Discussion: Developing a biopsychosocial evaluation.

Discussion: Developing a biopsychosocial evaluation.

Discussion: Developing a biopsychosocial evaluation.

Title

ABC/123 Version X

1

 

  Week Four Assignment Scenario

PSYCH/627 Version 1

1

 

 

University of Phoenix Material

 

Week Four Assignment Scenario

 

Context: Wendy was seen for evaluation at a pain treatment center. You are members of the behavioral health team, charged with developing a biopsychosocial evaluation. This should not be a treatment plan, but an assessment of the person’s current problems and level of functioning based on the information provided.

Discussion: Developing a biopsychosocial evaluation.

Personal Information: Wendy is a 51-year old Caucasian female who has been married for 24 years, with two grown children living in different states.

 

Current Problems: Wendy has complained of pain in various parts of her body for over 20 years. Major areas of pain include the neck, shoulders, and upper back, as well as her knees and calves. The pain is bilateral and intensity has increased lately. It is ongoing throughout the day, but is worse when she is active and is reduced when she sits in a reclined position or lies in a supine position. She rates her pain on a 0-10 scale as 7-9 when she is active and 4-6 when she rests. She also has restricted sleep and a history of gastrointestinal pain. She has consulted with many pain specialists, but only recently was diagnosed with fibromyalgia. She is currently taking a low dose of the opioid pain medication Vicodin, which she claims “helps somewhat.” She has never tried physical therapy, or any complementary therapies such as acupuncture, yoga, or biofeedback.

Discussion: Developing a biopsychosocial evaluation.

Psychosocial Data: Wendy was born and raised in the Midwest. Both parents are alive and live close to her. She describes her childhood and adolescence in a positive way, aside from several instances of sexual abuse involving her uncle. The incidents involved unwelcome touching when she was 7 or 8 years old, but she is unclear about any details. She never revealed this to her parents. She has a high school education and completed 1 year of college. Her marriage is close and her husband is supportive, as are her children and parents. She has worked full-time as an administrative assistant, employed by the same company for 21 years. Recently, she has been forced to work part-time, primarily due to her chronic pain. Her spouse works full-time.

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Appearance and Behavior: Wendy is a slightly overweight woman who looks about her stated age. She walks in a guarded manner and sits slowly. She is neatly dressed with good hygiene. Her speech is slowed. She exhibits some pain behaviors, including occasional grimacing, rubbing her neck, and shifting position in the chair. Her spouse was seen with her and he claims he will do anything he can to help her pain. He prepares all of their meals, shops, and cleans the house which, in addition to his regular employment, he claims keeps him “very busy.”

 

Psychological Profile: Wendy has never received any mental health evaluation or treatment. She and her spouse are devout Christians and she states, “I have a lot of people praying for me, and that’s all the therapy I need.” Her mental status appears anxious and mildly depressed, based on her statements about how much she has grown to fear her pain. She does not have good insight about the connection between her pain and her emotional state. Several friends have mentioned that she only talks about her pain, so conversation is difficult.

 

Behavioral Health Data: Wendy has a normal appetite and has gained “about 25 pounds” in the past 5 years. She states that, “with this pain, sometimes food is my only friend.” Sleep patterns are poor. She was evaluated at a sleep disorder center for sleep apnea several years ago and her average amount of restorative sleep is less than 4 hours per night. She does not use alcohol or smoke. Her level of activity is quite low, and even with her part-time work, she moves very little. She has no regular exercise pattern “because it hurts to do almost anything.” When she is not working, she is typically sitting, watching TV, or reading.

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