Biopsychosocial Evaluation - Case Study Example

Presenting Problem The patient is an 18 year old African American female atthe local penitentiary convicted of attempted suicide and possession of drugs. During the first visit the patient was very untidy, movements uncoordinated, unresponsive and very depressed. The patient also exhibited bouts of violence and had to be restrained by prison officials. The patient was also showing signs of cocaine withdrawal symptoms and the social worker confirmed that the patient was actually found in a coke house by the police 5 days prior to the day of first visit. The social worker also explained that the patient had also attempted suicide by slitting of the wrist. The social worker had recommended for psychiatric evaluation and treatment plan. Personal History The patient spent most of her childhood in foster after her single mother died of drug overdose when the patient was 8 years old. The patient had to be hospitalized for severe depression and Post Traumatic Stress Disorder (PTSD). At the age of 14 the patient ran away from a foster home and engaged in a casual romantic relationship with an 18 year old man. They stayed together for 3 months and then the relationship ended after the man complained that the patient had become abusive and was taking drugs. The patient continued to stay alone and survived by being picked up by men from bars and having casual sex with the men. The patient also reported to having 2 sexual relationships with women but confessed that she liked men and just experimenting. The patient has gotten pregnant twice but was forced to abort as a result of poor health. At schools teachers revealed that the patient was usually very withdrawn and avoided making friends. However, the patient was an averagely bright student but a few months prior to her disappearance the patient had shown an unusual untidiness, rudeness towards the teacher and students and was extremely irritable. The patient had ended up in a coke house after she could no longer afford the drugs. The patient has also not been able to keep a job for the past 5 years and the employers always complain of her negligence and disappearance from work for days. Psychiatric History The first instance where the patient was diagnosed for mental disorder was when the patient was years old after the death of her mother. The patient’s mother was found dead in the house for 3 days after the patient failed to go to school ad concerned teachers decided to visit their home. The patient was found in the house exhibiting symptoms of PTSD. According to the attending psychiatrist, the patient was in denial and kept on saying that the mother was just asleep. The patient also showed significant memory loss after the incident and had frequent nightmares. Due to her condition the patient had to be hospitalized and afterwards placed in a counseling program that involved a home environment where she would feel loved and appreciated, stayed out of school for three weeks to allow for enough rest and to give the patient time to recollect and recall the traumatic event in small bits. The patient was also allowed time to mourn the mother. The doctor reported that the mother had been raped at the age of 16 years and had also been diagnosed for PTSD. However, the mother quit the treatment sessions and resorted to drugs. During the rehabilitation of the patient the attending psychiatrist also diagnosed her with sleep disorders as the patient was afraid to sleep at night and slept the whole day. However, after 3 months the patient had shown signs of recovery and was allowed to resume her normal life and even to go back to school. As mentioned earlier it was difficult for the patient to adjust to the normal life and the patient seemed withdrawn and avoided making friends. The worst instance of PTSD was when the patient attempted suicide while in the foster but the attending psychiatrist reported that the patient had shown recovery symptoms prior to being allowed to resume her normal school life. The patient was also diagnosed with sexual disorder due to her behavior of sleeping with different men over a very short period of time despite the lack of any emotional attachment with the men. Medical History The patient has had 3 seizures for the days she has been at the penitentiary. The patient has also been extremely irritable and has an unusually higher appetite. The doctor diagnosed that these were probably withdrawal symptoms for cocaine. The patient has also been treated twice for Syphilis and is currently under treatment for Gonorrhea. However, the patient tested negative for HIV. Substance Abuse Currently the patient is on a rehabilitation program for cocaine abuse. The patient has been taking cocaine for the last four years. The patient exhibited high levels of desire for the drug and had turned violent on several occasions on the prison guards after they refused her request to give her cocaine in exchange for sex. The patient perceived the drug addiction as a problem but also complains that her life is hopeless and over and that she wants to stay on cocaine all the time to relieve stress. The pattern of use followed a pattern and there was the realization that she was triggered to use the drug after a very depressing or disappointing situation. The major route for administration of the drug is through injection. Since the patient has not been able to buy the drug, she opted to share the cost with other people at the coke house. The patient has also on several occasions accepted to be injected with blood drawn from a person who is high on cocaine because according to her “she was desperate and did not have money.” The patient confessed that the drug abuse has continuously affected their judgment and it is the major trigger for her sexual disorders. Clinical Presentation During the interview the patient was unkempt and very untidy. The patient expressed anxiety and behaved as if something bad was about to happen. The patient also expressed bouts of self-pity and crying and complained why the world had been so unfair to her. Although the patient could recall her name and where she was, the patient had lost a sense of time and was not able to mention the date. The patient also exhibited signs of aggression and had to be restrained for safety. In some instances, the patient became unresponsive and would just look out at the empty space. Such instances happened 3 times during the interview after which the patient resumed the conversation. Her movements were also uncoordinated and for instance she would just jerk the foot or strike the wall with her hand. These instances happened especially when the patient was talking about traumatizing moments or when asked information about her family. In one instance when the patient was asked whether she blamed herself for her mother’s death she became extremely violent. Diagnosis The patient was diagnosed on the DSM-IV scale. DSM 1: The patient exhibited symptoms of PTSD and the realization that even after prior treatment the disorder was not dealt with appropriately. DSM IV: The patient still harbored the pain experienced during the loss of her mother and also felt guilty for the two abortions that had to be done due to her poor health. The patient is also depressed by the kind of life she has lived as a prostitute. DSM V: Encounter severe traumatic condition as a child and other stressor have also been traumatic during her life. Case Conceptualization The patient’s difficulties are as a result of the perception she constructed towards life from a very early age. According to the humanistic model of abnormality human beings have a tendency of wanting to attain their full potential (Russell 83). However, the patient sees life as being unfair to her and preventing her from achieving her potential. The fact is evidenced by the patient’s ability to recognize that her life is hopeless which implies that she has an inherent concept of what her life ought to be. Her inability to achieve the hopes she has is connected to her mental situation and her tendency to take drugs. Had the patient experienced a normal life, the patient could have been a better person probably. The humanistic model outlines that under the right conditions any human being will develop into a normal person. However, due to her experiences the patient developed a dysfunctional perception of life. The patient’s abnormal behavior can also be explained from the perspective of the humanistic-existential model. The fact that the patient lacked the love and care from a very young age denied the patient the opportunity to develop in a healthy way thereby resulting in the observed dysfunctional behaviors (Gregoire 407). The death of her mother and denied her parental love and she sought comfort in drugs and by having multiple sexual partners. Her frustrations can be demonstrated by her suicidal tendencies. The patient’s drug addiction can be explained using the behavioral model. Perhaps at the very young age she made friends who were taking drugs and as a result she learnt to take drugs to relieve her stress. Treatment Plan Patient centered cognitive behavioral approach should be used to assist the patient explore the root cause of her stressors and the current triggers. The patient should be assisted so that they are able to deal with the stressors in a healthy way and to avoid further risky behavior. Cognitive behavioral therapy will also be used to assist the patient in changing the destructive self-concept she has built over the years and train her to deal with her past traumas, for instance the death of her mother and the abortion experiences. The patient will also be trained on techniques to avoid emotions that trigger her to resort to drugs (Wilson 34). Group therapy should be used to assist the patient to deal with the addiction because the patient can establish a sense of belonging and develop hopes that she can eventually get over the addiction. Institutionalization will also be important to assist the patient in avoiding circumstances that might tempt her to resort to drugs (Ovsiew 160). Group therapy can also be important in dealing with the sexual disorder the patient experiencing. Works Cited Gregoire, Jocelyn. The counselors companion: what every beginning counselor needs to know. New York: Routledge, 2007. Print Ovsiew, Fred. Principles of Inpatient Psychiatry. Philadelphia: Wolter Kluwer Health, 2009. Print. Russell, Julia. Angles on Applied Psychology. London: Nelson Thormes, 2003. Print. Wilson, John P. Treating Psychological Trauma and PTSD. New York: Guiford Press, 2001. Print. Read More