Tuesday, November 30, 2010

Biopsychosocial Assessment Example

Example-Biopsychosocial Assessment



The following is an abbreviated example of a BPS Assessment to demonstrate the basic components and content.

IDENTIFYING INFORMATION: Jane M. is self-referred 28 year old, divorced Caucasian female with no children or history of pregnancy seeking treatment to deal with feelings of hopelessness and depression.

PRESENT PSYCHIATRIC ILLNESS/SYMPTOMS: Client reports episodes of crying daily for the past month, difficulty focusing at work, inability to do chores at home (laundry, cleaning), isolating from friends and family, weight loss of 15 lbs in the past three weeks without dieting, insomnia (sleeping an average of 4-5 hours in 24), some thoughts of death, “it would be easier if I were dead”

PAST HX OF TREATMENT: Client reports one prior episode of major depressive symptoms three years ago for which she sought psychiatric care from Dr. Smith and underwent pharmacotherapy for 6 months with success, denying side-effects with the use of Paxil. She also reports attending a self-help group at her church and finding the support helpful. During her sophomore year in high school, she saw a school counselor for a few times following the separation and divorce of her parents to help with coping skills and grief/loss issues.

MENTAL HEALTH MEDICATIONS: No current use, previous course of Paxil with good efficacy, two trials of other medications during the same time that were unsuccessful. Client agrees to a release of information to seek additional information from Dr. Smith.

MEDICAL CONCERNS: Client reports recent gastro-intestinal upset, frequent diarrhea, nausea and headaches for which she has not sought medical attention. She denies any significant medical history, surgeries, pregnancies or disabilities.

CURRENT MEDICATIONS: Client reports taking over-the-counter anti-diarrheal medications and NSAID pain relievers.

DEPENDENCY/ADDICTION HISTORY: Client reports first use of alcohol at age 17, drinking two beers at a party and becoming intoxicated. She denied enjoying the experience but reports continued experimentation with alcohol one or two times per month until college when she stopped drinking following a binge-drinking episode prior to leaving for college in which she reports drinking until she began vomiting. Following that incident, she reported finding alcohol offensive. She did not drink again for five years. She now reports drinking primarily at holiday occasions, one to two servings, with choice of alcohol as wine. Last use was two months ago, one glass of wine at a holiday party. No current abuse or dependency issues suspected.

Client reports experimentation with cigarettes in high school when her parents divorced. She did not like the taste or smell and reports they made her lungs hurt, so she did not continue.

Client reports regular use of caffeine, up to five beverages per day of coffee and sodas.

FAMILY HISTORY OF PSYCHIATRIC/ADDICTION ILLNESS: Client reports her father suffers with clinical depression and her maternal grandmother and aunts drink alcohol to excess. She denies either of her parents ever drank in front of her, but she reports the belief her mother drinks and hides her alcohol, once finding a bottle of vodka in one of her mother’s shoe boxes.

SPIRITUALITY: Client was raised in a non-religious home but attended church with a friend in high school. She found comfort in the protestant church and has continued attendance and involvement. She reports inability to be involved when her symptoms are active, including inability to attend services, read her Bible or pray. She does have a support system at church who she reports call on her.

PERSONAL HISTORY: Client is the oldest of three children whose parents divorced when she was age 14. The parents remained in the same town and the children split roughly equal time between homes, experiencing considerable verbal conflict between mom and dad. She reports feeling responsible for their divorce, believing she did not help enough around the house, forcing her parents to be overworked and over-stressed because both worked outside the home. Mother was a bank-teller and dad was a plumber. Mother remarried within one year, having two more children. Client is now estranged from her mother and has limited contact with her father, despite living in the same town. She sees her younger siblings twice yearly, Christmas and 4th of July.

EDUCATION: Client completed high school and college with a degree in business.

WORK HISTORY: Client currently works in sales but has had a sharp decline in performance over the past month and is in jeopardy of losing her job due to her inability to focus. She has worked steadily since completing college in positions of increasing responsibility. During highs school and college, she waited tables.

LEGAL HISTORY: Client has no history of legal involvement and no pending legal action.

MARITAL/RELATIONSHIPS: Client married at age 22 to her college boyfriend, but they divorced three years later following what the client called “failed communication and an inability to get along.” She reports a history of brief relationships that end because she does not believe they are sustainable for the long-term. She denies any violent relationship, physically, verbally or emotionally.

MENTAL STATUS: Client appears casually dressed, neatly groomed and is cooperative. She is calm and there is no evidence of tremors, tics or muscle spasms. Her affect is appropriate to the conversation, and her mood is depressed. Speech is soft. Her thoughts flow logically and are organized with no perseverations, loose associations or thought blocking. There is no evidence of hallucinations or delusions. She is oriented to time, place and person. She does place devaluation on herself that is not supported by her situation.

SUMMARY IMPRESSION: Jane M. is a is self-referred 28 year old, divorced Caucasian female seeking treatment for recurrent depression that likely has a strong heredity component with possible contributing factors related to relationship issues and distorted beliefs about herself related to the divorce of her parents.

SHORT-TERM GOALS:

1) Refer to primary care physician to address ongoing GI symptoms client reports are uncontrolled for one month with OTC medications and to rule out any other medical etiology for symptoms.

2) Develop safety plan in case thoughts of death escalate to active suicidality.

3) Get client to engage in self-care plan discussed and written (see copy in chart).

4) Develop treatment plan during next session.

DIAGNOSTIC IMPRESSION:

Axis I:                Major Depressive Disorder, Recurrent

Axis II:         No diagnosis

Axis III:         Deferred, GI symptoms

Axis IV:         Difficulty functioning at work and home

Axis V:        (current) GAF 55              





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