All identifying factors (including service providers) have been changed. Assessment completed by Pam Kummerer

1. Pam Kummerer 1
BIOPSYCHOSOCIAL ASSESSMENT
Client’s Name: Patty Smith
Address: 335 Richardson Dr.
Toledo, Ohio 43608
Phone: 419-555-1122
PURPOSE OF ASSESSMENT: This 46 year old, Caucasian, divorced female was admitted,
on a voluntary basis to the psychiatric unit after being seen in the Emergency Department. The
purpose of this assessment is to evaluate reason for admission and develop a treatment plan.
SOURCE OF DATA: Information for the assessment was obtained through a face-to-face
interview with the patient in the patient’s room as well as information from previous admissions.
The patient was lying across the bed on her stomach/side. She maintained poor eye contact
during the interview, and was often looking down as she was running the blanket edge through
her hands. Basic hygiene has been attended to, and the patient is dressed appropriately.
PRESENTING PROBLEM: The patient was dropped off at the Emergency Department by a
neighbor. She reports symptoms of increasing depression with suicidal ideations, auditory
hallucinations, and paranoid delusions. Patient reports she has not been taking her psychotropic
medications for several weeks. The patient has a long history of psychiatric disorder and has had
multiple hospitalizations.
The patient reports that she has been “feeling down” lately and has been having suicidal
ideations without a specific plan. She has a flat affect and speaks in a quite tone of voice. She
admits that she has not been taking her medication for several weeks, and had not always been
taking it as prescribed prior to this. She states that sometimes she forgets to take her meds, and
then quit taking them all together because she thought she “did not need them.”
The patient admits to having auditory hallucinations. She reports the voices are negative, “put
me down,” and are “calling me a whore.” The patient believes these voices are from “a different
realm” but would not elaborate any further.
The patient has paranoid delusions and is religiously preoccupied. She believes she is the devil
and believes people are watching her and talking about her. When asked about her appetite, the
patient states, “I am not suppose to be eating, I am fasting.” When asked about her sleep, the
patient states, “I’m not suppose to go to sleep…I read it in the Bible.” The patient tends to focus
on the end of the world and going to hell. She expresses feelings of guilt over past things she has
done, which she will not discuss.

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ALCOHOL, TOBACCO, AND OTHER DRUGS: The patient has a history of polysubstance
abuse. She reports past alcohol, cannabis, and cocaine use, but states she has been clean for 3
years. She has been at Treatment Center in the past for substance abuse treatment, but was
kicked out after asking a peer for heroin because she wanted to kill herself. She also reports she
has attended AA meetings in the past, and states they had helped a little. The patient does not
use tobacco.
PAST PSYCHIATRIC HISTORY: The patient has a long psychiatric history with several
hospitalizations. The patient reports that her symptoms first appeared when she was in her early
20s. She has had previous psychiatric admissions at Regal Hospital, St. Bernice Hospital, and
Regional Stress Hospital. She has received ECT in the past. The patient has been on several
different psychotropic medications, and was last prescribed Haldol, Cymbalta, Tegretol, and
Cogentin. The patient states she thinks this combination of medication has been effective for
her. The patient receives outpatient psychiatric treatment at Northwest Community Mental
Health Center.
The patient has a history of suicide attempts by overdosing. The patient has not had a suicide
attempt in over 7 years. The patient has continued to have suicidal ideations, but has received
treatment prior to attempting.
HISTORY OF VIOLENCE AND ABUSE: The patient does not have a history of violence or
aggression. She denies having homicidal or violent thoughts.
She has been in several physically and emotionally abusive relationships. She reports her father
had been physically abusive to her and her siblings when she was young. She reports repeated
sexual abuse by a male friend of the family.
PSYCHOLOGICAL AND EMOTIONAL FUNCTIONING: The patient has a flat affect and
depressed manner. She is oriented to person, time, and place. The patient has decreased
psychological functioning due to auditory hallucinations and delusional thoughts. She has
thought blocking and poverty of thought. She has poor concentration. The patient is fidgety
during the interview and plays with her blanket. The patient is anxious and gets agitated at times
during the interview. She has low self-esteem and verbalizes feelings of worthlessness. She is
hopeless and does not believe she will ever get better.
CURRENT FAMILY/HOUSHOLD MEMBERSHIP: The patient had been living in a group
home, but moved into an apartment with her boyfriend in November. Patient reports that shortly
after moving in with her boyfriend, he went to jail and remains there until this May. The patient
states she felt she had been doing well living by herself in the apartment, and does not see this
hospital admission as a sign that this may not be the case.
The patient’s brother and sister-in-law is her legal guardian, and when signing the patient in, her
sister-in-law stated she felt the patient did better while in the group home, and plans for patient to
go to a group home upon discharge.

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FAMILY HISTORY: Both of the patient’s parents are deceased. She has 3 sisters and 2
brothers. She is the second youngest child. The patient reports that one of her brothers has
received psychiatric treatment, but was unable to give specifics. She also reports that both of her
parents had a drinking problem when she was growing up. She denies any family history of
suicide.
The patient reports physical and sexual abuse as a child. States her father physically abused her
when he was drinking. She reports repeated sexual abuse by a friend of the family.
The patient reports that she had a good relationship with her mother and she often misses her.
The patient states that when she was young she mostly got along with her siblings, but was never
very close to her oldest sibling.
The patient reports that she currently is not very close to any of her siblings and has very limited
contact with most of them. Her brother is her legal guardian, and from past admissions, her
sister-in-law seems to be supportive of the patient. In the past, she has lived with her brother,
sister-in-law, and their 2 children. Because of her delusions, paranoia, substance abuse, and
behaviors related to these, she is not able to stay with them due to the possible effects this could
have on the children. However, the sister-in-law remains supportive, and encourages the patient
to visit.
EDUCATION AND EMPLYMENT HISTORY: The patient dropped out of high school in
the 11th grade, but did obtain her GED several years later. The patient reported that she did not
like school but achieved average grades. She denies having any learning difficulties. The
patient appears to be of normal intellectual functioning.
The patient states she has had several entry-level laborer jobs in the past, but was always unable
to maintain employment. The patient has been receiving disability compensations for several
years.
ECONOMIC SITUATION: The patient receives disability compensation, and has Medicaid.
The patient reports having financial stressors and admits she sometimes gets overwhelmed with
her bills. When discussing the group home, the patient states, “Group homes are expense…they
take all my money.” The patient does not have a car, and relies on others for transportation.
INTERPERSONAL AND ROLE FUNCTIONS: The patient does not identify having any
close friends. She reports having only a few friends, but states they are not very close
relationships. The patient states “people just stab you in the back.” The patient tends to be
isolative to her home, and has limited interactions with people. Her boyfriend is currently in jail.
The patient was married once for 5 years. She has a history of relationships with men who prey
on her vulnerability and tend to use her for money. The patient does not have any children.

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CULTURAL BACKGROUD, RELIGIOUS BELIEFS, AND SPIRITUALITY: The patient
is religiously preoccupied and often has delusions related to religious beliefs. She does not
attend church but does read the Bible regularly. She expresses feelings of guilt related to her
religious beliefs, and has excessive fear of going to hell.
PYSICAL FUNCTIONING: Patient denies any medical conditions or physical complaints.
STRENGHTS AND USUAL WAYS OF COPING: The patient has much difficulty
identifying any strengths, even with prompting. Patient has a legal guardian. She is linked with
Northwest Community Mental Health Center. She has income and insurance. Her sister-in-law
is very supportive. She has remained free of alcohol and drugs for 3 years.
The patient identifies using music as her most used coping skills. She states she listens to music
to help herself relax. She also reports using deep breathing when she is feeling anxious, but
states this only helps her minimally. She stated that being around people makes her more
anxious and more paranoid.
She is often in denial of her illness and then becomes non-compliant with treatment. She is
avoidant of issues that cause her increased stress.
USE OF COMMUNITY RESOURCES: The patient receives services at Northwest
Community Mental Health Center. In the past, she attended partial hospitalization programming.
She has attended support groups and AA.
IMPRESSIONS AND ASSESSMENT: The patient is depressed with suicidal ideations
without a specific plan. The patient is experiencing paranoid delusions and auditory
hallucinations. She is guarded and suspicious. She maintains poor eye contact. The patient has
not been eating or sleeping, primarily due to her delusional thoughts. Judgment and insight into
illness are poor. She has limited family and social support and spends a majority of her time
alone in her apartment. She has a long history of psychiatric illness and non-compliance with
treatment. While on the unit, she has been spending most of her time in her room, and has not
been attending unit programming. She denies any thoughts of wanting to harm others.
DIAGNOSTIC IMPRESSIONS:
Axis I: 295.70 Schizoaffective Disorder, Depressed Type
304.80 Polysubstance Dependence, In Remission
Axis II: None
Axis III: None
Axis IV: housing issues, lack of family and social support, treatment non-compliance
Axis V: 29
TREATMENT PLAN: The patient will be started back on psychotropic medication prescribed
by admitting psychiatrist. Patient will be encouraged to participate is unit milieu. Group therapy
and supportive psychotherapy will be provided. Encourage patient to attend the dual diagnosis
groups. Patient will be placed on suicide precautions for safety. Social worker will meet with

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patient daily to explore coping skills and coordinate discharge plans. Social worker will
maintain contact with family/guardian in order to include them in treatment and offer a family
meeting to patient and family. Case manager will assist patient with finding an appropriate
group home. Patient will follow up at Northwest Community Mental Health Center. Encourage
patient to attend AA and get a sponsor after discharge.