Diagnostic and statistical manual of mental disorders

BIOPSYCHOSOCIAL ASSESSMENT

 

STUDENT’S NAME: Leticia I. Cordero

 

NAME OF FICTIONAL CHARACTER: Hilda Acevedo

DOB: 05-28-1997

AGE: 22

GENDER: Female

MARITAL STATUS: Single

OCCUPATION: Employee Part time

NATIONALITY/ETHNICITY: Dominican

RACE: Hispanic

RESIDENCE/LIVING CIRCUMSTANCES: Lives with maternal grandparents

REFERRAL SOURCE: Administration For Children Services

 

 

REASON FOR REFERRAL

 

The case was referred program through the Field Office on 10/26/19, with allegations of substance use against client related to her child. Client tested positive for marijuana at the birth of baby. baby was born on 2019 at hospital. She tested negative for all substances

 

 

HISTORY OF CHIEF COMPLAINT

 

Client reports that she began smoking cannabis at the age of 18 and steadily increased to smoking three times a day. She states that she stopped when she was four months pregnant, prior to that she was unaware of the pregnancy. She reports that she then stopped smoking for the duration of the pregnancy with the exception of one month before delivery when she was upset about the uncertainty of the baby’s paternity. She indicates that her main triggers for use were negative emotions (e.g., anger, sadness).

 

SIGNIFICANT MEDICAL HISTORY

 

There are no known medical concerns.

 

MEDICATIONS

 

No medications

 

 

BACKGROUND INFORMATION

 

BORN & RAISED

 

Client is a domiciled twenty-year-old woman who was born, raised and currently resides in the New York.

 

FAMILY

 

PARENTS: Age/living-deceased, client’s age and reaction to death and consequences

Personality characteristics of Mother (discipline, involvements, characteristics)

Personality characteristics of Father (discipline, involvements, characteristics)

General physical and mental health during client’s childhood

Parental history of substance abuse, physical, emotional, sexual abuse, or traumas

 

MARITAL: Single never being married. 1 sister. client currently lives with her maternal grandparents. Family has lived there for over 20 years

 

 

 

CHILDREN (NATURAL & ADOPTED)

 

Pregnancies: 1 unplanned; accepted.

 

GRANDCHILDREN: None

 

 

EDUCATION:

 

Complete 11 grade in high school.

 

OCCUPATION

 

Lifeguard

 

MILITARY SERVICE

 

None

 

LEGAL/CRIMINAL HISTORY

 

N/A

 

PSYCHIATRIC HISTORY

 

Client reports a history of trauma, including early separation from her mother due to her mother’s incarceration and subsequent deportation to country of birth, attempted sexual assault by a stranger last year and physical altercations in the community. Nevertheless, client denies any current symptoms of Posttraumatic Stress Disorder.

 

 

 

SUBSTANCE ABUSE HISTORY (Past/Present)

 

ALCOHOL: None

DRUGS: In terms of substance use, her reports on the ASSIST (Score = 19/Cannabis) and UNCOPE (Score = 2) are consistent with her clinical interview. She reports that she smoked one blunt one month prior to giving birth. However, prior to discovering she was pregnant, when she was 4 months along, she would smoke 3 “blunts” a day. She acknowledges that smoking cannabis helps her “forget” about the stressful aspects of her life. Client reports that she began smoking cannabis at the age of 18 and steadily increased to smoking three times a day. She states that she stopped when she was four months pregnant, prior to that she was unaware of the pregnancy. She reports that she then stopped smoking for the duration of the pregnancy with the exception of one month before delivery when she was upset about the uncertainty of the baby’s paternity. She indicates that her main triggers for use were negative emotions (e.g., anger, sadness).

 

TOBACCO: None

 

CAFFEINE: None

 

 

ABUSE HISTORY

 

SEXUAL: Attempted sexual assault by a stranger last year.

 

 

PHYSICAL: Client denies at this time

 

 

EMOTIONAL:

 

Client reported a significant loss when her mother was incarcerated then subsequently deported to country of birth. Client denies any negative feelings towards her mother and reports that her maternal aunt is to blame because she introduced her mother to criminal activities. Client reported that as an adolescent she initially used cannabis socially but then began using it more frequently. She often used cannabis to numb her emotions and no longer have to think about the stress that was going on in her life at any given moment. Client may be struggling with her identity as a mother given the history of her unexpected separation from her own mother. It is likely that she has attempted to fill that emotional void via substance use and poor relationships. Nevertheless, she appears motivated to engage in services that will support her and assist her in fulfilling her role as a new mother.

 

 

 

SEXUAL HISTORY

 

Client denies at this time

 

BEHAVIOR OBSERVATIONS

 

During the interview, Client was generally forthcoming and pleasant. She denied feeling overwhelmed by the involvement of ACS and she reported feeling grateful that baby was not removed from her care. Throughout the interview, Client presented with blunted affect and therefore at times it was difficult to ascertain her feelings or level of understanding on particular topics, especially related to the ACS process. Given Client’s history, it is a possibility that she lacks a sense of agency and therefore does not provide much input into decision making processes.

MOOD/AFFECT

 

SLEEP PATTERNS: N/A

 

EATING: N/A

 

ACTIVITIES OF DAILY LIVING: N/A

 

MOTIVATION: N/A

 

ANXIETY/AGITATION/PANIC ATTACKS: N/A

 

BEHAVIORAL CHANGES: N/A

 

IMPULSIVITY: N/A

 

RACING THOUGHTS: N/A

 

 

PROBLEM SOLVING

 

 

 

SHORT & LONG TERM MEMORY

 

ATTENTION :

 

 

CONCENTRATION:

 

 

MENTAL STATUS EXAM:

 

Orientation to:

Person

Place

Time

Situation

Familiar objects (hold up hand, pencil, watch…)

Other people (family members, doctor…)

 

 

THOUGHT PROCESSES & CONTENT

 

 

SUICIDAL/HOMICIDAL IDEATION

 

The client denies any current suicidal ideation, any past suicide attempts or any current non-suicidal self-injury. She reports a history of passive suicidal ideation as a teenager but did not have any plan, intent or previous attempts. She also reports a history of one event in which she engaged in non-suicidal self-injury in which she scratched herself superficially with her nails. She denies any current or past homicidal ideations.

 

INSIGHT/JUDGEMENT

 

 

PERSONALITY FACTORS

 

 

ADJUSTMENT

 

 

STRENGTHS:

 

• Client is willing to engage in MH services and substance abuse treatment.

• Client has identified sources of support in her community and family

• She exhibits a sense of self-awareness and the function of substances in her life.

• Client has been observed to exhibit warm and appropriate interactions with her child

• baby was observed to be well cared for during the evaluation and during home visits.

 

LIMITATIONS:

None

 

SUPPORT SYSTEMS:

 

Father, maternal grandmother, sister and mother.

 

 

 

PROGNOSIS

 

 

PATIENT CONCERN’S/GOALS:

 

 

CONCERNS: Client’s marijuana use and Client history of poor impulse control/lack of coping skills.

GOALS: Consistent engagement in MH services and substance abuse treatment.

 

 

DIAGNOSIS

Generalized Anxiety Disorder 300.02 (F41.1)

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least

6 months, about a number of events or activities (such as work or school performance).

B. The individual finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least

some symptoms having been present for more days than not for the past 6 months):

Note: Only one item required in children.

1. Restlessness, feeling keyed up or on edge.

2. Being easily fatigued.

3. Difficulty concentrating or mind going blank.

4. Irritability.

5. Muscle tension.

6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse,

a medication) or another medical condition (e.g., hyperthyroidism).

F. The disturbance is not better explained by another medical disorder (e.g., anxiety or worry about

having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia],

contamination or other obsessions in obsessive-compulsive disorder, separation from attachment

figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder,

gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived

appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder,

or the content of delusional beliefs in schizophrenia or delusional disorder).

 

 

 

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Signature Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reference

 

 

American Psychiatric Association. (2013). Diagnostic and

statistical manual of mental disorders (5th ed.). Washington, DC:

Author.

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