CLINICAL PSYCHOLOGICAL REPORT
Client ID: [Insert ID or Initials]
Date of Assessment: [Insert Date]
Clinician: [Insert Name]
Assessment Tool: Positive and Negative Syndrome Scale (PANSS)
I. Reason for Referral
The client was referred for a comprehensive assessment of psychotic symptomatology
using the PANSS, with differential diagnostic consideration for schizophrenia-spectrum and
personality-related pathology.
II. Background Information
[Insert relevant clinical history, psychiatric diagnoses, medical status, medications, family
history, and social functioning.]
III. Assessment Tool Description
The PANSS assesses positive symptoms, negative symptoms, and general psychopathology
in individuals with psychotic disorders. It consists of 30 items rated on a 7-point scale (1 =
Absent to 7 = Extreme), divided as follows:
- Positive Scale (7 items)
- Negative Scale (7 items)
- General Psychopathology Scale (16 items)
IV. PANSS Score Summary
Scale/Item Score
Positive Symptoms (Total: 19)
P1. Delusions 4
P2. Conceptual Disorganization 4
P3. Hallucinatory Behavior 1
P4. Excitement 3
P5. Grandiosity 2
P6. Suspiciousness/Persecution 2
P7. Hostility 3
Negative Symptoms (Total: 16)
N1. Blunted Affect 2
N2. Emotional Withdrawal 2
N3. Poor Rapport 2
N4. Passive/Apathetic Social Withdrawal 2
N5. Difficulty in Abstract Thinking 4
N6. Lack of Spontaneity 2
N7. Stereotyped Thinking 2
General Psychopathology (Total: 35)
G1. Somatic Concern 2
G2. Anxiety 2
G3. Guilt Feelings 2
G4. Tension 2
G5. Mannerisms and Posturing 2
G6. Depression 3
G7. Motor Retardation 1
G8. Uncooperativeness 1
G9. Unusual Thought Content 4
G10. Disorientation 1
G11. Poor Attention 2
G12. Lack of Judgment and Insight 3
G13. Disturbance of Volition 1
G14. Poor Impulse Control 2
G15. Preoccupation 3
G16. Active Social Avoidance 2
TOTAL PANSS SCORE 70
V. Interpretation
The client's total PANSS score of 70 suggests mild to moderate severity of psychotic
symptoms. Positive symptoms are evident in the form of delusions and conceptual
disorganization, while hallucinatory behavior is minimal. Negative symptoms are present
but mild, primarily affecting emotional expression and cognitive flexibility. General
psychopathology reveals moderate unusual thought content, depression, and limited
insight.
These features suggest a possible schizophrenia-spectrum condition, most consistent with
residual schizophrenia, but may also overlap with:
- Schizoaffective Disorder (due to mood components)
- Delusional Disorder (due to specific delusional thinking)
- Mixed Personality Disorder with Cluster A traits, particularly schizotypal and paranoid
features.
VI. Clinical Impression
Diagnosis (Provisional):
- Mixed Personality Disorder (Cluster A predominant: Schizotypal and Paranoid
features)
- Rule out: Residual Schizophrenia, Schizoaffective Disorder
VII. Recommendations
1. Structured psychotherapy focused on cognitive distortions and interpersonal
functioning.
2. Pharmacologic management if psychotic symptoms worsen or interfere with daily
functioning.
3. CBT for psychosis (CBTp) to address delusional beliefs and improve insight.
4. Personality-focused therapy (e.g., schema therapy) to address longstanding
interpersonal and cognitive patterns.
5. Ongoing monitoring for symptom progression or emergence of full psychotic episodes.
