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BIO-PSYCHOSOCIAL EVALUATION  

Ñame: Chrystal Williams   D.O.B:  09/20/2002       Client #    XXXX 

Age: 19    Gender: Female  Race/Ethnicity: Black/African American

Level of Education: Freshman in College

Employment Status: Unemployed, Full-time Student

Marital Status: Single 

Date of Evaluation: 2/27/2021 

Evaluator: Bobbie Slaughter  

Reason for Referral  

Chrystal Williams, a 19-year-old, African American, single female was referred to the Bright Light Treatment Center due to her symptoms of depression, anxiety, and stress.

Procedure and Test Administered 

Beck Depression Inventory, Second Edition (BDI-II) 

Presenting Problem     

Ms. Williams described the reasons for her coming was depressed and stressed. She stated her caught her boyfriend cheating on her. She reported that on Valentine’s day, he promised to spend the day with her and end the evening with dinner. Ms. Williams reported this affected her thinking pattern for that day. She became anxious and constantly thinking about why her boyfriend had not called her. She couldn’t function because this was not normal. They had been dating for one year and seemingly never had a disagreement that would leave to him not showing up. As she waited on him for hours and he did not show up, her anxiety level increased as she continues to being left alone on Valentine day. They talked about this being the love day of the year. She reported that he normally checks with her all day. She mentioned her continuous worrying caused her to experience more anxiety. Chrystal stated that she started to feel bad and decided to look for him. Additionally, she was worried that something had happened to him. She didn’t know where to start, so she started with the restaurant hoping he wouldn’t be there. She searched several restaurants with the hope and apprehension that he was not in one of them. However, she went to the restaurant they made reservations at for their Valentine date. When she walked in, she saw her boyfriend with another girl. This caused her to be overwhelmed with stress and anxiety. She confronted him asking him why. She wanted to know why he would do that to her. Chrystal had been dating him for a year. She reportedly got so upset and left the restaurant. She went home and became very sad. She stated that she stayed in the bed for three days. Furthermore, she became depressed, moody, restlessness, and didn’t have an appetite. She reported that she didn’t want to change clothes. Her depression led to more anxiety and a feeling of failure. She reported that she could not tell anyone. About her situation and what she had gone through. She reported wanting to roll up in bed and stay there. She was too embarrassed to share this information with anyone. In her culture, they don’t share there embarrassing moments with anyone. They feel other individuals will only judge them and use the situation against them in the future. Chrystal reported that she needed to talk with someone about this situation. She realized that she couldn’t talk to her family about her feelings.

History of Presenting Problem  

During the session the client shared that she had been cheated on once before and she began to have anxiety attack. This happened to her when she was a junior in high school. She had been invited to the junior/senior prom and her date never picked her up. She began to have self-esteem, anxiety issues and depression. Her mother explained to her that this had happened to her before and it caused her to have the same issues. She stated her mom was at the altar and the groom never showed up. This caused her mother to shut down and become withdrawn from society. However, her mother told her that she had to take medication to lessen her anxiety and depression episodes. Her mother also shared that she could not share her feelings with anyone when this happened. In addition, the client expressed that this was not easy for her to get on with her life and move on. This problem was lingering and she had to talk to someone. She was becoming stressed in her day-to-day activities. Ms. Williams reported that when she has flashbacks about Valentine Day it triggers her anxiety and depression. She becomes withdrawn, moody, and stressed.

Relevant Background Information: 

Birth and Developmental History; 

Chrystal shared that she comes from a two-parent household with a loving mother and father. She explained that her birth was planned. Her parent always wanted children; however, it took my mother five years to conceived. They planned this pregnancy with the anticipation of having a healthy baby. They would often share that it didn’t matter if I was a girl or boy, they would love me unconditionally. She mentions that they wanted a child so she refrains from any drugs and drinking. Also, her mother was a high-risk pregnancy because it took her a long time to conceive. She also reported that the client was a full-term pregnancy and the labor was not intense. The protective nature started early because she was not sent to a daycare. Her parent wanted to make sure she met all her developmental milestones without interruptions.

Family History: 

Ms. Williams stated that she is of African American lineage. She has always stayed in the Mississippi delta where she was born. She currently stays on campus where she attends Mississippi Valley State University. She moved out approximately two years ago to attend college. Ms. Williams reported that she was very anxious to move out of her mother and father’s home because of the protective hold they had on her. Her mother and father are still together. She reported that she has two other sisters who live at home with her mom and dad. Her parents treat them the same way. She always was respectful to her parent; however, she needed her space. Her parents are supportive parents but she felt it was time for her to move on. She reported that her parents always keep their promise to each other. The client expressed that they place high value on my sisters and I keeping our words to each other. She shared that her mother’s sister had a nervous breakdown. She mentions her aunt was a very pretty lady and was with the famous basketball player. The basketball player would shower her with gifts and take her on expensive trips. She was with him for two years and every year he told her he was going to marry her. The night he was supposed to propose to her he didn’t show up. She had a nervous breakdown and never recovered. She was committed to a mental facility. Ms. William stated that is the reason why her parent was so protective of her and they instilled keeping our promises.

Social History: 

Ms. Williams family was in the middle socioeconomic status in their community. She reported that she was bullied at school because her parent kept her dressed neatly and her hair was always neat. She didn’t have many friends. She reported her friends included her sisters and other family members who attended the same school. Ms. Williams shared the bullying did affect her self-esteem. She would eat lunch alone and read books. The other student would tease her and call her names. She reported being taunted so much she began to look at herself differently. She expressed that school was not a good place for her. She defined herself as heterosexual female. She did not date in high school. She was allowed to go to school functions but she had to take her sisters with her. Her parents would not let her go alone.

Medical/Psychiatric History: 

During the session Ms. Williams expressed that as a child she would go to her regular checkups. Her parent would make sure she had regular checkup and dental checkup annually. She was a healthy child who exercised on a regular basis.

Substance Use History: 

The client admits that she never used illegal drugs. She refrained from alcohol and smoking. Although she does have friends who smokes and drink. Her parents refrain from alcohol.

Educational/Professional History: 

The client went to a private school from elementary to six grade. When she entered middle school, she went to a public school. She was always an A and B student. Chrystal was always an advocate reader which placed her above her reading level. Upon graduating from high with honors, she enrolled in a local community college. Her parent felt she was not ready to attend a university. She was always sheltered and protected by her parents. She was not allowed to have a boyfriend. The client grades begin to suffer when she started dating.

Mental Status Examination and Behavioral Observations:  

Ms. Chrystal Williams, a 19-year-old African American female, was evaluated during routine session. She arrived on time with an anxious appearance on her face. She was about 5’5, wore a jogging suit, held a small wallet, and appeared appropriate her stated age. Her attire was suitable for a young female. She reported her mood as hurt and depressed because her boyfriend cheated on her. Her affect was characterized by sporadic hurt, anxiety, moody, and depressed, generally associated with her boyfriend cheating on her. Her speech was weak and soft. She repeatedly became concerned that her boyfriend did not keep his promise. She was extremely upset that this happened on Valentine day. The client recovered her pleasant style before leaving the office. The client reported that she had no thoughts of suicide or homicide.