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Discuss the following considerations related to the diagnosis used:
C. Describe the developmental patterns of the client. [COU-650-02]
- Describe the observable behaviors. [COU-650-02]
- Identify what other diagnoses that should be ruled out. Make sure to provide rationale. [COU-650-02]
- Identify limitations with this diagnosis. Make sure to provide rationale. [COU-650-02]
- Use evidence-based research to support your justification. [COU-650-02]
Runninghead: BIOPSYCHOSOCIAL SUMMARY 1
Biopsychosocial Summary Draft
Stephanie Badio
Southern New Hampshire University
BIOPSYCHOSOCIAL SUMMARY 2
Regarding the Biopsychosocial assessment of Amelia, it would be important to claim that
the client is involved in biological, psychological and also the socio-economic environmental
factors that are making her suffer from the situation she is suffering from. As an example,
Amelia is suffering from depression and this is not only a biological but also psychological and a
socio-environmental factor. Regarding the biological factor, it would be deemed that the family
members of Amelia had been associated with depression. Regarding the psychological factor, it
would be argued that Amelia is suffering from depression because of the situation that she is
undergoing and when it comes to the socio-environmental factor, it would be deemed that
Amelia is suffering from depression because of the environmental situation that she is being
exposed to them.
Description of the Problem
Amelia is seeking help for depression issues and anxiety and the problem arises from
multiple symptoms. As an example, she stated that she is not feeling like herself and also reports
days that she cannot go out of bed and at times or in certain days, she feels that a certain
individual might have gotten her out of her senses. Therefore, the above problems are all the
instances that Amelia is seeking help and she feels that if help fails or lacks in her situation, then
she is unlikely to survive. By assessing the situation presented by Amelia, then it would be
important to claim that the lady is suffering from numerous situations that also require the
intervention of a counselor to assist her with effective skills of coping with the situation that she
is facing and the one that will help her get out of the bed where she is lying and also leave alone
the destructive thoughts she is experiencing.
Problems, Issues and Challenges Faced
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BIOPSYCHOSOCIAL SUMMARY 3
The notable problems that Amelia is facing are being a depressant person and the one that
might not get out of her bed. She is also experiencing an issue that she cannot get out of her bed
and feel like herself. Regarding the issues that Amelia is facing, she feels like she is sick and at
times, she also feels that the environmental situation might be leading to her health problems.
Challenges exist as far as the presented case is concerned but the notable ones include the lady
not feeling like herself and this means that she cannot be assisted. The other challenge is that she
requires a person to counsel her, but it is unfortunate that due to her situation, she is unlikely to
find a person that will help her.
Symptoms affecting the client
Numerous symptoms exist that are affecting Amelia and they include, the behavioral
symptoms, i.e., she has anxiety which might affect her negatively and the cognitive symptoms is
that she feels that other individuals have been involved in the same situation. The other symptom
is that she felt that some of them recovered from the situation while the other failed to recover
from the incident and all of these are instances of cognitive symptoms that are affecting the lady.
The emotional symptoms are that are she feels not being like herself. She also feels that
somebody is making her to feel as if not being herself. The physiological symptoms are that she
feels the environment where she lives is not sufficient to enable her recover and the harmful
behavior that are making the woman suffer is that she feels that some people are getting her out
of her sense and this is a harmful behavior on the side of Amelia. The other harmful behavior is
not having effective coping skills as these are skills that have to be developed by a person even
before the situation occurs.
Potential harmful behaviors
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One of the potential harmful behaviors of Amelia is that she is highly aggressive. This is
a behavior that could harm her and also her family members. She feels that she needs to recover
from depression, and this is not a situation that can be made in a single week. However, she feels
that it can be done in a week. She is also aggressive in that she feels somebody is making her
suffer from the situation she is suffering from and if such people are eliminated, then she could
be well. Therefore, all of the above instances are harmful behaviors that would hinder the
recovery of Amelia.
Certain potential and harmful behaviors
Notable potential and harmful behaviors exist, and these include the consumption of
certain substances like alcohol where the person had been using alcohol as early as at the age of
14 years and it was oral. The individual also had been subjected to Marijuana and all of these are
instances that are likely to lead to depression.
Family history of diagnosis and its effect
As per the case and out of the life situation of Amelia, it would be important to argue that
she is finding it hard to make friends and once made, she is unable to keep them. This is a
notable characteristic of people suffering from depression and these are individuals that have a
family history of the situation. Therefore, it would be argued that Amelia has a family history of
depression.
Use of evidence-based research
Evidence-based research has not been used in case of this patient. The reason for
claiming this instance is that no information has been presented regarding the patient and
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this, revisit this detail
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BIOPSYCHOSOCIAL SUMMARY 5
especially, the medication for depression. In evidence-based practice, Amelia would have been
subjected to cognitive behavioral therapy.
Identification of the client
The client could be identified from her cultural practices and out of the situation, it would
be essential to argue that Amelia is a CIS-female. She believes in growing up like a roman
catholic, but she does not practice it. Since the cultural and religious practices of an individual
would influence the delivery of evidence-based medical practice, then it would be important to
argue that the identification of this client would not adversely affect the delivery of evidence-
based medication, (Melnyk & Fineout-Overholt. (2010). Therefore, an instance of evidence-
based practice is evident.
Commented [R4]: Need at least one research study to
support clinical practice with the symptoms Amelia is
presenting
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need to address for amelia
BIOPSYCHOSOCIAL SUMMARY 6
Reference
Melnyk & Fineout-Overholt. (2010). What is the role of evidence-based practice in the nursing
profession?
Commented [BS6]:
RunningHead: DIAGNOSIS JUSTIFICATION DRAFT 1
DIAGNOSIS JUSTIFICATION DRAFT 5
Diagnosis Justification Draft
Stephanie Badio
Southern New Hampshire
Justification of major depressive disorder
The overall descriptor of the diagnosis
The major depressive disorder may be described as a mood disorder that causes sadness and victims may lose interest in many activities. The disorder affects how people think and behave and is associated with several physical and emotional challenges. Victims of the disorder may see life as meaningless and may go to the extent of attempting to take their own lives. The diagnosis of the disorder involves a systematic physical and blood examination (Misaki et al., 2016). Doctors should keep track of the patient’s medical history, as medical events such as accidents may contribute to such a disorder. It also requires a long-term treatment for one to recover completely.
The criteria that must be met for the diagnosis
According to DSM 5 criteria, a patient must display at least two or more of the following symptoms; insomnia, appears to be depressed most of the time, the rapid loss of weight, diminished interest I most activities, frequent fatigue, a lot of guilt and feeling worthless, indecisiveness, poor concentration, and attempting suicide. A person experiencing these symptoms may have impaired social and occupational functioning (Park et al., 2017). The symptoms may lead to a diagnosis of major depressive disorder if they are not attributed to any other condition or abuse of drugs and substances.
Client behaviors that are used to meet the diagnosis criteria
Sarah, the client presented in the case study displays some behavior that may be used to meet the criteria for diagnosing the major depressive disorder. Sarah experiences restless nights and on several occasions, she has had nightmares reminding her of the phone call about the death of her fiancée. She is withdrawn and has lost interest in many activities she used to love. Sarah’s father reveals that the client has been emotionally detached, and no longer goes out with family and friends. She has lost appetite and has noted a drastic loss of weight too.
Cultural limitations that are known about the identified diagnosis
Different cultures have different perceptions about mental health and in such a diagnosis, the treatment may be limited by cultural perspectives. One of these limitations is that the stigma associated with poor mental health may make some patients fear to seek medical attention. In some cultures, depression is not regarded as a disease, and those suffering from depression do not consider medication as a way of treating the disease. In countries like China, they deny that emotional depression exists. These cultural perceptions hinder the successful treatment of depression through counselling and medical treatment processes.
Developmental patterns of the client
Sarah has an unpredictable pattern because she seems to display different symptoms at different phases of the disorder. Immediately the fiancée was involved in an accident, she stared hang restless nights that were accompanied by nightmares. The anxiety rolled out to her work and she was forced to quit the job because she could not concentrate anymore. Later, she became withdrawn and lost interest in what she loved most, as revealed by her father. She later lost appetite, and the last observable symptom is that she has lost a lot of weight.
Observable behaviors of the client
Sarah also displays some behaviors that can be observed. One of them is the restless nights that were full of nightmares. Also, the workplace became unbearable and she returned home earlier than usual. It is also observable that she is no longer that fun-loving and outgoing girl as she spends most of the time alone. She does not work out as she used to, because she seems to have lost interest in managing her body.
Other diagnoses that should be ruled out
When diagnosing a patient with major depressive disorder. Doctors may have to rule out suspected diseases that may have similar or related signs and symptoms. One of the disorders is seasonal depression which may have similar symptoms as major depression. However, contrary to major depression, patients who have seasonal depression usually gain weight instead of losing. Another disorder that should be ruled out is bipolar or manic depression which may also have related symptoms. The slight difference between maniac and major depression is that bipolar victims have too much confidence and self-esteem. They may also have too much energy which does not happen with patients suffering from a major depressive disorder. The last disease that needs to be ruled out is situational depression, whose only difference from major depression is that victims of situational depression often experience body pains and patients may cry often.
Limitations of this diagnosis
Using DSM to diagnose mental health is limited for various reasons. The first limitation is the possibility of over-diagnosing or misdiagnosing a patient. Based on the DSM criteria, a client may be diagnosed with a mental disorder simply because one’s actions and behaviors do not match with what the society considers to be ideal. The process may also lead to stigmatization because therapists may label patients if they do not work carefully and professionally (Ogasawara et al., 2018). Other critics also argue that the DSM criteria are oversimplified, and people may lose the human touch or element in the diagnosis process. It is advisable hat therapists should be professional to enhance the accuracy of the diagnosis
References
Misaki, M., Suzuki, H., Savitz, J., Drevets, W. C., & Bodurka, J. (2016). Individual variations in nucleus accumbens responses associated with major depressive disorder symptoms. Scientific reports, 6, 21227.
Ogasawara, K., Nakamura, Y., Kimura, H., Aleksic, B., & Ozaki, N. (2018). Issues on the diagnosis and etiopathogenesis of mood disorders: reconsidering DSM-5. Journal of Neural Transmission, 125(2), 211-222.
Park, S. C., Kim, J. M., Jun, T. Y., Lee, M. S., Kim, J. B., Yim, H. W., & Park, Y. C. (2017). How many different symptom combinations fulfill the diagnostic criteria for major depressive disorder? Results from the CRESCENT study. Nordic journal of psychiatry, 71(3), 217-222.
Biopsychosocial Assessment
Client Name:_Amelia yee Jones________________________________ Chart # _________________NA_____
Evaluating Counselor __Stephanie Badio___________________________________ Date ______7-4-2020____________
Please indicate “NA” if the question/section is not applicable to the client’s history. DO NOT LEAVE ANY SECTION/LINE BLANK.
Presenting Problem: (Include the client’s own words about why the services are needed, any referrals, and major stressors over the past six months.)
Amelia is a 42-year-old female who is presenting with depression issues and anxiety followed by multiple symptoms. Amelia stated, “not feeling like herself”. She also reported that she has days she can’t get out of bed, while other days she is concerned that someone is “out to get her”. Client is in need of seeing a counselor to help with effective coping skills to get out of bed and destructive thoughts. Amelia significant other also observed her staring out of space at times which can be concerning considered her symptoms. Over the past six months these are some stressors she experienced abnormal thoughts, anxiety, appetite disturbance and more. Amelia was severely bullied and mentally abused while in school between the grades 2-11th.
Past Treatment History: (Include past treatment history for substance abuse AND mental health services) Amelia was physically abused by both her father and significant other. Amelia been to counseling therapy and consulted several therapists off and on since the age of 13 years old and last one was 2006 along with psychiatric hospitalization. Amelia has participated in traditional talk therapy, EDMR, CBT, ECT, psychoanalysis, play therapy, and lmogo therapy. She has been notified by professional to take medications prescribed such as antidepressants, antianxiety, and mood stabilizers which Amelia believed was not effective because symptoms did not change.
Family History: (Include biological family members, number of children, divorce, separations, describe what it was like growing up in this family, and include substance abuse and psychiatric history of family members)
Amelia has 2 brothers and 2 sisters her father deceased at the age of 12-year-old when he was working on a construction site. Her parents were separated she did not get along well with her parents. Although her siblings live close to her, she does not have a good relationship with them except for the youngest one. Amelia has no children and has been married for 22 years by her wife. No substance abuse on Amelia part but mentioned mental health history in family history from mother, brother, and sister. Amelia described her relationship with her mother as they talk 2-3 times a day. Amelia was married at the age of 20 years old. Amelia resides in a 3-bedroom house. Both parents used drugs and alcohol. Mom is a widowed.
Substance Abuse Drug History: (Include top three drugs of choice)
1.alcohol
2. marijuana
3.NA
Substance Type
Age of First Use
Route of Administration
Amount Used
Frequency of Use
Date of Last Use
Treatment Where/When
Alcohol
14
oral
2-3glasses
week
n/a
na
Cocaine
na
na
na
na
na
NA
Marijuana
14
Smoking
na
14-23
na
No longer
Heroin
NA
NA
NA
NA
NA
NA
Other Opiates
Na
BZs
NA
Methadone
NA
Suboxone
NA
Tobacco
NA
(List any withdrawal symptoms as reported by client (sweats, constipation, DTs, seizures, etc.):
No none withdrawal symptoms reported by client
Social History
Client’s Current Life Situation: (Summarize present living arrangements, and any current social supports)
Amelia finds it very difficult to make friends but once make friends its easy for her to keep them. Amelia has 3 close friends
Sexual Orientation:
Amelia is a CIS-female
Spiritual Beliefs: She grew up as a roman catholic and no longer practice.
Employment History
Employment: (Include longest continuous employment, type of employment, typical length of stay, present employment, and military history)
Amelia is currently employed in the American school district and client is a LPC treating children who struggles with school performance and family issues. No history of military known. Amelia has been at her current job for the past 10 years. Amelia mentioned finding difficulty maintain employment.
Education: (Note highest level of schooling completed, school performance, peer relationships, learning problems)
Amelia obtained her master’s degree graduated in 1999 she was a A/b student, excellent in math and science. Struggles in English, spelling, and reading. Amelia was diagnosed with dyslexia but was never suspended from school.
Medical Health History: (Include illnesses, surgeries, medications [OTC and prescription]. Note any current medical problems, physical disabilities, and/or eating disorders. Please include gynecological history and pregnancies):
Amelia was diagnosed with dyslexia, severe allergies and asthma, hysterectomy at age 38, broken legs as a toddler due to a car accident.
Primary Care Physician:
Name: ____PCP_____________________________________________________
Address: _123 street______________________________________________________
Phone: ____1234567899__________________________ Fax: ___NA____________________
Date of Last Physical Exam: ___NA_________________________________
Hospital of Choice: ____NA_______________________________________
Allergies: _______dust, animal, nuts, pollen,dairy_______________________________________________
Medical Medications: (Include name of medication, dose, the condition it is treating, and its effectiveness)
___anti-depressants__________________________________
___________mood stabilizers________________________
__________________NA___________________ ________________NA___________________
_______________NA______________________ __________________________NA_________
Mental Health/Psychiatric History:
Have you ever been treated for a psychiatric illness: Yes or No
Please explain: (Include if client had been hospitalized, seen by a mental health professional, what they were seen for, and how long they were seen)
Client been to therapy at the age of 13. Seen and professional suggested medication. Amelia was seen for psychiatric issues.
Any SI/HI or plan in past or present? (Please explain if “yes”)
No known SI/HI plan by client
Psychiatric Medication History:
Drug Name
Antidepressant
Prescriber
NA
Dosage
How long have you been taking it?
Are you currently taking this medication?
Reason for this medication/diagnosis
Mental health and anxiety
NA
NA
NA
NA
Legal History:
(Note any charges and dates, any outstanding warrants, court dates, description of crimes, convictions, incarcerations, etc.) no legal issues or involvement
· No legal issues. no
· Currently on probation. no
· Pending warrants. no
· Jail term served. no
· Court cases pending no
· Parole no
Please explain with detail any and all of the above checked:
Clients Self-Assessment of Strengths: Clients Self-Assessment of Weaknesses
1. __compassion____________________________ 1. __ability to forgive_________________________________
2. _______make sure my relationship is fulfilling for my partner_______________________ 2. _feel better about myself and be able to feel more motivated to do the things I want/ need to do. I want to be able to manage my emotions better and not let things overwhelm me. _________________________________
3. ______________________________ 3. ___________________________________
Recommendations:
(This narrative section pulls all of the information together, with a clinical opinion about what the primary issues are, and what should be done to address them. Also, state potential referrals to rehabilitative, IOP, and others that are appropriate at this time.)
Client presents as a 42-year-old multi-race CIS-female who has been married for about 22 years. She got married at the age of 20 years old. Amelia was abuse mentally physically by both her father and boyfriends. Amelia has four siblings but only close to the youngest one. Amelia has been diagnosed with dyslexia asthma and severe allergies to pollen, animals, and nuts. Amelia’s father passed while on site at work left her mother as a widow. Her relationship with her mother is described as fair. Growing up she did not get along with her parents and was bullied at school. She has no legal issues although she had some issues with substance use at the age of 14 from both alcohol and marijuana. She currently has her masters and work as a LPC with children having difficulties in a school district where she been working for 10 years. She has been prescribed medication form her pcp antidepressants, mood stabilizers for her status. She struggles with several symptoms and especially lack of sleep. For Amelia’s condition this clinician suggest Amelia to seek further counseling and 1:1 session regarding her lack of sleep. Amelia should also consider identify her triggers, and underlining issues.
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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Clinician/Counselor Signature: ________stephanie Badio____________________________ Date: __________today_
Clinical Director Signature: _____________NA__________________________ Date: _____today______