Theory Practice

Biopsychosocial Assessment

Ciatta Kollie

Identifying information

Norma Balaban, is a 37-year-old married woman. She lived with her husband and their daughters, ages 10 and 6 years. Her husband was undergoing treatment for depression. She reported to have had healthy childhood and said that she did not have any experiences of physical and sexual abuse. Mrs. Balaban did not have any history of substance abuse. She was referred for evaluation by her primary care physician to be assessed for depression and multiple somatic symptoms.

Presenting problem

She reported that she does not spend enough time with her family. She reports bouts of depressed moods and occasional thoughts of suicide (she had considered crashing her car). However, she does not report anorexia or feeling of guilt. Mrs. Balaban also reported that she has been having premenstrual depressive symptoms for about a year. She challenges on concentrating with work and often spends time on the internet searching for her symptoms.

Background information

Mrs. Balaban was diagnosed and treated for postpartum depression 6 years ago after the birth of her second child. Her family had history for depression, cancer, and hypertension. Her husband was undergoing treatment for depression. Mrs. Balaban reported nocturnal leg spasms and daytime leg aches as initial concerns and later developed problems that led to sleep difficulties, which led to heaviness and “brain fog.” In addition, she reported intermittent cold sensations in her extremities, ears, eyes, face, and nasal passages. The client has reported difficulties in urinating, multiple muscle complaints, menstrual irregularity, and also has neck stiffness with accompanying thoracic back spasms. Her primary physician had diagnosed her with mechanical back pain and possible migraines and was suspected to have a significant degree of depression. The client graduated from college and was the longtime administrative assistant to the dean at the local university.

Assessment

The client reports of spending less time with her children and her husband. She also reported to have suicidal thoughts, attempt to crash her car. She has difficulty in concentrating at work, and spends much time on the internet to search for her symptoms. She reports bouts of depressed mood and also has sleep difficulties. Her family has an history of depression and her husband is undergoing treatment for depression.

Mental status assessment/exam

The client appears neatly dressed, alert, cooperative and not at all defensive. She reported muscle spasms and bouts of depressed mood. She has a history of postpartum depression. The client did report episodes of hallucinations or delusions.

Summary impression

Mrs. Balaban is 37-year-old married women with two children referred by her primary physician to seek for assessment for her symptoms, which portray that she is depressed. Her family has history of depression, cancer and hypertension and thus her condition might be hereditary. She seems to be intelligence and motivated to understand her condition since she spends time on the internet searching for her symptoms. She is willing to give all information regarding her symptoms and family history in order to get help.

Diagnosis and rationale

Mrs. Balaban appears to have Major Depressive Disorder (DMM) according to her biopsychosocial assessment. She has been diagnosed with postpartum depression six years ago after birth of her second child. Assessment shows that she has migraines and episodes of depression. She reported to have episodes of depressed mood. The symptoms meet the minimum requirements for MDD.

Recommendations/proposed intervention

Cognitive behavioral therapy (CBT) is important to help the client change her distorted thoughts. The therapy can help the client to learn how to avoid thoughts that might trigger depressed mood and suicidal thoughts and cultivate positive thoughts.