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BIOPSYCHOSOCIAL ASSESSMENT

Client’s Name: Patty SmithAddress: 335 Richardson Dr.

Toledo, Ohio 43608Phone: 419-555-1122

PURPOSE 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. The purpose 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-face interview 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 contact during the interview, and was often looking down as she was running the blanket edge through her 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 a neighbor. She reports symptoms of increasing depression with suicidal ideations, auditory hallucinations, and paranoid delusions. Patient reports she has not been taking her psychotropic medications for several weeks. The patient has a long history of psychiatric disorder and has had multiple hospitalizations.

The patient reports that she has been “feeling down” lately and has been having suicidal ideations without a specific plan. She has a flat affect and speaks in a quite tone of voice. She admits that she has not been taking her medication for several weeks, and had not always been taking it as prescribed prior to this. She states that sometimes she forgets to take her meds, and then 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, “put me down,” and are “calling me a whore.” The patient believes these voices are from “a different realm” but would not elaborate any further.

The patient has paranoid delusions and is religiously preoccupied. She believes she is the devil and believes people are watching her and talking about her. When asked about her appetite, the patient states, “I am not suppose to be eating, I am fasting.” When asked about her sleep, the patient states, “I’m not suppose to go to sleep…I read it in the Bible.” The patient tends to focus on the end of the world and going to hell. She expresses feelings of guilt over past things she has done, which she will not discuss.

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ALCOHOL, TOBACCO, AND OTHER DRUGS: The patient has a history of polysubstance abuse. She reports past alcohol, cannabis, and cocaine use, but states she has been clean for 3 years. She has been at Treatment Center in the past for substance abuse treatment, but was kicked out after asking a peer for heroin because she wanted to kill herself. She also reports she has attended AA meetings in the past, and states they had helped a little. The patient does not use tobacco.

PAST PSYCHIATRIC HISTORY: The patient has a long psychiatric history with several hospitalizations. The patient reports that her symptoms first appeared when she was in her early 20s. She has had previous psychiatric admissions at Regal Hospital, St. Bernice Hospital, and Regional Stress Hospital. She has received ECT in the past. The patient has been on several different psychotropic medications, and was last prescribed Haldol, Cymbalta, Tegretol, and Cogentin. The patient states she thinks this combination of medication has been effective for her. The patient receives outpatient psychiatric treatment at Northwest Community Mental Health Center.

The patient has a history of suicide attempts by overdosing. The patient has not had a suicide attempt in over 7 years. The patient has continued to have suicidal ideations, but has received treatment prior to attempting.

HISTORY OF VIOLENCE AND ABUSE: The patient does not have a history of violence or aggression. She denies having homicidal or violent thoughts.

She has been in several physically and emotionally abusive relationships. She reports her father had been physically abusive to her and her siblings when she was young. She reports repeated sexual abuse by a male friend of the family.

PSYCHOLOGICAL AND EMOTIONAL FUNCTIONING: The patient has a flat affect and depressed manner. She is oriented to person, time, and place. The patient has decreased psychological functioning due to auditory hallucinations and delusional thoughts. She has thought blocking and poverty of thought. She has poor concentration. The patient is fidgety during the interview and plays with her blanket. The patient is anxious and gets agitated at times during the interview. She has low self-esteem and verbalizes feelings of worthlessness. She is hopeless and does not believe she will ever get better.

CURRENT FAMILY/HOUSHOLD MEMBERSHIP: The patient had been living in a group home, but moved into an apartment with her boyfriend in November. Patient reports that shortly after moving in with her boyfriend, he went to jail and remains there until this May. The patient states she felt she had been doing well living by herself in the apartment, and does not see this hospital 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, her sister-in-law stated she felt the patient did better while in the group home, and plans for patient to go to a group home upon discharge.

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FAMILY HISTORY: Both of the patient’s parents are deceased. She has 3 sisters and 2 brothers. She is the second youngest child. The patient reports that one of her brothers has received psychiatric treatment, but was unable to give specifics. She also reports that both of her parents had a drinking problem when she was growing up. She denies any family history of suicide.

The patient reports physical and sexual abuse as a child. States her father physically abused her when 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 never very close to her oldest sibling.

The patient reports that she currently is not very close to any of her siblings and has very limited contact with most of them. Her brother is her legal guardian, and from past admissions, her sister-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, and behaviors related to these, she is not able to stay with them due to the possible effects this could have on the children. However, the sister-in-law remains supportive, and encourages the patient to visit.

EDUCATION AND EMPLYMENT HISTORY: The patient dropped out of high school in the 11th grade, but did obtain her GED several years later. The patient reported that she did not like school but achieved average grades. She denies having any learning difficulties. The patient appears to be of normal intellectual functioning.

The patient states she has had several entry-level laborer jobs in the past, but was always unable to maintain employment. The patient has been receiving disability compensations for several years.

ECONOMIC SITUATION: The patient receives disability compensation, and has Medicaid. The patient reports having financial stressors and admits she sometimes gets overwhelmed with her bills. When discussing the group home, the patient states, “Group homes are expense…they take 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 any close friends. She reports having only a few friends, but states they are not very close relationships. The patient states “people just stab you in the back.” The patient tends to be isolative 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 prey on her vulnerability and tend to use her for money. The patient does not have any children.

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CULTURAL BACKGROUD, RELIGIOUS BELIEFS, AND SPIRITUALITY: The patient is religiously preoccupied and often has delusions related to religious beliefs. She does not attend church but does read the Bible regularly. She expresses feelings of guilt related to her religious 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 difficulty identifying any strengths, even with prompting. Patient has a legal guardian. She is linked with Northwest Community Mental Health Center. She has income and insurance. Her sister-in-law is 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 music to help herself relax. She also reports using deep breathing when she is feeling anxious, but states this only helps her minimally. She stated that being around people makes her more anxious and more paranoid.

She is often in denial of her illness and then becomes non-compliant with treatment. She is avoidant of issues that cause her increased stress.

USE OF COMMUNITY RESOURCES: The patient receives services at Northwest Community 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 ideations without a specific plan. The patient is experiencing paranoid delusions and auditory hallucinations. She is guarded and suspicious. She maintains poor eye contact. The patient has not been eating or sleeping, primarily due to her delusional thoughts. Judgment and insight into illness are poor. She has limited family and social support and spends a majority of her time alone in her apartment. She has a long history of psychiatric illness and non-compliance with treatment. While on the unit, she has been spending most of her time in her room, and has not been 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 RemissionAxis II: NoneAxis III: NoneAxis IV: housing issues, lack of family and social support, treatment non-complianceAxis V: 29

TREATMENT PLAN: The patient will be started back on psychotropic medication prescribed by admitting psychiatrist. Patient will be encouraged to participate is unit milieu. Group therapy and supportive psychotherapy will be provided. Encourage patient to attend the dual diagnosis groups. Patient will be placed on suicide precautions for safety. Social worker will meet with

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patient daily to explore coping skills and coordinate discharge plans. Social worker will maintain contact with family/guardian in order to include them in treatment and offer a family meeting to patient and family. Case manager will assist patient with finding an appropriate group home. Patient will follow up at Northwest Community Mental Health Center. Encourage patient to attend AA and get a sponsor after discharge.