Clinical Assessment and Treatment Plan UOP CMH 544 wk 8

College of Social Sciences Master of Science in Counseling

Biopsychosocial Assessment

NAME(S): Delores Hoffman

DATE OF BIRTH: 27 years old

PRIMARY LANGUAGE: English

REFERRED BY:

INTAKE DATE: 10/25/2017

EVALUATED BY: Claudia Rangel

DESCRIPTION OF CLIENT(S):

Write what you observe about the client—age, sex, ethnicity, appearance, behaviors, and impressions.

Mrs. Delores Hoffman who is 27 years of age. Caucasian, female who lives with her boyfriend, never been married. Patient works as an office manager for the past 4 years. Patients is well dressed and attractive. Patient was staring out the window, virtually motionless when I introduced myself.

PRESENTING PROBLEM:

Describe the problem as the client has presented it, including perspective, function impairment, and symptoms.

Delores Hoffman called to make an appointment to see a counselor due to her “growing preoccupation with suicide.” When Mr. Delores was screened for suicide risk she had no history of past attempts or a present plan. Nonetheless, an initial appointment was arranged for later that day.

For the past 6 or 7 months, Patient stated that her feelings have gotten much worse. Patients boyfriend moved in with her and feels that its gotten much worse since then. The couple is planning on getting married in the summer but patients feels like her world has fallen apart. Patient has lost interest in her boyfriend sexually, patients has a hard time sleeping, patient has no energy during the day which is affecting her at work. Patient lost interest in cooking and lost weight which is uncommon for her.

HISTORY OF PROBLEM:

Describe the course of the problem and specific onset and symptoms.

felt this way since I was 10, maybe 12. Younger than that, I don't remember very well. I don't think I thought about much of anything. But around that age, I realized I didn't really have anything going for me. Do you know what I mean?” she asks.

just never been happy. I've never really liked myself. I'm just a big nothing. Always have been. No energy, no plans, no future, nothing to look forward to. I thought I was used to it and I had accepted it. Some people have lives worth living; the rest of us take up space,” she observes.

Patient does not have friends, she hasn’t seen her family since she moved out. Patient is depressed and unhappy with herself for most of her life. This has taken away her social life.

MENTAL STATUS:

Activity: Patient has felt unhappy with no energy, no plans no future and stated that “that she has nothing to look forward to”.

Mood and Affect: Patient stated that she has never been happy. Patient has never really liked herself and degrades herself. Patient stated that she has no energy, no plans, no future, nothing to look forward to. Patient stated that “some people have lives worth living; the rest of us take up space,” Patient feels hopeless at this moment. Patients mood is both negative and has no positive affect. Patient has lost interest and pleasure in mose activities. Patients feels no emotions.

Thought Process, Content, and Perception:

Cognition, Insight, and Judgment:

Suicidal and Homicidal Assessment

If a more thorough suicide/homicide evaluation is conducted, it may be documented in a separate section.

SOCIAL HISTORY:

Describe the client's present living situation:

Patient does not have friends, she hasn’t seen her family since she moved out. Patient is depressed and unhappy with herself for most of her life. This has taken away her social life. Patient stated “as soon as he moved in, I pretty much lost interest in everything”.

Family: Patient has two sisters, one older and one younger. Growing up patient and family lived in a nice suburban neighborhood. Growing up everything was ordinary and in order.

School: NA

Health: Patient does not have any energy and she feels like if she drags herself during the day.

Occupational/Work: Office Manager for the past 4 years. Patient has lost interest in her job. Patient stated that her job is a good job but doesn’t like it when they ask if she is ok.

Spiritual/Religious: NA

Legal: NA

Social History (include history of abuse/trauma): Patient does not have friends, she hasn’t seen her family since she moved out. Patient is depressed and unhappy with herself for most of her life. This has taken away her social life.

HEALTH & WELLNESS HISTORY:

Substance use (including alcohol, drugs, tobacco and caffeine intake): NA

Sleep habits: Sleep has gotten worst since her boyfriend moved in with her. I wake up before my alarm goes off!

Exercise habits: Patient lost interest in everything including exercise. Patient living situation with her boyfriend has set her back and doesn’t feel like doing anything.

Eating habits and appetite: Patient has lost 15 pounds since her boyfriend moved in with her. Patient doesn’t feel like cooking. Her boyfriend gets fast food and she doesn’t eat. Patients eating habits and appetite have gotten worst since he moved in.

PREVIOUS THERAPY / PSYCHIATRIC SERVICES:

Have you ever been in counseling before? xNo Yes, Inpatient Outpatient Day Treatment

Name of Provider Clinic Year Diagnosis / Problem

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Have you ever seen a Psychiatrist before? xNo Yes, Inpatient Outpatient Day Treatment

Name of MD: _______________________________________ Clinic: _____________________________

Was any of your previous therapy related to substance abuse? xNo Yes

Have you ever had serious thoughts of suicide or homicide? No xYes

Have you ever made a suicide / homicide attempt? xNo Yes Explain: ____________________________

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Do you presently feel suicidal or homicidal? No xYes Explain: Patient daydream about suicidal thoughts all the time. Instead of focusing on what she needs to do patient will also dream up ways to end it all. When patient is dreaming of these thought patient is so preoccupied with her dream. Patient stated that she is afraid to die and she doesn’t know why she has those thoughts of suicide in her head.

FAMILY RELATIONSHIP HISTORY:

Describe the client's current and historical family status and relationships, including during childhood/adolescence.

They're okay, I guess. Just dull people like me. I have two sisters, one older and one younger. We lived in a nice suburban neighborhood. If my parents had any problems, we kids didn't know about them. Everything was ordinary and orderly.” We didn't talk about much in my family. We just did the things we were supposed to do,

I haven't really seen them since I left home.”

STRENGTHS:

Describe assets that will facilitate progress and change, such as motivation, intelligence, self-discipline, and willingness to utilize resources.

She likes her job of 4 years but patient doesn’t like that the employees ask her if she is ok.

No, I don't think you're crazy! I do think you need to take some hard looks at yourself and your life. No one can just go along being as unhappy as you are. Does that sound like something you're willing to do?”

“I think it is. Really, I know it is. I've thought about seeing a therapist for a long time. I wouldn't have made this appointment if I weren't ready to try something,” she says.

CHALLENGES

Describe aspects’ of the client’s life circumstance that may impede progress/change, such as homelessness, major psychiatric disorder, financial hardship, etc.

Some people are really smart; I'm not. I'm not retarded or anything but just not brainy. Some people are beautiful; I'm not. I'm not ugly or anything but just not remarkable. I'm not ambitious. I'm not clever. I'm destined to just go along, probably get married, get left by my husband after the kids are grown, and end up lonely

I've just never been happy. I've never really liked myself. I'm just a big nothing. Always have been. No energy, no plans, no future, nothing to look forward to. I thought I was used to it and I had accepted it.

Well, I used to really enjoy cooking. Now it just seems like a chore. I've probably lost 15 pounds since he moved in just because I don't want to cook! He'll go ahead and get some fast food or something, but I just don't eat,”

For the past 6 or 7 months, I've been feeling much worse. I think it's about my boyfriend. He moved in with me around the time things got worse. I know that sounds weird. I'm supposed to be happy to find someone who seems to love me. We're planning on getting married in the summer. But really, my life has sorta fallen apart since he moved in,

a little strange. I daydream about it all the time. Instead of focusing on what I need to do or something, I dream up ways to end it all. No, not really. I know that seems strange since I'm so preoccupied with it, but I'm afraid to die! I don't know why all these thoughts are in my head, really. Do you think I might be going crazy

DIAGNOSIS:

Using the information gathered thus far, make a diagnosis using DSM 5.

Diagnostic Criteria for Major Depressive Disorder / Major Depressive Disorder DSM-5 296.20-296.36

•Persistent sadness or low mood nearly every day.

•Loss of interests or pleasure in most activities.

•Fatigue or loss of energy.

•Worthlessness, excessive or inappropriate guilt.

•Recurrent thoughts of death, suicidal thoughts, or actual suicide attempts.

•Diminished ability to think/concentrate or increased indecision.

•Psychomotor agitation or retardation.

•Insomnia/hypersomnia.

•Changes in appetite and/or weight loss.

DISCUSSION/CLINICAL FORMULATION:

Provide your rationale for the provided diagnosis. Describe the appropriate theory to consider using with this client. Note the basics of this theory and how it might apply to this client.

Symptoms should have been present persistently for at least two weeks and must have caused clinically significant distress and impairment. They should not be due to a physical/organic factor (eg, substance abuse) or illness (although illness and depression commonly co-exist). Severity is based on the extent of symptoms and their functional impact:

During the past month the patient felt depressed, hopeless, little interest or pleasure in doing things.

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Student/Counselor in Training Date

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Supervisor Date