Biopsychosocial assessment of a trauma survivor with PTSD

Biopsychosocial Assessment

Grace Manchester

D.O.B: 12/4/1983

Presenting problem

The client has a rather extensive history of sexual abuse that began at age 8 and which subsequently led her to develop an acute case of PTSD. The patient reports a lot of flashbacks of feeling frightened whenever she is in the dark. She also has a long history of problems associated with socializing, self-harm, low-self-esteem, severe migraine, insomnia as well as depression. As of last year, she has had a strong urge to commit self-harm. The most recent case led to hospitalization at the Jackson Memorial Hospital (Miami). This was a result of suicidal ideation that resulted to suicide attempt that required a total of 9 sutures for a cut sustained on her left wrist. He wish is to begin an extensive outpatient therapy. She said that her wish it to have a normal life like everyone else, end her behavior of self-harm as well as address her traumatic issues as well as improve her rather low self-esteem

Social history

The client is a 28-year-old Caucasian female who was born in Texas but now living in Miami, Florida. She speaks English as her primary language. She lives with her parents. She attends university at Miami University; College of Arts & Sciences where she is enrolled in Masters in Political Science. She is typically a good student with exceptional grades. Her parents divorced when she was 10 upon her mother realizing that her father was sexually abusing her. The client describes her mother as a strict disciplinarian who is also a 'cleanliness freak'.

Family Dynamics

The client mentioned that she is an only child. She has also never had any form of contact with her father. The mother works as an auditor with Deloitte.

Medical history

The client reported no developmental problems. Her mother mentioned that she began to walk at a pretty younger age. She suffered from measles in her younger days. She also broke her left leg in a fall from a tree when she was five. During early puberty, she developed migraines. The patient has no form of allergies or any form of food sensitivities. She has a healthy sexual life with her boyfriend.

Legal history

The client has no idea if her father was charged for the sexual abuse case since her mother often refuse to comment on the incident.

Offender issues

She has not been charged with any offence in her background.

Victim issues

The client was unfortunately abuse sexually by her biological father when she was nine years old. He mother's boyfriend also physically abused her when she was fourteen.

History of substance abuse

Substance

Quantity/Amount

Frequency of usage

Duration of usage

First use

Last use

Alcohol

Reported fair use

Many times

Long time

Age 14

Tobacco

Tried

Several times

Several times

Age 16

Marijuana

Denied

Narcotics/Opioids

Medication as appropriately prescribed

Cocaine

Denied

Amphetamines

Denied

Hallucinogens

Denied

Others

Denied

Personal Assets as well as Liabilities

The client reports that she is very spiritual as opposed to religious. She attends Catholic church service with her family and friends on special occasions like Easter and Christmas as this seems to please her mother.

Her favorite hobby is reading novels.

The act of cutting her wrist frightens her. She has no transportation problem; therefore her Initial Diagnostic Interview with Dr. Philips is scheduled for 12/1/11.

Summary

The 28-year-old female demonstrates a high level of depression as well as anxiety as indicated by the symptoms of flashbacks, repetitive nightmares, insomnia, poor appetite as well as a general feeling of emptiness. Her behavior of self-harm (cutting) has also increased. She has a physical and sexual abuse history all of which affect her current mood.

Diagnosis

The client was diagnosed with Post-Traumatic Stress Disorder, Depression and migraines.

Master problem list

Client: Grace Manchester

Date of Identification

Problem Code

Problem Statement

Status

Date of Resolution

6/23/11

M2

The client has a chronic medical problem which interferes with her life

A/C1

Reports incidents of self-harm

A/C2

Reports incidents of migraine

A/C3

Reports suicide ideation

A/C4

Reports anxiety

A/C5

Reports severe migraines and headaches

P1

Reports psychological as well as mental problems for the past one month

P2

Reports severe depression which has increase in intensity for the last one month.

Treatment plan

The client should be enrolled for a cognitive behavioral outpatient therapy to help in addressing her recent increase in depression as well as self-harm behaviors. The most appropriate therapy at this time is individual therapy which should be carried out weekly with a re-evaluation to be carried out at the end of every two months.

Relaxation therapy as well as cognitive behavioral therapy should be administered to cure the symptoms of anxiety.

A safety plan must also be created for he own protection just incase she continues with her cutting behavior.

Beck's Depression Inventory should be administered to her to take care of her measure depressive though pattern. This would then be used to measure he current baseline symptoms

Empirical- based therapeutic intervention for the client

For the depression, the client should be enrolled for psychotherapy (Nemade, Reiss and Dombeck,2007) as the evidence-based treatment for the major depression. The modalities the psychotherapeutic treatments are; Cognitive and behavioral therapies (CBTs), psychoanalytic therapies (both focal and long-term),systematic therapy / family therapy, personal construct and eclectic therapies (Whifield and Williams,2003).

The psychotherapy as an intervention was chosen due to its effectiveness in curing depression while modalities of psychotherapies such as Cognitive and behavioral therapies (CBTs) was chosen for its effectiveness in curing anxiety and depression, psychoanalytic therapies was chosen to cure the patient's fears, systematic therapy / family therapy was chosen so that her relationship with her mother can be improved, personal construct and eclectic therapies were chosen to help her build her self-esteem

Discharge Goals

The following are the discharge goals;

By the end of the first three months, the client should be able to;

Have a high-self-esteem

Must be able to take her medication as prescribed

Must be able to socialize easily

Must report to the psychiatrist every 2 weeks

Must be able to resist suicide ideation

Will verbalized a decreased anxiety level