Biopsychosocial Assessment

Biopsychosocial Assessment

Identifying Information:

Eliza is a Freshman in College. She is Caucasian, of average height, slender, and taking an Engineering major. School has caused Eliza to have increased stress levels. Her family lives two hours away from her college in a small town, and she cannot go home often. She has two brothers who are successful engineers, which gives her a lot of pressure to succeed. She does not get to spend enough time with her family because of the distance. She was caught with alcohol in her dorm, which led to her counseling session. She has also experimented with drugs in some instances of her life. She has problems socializing with friends and peers. Her problems started in high school because learning became tougher; thus, she took alcohol to relieve her stress.

Presenting Problem:

Eliza’s schoolwork is making her extremely stressed and overwhelmed. She attends tutorials which she is not happy about, and struggles to maintain her GPA. She found learning to be simple in high school because she got A’s. However, it has been difficult in college because she has to work harder. There is intense pressure from home because she feels that she must succeed like her father and brothers. She has not made friends in college and does not have anyone she can trust to tell her problems. She copes with stress by taking alcohol and drugs.

Life Stressors:

Eliza’s stressors are the struggles she has with making friends and having a support system. She struggles to maintain her GPA and does not like to attend tutorials to keep up. In addition, the coursework she takes to become an engineer is stressful. The coursework is overwhelming for her.

Substance Use: FORMCHECKBOX Yes FORMCHECKBOX No

Yes. Eliza has used alcohol, drugs, and pills. She attends 2 to 3 parties on the weekend and takes 5 to 6 beers and 3 to 4 liquor shots per party.

Addictions (i.e., gambling, pornography, video gaming):

Eliza is addicted to multi-player video games and alcohol. She engages in drinking a lot to relieve her stress. She plays online games once or twice a week for 3 to 5 hours a day. The games help her forget the stress from school.

Medical/Mental Health Hx/Hospitalizations:

Eliza has never been hospitalized. However, she did mention her cutting behavior which is a mental health issue. She cuts herself using a razorblade 2 to 3 times a week, but the behavior has been 2 to 3 cuts per day in the last week. Therefore, she has a mental issue that needs to be addressed.

Abuse/Trauma:

The client denies any form of abuse currently and in the past. However, she experienced teasing back in high school, as she mentioned but refused to expand on the issue.

Social Relationships:

The client has problems with developing relationships that are healthy and happy. She mentions that friends force her to do their homework and push her to have parties in her dorm. However, she mentions that the actions are not a big deal to her.

Strengths:

Eliza cares about her family and other people. She is smart, hardworking, and achieved good grades.

Legal History:

The only legal problem the client has been involved in is when the RA reported her to the campus police for the drinking incident.

Educational History:

The client achieved good grades in high school without much studying. She achieved A’s in her senior year without effort. She did not need extra tutoring to pass. She likes the engineering course, but it is stressful for her. She needs extra tutoring to keep up with others, which she does not like, and it is overwhelming.

Family Information:

Eliza has a mother, father, and two brothers. She is the youngest child. Her mother is controlling while the father is good. Her brothers are successful engineers, and the father, which made her major in the Course because she felt like she did not have any option. Her brothers are both single, and the parents have a strained relationship. While in college, she never gets to communicate with her brothers unless she gets home.

Spiritual:

Eliza is Agnostic. Her parents are Irish Catholics, and she mentioned that they go to church during Easter and Christmas.

Suicidal:

Eliza has not shown any suicide attempts.

Homicidal:

She is not homicidal.

Mental Status Exam (MSE):

The client is confused and troubled and is going crazy. It is a form of emotional distress she is going through (MediLexicon International, n.d.). At first, the client was refusing to sit down and paced in front of the desk. She was untidy and dressed in jeans and a t-shirt. Untidiness was due to wrinkled clothes and uncombed hair. She was extremely tired and did not make eye contact. She claims that weekends are when she gets enough sleep, but she parties and drinks to help her sleep. She has hangovers even though she claims not to have them. She is stressed out from schoolwork and a lack of friends. She has a mental problem because of the cutting incidences. She might be depressed.

Reference

MediLexicon International. (n.d.). Emotional distress: What are the causes and symptoms? Medical News Today. https://www.medicalnewstoday.com/articles/emotional-distress#symptoms.

Clinical Justification (Provide clinical justification related to client symptomology along with a DSM and ICD diagnosis based on client assessment):

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