Biopsychosocial_Assessment

Biopsychosocial Assessment Identifying Information Jake, whom I will refer to as JR in this report, is a 31 year old Caucasian male. He is married with 2 children that were lost to adoption. JR is approximately 5 foot 9 inches and weighs 160 pounds. Chief Informant: The information for this assessment came through an interview with the client. Presenting Problem: JR claims a few physical problems, but says that they do not bother him. * Several fingers had been broken * He has suffered a couple of skull fractures * His nose had been broken twice * His left arm and right leg had been broken JR has a couple of pending legal issues. * 2012 Parphanelia charge * 2012 Forgery charge Psychiatric History JR states that he has been treated for depression in the past. He also said that he had entertained thoughts of suicide. His words were, “thought it but would never do it”, and I believe that to be true. JR said that last night he heard voices telling him not to screw up but that he would. He also stated that twice in his life he was very violent while on alcohol. JR seemed paranoid over answering questions. He was obviously anxious and nervous which showed ion his body language. He was over talkative and seemed to change his story. Personal History: JR has been in the county jail for the last 60 days. Prior to that he lived with his wife and children for 6 years. He states that while he was incarcerated that his wife lost the children to adoption because of her drug use. Job History JR has never held a full time job for any extended period of time. His profession by his statement is that of a plumber. Drug/Alcohol History JR states the following: * Alcohol age 11, drank - mainly parties * Meth, age 16, used daily for 4 years * Opiates, age 20, after surgery and loved them. * Heroin, age 23, became main addiction but still done everything else. JR states that he OD on drugs 3 years ago on a mixture of everything. JR states that Heroin is the drug of choice. Education JR does have his GED. Military History JR states that he was never in the military. Abuse History * JR says that he has never been abused by anyone other than his wife, which was verbally and emotionally. * JR said that his father was physically abusive. Family History JR has an older sister and a younger brother and no problems there. His relationship with his mother is good, but not with his father. Strengths/Assets JR states that he is strong willed, yet he does not want to be alone. Limitations JR does not know how not to use it has been a part of him most of his life. He feels like he needs to stay clean now. Mental Status JR is OX4 (to time, place, person, and common things). JR was nervous in the beginning of the interview. CT scored 10.21 on the URICA scale, which is the middle range of Contemplators. Unchain your Brain questionnaire shows JR as a type 3 Impulse - Compulsive Addict as well as a type 4 Sad or Emotional addict. Diagnostic Impressions Axis I: 305.50 Opioid Abuse 305.70 Amphetamine Abuse 305.20 Cannabis Abuse 301.4 Obsessive – Compulsive Personality Disorder Axis II: Extreme anxiety, distress, depression Axis III: Broken fingers, skull fractures, broken arm and leg Axis IV: Economic, family conflicts, legal issues, health, loss of children Axis V: GAF 60 - 70