear to you. You also dislike
problems that rely on intuition or that have no clear right-or-wrong answer. This would include many social
problems, which often do not have one right answer. Even though you can solve ambiguous problems just fine,
you often feel you are “not good” at these types of problems compared to how brilliant you are at solving more
straightforward problems.

You also scored at a very high level on all the other neurocognitive tests administered to you. All these tests look
for problems rather than for strengths, so exceptionally high scores (like you obtained on the WAIS-IV) are often
not possible because of the tests’ upper limits (that is, the highest score you can get). You scored at this upper limit
– obtained a “perfect” score – on tests of your language, memory, and organizational skills. You also scored at high
level on other tests of your attention and executive functioning. All your scores on all these tests were at the 84th
to 99th percentile for your age (and as noted, your score was often the highest score you could achieve on these
tests). There are no concerns about an underlying attention deficit based on your scores. You also do not show
signs of any other cognitive, processing, or learning problems.

On tests looking at your fine-motor skills and hand-eye coordination, you showed high muscle tone. That is, there
was visible tension in your body while you completed the tasks. This tension may make it difficult for you to feel
relaxed and comfortable. You also always improved with practice on motor tasks. This is a common pattern in
individuals with anxiety. This pattern suggests you are better able to perform when you feel more comfortable
with the task expectations. However, there were no concerns about your basic motor skills based on your test
results. Indeed, overall, your neurocognitive profile is exceptional. You have a great many strengths that you can
rely on to help you achieve your goals.

Your Social Style and Autism-Specific Testing

Terry, I really enjoyed spending time with you and found you thoughtful, introspective, sensitive, and funny. We
completed a comprehensive interview and a loosely-structured social interaction using tests called the Autism
Diagnostic Interview Revised (ADI-R) and the Autism Diagnostic Observation Schedule Second Edition (ADOS-2).
During these tests, you easily shared information about yourself. You showed a clear interest in other people and
their experiences. You also had a lot of insight into your own emotions and your role in social situations. During
our interaction, you did not show any social communication deficits. For example, you did not have trouble making
eye contact with me. You used frequent gestures, changes in your tone of voice, and vivid facial expressions to
communicate. You did not report any highly restricted interests, excessively repetitive behavior, or preoccupation
with parts of objects. I did not see, and you did not report, substantial problems being flexible, such as when plans
changed or tasks needed to end. You were able to be quite creative, despite saying you felt uncomfortable during
the imaginative tasks due to their unstructured nature.

Overall, you have above average social skills, social reciprocity, social problem-solving skills, and social sensitivity.
As we reviewed in detail when we last spoke, your test results therefore do not support an autism diagnosis. You
reported feeling relieved to hear that you have good social skills. But in some ways, I imagine that finding out you
do not have autism comes as a disappointment to you. My impression is that you were hoping there is an
underlying, crystal-clear “explanation” for your perceived social challenges.
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I want to emphasize that the finding that you do not have autism is not meant to minimize your social concerns. In
interacting with you, I learned that social situations can be intensely uncomfortable for you. You also sometimes
have difficulties meeting your social goals because of your discomfort. We also learned that you do best when you
have a lot of “down time” to recover after a social interaction. This down time is especially crucial if you were
worried about the interaction.

Your presentation and your test results suggest to me that you have a “hyper-mentalizing” social style. By this I
mean that you very much overthink most social interactions. You appear to strongly desire clear social rules to
follow in all situations. Since most social situations do not come with those rules, you intensely analyze your
interactions for possible breaches of rules. In interpersonal situations, you present as very anxious about making a
social mistake. For example, you often apologized to me about very normal behaviors, like inadvertently bumping
the table between us, or not being able to perfectly articulate your thoughts about a subject. You also seemed to
be scanning me, both for mistakes I might be making and for signs that I thought you were doing something wrong.
You will remember that you pointed out a mistake you thought I had made. You also often asked me if I thought
something you had done was “the wrong thing to do in this situation.”

I received a lot of “mixed signals” from you when we were interacting. These mixed messages may be helpful for
you to know about as you work towards gaining more social confidence and success. On the one hand, I felt like
you genuinely wanted to connect with me during our time together. You engaged in a lot of social approach
behaviors. For instance, you asked me questions, shared information about yourself, and used body language to
signal interest in making a connection with me. On the other hand, you also presented as guarded, defensive, and
tense. You engaged in a lot of social avoidance behaviors in between your social approach behaviors. For example,
at times you needed me to ask you questions to draw you out and get you talking about something. Sometimes,
you told me your story and ideas in a way as if you thought I would find them boring or uninteresting. You used
phrases like, “I know I should get to the point here, but…” You also sometimes used your body language to signal
you were uncomfortable and wanted to be left alone. Internally, I felt an intense tension between wanting to get
to know you better, and wanting to leave you alone since it seemed like I was making you uncomfortable. In other
words, you presented as if you were saying both “come closer” and “leave me alone.” I wonder if other people you
interact with also feel this way.

If you are sending these mixed signals to others, people who very much want to connect with you may be
confused. Some of those people may not be able to overcome their internal discomfort well enough to be able to
follow up with you. I wonder if your social tension, social anxiety, mixed signals, and preference for structured
situations limits the potential pool of people you could connect with. I suspect that you are unintentionally limiting
your social opportunities to the following three groups. First, casual acquaintances with whom you share
experiences rather than deep connections. Perhaps “doing something” while you interact gives these social
situations more structure or gives the other person a reason for spending time with you even if they are not sure
you like them. Second, relationships that are unequal, with clear hierarchies to follow (such as a clear leader and a
clear follower). You told me you often feel like a “follower” when you spend time with your closest friend, whose
social skills you described as “magic.” Perhaps these hierarchical relationships have more structure and thus feel
safer to you. The third group would be you’re the deeper relationships you find with only the most socially skilled
and extroverted people you know. These people seem able to overcome the social barriers that may come from
grappling with your mixed signals. All these relationship types are common and can provide you with a lot of
satisfaction. However, you seem to long for deeper connections with true equals who share some aspects of your
temperament and personality traits.

To have the types of relationships you crave, you will have to change some aspects of your social behavior. The
best ways to do that are in the context of a therapeutic relationship. In therapy, you can get real-time, empathetic,
yet constructive feedback about how you present in social situations. You can also try out different ways of
behaving, to see what works best for you and your goals. Two therapeutic methods for doing this are interpersonal
therapy and group therapy. You told me you are willing to try both.

Your hobbies (like your murder mystery adventures and your sports activities) will be helpful places to practice the
behavior changes you are making. Once you feel more confident in those settings and feel your social behaviors
are truly aligning with your social goals, you can move on to more challenging, less structured social situations.
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During this time, you will want to remember that most social situations are nebulous, unpredictable, and
ambiguous. Unstructured social situations are highly challenging for most people. I would suggest making sure you
have therapeutic support during this process of challenging yourself. Therapy will provide you with honest
reflection, feedback, safety, and suggestions while you navigate the often-fraught tasks of finding meaningful
relationships that meet your social needs.

Your Temperament
Your temperament was assessed through the Student Styles Questionnaire (SSQ). This self-report questionnaire
compares your motivations and preferences to others. As we discussed, this questionnaire was originally designed
for younger individuals, so we must interpret the results with some caution since you are an adult. However, we
agreed that this questionnaire might provide us with useful insights about you. The SSQ assesses four dimensions:

• Extroverted versus Introverted, which looks at how oriented you are towards activities that involve others
• Imaginative versus Practical, which looks at whether you prefer more abstract and theoretical thinking, or
more practical, real-life tasks and activities
• Thinking versus Feeling, which looks at whether you prefer tasks that require logical reasoning, or tasks that
place a stronger emphasis on empathy and intuition
• Organized versus Flexible, which looks at whether you prefer structured and sequenced activities, or whether
you enjoy less regimented schedules and activities.

Each style is valid, and no temperamental style is preferable to any other. Rather, an understanding of your specific
preferences tells us more about the types of activities and situations that will be most comfortable for you.

Based on your self-report, your temperament style is Introverted, Practical, Feeling, Organized, with your
strongest preference being introversion (99th percentile). Individuals with your temperament are oriented towards
things that are realistic, useful, and practical. You prefer to focus on details and facts rather than the big picture.
You do not see much use for abstract or theoretical discussions unless these discussions lead to something
concrete or a clear plan of action. At work, others probably consider you loyal, responsible, and hard-working. You
probably enjoy helping your colleagues and like to promote harmony in your teamYou are much more likely to
prefer having a few, carefully-chosen friends rather than a wide circle of acquaintances. You might be very quiet in
social situations. However, you likely enjoy conversing with and sharing your feelings with your close friends.

People with your temperament often enjoy working hard for community or traditional organizations like church or
charity groups. However, you probably do not seek out public roles. In fact, in many situations, you may not get full
credit for your work, because you are so modest and self-sacrificing. You generally do not expect to get credit for
how much work you put in. People with your temperament are usually very cooperative with rules and routines at
work, at home, and in the community. Others are almost certain to describe you as a “good citizen.” They are also
likely to describe you as a quiet but valuable contributor to groups, and an excellent team player.

People with your temperament prefer to work on practical tasks, like projects where you can see a clear
application to your own or others’ lives. You probably prefer logical, sequenced, well-organized tasks. You probably
also want an organized, quiet workspace and clear expectations from your supervisor. Most individuals with your
temperament prefer a neat, clean office, and are disturbed by messy, loud, or chaotic workspaces. Please keep in
mind that these are normal preferences. You should feel comfortable and confident advocating for a job
environment that matches your wants and needs.

When talking with your supervisors, it may be helpful to explain that precise, step-by-step directions work best for
you. Individuals with your temperament often enjoy pleasing their supervisors. So, you probably work hard
complete to complete your assigned tasks. This means most supervisors will appreciate having you on their team.
However, supervisors may not consider you for leadership or customer-facing roles. They may instead place you in
situations that they believe are a better fit for your steady work performance, keen eye for details, and quiet
contributions to the team. At times, they may think you don’t want or need praise from them. This means they
may overlook showing you how much they value you. Asking for regular performance reviews may help you see

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how much you contribute to your team, and how much your supervisors value you. You may also want to know
that supervisors who appear impractical or unpredictable will probably be upsetting for you.

People with your temperament style tend to work slowly and thoroughly. As a result, they do not make many
mistakes. But in time-sensitive or fast-paced environments, you may need support around managing your time.
For example, asking your supervisors how to best prioritize tasks, and what level of “perfection” is truly necessary
for the task, may help. This will allow you to decide when to settle “good enough” so you can complete a task
quickly. It will also let you know when you can work at your more preferred slow and methodical pace. When
learning new information, you are likely to have an outstanding memory for details. If you need to take a test to
get to the next level in your career, you will prefer a test where the questions replicate the format in which you
learned the target information (e.g., matching, multiple choice, fill-in-the-blank). Practice with mock tests will also
help you perform your best. You are less oriented towards essay tests that ask you to come up with your own
unique explanation, or tests that ask you to compete with others.

People with temperaments like yours usually respond well to compliments for their finished projects. You will
especially like praise that focuses on the match between what was expected and what you delivered. You may
want to ask your supervisors for this kind of feedback. A checklist showing that you delivered exactly what was
needed may be a very effective way to evaluate your work, for both you and your supervisor. You probably also
like to be complimented for being tactful and empathetic, and for abiding by the rules. Supervisors who give you
special jobs to do based on your great eye for detail and meticulous nature are also likely to be good matches.

Your temperament suggests you may sometimes focus on the details of a task at the expense of the “big picture.”
You may also not always recognize when you need to change your approach to a task. Asking for regular check-ins
with your supervisor for larger projects may help you keep the big picture in mind and stay on the right track.
People with your temperament also tend to become distracted from their work by others’ personal problems.
They also get derailed if others are breaking the rules or being disrespectful. This is something that a therapist
could help you notice. That way, you get stronger at redirecting your focus back to yourself if you have slipped into
focusing on what others are doing to distract yourself or cope with stress.

There is a possibility that your contribution to projects will be overlooked due to your modest nature. You may also
have to contend with a tendency to become upset when something disrupts your plan or schedule. You may want
to be aware that this makes you uncomfortable, so that you’ll know you need some extra time to “regroup.” This
will allow you to give yourself some extra compassion when your schedule gets disrupted.

Your Self-Reported Personality Traits

We also looked at your personality through questionnaires called the Minnesota Multiphasic Personality Inventory,
Second Edition, Restructured Form (MMPI-2-RF) and the Millon Clinical Multiaxial Inventory, Fourth Edition (MCMI-
IV). On both questionnaires, you reported feeling very depressed, nervous, and physically uncomfortable. We
discussed how this means your physical and emotional state is closely intertwined. As a result, you experience a lot
of health problems and sensory complaints that go with feeling depressed and anxious. For example, you have
sleep problems and feel a lot of fatigue. You are also uncomfortable with everyday sensory sensations such as how
clothing feels on your body.

Thinking about your health and sensory concerns helps distract you from your anxieties and depression. However,
it also makes you feel more anxious and alone, since you worry these concerns mean something is “wrong” with
you. You also spend a lot of time anticipating problems before they occur. When you do experience a problem you
cannot immediately solve, you feel overwhelmed or in total despair. This could be because you expect to be able
to solve problems “perfectly.” You may even blame yourself for not having predicted or prevented the problem in
the first place.

Others probably describe you as reliable, perfectionistic, conscientious, cooperative, and meticulous. However,
your impression of yourself may be quite different. Specifically, you rated yourself as feeling somehow
“inadequate” socially, professionally, and emotionally. You also rated yourself as insecure and easily overwhelmed
by life. On the straightforward emotion-rating scales on these questionnaires, you reported very high levels of
anxiety. You feel more anxious than 99% of adults. You also reported stress, worry, and feelings of hopelessness.
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Underneath all these more accessible concerns about anxiety and depression, your test results suggest you feel a
lot of anger. I wonder if you resent about how your life has turned out and the sacrifices you have had to make.
You may feel, deep down, that others have treated you unfairly. You may feel they have not given you what you
needed, taken advantage of you, not supported you, and not appreciated you as much as they should have. You
might also feel like others somehow get away with breaking rules that you would never break. You may both
resent these rule-breakers while also envying their freedom. You might worry that these are shameful feelings that
you should try to hide. I want to emphasize that these are normal ways that people often feel.

I am not sure if you are aware of your normal yet intense feelings of anger and resentment. When we talked about
these feelings in our feedback session, you said you “do and you don’t” feel angry and mistreated. You said you
“wished” you “never felt mad,” and I got the impression that you think it is morally wrong to resent your life when
you “have so much.” Your test results suggest these subtle feelings of anger, resentment, and envy may bubble up
for you in therapy, if you trust in the process and are open to exploring some of your deeper experiences. This is a
very normal part of the therapeutic process. Therapy helps you gradually feel safe enough to explore those less
convenient, darker, less comfortable feelings that we all have (but that many of us bury, because we learned early
in childhood that these feelings are somehow “not okay” to express or even to have). Giving some time and space
to those feelings will go a long way towards unlearning those patterns of suppression that you developed in
childhood and adolescence. Those patterns helped keep you safe then. But now, they are getting in the way of you
reaching your goals.

As you did on the SSQ, you also reported very high levels of introversion, or needing time alone to recharge and
replenish your energy, on the MMPI-2-RF. You also reported elevated levels of “disaffiliativeness” which is a
related term that means a preference for being on your own. However, consistent with what I noticed when
interacting with you socially, your scores were mixed and ambivalent. For example, in addition to expressing a
preference for being on your own, you also expressed a powerful desire for closeness with others. You also
reported deep fears about what it would mean to be close to others, and how it could affect your identity. You also
reported you do not feel accepted or valued by your family.

From a diagnostic perspective, people who complete the questionnaires in the same way you did usually have
social anxiety and depression. I think those are the right diagnoses for you. However, since your inner world is
dampened, you may not resonate with typical descriptions of anxiety or depression. Indeed, you may even feel
puzzled by those descriptions. You might relate only to the physical symptoms (like muscle tension), cognitive
symptoms (like everyday attention problems), or behavioral symptoms (like avoiding anxiety-provoking situations)
that come with anxiety and depression. As you continue to explore your inner psyche, and as you feel more
comfortable expressing your emotions, the descriptions of anxiety and depression may start to feel more apt.

Your Self-Reported Coping Style

Based on those questionnaires and a storytelling task called the Thematic Apperception Test (TAT), you are a highly
conscientious, self-sacrificing, and loyal individual. Others may describe you as a rule-follower who always does the
right thing, and who rarely causes anyone even the slightest inconvenience. These are wonderful personality
qualities. Yet, having to live up to these incredibly lofty standards for yourself is likely exhausting and
overwhelming. You may even experience health complaints and fatigue from the stress of “holding it all in” and
trying to be socially and emotionally “perfect.” Having to constantly watch yourself for any possible mistakes or
inconvenience you could cause others may even have lowered your self-worth. True self-esteem comes from being
able to express your true self. You cannot build deep self-esteem if you are continuously inhibiting your emotions
and desires. When we talked about this during feedback, you resonated with a quote from psychologist Brene
Brown. Dr. Brown explains the importance of being able to be your true, authentic self when she says “Belonging is
the opposite of fitting in.”

One of the main ways you cope with stress is by dampening your emotions. This pattern of dampening your
emotions extends to both ‘negative’ emotions like anger and sadness, but also positive emotions like joy and
optimism. Based on what you told me about your childhood, I suspect that at some point, you learned that your
emotions were unwelcome or uncomfortable for others. You may have found that – for your own safety and
protection as a child or adolescent – you had to suppress your own emotions and desires. This has led you to have
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a relatively depressed or “flat” inner experience. This coping pattern was almost certainly essential to you as a
child and teen. But it means that over the years, you have had less opportunities to practice grappling with
complex emotions than your peers. You have also had less practice being in interpersonal relationships that
involved full, reciprocal, authentic expressions of feelings and needs. This lack of practice may have resulted in you
feeling socially awkward, or “unable” to fully understand emotions.

You have also begun to believe that others are somehow much more capable of navigating the intricacies of a
complex emotional and social world than you are. You hold this strong belief despite having well above average
social-emotional sensitivity and problem-solving skills. This has created a negatively reinforcing cycle. You actively
look to avoid potential social rejection, emotion-provoking experiences, or painful memories, since you think you
are “not good” at them or are “too fragile” to cope with them. This is self-protective in the short-term. But in the
long term, it precludes opportunities to experience a socially and emotionally-rewarding lifestyle. This then
reinforces your beliefs that you are not capable of managing social and emotional challenges, increasing your need
to withdraw into a self-protective shell. Talking about this pattern and exploring ways to break out of it will be an
important part of your therapeutic journey.

Therapeutic Treatment Suggestions

Unfortunately, your life has required you to become skilled at coping with solitude, disappointment, and
discouragement. As a result, in therapy, you might minimize your distress or express pessimism that things can
change. You may also be mostly unaware of your buried anger, resentments, desires for closeness, and deep fears.
Discussions of these emotional experiences may not elicit feelings of recognition or relief at first. These discussions
could even leave you feeling even more “different” from other people who have more ready access to their anger,
worry, and longing. For that reason, I think therapy will be stressful or confusing for you if it focuses too much at
first on underlying emotions and desires. These feelings and desires were dangerous or uncomfortable for you to
express when they were younger. You have carefully constructed a way to keep yourself safe. Therapy that seeks
to strip away this safety without replacing it with something else will be unwelcome and unhelpful.

Therapy will be most helpful for you if it focuses on realistic and attainable goals. Therapy will invite you to process
your feelings and construct new meaning out of past experiences. Therapy will also help you restructure mistaken
beliefs you have about your personal shortcomings and the attitudes of others towards you. It will be a safe place
to explore your ambivalence about wanting social acceptance but being unwilling to be vulnerable to rejection.
Over time, I think it will also bolster your sense of your own competence. However, these are all likely to be
uncomfortable processes for you. This growth will feel more tolerable for you if you partner with your therapist to
make sure you have clear, structured goals that relate directly to specific things you want to accomplish.

I want to add that individuals who completed the questionnaires the same way you did often make initial quick
progress in therapy. You are self-aware, highly verbal, and seem motivated to change things that are
uncomfortable. Any therapist you work with will truly enjoy your work together and getting to know you on a
deeper level. Your therapist will probably also have a lot of optimism about how quickly therapy can help you.
However, keep in mind that you will be truly “rebuilding” yourself from the inside out, as you decide who you want
to be and what your values are. This may be hard, slow work that does not follow a linear path. Give yourself the
gift of patience, time, and self-compassion.

In addition to long-term, thoughtful therapy, there are a few other treatment options you can consider. For one,
medication is often helpful for individuals with your pattern of test results. The right medication should increase
your energy and help you feel more optimistic. It should also moderate your emotions, so you can get more
practice grappling with your feelings instead of having to suppress them. . I also want you to get an updated
neurological consultation around your non-epileptic seizures since you reported you have not seen a neurologist in
the past 15 years. Occupational therapy may help you learn to relax your muscles and feel more comfortable with
uncomfortable sensory sensations. Group therapy is another great option for treatment, so you can practice the
skills you’ve learned and get real-time feedback from others in a safe, supportive environment. I recommend
LOCAL AGENCY, since they offer individual, group, and occupational therapy all in the same location.

I will follow up with you in 1 month, 3 months, and 6 months to see how you are doing. I am looking forward to
talking with you about how these test results feel after you have had more time to process this information. At our
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CONFIDENTIAL Neuropsychological Evaluation

check-ins, I will be happy to answer any questions that have come up, or to explore any areas where we need to go
deeper or get more clarity.

It was such a pleasure meeting you, Terry. If you have questions about the information in this letter, feel free to
contact me at (360) 334-6156.

Sincerely,

Stephanie Nelson, Ph.D., ABPdN, ABPP-CN

YOUR SPECIFIC RECOMMENDATIONS

Medical
1. You may find it helpful to discuss medication options with your GP or a psychiatrist. The right medication will
reduce your anxiety, increase your levels of positive emotions, and help you feel more physically comfortable.

2. I would also recommend discussing treatment options for your non-epileptic seizures with your medical team. This
is likely to increase your physical comfort and decrease your anxiety. Neurofeedback may be a helpful option to
pursue to help reduce muscular tension, anxiety, and sensory sensitivities.

Therapeutic
3. Continued participation in individual therapy is strongly recommended. Following the general suggestions above,
more structured therapeutic modalities that focus on specific goals using concrete, clear techniques may be the
best fit for your personality style. In individual therapy, this may look like therapy that uses cognitive behavioral
techniques, which are structured, step-by-step techniques for identifying and managing anxious and depressed
thoughts and behaviors. It may also be helpful to take part in some more ‘free form’, person-centered therapy
later in treatment, to provide you with practice navigating more-ambiguous, less-structured social situations and
forming authentic relationships in those circumstances.

4. Participation in group therapy is also strongly recommended. A group focusing on increasing social confidence
through providing you with real-time, constructive feedback about your social presentation and social behavior will
be immensely helpful in supporting you in reaching your social goals. You may want to find a group that is highly
structured, since this is likely to be more comfortable for you, at least at first. However, you should partner with
the therapist and group members to help you guard against a tendency to want to memorize all the “rules” of
every social situation, since this may contribute to further solidifying your urge to overthink all social situations. It
will be more helpful to instead focus on increasing your trust in your own social skills and intuition, becoming
comfortable with ambiguous social feedback, and presenting yourself in a way that is authentic to who you truly
are – without having to suppress any parts of yourself for others’ comfort or convenience.

Other Treatment Options

5. You may benefit from occupational therapy addressing your high muscle tone and sensory sensitivities. At the
same time, it will also be helpful to obtain feedback from the occupational therapist about how common your
specific sensory sensitivities are, to ease your worries that there is something “wrong” with you because you do
not prefer open floorplans, uncomfortable clothing, or other commonly-disliked situations and sensations.

At Home and In the Community

6. I will also strongly recommend continued involvement in structured activities, such as your individual hobbies,
social hobbies (e.g., murder mysteries), volunteer work, involvement with your favorite charity, and sports
activities. These activities will give you safe and supportive environments in which to practice the social behaviors
you are learning, develop your social confidence and social intuition, and continue to build your self-esteem.

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CONFIDENTIAL Neuropsychological Evaluation

At Work
7. I would strongly encourage you to advocate for your preferences and needs at work and in other environments
that you find yourself in. For example, it may be helpful to set goals with your therapist around feeling more
comfortable and confident enough in asking for a quieter work-space, asking your coworkers to respect your
preferences, and asking your supervisor for the type of deadlines, project instructions, and feedback that works
best for you. These are all very valid, common, and appropriate requests to make and are likely to have a
significant impact on your productivity at work, general quality of life, and emotional well-being.

Self-Discovery
8. I hope you will use this evaluation and your experiences in therapy as opportunities to gain a true appreciation for
your many great qualities and a deep respect for your personal preferences. You are a brilliant, likeable,
thoughtful, and socially sensitive individual with – like all of us – some unique qualities, quirks, and preferences. I
would love for you to be able to fully value all your gifts, while honoring the unique qualities that make you who
you are.

TEST RESULTS AND BRIEF INTERPRETATIONS

[Note: All other scores redacted in this de-identified report]
COGNITIVE FUNCTIONING
Wechsler Adult Intelligence Scale, Fourth Edition

Index Standard Score Percentile Interpretation of Your Performance

You have exceptional skills that will help you take in verbal
Verbal Comprehension 149 99 info, use words to compare ideas, and effectively explain
what you know about a subject.
Your abstract nonverbal reasoning skills are also well
Perceptual Reasoning 136 99 above average. You can easily build, design, or think about
patterns, sequences, and quantities.
Your short-term memory is also in the very superior range.
Working Memory 139 99 You can easily keep info in mind while following directions
or performing some task with that information.
Your processing speed is truly exceptional, falling in the
Processing Speed 150 99 very superior range. When you understand the task, you
are likely to complete the task extremely quickly.
Based on your overall score, your cognitive skills are
Full Scale IQ 155 99 exceptional for your age. You excel at a wide range of tasks
that require problem-solving and deep thinking.
Subtest Scaled Score Percentile What the Test Involves
Similarities 17 99 Explaining how 2 words are alike. Flower and tree are both plants.
Vocabulary 19 99 Defining what words mean. E.g., to confess means to tell a secret.
Information 18 99 Answering factual questions, e.g. “What is the capital of the US?”
Block Design 17 99 Putting together designs using three-dimensional blocks.
Matrix Reasoning 16 98 Figuring out the next element in a pattern or sequence.
Visual Puzzles 15 95 Solving visual puzzles by seeing how parts relate to a whole.
Digit Span 17 99 Repeating strings of numbers forward and backward.
Arithmetic 17 99 Solving mental math problems, e.g., “You have 5 books and sell 2…”
Coding 19 99 Transcribing symbols using a key, e.g., 5 = ^ and 9 = &.
Symbol Search 19 99 Scanning visual information to quickly find a match.

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