The client denied having any ideation
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 reason for her coming was depressed and stressed. She stated her caught her boyfriend cheating on her. She reported that on Valentine day, he promised to spent the day with her and end the evening with dinner. Ms. Williams reported this affected her thinking pattern for that day. She became anxious constantly thinking 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 of being left alone on Valentine day. They had talked about this being the love day of the year. She reported that he normally checks with her all day. She reported her continuous worrying cause her to experience more anxiety. Chrystal stated that she started to feel bad and decided to look for him. Additionally, she was worrying 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 searches several restaurants with the hope and apprehension that he was not in one of them. However, she went to the restaurant they had made reservation at for their Valentine date. When she walked in, she saw her boyfriend with another girl. This cause 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. She had been dating him for a year. She reported got so upset and left the restaurant. She went home and became very sad. She stated that she stayed in the bed for three day. Furthermore, she became depressed, moody, 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 individual 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 feeling.
History of Presenting Problem
During the session the client share that she had been cheated on once before and she began to have anxiety attack. This happen 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 self-esteem and anxiety issues and depression. Her mother explained to her that this had happen to her before and it caused her to have the same issues. She stated her mom was at the alter 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 feeling 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 flashback about Valentine Day it triggers her anxiety and depression. She becomes withdrawn, moody, and stress.
Relevant Background Information:
Birth and Developmental History;
Ms. Williams 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. The 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. William reported that she was very anxious to move out of her mother and father’s home because the protective hold they had on her was stifling. Her mother and father are still together. She reported that she has two other sister 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. She shared that her parents are good supportive parent but she felt it was time for her to move on. She reported that her parents always keep there 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 recovery. She was committed to a mental facility. Ms. William state that is the reason her parent was so protective of her and they instilled keeping our promises.
Social History:
Ms. Williams family was in the middle social economic 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 her self 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 function 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 exercise 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 parent did not have liquor around the home.
Educational/Professional History:
The client went to a private school from elementary to six grade. When she entered middle school, she went to public school. She was always an A and B student. She graduated from public school. Ms. Williams was always an advocate reader which placed her above her reading level. Upon graduating from high with honor. 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:
Needs to be completed
Teacher’s example template
BIO-PSYCHOSOCIAL EVALUATION
Name: Maria Vasquez D.O.B: 05/04/2000 Client # XXXX
Age: 20 Gender: Female Race/Ethnicity: White Hispanic
Level of Education: High School Diploma
Employment Status: Unemployed, Full-time Student
Marital Status: Single
Date of Evaluation: 5/24/2020, 5/29/2020
Evaluator: Odette Smith, Psy.D.
Reason for Referral
Maria Vasquez, a 20-year-old, Hispanic, single female was self-referred to the Anxiety Treatment Center (ATC) at Nova Southeastern University’s (NSU) Psychology Services Center (PSC) due to symptoms of persistent worry, fear, and physiological distress.
Procedures and Tests Administered
Anxiety Disorders Interview Schedule for DSM-IV- (ADIS-DSM-IV)
Panic Disorder Severity Scale (PDSS)
Penn State Worry Questionnaire (PSWQ)
Anxiety Sensitivity Index-Revised 36 (ASI-R-36)
Beck Depression Inventory, Second Edition (BDI-II)
Social Phobia Anxiety Inventory 23 (SPAI 23)
Obsessive Compulsive Inventory-Revised (OCI-R)
The Alcohol Use Disorders Identification Test (AUDIT)
Presenting Problem
Ms. Vasquez reported feeling anxious “all the time about everything” and being unable to control it. She reported it has significantly interfered with her social and academic functioning. For instance, the client reported that her anxiety impedes her ability to go out and be social because she does not drive due to the fact that she worries about something “bad” happening. Additionally, she stated she does not like to depend on others to drive her to places she needs to go such as school. She also reported worrying about what others might say about her. She reported having very few friends because she feels no one wants to be her friend. She stated “I don’t have anything to offer to people, why would anyone want to be my friend?” She reported having overwhelming anxiety in her life, which has led to panic attacks, and included symptoms such as palpitations, sweating, shortness of breath, shaking, dizziness, and fear of dying. Ms. Vasquez reported that the she experiences unexpected and expected panic attacks about once every two to three months. However, she reported that on average, she experiences the expected panic attacks more often than the unexpected. These panic symptoms, however, present themselves following Ms. Vasquez’s worries. For example, she explained that if she is worrying about an upcoming midterm or exam, she will most likely experience a panic attack.
Ms. Vasquez reported worrying about school, her health, others’ health, finances, and her future. Client described also worrying about not having friends and not being “likeable”. She also reported worrying about the fact that she does not drive due to the fear that she might get into a car accident. Client reported that these worries have occurred more days than not since she was in high school. She reported that she has a tendency of taking a small worry and blowing it out of proportion, until it overwhelms her. Some of the anxiety symptoms she described were muscle tension, fatigue, problems falling and staying asleep, and irritability. Ms. Vasquez reported she decided to seek help because she realized it was affecting different areas of her life and understood a change was necessary in order to have a better quality of life.
History of Presenting Problem
The client reported experiencing her first panic attack in December of 2012, when she was experiencing interpersonal difficulties with family members. At that time, her uncle, a heavy smoker, was living at her house with her mother and twin sisters. The client reported her uncle’s smoking induced several asthma attacks, which resulted in various visits to the emergency room. The client stated she tried to convince her mother to ask her brother to leave the home but her mother declined and that is when she reported experiencing her first panic attack. The client stated she felt as though her mother did not care about her. Ms. Vasquez expressed that this was an extremely stressful time for her because she was having frequent asthma attacks and her family turned against her stating she had to be more understanding due to the fact that her uncle had nowhere to live. She described her uncle as a “monster” who was verbally abusive and even told her he was not going to stop smoking because he did not care about her. When she experienced a panic attack, she reported shaking, sweating, palpitations, chest pain, shortness of breath, dizziness, and fear of dying. She explained that when she first began having panic attacks, they lasted nearly 10 minutes. Currently, she reported they last about five minutes. Ms. Vasquez reported that the panic symptoms occur whenever she is under extreme stress.
Relevant Background Information:
Birth and Developmental History;
According to Ms. Vasquez, her birth was planned, and her mother’s pregnancy and labor were unremarkable. Maria mentioned that her mother did not use any illicit substances, caffeine, or alcohol during her pregnancy with Jane. The client reported being born after a full-term pregnancy. She also stated that she met her developmental milestones on time with no significant delays.
Family History:
Ms. Vasquez reported she is of Nicaraguan descent but was born in California and moved to Florida at the age of 5. She currently lives in Hollywood, Florida with her mother and two sisters (ages 10 and 12). She reported her maternal grandmother helped raise her because her mother was working most of the time as she was the sole provider. She stated she has never gotten along very well with her mother. The client described her mother as “a very anxious person” who does not know how to listen or be supportive. She reported that her mother suffers from anxiety and depression. Client revealed that her mother is not supportive of her coming to therapy and stated that therapy was a waste of time. She reported that her father abandoned them when she was six years old. She also stated she was very close to her father and became really “distressed and miserable” when he left. She also reported that her father was verbally and physically abusive towards her mother. She described her grandmother as a “horrible person” who was verbally abusive towards her and her twin sisters. Ms. Vasquez stated her grandmother always had favorite grandchildren and she was not one of them. For example, she explained that when her cousin would hit her, her grandmother would do nothing to stop it. Additionally, the client reported her grandmother would always criticize her and make her feel inferior. She stated her grandmother would call her “ugly” and a “disgusting lesbian” because she did not wear dresses like her cousins. The verbal abuse lasted approximately 14 years until her grandmother moved out of the house. She reported that as a result of the abuse, she began to believe “no one will treat me right if my own family does not treat me right”. She also stated she believes the verbal abuse is a main contributor to why she is so afraid of what others may think. Ms. Vasquez explained she has assumed the caregiver role in her sisters’ lives due to the fact that her mother is never around. Furthermore, she described she had to be protective of her sisters at all times to ensure her grandmother would not mistreat them too.
Social History:
Ms. Vasquez reported that she was insecure growing up. The client reported that she did not have many friends growing up because her cousin, who was popular at school, would spread rumors about her because she did not like her. As a result, she reported no one liked her nor wanted to be her friend. She reported this lead her to believe she was not “good enough” to be anyone’s friend. The client stated it was very difficult growing up without many friends and caused her a significant amount of distress. Maria described herself as heterosexual and reported she has been in a relationship with her boyfriend for five years. The client reported she is not sexually active. She described her boyfriend as her only true friend and main source of support. She explained she wishes to be able to go out and be more social but feels no one wants to be her friend because she is not “good enough”.
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Medical/Psychiatric History:
Ms. Vasquez suffers from asthma since she was a child. In 2018, she had to go to the emergency room several times due to her asthma attacks. She was prescribed albuterol sulfate for her asthma by her general practitioner. She expressed she takes it as needed. Client reported her last physical exam was on July 12, 2019, which indicated everything was normal.
Substance Use History:
The client denied substance use. She denied ever drinking alcohol, smoking, or using any illegal substances. She expressed that her father is an alcoholic and that her uncle is a smoker and an alcoholic.
Educational/Professional History:
The client has never repeated a grade or skipped a grade in school. Ms. Vasquez reported performing at an average level, academically. She reported being a B student throughout her life. During high school, the client reported her GPA dropped due to the anxiety she was experiencing, which interfered with her ability to concentrate. In 2018, the client reported graduating from high school and enrolling in a local community college. In 2019, she enrolled in Florida International University and majored in social history education. She stated transitioning from a local college to a university has been challenging due to the fact she had to increase her class load. Ms. Vasquez reported that she is not currently employed and has never been employed.
Mental Status Examination and Behavioral Observations:
The client presented as a 20-year-old, Hispanic, female whose appearance was consistent with her chronological age. She was neat in appearance and appropriately dressed for the evaluation. She was visibly tense throughout the evaluation evidenced by the clenching of her hands. Ms. Vasquez was soft-spoken but very cooperative. Ms. Vasquez was oriented to person, place, and time. Her speech was clear and audible. Rapport was slowly established throughout the interview. The client managed to maintain good eye contact with the examiner and interacted positively. Client’s anxiety visibly declined by the end of the session. Her gait appeared to be within normal limits as well as her fine and gross motor movements. The client arrived half- hour late to the second evaluation and apologized about it. She expressed distress about being late and attributed the tardiness to the traffic. Client presented herself as less anxious and tense during the second evaluation. Ms. Vasquez denied past or present hallucinations or delusions and denied past or present suicidal or homicidal ideation, plan, or intent.
Teacher example template
Part 2
DSM-V Diagnostic Impression
300.4(F34.1) Persistent Depressive Disorder (Dysthymia), with Anxious Distress, Moderate
Sharon meets criteria for Persistent Depressive Disorder. Sharon demonstrates a depressed mood that occurs more days than not, for most of the day for at least 2 years. Depressed mood is manifested in the following examples: Feelings of sadness and hopelessness (e.g. as indicated in intake evaluation by client self-report); Low energy and fatigue nearly every day (e.g. client can no longer take walks or keep her room clean). Hypersomnia (e.g. client reports having to take a nap during the day even when she sleeps well); Insomnia (e.g. client often has trouble falling or staying asleep); Decrease in appetite (e.g. Sharon reports not having an appetite and weight loss over the past two years).
Additional symptomology includes difficulty concentrating because of worry, fear that something awful may happen, and feeling tense or keyed up, low self-esteem, anhedonia, and isolation from others. Sharon’s results from the Beck Depression Inventory II supports criteria for Persistent Depressive Disorder (28 out of 63 indicating moderate depression). Case analysis indicates that Sharon has a history of depressed mood dating back to childhood which she describes as always feeling sad or down. No signs of cognitive impairment have been noted. Sharon’s depression has been present for a duration longer than two years and cannot be explained by another disorder or medical condition.
Conceptualization
Cognitive-Behavioral Framework
Sharon’s mental model of which she operates on the world is one that is essentially on auto pilot. Her depressive thoughts that she has carried from childhood have crippled her throughout her life from participating in life. Sharon’s rumination about potential scenarios paralyze her when challenges do arise. Sharon’s history of depressed mood and feelings of anxiety can be traced back to when she was young. Her mother often criticized her for everything even as a young child. Sharon’s recollection of being a small child and her mother shaming her and screaming at her because she was innocently touching her genitalia as young kids often do. Sharon described many instances where she felt sad and isolated in her room when her mother was screaming and angry with her father. She described feeling panic and excessive worry over the possibility that she might faint after seeing classmates faint in school due to the heat and no air conditioning. These experiences led to Sharon interpreting the world as a scary, judgmental place that wasn’t kind, patient, or loving. The construction of her cognitive schema that made led her to feel judged, and not good enough and led to her belief that everyone would judge her, and she wouldn’t be up to par or accepted. Sharon’s marriage has been not only a result of this negative schema but has strengthened her belief that there is no hope for her life or happiness which has exacerbated her symptoms.
Sharon was referred to therapy by her children who gave her an ultimatum to get help as they were concerned with worsening mood. She presented with feelings of hopelessness and sadness, low energy, and anxiety. Sharon’s depression has been encouraged throughout her life by automatic, negative thought processes that she has never recognized nor challenged. Her maladaptive thinking has trapped her in a cycle that stops her from exploring the world as an active participant. Sharon’s depressive symptoms have worsened over the past several years due to her resistance to aging and beliefs about how the world perceives she is aging compared to her friends and family.
From a cognitive-behavioral approach Sharon’s depression is not specific to certain life events but rather due to her perception of them and how it relates to her. How she thinks others view her is based on how she feels they see her rather than the reality. Sharon’s maladaptive thinking might tell her that people are going to judge me, so I am going to be uninterested, so they think I don’t care how they think. Others may see her behavior as being rude or uninviting which will then result in an unsuccessful connection. This cycle reinforces Sharon’s belief that people don’t like her because they are judging her and she’s unlikeable so “why bother?” This schema has been reinforced as she ages and her “looks” fade.
Sharon has some noticeable strengths that she brings to therapy. Despite growing up with two parents who were emotionally detached and a mother that was critical, unsupportive, and not loving, she has an abundance of love for her children and grandson. She is particularly involved with her grandson and has a close bond with him. She also has a long history of maintaining and exceling at her jobs in the past which will be helpful to her as it shows that she can rise to the occasion and support herself which shows her desire to thrive. Treatment goals will be a collaborative effort between Sharon and I and interventions will aim to reduce her depressive symptoms while improving her current level of functioning.
Treatment Plan
Long Term Goal 1: Symptoms of depression will be reduced and no longer interfere with Sharon’s daily functioning. This will be measured by utilizing the Beck Depression Inventory II weekly. Scores will show a reduction from ‘moderate’ to ‘minimal’ or’ mild’.
- Learn to recognize negative self-talk/automatic thoughts by doing “thought challenging record.” The record will have a space for situation, bodily sensations, self-critical thought, and alternative
- Sharon will learn to identify negative self-talk and learn to replace maladaptive thoughts with adaptive ones. She will practice this in session and will complete cognitive restructuring worksheets for homework to bring with her to sessions.
- Sharon will learn to identify different patterns of negative thought patterns by keeping a journal to record different life events and her reaction to them.
Long Term Goal 2: Sharon will work to improve her mood and energy by engaging in social activities and physical exercise. She will explore new interests that align with her strengths and her progress will be tracked through CBT workbook and journal. We will talk about activities and review progress in session.
- Sharon will seek out a weekly activity to try that meets once a week to expand her social engagement.
- Sharon will begin to increase physical activity by incorporating mindfulness walking around her pool area every day. While walking around she has to use her senses to focus on what she hears, sees, and feels. She will use an activity log worksheet to track each day’s activity including a description of things she saw, heard, or felt on her walk.
- Sharon will connect with her daughter and/or grandson once a week to remain engaged socially and increase support.
Long Term Goal 3: Sharon will recognize and change the internal relationship she has with thoughts and behaviors to maintain progress made in therapy and prevent relapse. Sharon’s treatment will utilize Mindfulness-Based Cognitive Therapy (MBCT) and psychoeducation and will be tracked through her journal and worksheets.
- Sharon will learn the eight skills of MBCT that includes concentration, awareness/mindfulness, being in the moment, decentering, acceptance, letting go, being, and bringing awareness to a manifestation of the problem (Berman, 2018, p. 303).
- Sharon will do body scan exercise to become aware of herself in the moment. She will focus on each area of her body from her head to her toes bringing awareness to each area and talk about what her experience was.
- Daily mindfulness activities and worksheets. Sharon will practice mindfulness in her daily life choosing one activity in her day to experience with all of her senses. She will chart one experience of her choice a week.
References
American Psychiatric Publishing. (2013). Diagnostic and statistical manual of mental disorders: Dsm-5. Washington, DC.
Berman, P. S. (2018). Case conceptualization and treatment planning: Integrating theory with clinical practice. SAGE Publications.
Part 2 needs to be completed in its entirety
I would like to use Generalized Anxiety disorder
