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Biopsychosocial assessment no identifiers


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All identifying factors (including service providers) have been changed. Assessment completed by Pam Kummerer

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Biopsychosocial assessment no identifiers

  1. 1. Pam Kummerer 1 BIOPSYCHOSOCIAL ASSESSMENTClient’s Name: Patty SmithAddress: 335 Richardson Dr. Toledo, Ohio 43608Phone: 419-555-1122PURPOSE OF ASSESSMENT: This 46 year old, Caucasian, divorced female was admitted,on a voluntary basis to the psychiatric unit after being seen in the Emergency Department. Thepurpose of this assessment is to evaluate reason for admission and develop a treatment plan.SOURCE OF DATA: Information for the assessment was obtained through a face-to-faceinterview with the patient in the patient’s room as well as information from previous admissions.The patient was lying across the bed on her stomach/side. She maintained poor eye contactduring the interview, and was often looking down as she was running the blanket edge throughher hands. Basic hygiene has been attended to, and the patient is dressed appropriately.PRESENTING PROBLEM: The patient was dropped off at the Emergency Department by aneighbor. She reports symptoms of increasing depression with suicidal ideations, auditoryhallucinations, and paranoid delusions. Patient reports she has not been taking her psychotropicmedications for several weeks. The patient has a long history of psychiatric disorder and has hadmultiple hospitalizations.The patient reports that she has been “feeling down” lately and has been having suicidalideations without a specific plan. She has a flat affect and speaks in a quite tone of voice. Sheadmits that she has not been taking her medication for several weeks, and had not always beentaking it as prescribed prior to this. She states that sometimes she forgets to take her meds, andthen quit taking them all together because she thought she “did not need them.”The patient admits to having auditory hallucinations. She reports the voices are negative, “putme down,” and are “calling me a whore.” The patient believes these voices are from “a differentrealm” but would not elaborate any further.The patient has paranoid delusions and is religiously preoccupied. She believes she is the deviland believes people are watching her and talking about her. When asked about her appetite, thepatient states, “I am not suppose to be eating, I am fasting.” When asked about her sleep, thepatient states, “I’m not suppose to go to sleep…I read it in the Bible.” The patient tends to focuson the end of the world and going to hell. She expresses feelings of guilt over past things she hasdone, which she will not discuss.
  2. 2. Pam Kummerer 2ALCOHOL, TOBACCO, AND OTHER DRUGS: The patient has a history of polysubstanceabuse. She reports past alcohol, cannabis, and cocaine use, but states she has been clean for 3years. She has been at Treatment Center in the past for substance abuse treatment, but waskicked out after asking a peer for heroin because she wanted to kill herself. She also reports shehas attended AA meetings in the past, and states they had helped a little. The patient does notuse tobacco.PAST PSYCHIATRIC HISTORY: The patient has a long psychiatric history with severalhospitalizations. The patient reports that her symptoms first appeared when she was in her early20s. She has had previous psychiatric admissions at Regal Hospital, St. Bernice Hospital, andRegional Stress Hospital. She has received ECT in the past. The patient has been on severaldifferent psychotropic medications, and was last prescribed Haldol, Cymbalta, Tegretol, andCogentin. The patient states she thinks this combination of medication has been effective forher. The patient receives outpatient psychiatric treatment at Northwest Community MentalHealth Center.The patient has a history of suicide attempts by overdosing. The patient has not had a suicideattempt in over 7 years. The patient has continued to have suicidal ideations, but has receivedtreatment prior to attempting.HISTORY OF VIOLENCE AND ABUSE: The patient does not have a history of violence oraggression. She denies having homicidal or violent thoughts.She has been in several physically and emotionally abusive relationships. She reports her fatherhad been physically abusive to her and her siblings when she was young. She reports repeatedsexual abuse by a male friend of the family.PSYCHOLOGICAL AND EMOTIONAL FUNCTIONING: The patient has a flat affect anddepressed manner. She is oriented to person, time, and place. The patient has decreasedpsychological functioning due to auditory hallucinations and delusional thoughts. She hasthought blocking and poverty of thought. She has poor concentration. The patient is fidgetyduring the interview and plays with her blanket. The patient is anxious and gets agitated at timesduring the interview. She has low self-esteem and verbalizes feelings of worthlessness. She ishopeless and does not believe she will ever get better.CURRENT FAMILY/HOUSHOLD MEMBERSHIP: The patient had been living in a grouphome, but moved into an apartment with her boyfriend in November. Patient reports that shortlyafter moving in with her boyfriend, he went to jail and remains there until this May. The patientstates she felt she had been doing well living by herself in the apartment, and does not see thishospital admission as a sign that this may not be the case.The patient’s brother and sister-in-law is her legal guardian, and when signing the patient in, hersister-in-law stated she felt the patient did better while in the group home, and plans for patient togo to a group home upon discharge.
  3. 3. Pam Kummerer 3FAMILY HISTORY: Both of the patient’s parents are deceased. She has 3 sisters and 2brothers. She is the second youngest child. The patient reports that one of her brothers hasreceived psychiatric treatment, but was unable to give specifics. She also reports that both of herparents had a drinking problem when she was growing up. She denies any family history ofsuicide.The patient reports physical and sexual abuse as a child. States her father physically abused herwhen he was drinking. She reports repeated sexual abuse by a friend of the family.The patient reports that she had a good relationship with her mother and she often misses her.The patient states that when she was young she mostly got along with her siblings, but was neververy close to her oldest sibling.The patient reports that she currently is not very close to any of her siblings and has very limitedcontact with most of them. Her brother is her legal guardian, and from past admissions, hersister-in-law seems to be supportive of the patient. In the past, she has lived with her brother,sister-in-law, and their 2 children. Because of her delusions, paranoia, substance abuse, andbehaviors related to these, she is not able to stay with them due to the possible effects this couldhave on the children. However, the sister-in-law remains supportive, and encourages the patientto visit.EDUCATION AND EMPLYMENT HISTORY: The patient dropped out of high school inthe 11th grade, but did obtain her GED several years later. The patient reported that she did notlike school but achieved average grades. She denies having any learning difficulties. Thepatient appears to be of normal intellectual functioning.The patient states she has had several entry-level laborer jobs in the past, but was always unableto maintain employment. The patient has been receiving disability compensations for severalyears.ECONOMIC SITUATION: The patient receives disability compensation, and has Medicaid.The patient reports having financial stressors and admits she sometimes gets overwhelmed withher bills. When discussing the group home, the patient states, “Group homes are expense…theytake all my money.” The patient does not have a car, and relies on others for transportation.INTERPERSONAL AND ROLE FUNCTIONS: The patient does not identify having anyclose friends. She reports having only a few friends, but states they are not very closerelationships. The patient states “people just stab you in the back.” The patient tends to beisolative to her home, and has limited interactions with people. Her boyfriend is currently in jail.The patient was married once for 5 years. She has a history of relationships with men who preyon her vulnerability and tend to use her for money. The patient does not have any children.
  4. 4. Pam Kummerer 4CULTURAL BACKGROUD, RELIGIOUS BELIEFS, AND SPIRITUALITY: The patientis religiously preoccupied and often has delusions related to religious beliefs. She does notattend church but does read the Bible regularly. She expresses feelings of guilt related to herreligious beliefs, and has excessive fear of going to hell.PYSICAL FUNCTIONING: Patient denies any medical conditions or physical complaints.STRENGHTS AND USUAL WAYS OF COPING: The patient has much difficultyidentifying any strengths, even with prompting. Patient has a legal guardian. She is linked withNorthwest Community Mental Health Center. She has income and insurance. Her sister-in-lawis very supportive. She has remained free of alcohol and drugs for 3 years.The patient identifies using music as her most used coping skills. She states she listens to musicto help herself relax. She also reports using deep breathing when she is feeling anxious, butstates this only helps her minimally. She stated that being around people makes her moreanxious and more paranoid.She is often in denial of her illness and then becomes non-compliant with treatment. She isavoidant of issues that cause her increased stress.USE OF COMMUNITY RESOURCES: The patient receives services at NorthwestCommunity Mental Health Center. In the past, she attended partial hospitalization programming.She has attended support groups and AA.IMPRESSIONS AND ASSESSMENT: The patient is depressed with suicidal ideationswithout a specific plan. The patient is experiencing paranoid delusions and auditoryhallucinations. She is guarded and suspicious. She maintains poor eye contact. The patient hasnot been eating or sleeping, primarily due to her delusional thoughts. Judgment and insight intoillness are poor. She has limited family and social support and spends a majority of her timealone in her apartment. She has a long history of psychiatric illness and non-compliance withtreatment. While on the unit, she has been spending most of her time in her room, and has notbeen attending unit programming. She denies any thoughts of wanting to harm others.DIAGNOSTIC IMPRESSIONS: Axis I: 295.70 Schizoaffective Disorder, Depressed Type 304.80 Polysubstance Dependence, In Remission Axis II: None Axis III: None Axis IV: housing issues, lack of family and social support, treatment non-compliance Axis V: 29TREATMENT PLAN: The patient will be started back on psychotropic medication prescribedby admitting psychiatrist. Patient will be encouraged to participate is unit milieu. Group therapyand supportive psychotherapy will be provided. Encourage patient to attend the dual diagnosisgroups. Patient will be placed on suicide precautions for safety. Social worker will meet with
  5. 5. Pam Kummerer 5patient daily to explore coping skills and coordinate discharge plans. Social worker willmaintain contact with family/guardian in order to include them in treatment and offer a familymeeting to patient and family. Case manager will assist patient with finding an appropriategroup home. Patient will follow up at Northwest Community Mental Health Center. Encouragepatient to attend AA and get a sponsor after discharge.