Referral Reasons HERE YOU NEED TO IDENTIFY THE PRESENTING PROBLEMS AND REFERRAL

Referral Reasons
HERE YOU NEED TO IDENTIFY THE PRESENTING PROBLEMS AND REFERRAL SOURCE. FOR EXAMPLE:
PT PRESENTING WITH CHRONIC HISTORY OF EMPLOYMENT AND MARITAL PROBLEMS. HE REPORTS THAT HIS WIFE RECENTLY FILED FOR DIVORCE WHICH WAS BOTH SUPRISING AND EXPECTED. PT REPORTS THAT HIS BOSS AT HIS NEW JOB GAVE HIM NOTICE OF TERMINATION EVEN THOUGH HE HASN’T MISSED A DAY OF WORK IN THE PAST SIX MONTHS. PT REPORTS THAT THESE HAVE BEEN RECURRING ISSUES IN HIS ADULT LIFE AND HE CAN’T SLEEP, WORRIES ALL OF THE TIME, AND IS FEELING LIKE LIFE WILL NEVER CHANGE AND THEREFORE DECIDED THAT HE NEEDED TO SPEAK TO A PROFESSIONAL.
Biopsychosocial
THIS IS THE SECTION WHERE THROUGH A CLINICAL INTERVIEW THE ASSESSOR LEARNS ABOUT THE HISTORY OF THE INDIVIDUAL LEADING UP TO THE CURRENT SITUTATION. I HIGHLY RECOMMEND USING THE FOLLOWING HEADINGS TO KEEP ORGANIZED: FAMILY; DEVELOPMENTAL; EDUCATION; EMPLOYMENT; SOCIAL; PSYCHIATRIC; MEDICAL, ETC
Assessments
HERE YOU LIST THE ASSESSMENTS THAT YOU USED. FOR THE MIDTERM PAPER (THIS ONE) YOU WILL USE THE BECK DEPRESSION INVENTORY, 1ST EDITION; BECK ANXIETY INVENTORY, AND THE ST. LOUIS MENTAL STATUS EXAMINATION. YOU WILL WANT TO LIST THE ASSESSMENT AND PROVIDE A BRIEF DESCRIPTION INCLUDING ORIGINAL NORMATIVE STUDIES, OVERALL PURPOSE, RELIABILITY/VALIDITY, LENGTH, AND TIME OF COMPLETION.
Testing Environment
HERE YOU “PAINT A PICTURE” OF THE ENVIRONMENT WHERE THE PT IS INTERVIEWED AND TESTED. THE BELOW IS A GOOD EXAMPLE:
The assessment was conducted in a quiet closed room for patients in the clinic. The room
had medium-sized windows that allowed for ample sunlight and air if needed. The daylight was
bright enough that the lights did not need to be turned on. There was one large sofa for patients
and another small armchair for myself. The walls consisted of printed photographs on canvas of
nature scenes. The photos were of a bamboo forest, waterfall, and field of flowers. Shia had sat
upright on the large blue sofa with his hands on his lap during our meeting. The door and room
remained closed the entire session.
Mental Status
HERE YOU “PAINT A PICTURE” OF THE PERSON AS THEY ARE PRESENTING AT THE MOMENT THEY ARE BEING SEEN. HOW DO THEY LOOK? SOUND? ARE THEY THINKING LOGICALLY AND CLEARLY? ARE THEY WELL-PUTOGETHER OR UNKEMPT? THERE ARE DOZENS OF DESCRIPTORS IF YOU WANT TO SEARCH INTERNET. EXAMPLE: PT ARRIVED ON TIME AND WAS AWARE OF THE PURPOSE OF THE MEETING. PT WAS POLITE, CONSIDERATE, AND INTRODUCED HIMSELF IMMEDIATELY. HE WAS DRESSED CASUALLY BUT APPROPRIATELY. THROUGHOUT THE MEETING HE MAINTAINED AN APPROPRIATE DEGREED OF EYE CONTACT AND ENGAGED IN APPROPRIATE TURN-TAKING DURING CONVERSATION. HE SPOKE SOFTLY YET WAS COMPREHENSIBLE. HE INDICATED THAT HIS MOOD WAS “DOWN” WHICH WAS CONGRUENT WITH HIS OUTWARDLY OBSERVABLE AFFECT. THROUGHOUT THE MEETING HE DID NOT APPEAR TO BE INTERNALLY PREOCCUPIED WITH INTERNAL STIMULI AND DID NOT EXHIBIT ANY ODD BEHAVIORS OR BELIEFS SUGGESTIVE OF ABERERANT EXPEREINCES SUCH AS HALLUCINATIONS OR DELUSIONS. HE DENIED ANY CURRENT THOUGHTS/INTENTIONS TO HARM HIMSELF OR OTHERS AND DENIED PAST SUICIDAL IDEATIONS, INTENTIONS, AND/OR ATTEMPTS.
Diagnostic Considerations
THIS IS THE “HEART” OF THE PAPER AND THE SECTION I WILL BE LENDING MOST OF MY ATTENTION TOWARDS GRADING. REMEMBER THAT ASSESSMENT IS A PROCESS WHERE WE LOOK AT A PERSON’S REFERRAL SOURCE, PRESENTING PROBLEMS, BIOGRAPHICAL HISTORY, AND CURRENT MENTAL STATUS FROM MULTIPLE PERSPECTIVES INCLUDING WHAT THE PERSON SAYS, WHAT OTHERS SAY ABOUT THE PERSON, OUR CLINICAL JUDGEMENT, AND THE VARIOUS ASSESSMENT INSTRUMENTS. FOR EXAMPLE:
PT REFERRED HERE BY SELF DUE TO “WANTING TO KNOW THEMSELVES BETTER.” HOWEVER, PT PROVIDED MINIMAL INFORMATION DURING CLINICAL INTERVIEW AND PROVIDED MINIMAL EFFORT ON THE INSTRUMENTS INDICATING A POSSIBLE UNDER-REPORTING.
PT PRESENTS WITH RECENT HISTORY OF BEING FIRED AND DIVORCED. BASED ON THE PT’S BIOPSYCHOSOCIAL HISTORY THE PT HAS BEEN FIRED FROM MANY JOBS THROUGHOUT HIS LIFE AND HAS BEEN PREVIOUSLY MARRIED X3. PT INDICATED THAT “THINGS TYPICALLY START OUT FINE AND THEN 6 MONTHS LATER MY BOSSES AND MY WIFES START COMPLAINING ABOUT MY BEHAVIOR AND ULTIMATELY LOSE INTEREST IN ME AND EITIHER FIRE ME OR FILE FOR DIVORCE.” ALTHOUGH THE PT’S BDI SUGGESTED AN OVERALL MILD DEPRESSION, SCORES ON ITEMS #, #, AND # WERE SLIGHTLY HIGHER AND SUGGEST A MORE PROFOUND DEPRESSION. THIS IS SUPPORTED BY THE FACT THAT THE PT REPORTED HE WAS HOSPITALIZED HIS SECOND YEAR IN COLLEGE FOR “LOSING INTEREST IN CLASS AND SOCIAL CLUBS.”
PT REPORTS A HISTORY OF ANXIOUSNESS AND BELIEVES HE SUFFERS FROM CLINICAL ANXIETY. HIS SUMMARY SCORE ON THE BAI SUGGEST MILD ANXIETY HOWEVER ELEVATED SCORES ON ITEMS #, #, AND # SUGGEST THE PT DOES EXPERIENCE SOME ACUTE SYMPTOMS OF ANXIETY. THIS IS CONGRUENT WITH THE PT’S BIOGRAPHICAL REPORT THAT IN THE EARLY WEEKS OF STARTING A NEW JOB HE FEELS LIKE HIS “BRAIN WON’T SHUT OFF” WHICH AFFECTS HIS SLEEP. THESE SYMPTOMS WERE ADDITIONALLY CAPTURED ON BDI ITMES # AND # SUGGESTING A CONGRUENCY BETWEEN ASSESSMENT INSTRUMENTS.
PT BELIEVES THAT IN ADDITION TO ANXIETY HE SUFFERS FROM EARLY ONSET DEMENTIA BECAUSE HE IS CONSTANTLY FORGETTING WHAT PEOPLE TELL HIM AND HAS A DIFFICULT TIME CONCENTRATING. PT’S SUMMARY SCORE ON THE SLUMS INDICATES THE PT DOES NOT MEET CRITERIA FOR NEUROCOGNITIVE IMPAIRMENT. HOWEVER, AN ITEM REVIEW ANALYSIS SUGGESTS THAT WHEN UNDER TEST CONDITIONS THE PT APPEARED TO STRUGGLE WITH QUESTIONS AT THE BEGINNING OF THE EXAM SUGGESTING PERFORMANCE ANXIETY. THIS WAS CONGRUENT WITH THE TEST ADMINISTRATOR’S OBSERVATIONS WHICH INCLUDED THAT THE PT APPEARED TO SWEAT AND SHIFT IN HIS SEAT AT THE BEGINNING OF THE EXAM.
Diagnostic Conclusions
HERE YOU WILL SIFT ALL OF THE RELEVANT INFORMATION DOWNWARD INTO A FEW SUCCINT POINTS WHICH WILL LEAD TO ONE OR MORE DIAGNOSTIC IMPRESSIONS. FOR EXAMPLE:
PT WAS SELF-REFERRED FOR BETTER UNDERSTANDING OF CHRONIC PROBLEMS RELATED TO EMPLOYMENT AND INTERPERSONAL ISSUES. PT WAS GUARDED IN HIS PERSONAL DISCLOSURES DURING CLINICIAL INTERVIEW AND THIS WAS SUPPORTED BY TEST RESPONSES. HOWEVER, WHILE SUMMARY SCORES OF TESTS WERE NEGATIVE FOR CLINICAL DEPRESSION, ITEMS ANAYLSIS ACROSS TESTS WERE CONGRUENT WITH PT’S BIOGRAPHICAL HISTORY SUGGESTING THE PRESENCE OF MAJOR DEPRESSIVE DISORDER. FOR INSTANCE, PT REPORTED A HOSPITALIZATION IN EARLY 20s CHARACTERIZDED BY LOW MOOD RESUTLING IN FUNCTIONAL IMPAIRMENT ACROSS EDUCATION AND SOCIAL DOMAINS. ADDITIONALLY, THE “6 MONTH” TIME-FRAME OF THESE MOODS REPORTED BY THE PT IN THE CONTEXT OF HIS EMPLOYMENT AND MARITAL PROBLEMS ARE ALSO SUGGESTIVE OF MAJOR DEPRESSIVE DISORDER. WHILE PT’S BELIEF THAT HE HAS CLINICAL ANXIETY WAS NOT SUPPORTED BY HIS TESTS AND HISTORY, DATA AND OBSERVATIONS (SLUMS) SUGGEST THAT THE PT DOES SUFFER FROM EXCESSIVE WORRY. THIS EXCESSIVE WORRY APPEARS TO BE RESTRICTED TO NEW EMPLOYMENT OPPORTUNITES AND GIVEN HIS EMPLOYMENT HISTORY WOULD BE CONSIDERED TO BE WITHIN NORMAL LIMITS.
Diagnosis
1. Major Depressive Disorder, Recurrent, Moderate
Referrals
1. Cognitive Behavioral therapy for MDD
2. Employment training
3. Interpersonal Therapy for Relationship Building
References
Burger, J. M. (2019). Personality (10th ed.). Boston, MA: Cengage.
Cooper, M. (2020, March 30). Shia LaBeouf reunites WITH EX-WIFE Mia GOTH nearly 2 years after separating. Retrieved April 21, 2021, from https://www.usmagazine.com/ celebrity-news/news/shia-labeouf-reunites-with-ex-wife-mia-goth-nearly-2-years-afterseparating/#:~: text=Us%20Weekly%20confirmed%20in%20September,divorce%20procee dings%20will%20remain%20private.%E2%80%9D
Coyle, J. (2019, November 09). Shia LaBeouf thought he was finished, then he wrote ‘Honey
Boy’. Retrieved April 22, 2021, from https://www.timesofisrael.com/shia-labe
ouf-thought-he-was-finished-then-he-wrote-honey-boy/
Good Morning America. (n.d.). Shia LaBeouf says 2017 arrest ‘CAME from a place of
self-centered delusion’. Retrieved April 21, 2021, from https://www.goodmorningamerica
.com/culture/story/shia-labeouf-2017-arrest-place-centered-delusion-53741286
Maloney, A. (2020, December 14). Abusive dad & hearing mum’s rape led child star Shia
LaBeouf to self-destruct. Retrieved April 23, 2021, from https://www.the-sun.com/enter
tainment/1971295/shia-labeoufs-childhood-abusive-dad-mums-rape/
Todisco, E. (2020, December 14). Inside Shia Labeouf’s turbulent relationship history as FKA
Twigs accuses him of sexual abuse. Retrieved April 22, 2021, from https://people.com/movies/inside-shia-labeouf-turbulent-relationship-history/