CED454-Analysis of The Individual
BIOPSYCHOSOCIAL ASSESSMENT
I. AGENCY & STUDENT’S ROLE
Jena Jozwicki
II. IDENTIFYING INFORMATION
Pt is a 15-year-old high school student referred to a psychiatrist with the stress
from being involved in a car accident two weeks ago. Pt lives with his parents.
III. PRESENTING PROBLEM
What: Pt describes himself to be “jumpy” around loud noises and has images
about his unresponsive friend during the car accident. Pt has been having sleep
difficulties as well as trouble concentrating. He is unable to do his homework
effectively. He is short-tempered with his family and friends.
When: Pt has been presenting symptoms the past two weeks
Where: Pt experiences stress and anxiety while in the car, as well as places that
elicit memories and sounds of the car accident like the movie theater.
Why: Pt is experiencing these symptoms now after his traumatic event of the car
accident.
IV. CURRENT AND HISTORICAL INFORMATION
Social History: Two of his friends were also involved in this car accident.
Trauma History:
o Five years ago, pt witnessed the near drowning of one of his younger
sisters.
V. RISK & PROTECTIVE FACTORS
Risk Factors:
o 1st anniversary of his grandfather’s death
o Witnessing his sisters near drowning experience
Protective Factors:
o Parents
o Teacher
o Motivated to seek therapy
VI. MENTAL STATUS EXAM (A way of organizing and recording information about
the mental state of the client)
Pt reported to feel “jumpy” around loud noises and constantly thinks of the image
of his unresponsive friend during the accident. Pt reports being anxious when in
the car going onto the intersection. He also has trouble concentrating and
effectively do his homework. Pt seems to be oriented x4. Pt was cooperative.
CED454-Analysis of The Individual
VII. FORMULATION
15 Sentence Case Formulation Formula
1: Identifying sentence
Dylan is a 15-year-old high school student referred to a psychiatrist with the
stress from being involved in a car accident two weeks ago.
2 (Bio): Genetic predisposition
There are no presented genetic dispositions.
3–4 (Psycho): Differential diagnosis
Dylan meets the criteria for acute stress disorder. He was directly involved in a
traumatic car accident with his friends. (Criterion A). Within the last two weeks,
Dylan has had trouble sleeping and visions of oncoming headlights. He also has
trouble concentrating and is anxious when in the car going onto the streets.
Dylan also is short-tempered with his family and friends and would be irritable
towards them. He also avoided the movie theater for its “loud noise.” He
expressed waves of anger towards the oncoming driver and has images of his
unresponsive friend. Dylan has met 9 of Criterion B of acute stress disorder. The
duration of these disturbances has been going on for two weeks now (Criterion
C).
5–11 (Psycho): How patient presentation relates to/is explained by theory
(psychodynamic, family systems, cognitive behavioral, etc.)
Dylan’s presenting symptoms seems to be best explained on cognitive
behavioral therapy as well as exposure based cognitive behavioral therapy.
Exposure based cognitive behavioral therapy is recommended to expose Dylan
of his recurring fears and to reduce anxiety and stress. Treatment is advised so
that symptoms will not continue or worsen.
12–13 (Social): Social factors/recent stressors
Dylan was a witness in the near drowning of one of his younger sisters 5 years
ago. This month is also the 1st anniversary of his grandfather’s death. It is
important to explore these areas as it may add on to stress.
14: Strengths/protective factors/spiritual factors
He has a supportive family and supportive teacher in support of seeking out
counseling.
15: Concluding sentence—risk level, treatment implications
CED454-Analysis of The Individual
Risk level of suicide is low. Treatment recommendations is cognitive behavioral
therapy once a week to reduce stress and anxiety. Medications to reduce
anxiety will be discussed.
VIII DIAGNOSIS
Acute Stress Disorder
o Code 308.3
