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September 10, 2012

Example Biopsychosocial Assessment

January 16, 2012 3-4 PM
Present for this assessment are the client, Chloe (pseudonym); and evaluator Alissa Bleecker, MSW intern

Identifying Information and Referral Source
Chloe is a 28 year old African American female presenting for evaluation of possible depression and anxiety. She is referred by her primary care physician, Dr. Albanese.

Presenting Problem
Chloe reports that since her boyfriend, Eric, has come back into her life, she has been “feeling anxious, overeating and sleeping 10-12 hours at a time”. Chloe is “looking for guidance and direction” in regard to her relationship with Eric, who is also the father of her daughter, Drew. Eric had been absent from her life in the last 10 months and has recently returned stating that he wanted to marry Chloe. Chloe reports often feeling “anxious” about decisions concerning Eric, and that her “over-eating and over-sleeping” are recurring symptoms from times in which he has broken-up with her in the past and also when he has re-entered her life. Chloe also stated that she has withdrawn from her friends because “they don’t support [her] relationship with Eric”.

Psychiatric History
Chloe was seen briefly at an outpatient facility once because of a professor’s referral “during undergrad. But I wasn’t trying to address issues, and she thought it was just silly college girl problems. She didn’t take me serious”. She has never been hospitalized or prescribed psychiatric medication.

Medical History
Chloe’s had two abortions, one in 2011 and another during her undergraduate work. Other than this, Chloe’s history is negative for hospitalizations, surgery, or major illness. Due to working third shift, Chloe sleeps during the day and reports sleeping 10-12 hours each day. Chloe is “constantly eating throughout the day, even when she is not hungry”. She reports eating more when thinking about Eric.

Family of Origin History
Chloe states that she has a pretty good relationship with her family. Her mother is “a huge support, even though [she] can’t tell her everything because she can be judgmental” due to her religious beliefs. Chloe’s relationship with her mother was strained when she had her daughter out of wedlock, and said that this was difficult for her mother to accept. Chloe also has a good relationship with her stepfather, although he “works all the time and is not there very often”. However, when he is home, they get along.

Chloe has two siblings, a younger brother and sister. Chloe’s sister is 21 and it’s “a typical sister relationship. She looked up to me growing up”. However, now that her sister is an adult, she “is out of control”. Her sister and mother often argue and do not get along very well. Chloe reports that her relationship with her brother is also good, but “he’s too spoiled”, and he has an “unrealistic relationship with her daughter”. Chloe thinks he has too high of expectations for her daughter, Drew.

Chloe’s daughter, Drew, is three years old, and she “loves her to death”. Although Drew “gets on [her] nerves sometimes”, Chloe thinks they are well bonded.

Current Relationship/Family Issues
Chloe reports that her relationship with Eric has been rocky with multiple break-ups and a history of domestic violence. Chloe and Eric first met when Chloe was 15 and working at a bagel shop. Eric is 12 years older than Chloe and has always been a flirt. When they became friends, he had a girlfriend, and as soon as they broke-up, Chloe and Eric began dating. Chloe believes dating him so soon after his break-up was a mistake because “he had unresolved issues”.

Chloe says that the first time that there was conflict in their relationship was when she became pregnant with Drew. After learning of her pregnancy, Eric left her for a year, and Chloe moved in with her parents. After his return, things were better until Eric’s mom passed away. After her death, “he wouldn’t communicate”. They were in danger of losing their home, so Chloe put her and Drew’s things in storage. Then Chloe did not see Eric for 10 months until he recently returned stating that he wanted to marry her.

Chloe states that she and Eric have “normal sexual health”, and she had only been with one man until the most recent break-up. After the break-up, she slept with another man but “didn’t enjoy it”.

Social History
Spirituality- Chloe is a Christian and states that her beliefs are important to her. Her beliefs cause her to feel “guilt over the abortions, premarital sex, and having a child out of wedlock”.

Peers-Chloe reports having a couple of really good friends whom she “sees from time to time”. She can “rely on them to vent” but has recently “pulled back from them” because they do not approve of her relationship with Eric.

Culture-Chloe identifies as African American. Chloe reports no concerns or stressors related to cultural or ethnic factors.
Strengths- Chloe reports that her strengths include that she “gives everyone the benefit of the doubt”. She also is “intelligent, a hard worker, and a good mother”.

Educational/Occupational History
Chloe completed her bachelor’s degree in Philosophy and would like to obtain a master’s degree in health administration. She currently works for the State Government “as a paper pusher”, as she is in charge of the mailings. Chloe has been employed here for eight years, and is not very enthusiastic about her job. Chloe reports that she does not get along with her supervisor and “calls off a bit when dealing with Eric”.

Legal History
Chloe denies any history of involvement with the legal or criminal justice system.

Critical Issues
Chloe and Eric have a history of domestic violence. When Eric becomes angry he often is destructive and has destroyed her glasses and laptop. Chloe reported one incident of domestic violence to the police, in which Eric was arrested and took anger management courses. Although there has not been an incident since then, Chloe is worried that “he might do it again”.

Chloe denies homicidal ideation, plan or intent, as well as current or past abuse or trauma. She denies current suicidal plan or intent. Chloe is able to contract for safety at this time.

Substance Use/Abuse History
Chloe denies any substance use for herself, Eric, and her immediate family.

Mental Status Exam
At the assessment, Chloe’s appearance and grooming were appropriate and casual. Physical abnormalities were not observed. Psychomotor activity was within normal limits. Tics/stereotypes were absent. Behavior and responsiveness to examiner was subdued but cooperative. Consciousness and orientation were alert. Affect was limited and mood was “anxious”. Thought processes seemed normal, as did thought content and perception. Cognitive functions, while not formally measured, seemed appropriate. Chloe displayed excellent insight and psychological mindedness.

Cultural Formulation
Chloe identifies as an African American female. She does not note any concerns related to her cultural identity. When asked about why she believes she is experiencing her presenting symptoms, Chloe attributes her current difficulty to Eric, saying “he tells me the type of life he wants to lead, but he doesn’t act it. He seems changed now though because he’s talking about marriage. I used to be the only one talking about getting married. I just don’t want to make another mistake”.
Chloe has treated her feelings of anxiety by eating and sleeping. She states that sleeping helps because she when she is asleep, she does not have to think about Eric. She recognizes that her anxiety is negatively impacting her life because “any time not devoted to [her] daughter is negative.”

Chloe has chosen to participate in therapy with the hope that a therapist can “help [her] make a decision.” She says she “needs a sounding board for a new perspective.”

Formulation/Diagnostic Summary
Chloe is a 28 year old African American female presenting with symptoms of depression and anxiety. The following symptoms and findings are prominent and clinically significant: over-sleeping, over-eating, isolative behavior, and feelings of anxiety. The symptoms are relatively acute. Protective factors include supportive family and friends, as well as Chloe’s insight and motivation for treatment. Significant Biopsychosocial stressors include absences from work and her relationship with her supervisor. Other stressors include her relationship with her partner and a history of domestic violence. Differential diagnosis should include depression as well as anxiety.

Diagnosis
Axis l: 300 Anxiety Disorder NOS Axis ll: deferred Axis lll: deferred Axis lV: mild-moderate stressors: work difficulty, relationship conflicts Axis V: 60

Recommendations
1. Weekly individual psychotherapy to reduce depressive symptoms and improve social and occupational areas.
2. Psychiatric evaluation to address potential use of antidepressant medication.
3. Biweekly couples Therapy session
4. Meeting with PCP to rule out any medical etiology for symptoms.

Posted by desolada at September 10, 2012 08:44 PM

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