University of Phoenix Material



University of Phoenix Material

Guidelines for Writing Assessments and Making Diagnoses

According to Fong (1993), assessment and diagnosis, using the DSM, involves two stages:

Stage I is assessment and data gathering, and the goal is to gather the required information to make tentative diagnoses. The skills utilized are behavioral observation, intake interviewing, and doing the mental status examination.

Stage II is forming a working diagnosis, and the goal is to organize the obtained information into an accurate multiaxial diagnosis. The skills utilized are processing the information by sorting, categorizing, and using decision trees. When writing your assessment, do not include the descriptions contained in parentheses; they are for your information.

Assessment reports may be organized as follows:

1. Name:

2. Date of birth:

3. Primary language:

4. Referred by:

5. Intake date:

6. Evaluated by:

7. Description of client:

Write what you observe about the client, such as age, sex, appearance, behaviors, and impressions.

For example: The client is a 30-year-old female, dressed casually in neat, clean clothing. She makes normal eye contact, speaks in an expressive voice, and appears ill at ease, manifested by nervous hand movements and a foot jiggling.

8. Presented problem:

Describe the problem as the client presented it.

For example: The client reports having increased anxiety about her job, which has resulted in symptoms that are diminishing the enjoyment and quality of her life, particularly in the past 6 months.

9. History of the problem:

Describe the course of the problem and the client’s symptoms.

For example: The client has worked as a long-distance operator for the past 10 years. She states that she enjoys her work, but finds it more stressful each year. For the past 2 years, the company has increased its layoffs and, whereas seniority protected her before, longer-term employees have recently been affected. She only has a small amount of savings and has credit card debts. She is fearful that she will be laid off and will not be able to get a job that pays as well, because she has never done anything but work as an operator. Prior to 6 months ago, she reports occasional anxiety around specific events, such as a test at school or a problem with a boyfriend, but none to the extent that she has experienced in the past 6 months.

10. Mental Status:

Describe the client's cognitions, affect, behaviors, and physiological functioning.

• Cognitions

For example: The client is oriented to person, place, and time. She speaks precisely, and her thinking appears to be clear and goal-directed. She reports that she is worried and goes over and over her fears about the layoffs at work.

• Affect

For example: The client's range of affect is somewhat limited and flat.

• Mood

For example: The client appears to be depressed.

• Behaviors

For example: She reports that she experiences insomnia several nights per week. She states that she is able to work effectively, but sees her concentration diminishing and it is taking her longer to accomplish her usual tasks. She has begun to drink more than in the past, specifically, two or three glasses of wine almost every night. Her previous alcohol consumption was about four drinks per week, usually on the weekend. She has become irritable and reactive at home and, to a lesser degree, at work.

• Physiological functioning

For example: The client has a knee injury sustained in a volleyball accident 5 months ago and it has improved slightly, but surgery may be needed. The client has mitral valve prolapse and experiences occasional heart palpitations, about which she is not concerned. She reports recent headaches about three times a week, has taken thyroid medication for the past 10 years, birth control medication for the past 8 years, and an antihistamine for allergies during the spring and fall of each year.

• Suicidal and homicidal assessment

For example: The client reports having thoughts about ending her life. She voiced ruminations about taking all of her medications and drinking excessive amounts of alcohol. However, she indicates that her she could never hurt herself. She said, “I need to be there for my kids.” She also projects herself into the future. She stated, “These are fleeting thoughts, but not something I would act on.” Therefore, she is not considered a substantial or immediate danger to self. The client denied any homicidal ideation or ruminations.

11. Social history:

Describe the client's present living situation and his or her family, school, health, and social history.

For example: The client reports that she is divorced and has one child, who is 6 years old. She was married for 6 years and has been divorced for 1 year. She states that her former husband harasses her about her child-rearing practices and her dating. He is always late with child support payments, which causes worry and anger and contributes to her concerns about money. She owns a condominium and lives with her daughter.

Her family of origin lives in New Jersey and consists of her five older brothers, one younger sister, and her parents, who have been divorced for the past 15 years. She reports a typical childhood in a large family that was, she says, fairly happy until her parents divorced. Both her mother and father worked, although her mother was usually home by the time she came home from school. She describes her mother as a nag, but loving. Her father was quiet, did not interact with the children much, and traveled in his work as a construction foreman.

She was an above-average student and especially liked attending sports events. She always had a few close friends with whom she shared activities and phone calls. She had no serious illnesses and lived in the same house for almost all of her childhood, until her mother and father divorced. At that time, the family moved into a smaller house, and her father lived in an apartment.

All but one of her brothers had left home by that time. She reports that her parents' divorce was upsetting because of financial worries; but that she thought they were better off apart. She worked at a department store until she went to work at the telephone company at the age of 20. She attended community college part-time for about 1 year and received above-average grades. At present, she has a few close friends, but has seen less of them recently. She said, “She hasn't felt like it."

12. School history:

Note. Fill this section out for minors only.

13. Strengths:

Describe assets that facilitate progress and change, such as motivation, intelligence, self-discipline, and willingness to utilize resources.

For example: The client has a history of hard work and determination, is motivated to make a better life for her child, and appears to be extremely frustrated with her present situation.

14. Diagnosis:

Using the information gathered, make a five-axis diagnosis. If more information is discovered in future meetings with the client, the diagnosis may change. Therefore, the diagnosis is your best guess given the information you have at this time, using the guidelines of the DSM-IV-TR®.

• AXIS I: Clinical disorders

For example: 300.02 Generalized anxiety disorder

• AXIS II: Personality disorders or mental retardation

For example: 799.9 Deferred; at this point, no personality disorder is evident.

• AXIS III: General medical conditions relevant to management of the client's condition

For example: Headaches three times per week and a knee injury that may require surgery

The client's mitral valve prolapse is not mentioned because it appears to be unrelated to the problem and not a source of concern to the client. If she were experiencing panic attacks, however, that condition might be relevant.

• AXIS IV: Psychosocial and environmental problems

For example: Job stress because of fear of layoffs, conflicts with ex-husband about money and child rearing

• AXIS V: The Global Assessment of Functioning Scale found in the DSM-IV-TR®

For example: Current – 62

Reference

Fong, M. (1993). Teaching assessment and diagnosis within a DSM-III-R® framework. Counselor Education and Supervision, 32, 276–286.

Adult Assessment

Calvin Counselor

Note. The following is an example of a professionally-written assessment, with the Discussion section augmented by a theoretical perspective for the purpose of demonstration. Other sections may need to be added, such as a spiritual assessment, substance abuse assessment, or discussion of legal or ethical issues involved, if deemed appropriate to the assignment or the client’s situation.

University of Phoenix

CONFIDENTIAL BIO/PSYCHO/SOCIAL ASSESSMENT

NAME: Charlotte Carolina ADDRESS: 1234 NiceView Lane

Scottsdale, AZ 85344

DATE OF BIRTH: January 4, 1959 PHONE: 602-555-1234

PRIMARY LANGUAGE: U.S. English EDUCATION: A.A. in Nursing Registered Nurse

REFERRED BY: Scottsdale Police OCCUPATION: Mental Health Insurance Case Manager

ASSESSMENT DATE: March 8, 2004 EVALUATED BY: Calvin Counselor

Description of client:

The client was a well-dressed woman who appeared to be in her mid-40s. She wore several pieces of jewelry, with heavy, but appropriately applied makeup. She had a dark mark on her left cheekbone that she said was a beauty mark, which appeared to be applied with a dark pencil. She made good eye contact with the interviewer, though she often scanned the room.

Presenting problem:

The client was referred by the Scottsdale Police Department that stated she was found her sitting outside a large home in North Scottsdale, watching the house, and refusing to leave when asked by its residents, a prominent insurance underwriter and his wife. The client denied any criminal intent, stating she felt compelled to watch the house because its owner was formerly her lover. She believed that she and he were soul-mates and that the relationship with his present wife is one that he regrets. She believed the man felt the same way, but has not been able to tell his wife the truth. She stated she doubts that she needs help, but was quite happy to discuss the matter with the interviewer.

History of problem:

The client stated that 2 years ago she met the man at an annual conference for the insurance industry. The Scottsdale policeman who referred the client said he interviewed the man, who noted that he did meet the client in a committee meeting and had a drink with her at the conference. He said he was happily married and never contacted her again. The client stated that their meeting at the conference was love at first sight and that they had spent the evening at the bar discussing their lives, where they both felt an intense attraction to each other; he agreed to contact her back home.

Since that time, she said she had many hang-up calls she was certain were from him. In the past few months, she suspected he had been watching her; that he had been obsessed with her, that he had been sending e-mail messages using various aliases written in code. She believed that his wife may be forcing him to stay in the marriage and that he knows that he belongs with the client. She noted she called and wrote him frequently, expressing her love and insisting he felt the same. Recently, the man obtained a restraining order prohibiting the client from contacting him and she violated it repeatedly. She has been missing days from work and has withdrawn from social relationships. The man and the Scottsdale Police representative suggested that the client might have a mental disorder.

Mental status:

Activity: The client displayed psychomotor agitation, frequently scanning the room.

Mood and affect: The client appeared moderately depressed with a restricted range of affect, which was congruent with mood and appropriate to content.

Thought process, content, and perception: The client’s thought process was concrete; she denied suicidal or homicidal ideations. She ruminated over the man who placed the restraining order on her and spoke of details in his life in a way that revealed erotomanic delusions. She denied perceptual disturbances and response to internal stimuli was not observed.

Cognition, insight, and judgment: The client was oriented to person, place, and time with no cognitive anomalies observed. She demonstrated no insight into her problematic behavior or delusional thinking. Her judgment seemed impaired, given the legal entanglements in which her behavior had placed her.

Physiological functioning: The client appeared to be in good health and reported she felt well, with the exception of occasional lower-back pain and seasonal allergies. She drinks 1 to 2 mixed drinks once every 1 to 2 weeks; she denied use of illicit drugs. She takes aspirin occasionally and 25 mcg. Synthroid daily for hypothyroidism.

Social history:

The client reported she has been divorced for 3 years, has no children, and lives alone in a house that she owns. She said she did not want the divorce from her husband and that he left her for a younger woman. She has worked at her present job for 8 years.

She stated that her parents are living in New York and that she has regular phone contact with them. Contact with friends has diminished, partly due to her lack of leisure time and partly due to their disapproval of her affair with the man.

The client reported a normal childhood in an emotionally-close family that included two older brothers and her parents. She noted that her brothers were both high achievers and that she generally felt inferior to them. She said she was a good student and was involved in several social clubs during high school. She attended community college and married after graduation. She stated that her mother was involved in community activities until midlife, when she became depressed and withdrew from social activities. When asked by the interviewer about other family members with mental illness, she said they were a normal family, with the exception of her maternal grandfather, who was hospitalized in 1968 for a nervous breakdown.

Strengths:

The client appears to be intelligent, articulate, and able to support herself financially.

Discussion:

This client is currently suffering from delusions of an alleged intimate relationship with a man whom she has known only briefly. This delusion has become a central focus in her life, influencing virtually all other activities. Until now, she seemed to have functioned adequately both at work and in social settings. It is unclear what events precipitated her present condition. Additionally, the depth of her delusional thinking suggests the possible presence of a psychotic disorder.

An Adlerian interpretation of the client’s problem behavior suggests that—given her fairly recent divorce and having lived in the shadow of male success from childhood—she purposefully developed the delusion. This has the goal of creating feelings of significance and superiority as a means of coping with feelings of inferiority underscored by the divorce. Living by the fiction of her love relationship with a man of status, then, creates a style of life where she is able to live as if she is in control of her life.

Provisional diagnosis:

Axis I: 297.1 Delusional disorder, erotomanic type

R/O schizophrenia

Axis II: Histrionic personality features

Axis III: Hypothyroidism

Axis IV: Restraining order against her

Axis V: 50 – current; 65 – highest past year

Recommendations:

• Adlerian individual counseling in weekly, 1-hour sessions for 8 weeks

• Referral to a support group, such as Codependents Anonymous

• Referral to psychiatrist for medication evaluation

Treatment plan:

Short-term goals:

• Establish the therapeutic relationship.

• Assess and analyze the dynamics working within the client.

• Make a referral for psychiatric evaluation.

Beginning-stage interventions:

• Establish a therapeutic relationship with the client through active, empathic listening, and facilitate awareness of her personal strengths and competencies.

• Examine the following:

o The client’s family constellation through early life recollections and dreams

o The client’s priorities and how she works to promote them

• Refer the client for psychiatric evaluation; if medication is prescribed, support compliance.

Progressive-stage interventions:

• Maintain the therapeutic relationship with the client and introduce supportive confrontation.

• Educate the client about choices she can make regarding her roles in life.

• Educate the client about her private logic, which she can alter to create priorities more in line with her style of life choices.

Long-term goals:

• Encourage insight into mistaken goals.

• Reorient the client to make new choices.

Interventions:

• Facilitate interpretation of the client’s behaviors based on her private logic.

• Utilize immediacy, encouragement, task setting, and commitment for taking concrete steps toward being delusion-free.

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