Initial Treatment Plan A Case Study Of Eliza
Bio psychosocial assessment is a critical document used in setting up the foundation for patient treatment. A therapist utilizes clinical interviews as well as observation techniques to not only come up with a descriptive assessment but also to understand a client’s experiences in developing a diagnostic process. Sperry (2006) in his acknowledgment describes biopsychosocial assessment as a construct of an individual’s emotional and cognitive functioning.
Eliza Doolittle Biopsychosocial Assessment
Eliza Doolittle (the client), is an 18 year-old Caucasian female university engineering student. During the first session, she was requested to fill in an intake document. Eliza provided limited information by only revealing that she sometimes experiences anxiety and low self esteem. The client indicated that she has a good relationship with Burt
(father), a truck driver. However, the relationship between the client and her mother (Joan), an elementary school teacher, is just okay. The client has a history of substance abuse. She denied being a drug or an alcohol addict, but acknowledged to have smoked bhang once while in high school. She sometimes drinks with her friends during weekends but denies drinking a lot of alcohol or ever experiencing hangover symptoms.
When asked about addiction, the client admitted to playing Massive Multiplayer Online games at least once or twice per week for between 3 and 5 hours. However, she denied experiencing gambling as well as pornographic problems. Moreover, the client denied suffering from any abuse in her lifetime stating that she only experienced some form of teasing in high school. When asked about social relationships, she indicated that she has quality relationships with her friends. However, she feels that sometimes her friends take advantage of her. The client has not voluntarily presented herself for treatment.
To complete the biopsychological assessment I would request the client to fill in the Level 01 Cross Cutting Measure (CCM-1). I will use the Level 01 Cross Cutting Measure as a screening tool to identify the client’s symptoms and diagnosis. According to Clarke and Kuhl (2014) Level 01 Cross Cutting Measure is a 23 item (for adults) or 25 item (for children and adolescents) measure of both the presence as well as the severity of symptoms within the last 2 weeks.
The items apart from suicide attempt, substance use as well as suicide ideation in children and teenagers are rated from 0 to 4. (that is, 0= none or never; 1= slight or rare; 2= several days or mild; 3= more than half the number of days or moderate; 4 = almost daily or severe).
A higher score signifies a greater severity or a higher frequency of occurrence. The suicide attempt, substance use as well as suicide ideation items for children and teenagers are always scored as either a yes or a no. The completed Level 01 Cross Cutting Measure indicates that Eliza has mild anxiety. The other important questions I will ask the client include:
- whether she has in the past 6 months experienced apprehensive expectations about her academic performance;
- whether she is experiencing muscle tensions or not and;
- whether she has been a victim of sexual abuse or not.
A Diagnosis of Eliza’s Symptoms
Based on the client’s biopsychosocial assessment she is suffering from generalized anxiety disorder. She suffers from mild anxiety and also has a slight interest in doing things. In addition she is experiencing a slight sleeping disturbance and lacks self esteem. The DSM -5 diagnostic criteria as espoused by Starkstein et al. (2007) include: apprehensive expectation (for more than 6 months) about several activities like school performance; difficulties in controlling oneself; restlessness; fatigue; loss of concentration and irritability.
Other symptoms include muscle tension and sleep disturbance. The anxiety leads to social and functional distress. There is no link between generalized anxiety disorder and effects of substance abuse or medical condition. Also the disturbance cannot be associated with any medical disorder such as panic disorder, social anxiety disorder, obsessive- compulsive disorder and separation anxiety disorder. The other disorders not linked with generalized anxiety disorder include; posttraumatic stress disorder, symptomatic stress disorder, dysmorphic disorder, illness anxiety disorder and schizophrenia.
The International Classification Diseases, Tenth Edition, Clinical Modification diagnosis code F41.1 for generalized anxiety disorder contains clinical information for the disorder. General anxiety disorder is a condition characterized by excessive feelings of uneasiness and fear that lasts for at least 6 months. The excessive fear always interferes with an individual’s functioning due to the fact that he or she always anticipates a disaster.
Moreover, it could impair an individual’s functioning as he or she may be more concerned with his or her everyday matters like family problems, interpersonal problems and work issues. Apart from excessive fear individuals exhibit several physical symptoms like restlessness, irritability, lack of concentration, sleeping disturbance, muscle tension and dizziness. Also it is associated with faster heartbeat, difficulties in breathing and sweating (American Psychiatric Association, 2013).
Client’s Treatment Goals and Plan
Eliza’s anxiety is a passive problem that requires treatment. She is suffering from generalized anxiety disorder characterized with excessive apprehension about her academic performance, which has slightly impaired her functioning. The client may benefit from relaxation therapy as well as cognitive behavioral therapy to address the symptoms of generalized anxiety disorder. It is important to create a safety plan in case the client’s drinking behavior gets worse.
Long Term Goal:
To reduce the overall level, intensity as well as frequency of the client’s anxiety problems so that it does not impair her daily functioning.
Short Term Goals:
Eliza will reduce her anxiety symptoms by more than 50 percent in the first month of her treatment program.
Eliza will improve on her self esteem (which is at rating 1 as reported in the Level 1
Cross –Cutting Symptom Measure report) after 2 months.
Level 02 Cross Cutting Measure
After completing Level 01 Cross Cutting Measure, Eliza will have to complete the
PROMIS Emotional Distress Anxiety Short Form (a Level 02 Cross Cutting Measure). Clarke and Kuhl (2014) indicate that any item with a rating 2 or more will always trigger the need to complete a highly detailed assessment for that particular symptom using the level 2 Cross Cutting Symptom Measure. This is an inquiry about the presence as well as the severity of a particular symptom within the last 7 days. The American Psychiatric
Association (2017) provides that an adult client with mild anxiety should complete the Level 2 Cross-Cutting Symptom Measure (PROMIS Emotional Distress Anxiety Short Form).
The PROMIS Anxiety Short Form assesses anxiety domain in persons aged 18 years and above. The client completes this form before meeting a therapist. In the case of a client with impaired capacity, a knowledgeable informant should complete the form on behalf of the client. Also the American Psychiatric Association indicates that a client’s parents should also fill in the Personality Inventory for DSM5 Informant Form- Adult.
For these reasons I would request the client to complete the PROMIS Emotional Distress Anxiety Short Form. Also, I would request Eliza’s parents to fill in this form because of her involuntary attendance. This information will help in gaining a clear insight about the client as well as her pressing concerns.
The Hamilton Anxiety Rating Scale is another important interview measurement tool designed for assessing anxiety issues. Therapists can use it in assessing several symptoms of generalized anxiety disorder and it comprises both somatic as well as psychic anxiety subscales. The psychic subscale contains items addressing a client’s subjective cognitive as well as affective components. The somatic subscale, on the other hand, emphasizes on the less typical features of generalized anxiety disorder including cardiovascular symptoms, respiratory symptoms and autonomic arousal (Belzer & Schneier, 2006).
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM- 5®). Washington, DC: Author.
- American Psychiatric Association. (2017). Online assessment measures. DSM-5-rated level cross cutting symptom measurement, adult. Washington, DC: Author
- Belzer, K. D., & Schneier, F. R. (2006). Tools for assessing generalized anxiety disorder. Psychiatric times. Retrieved from. http://www.psychiatrictimes.com/articles/tools-assessing-generalized-anxiety-disorder
- Clarke, D. E., & Kuhl, E. A. (2014). DSM‐5 cross‐cutting symptom measures: a step towards the future of psychiatric care?. World Psychiatry, 13(3), 314-316.
- Sperry, L. (2006). Personality and Chronic Illness. American Psychological Association.
- Starkstein, S. E., Jorge, R., Petracca, G., & Robinson, R. G. (2007). The construct of generalized anxiety disorder in Alzheimer disease. The American journal of geriatric psychiatry, 15(1), 42-49.