Complete part two of the biopsychosocial assessment attached
Name: _____E D__________________ Date: _________________ DOB: ________________
Age: ________________________________ Start Time: ____________ End Time: ___________
Identifying Information:
_E is a Caucasian female with slender build and average height. She is a freshman in college and her major is engineering.
Presenting Problem:
The client was referred to the office in the university counseling center after being caught with alcohol in the campus dorm. The client is a minor and the campus is alcohol free. She appears visibly distraught and disheveled.
Life Stressors:
- Pressure from her high achieving family to perform well in school
- School: Demanding coursework and attending tutorial between classes. The client resents having to attend weekly tutorial sessions to keep up with course material.
- Difficulty making friends
Substance Use: Yes No
- Frequent alcohol use in parties
- Client uses pills in parties although she is not sure how much or what kind
- Client tried marijuana once in high school but has not tried it again since she did not like how it made her feel.
Addictions (i.e., gambling, pornography, video gaming):
_Video gaming: Client admits to occasionally playing a multiplayer online game once or twice a week. Most of the gaming sessions last between three to five hours. The client likes to play video games after the weekly tutorials as a way of unwinding.
Medical/Mental Health Hx/Hospitalizations:
No history of hospitalizations
Abuse/Trauma:
____No history of abuse or trauma although the client mentions that she was teased in high school but did not provide more details.
Social Relationships:
__The client described having quality relationships although she felt that sometimes her friends took advantage of her by pressuring her to complete their homework or pushing her to party in the dorm area where alcohol was prohibited. The client never talked to her friends about these issues because they were not a big deal. The friends she had in high school attend college in other places hence she is no longer close to them. Eliza described her mother as a controlling person and her father as a good guy. Her parents have a strained relationship and she is often caught in the middle.
Strengths:
_The client is trying her best to cope with issues she is experiencing in college
The client considers her family as her support system
The client was willing to talk about her issues including cutting herself to cope with overwhelming stress.
Legal History:
No legal history but the drinking incident in the campus dorm was reported to the campus police.
Educational History:
The client is currently a freshman in college. Her major is engineering.
Family Information:
__The client comes from a family of high-achieving individuals. Her father and older brothers are successful engineers and as the last born, she felt that she had no option but to pursue engineering as a career. Her mother requires her to make a call at least once a week. Her parents have a strained relationship and the two complain to her about their marriage problems. The client stated that sometimes she feels like the middle man. She rarely talks to her brothers while at school.
Spiritual:
_The client is agnostic. Her parents are Irish Catholic although they only attend church on special occasions such as Easter and Christmas.
Suicidal:
__The client denies being suicidal although she admits that she has been self-harming by cutting when she feels overwhelmed with stress. She discloses cutting two to three times daily within the past week.
Homicidal:
__No__
Mental Status Exam (MSE):
_During the session, the client is visibly distraught. The client demonstrates symptoms of anxiety and depression as evidenced by her drinking patterns, self-harming behavior, and frequent partying.
Clinical Justification (Provide clinical justification related to client symptomology along with a DSM and ICD diagnosis based on client assessment):
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Initial Diagnosis (DSM 5):
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Initial Treatment Goals:
Goal:
Objective:
Intervention:
Target Date:
Discharge Plan:
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Solution
Name: _____________________________________________ Date: __________________
Name: _____E D__________________ Date: _________________ DOB: ________________
Age: ________________________________ Start Time: ____________ End Time: ___________
Identifying Information:
_E is a Caucasian female with slender build and average height. She is a freshman in college and her major is engineering.
Presenting Problem:
The client was referred to the office in the university counseling center after being caught with alcohol in the campus dorm. The client is a minor and the campus is alcohol free. She appears visibly distraught and disheveled.
Life Stressors:
- Pressure from her high achieving family to perform well in school
- School: Demanding coursework and attending tutorial between classes. The client resents having to attend weekly tutorial sessions to keep up with course material.
- Difficulty making friends
Substance Use: Yes No
- Frequent alcohol use in parties
- Client uses pills in parties although she is not sure how much or what kind
- Client tried marijuana once in high school but has not tried it again since she did not like how it made her feel.
Addictions (i.e., gambling, pornography, video gaming):
_Video gaming: Client admits to occasionally playing a multiplayer online game once or twice a week. Most of the gaming sessions last between three to five hours. The client likes to play video games after the weekly tutorials as a way of unwinding.
Medical/Mental Health Hx/Hospitalizations:
No history of hospitalizations
Abuse/Trauma:
____No history of abuse or trauma although the client mentions that she was teased in high school but did not provide more details.
Social Relationships:
__The client described having quality relationships although she felt that sometimes her friends took advantage of her by pressuring her to complete their homework or pushing her to party in the dorm area where alcohol was prohibited. The client never talked to her friends about these issues because they were not a big deal. The friends she had in high school attend college in other places hence she is no longer close to them. Eliza described her mother as a controlling person and her father as a good guy. Her parents have a strained relationship and she is often caught in the middle.
Strengths:
_The client is trying her best to cope with issues she is experiencing in college
The client considers her family as her support system
The client was willing to talk about her issues including cutting herself to cope with overwhelming stress.
Legal History:
No legal history but the drinking incident in the campus dorm was reported to the campus police.
Educational History:
The client is currently a freshman in college. Her major is engineering.
Family Information:
__The client comes from a family of high-achieving individuals. Her father and older brothers are successful engineers and as the last born, she felt that she had no option but to pursue engineering as a career. Her mother requires her to make a call at least once a week. Her parents have a strained relationship and the two complain to her about their marriage problems. The client stated that sometimes she feels like the middle man. She rarely talks to her brothers while at school.
Spiritual:
_The client is agnostic. Her parents are Irish Catholic although they only attend church on special occasions such as Easter and Christmas.
Suicidal:
__The client denies being suicidal although she admits that she has been self-harming by cutting when she feels overwhelmed with stress. She discloses cutting two to three times daily within the past week.
Homicidal:
__No__
Mental Status Exam (MSE):
_During the session, the client is visibly distraught. The client demonstrates symptoms of anxiety and depression as evidenced by her drinking patterns, self-harming behavior, and frequent partying.
Clinical Justification (Provide clinical justification related to client symptomology along with a DSM and ICD diagnosis based on client assessment):
_Before the client joined university, she stayed at home where there was a lot of pressure to perform. As a high school student, she could easily perform well. However, when she joined university, she realized that she needed to struggle to achieve good grades. Therefore, she began consuming excess alcohol and engaging in excessive gaming.
Diagnosis:
F43.23: Adjustment Disorder mixed with depressed and anxiety mood
F10.10 Mild Alcohol Use Disorder
Initial Diagnosis (DSM 5):
Adjustment Disorder mixed with depressed and anxiety mood.
The symptoms include: Marked distress that exceeds the intensity of the stressor, impairment in social and academic functioning, symptoms of stress and anxiety. Eliza is stressed because her school work is difficult and she has to perform well and excel in her engineering career like her parents and siblings. High stress levels have impacted her sleeping patterns. She also parties and drinks a lot of alcohol to cope with the pressure at school. She also reports gaming to handle stressful days.
Initial Treatment Goals:
Goal: To help E adjust to university and communicate with her parents and siblings about how she feels.
Objective: To help E adjust to university without the need for alcohol and excessive gaming.
Intervention: Cognitive behavioral therapy (CBT). CBT for adjustment issues incorporates communication techniques, problem-solving skills, and stress management skills to deal with stressors (O’Donnell et al., 2018).
Target Date: 20th December 2022
Discharge Plan:
E will be discharged when she demonstrates better coping skills, reduced alcohol use, and improved communication about her feelings with her parents and siblings.
Name: _____________________________________________ Date: __________________
References
O’Donnell, M. L., Metcalf, O., Watson, L., Phelps, A., & Varker, T. (2018). A systematic review of psychological and pharmacological treatments for adjustment disorder in adults. Journal of Traumatic Stress, 31(3), 321–331. https://doi.org/10.1002/jts.22295