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Psychosocial Assesment

A 30-year-old woman named Asma experienced a breakdown after learning her brother was arrested for drug abuse. She stopped working and attempted suicide multiple times. Her sisters took her to a doctor and she was found to have hepatitis B and started abusing heroin. A psychosocial assessment was performed, which involved collecting her history, mental state examination, and diagnosis.

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32 views37 pages

Psychosocial Assesment

A 30-year-old woman named Asma experienced a breakdown after learning her brother was arrested for drug abuse. She stopped working and attempted suicide multiple times. Her sisters took her to a doctor and she was found to have hepatitis B and started abusing heroin. A psychosocial assessment was performed, which involved collecting her history, mental state examination, and diagnosis.

Uploaded by

rushna
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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PSYCHOSOCIAL ASSESSMENT

PSYCHOSOCIAL ASSESSMENT

• A psychosocial assessment is an evaluation of an


individual's mental health and social well-being
Case Scenario
• Asma is a 30 years old lady, single ,graduate and is currently working
as a receptionist in a hotel. She has to support her 4 younger sisters
and one brother as her parents passed away in a road traffic accident
10 years back. Lately she came to know that her brother has started
abusing drugs and he has been caught by the police. Asma is very
caring and sensitive, this event has led to total break-down. She has
stopped going to work and has attempted suicide multiple times .Her
younger sisters were worried and they took her to a doctor where it
was discovered that she has hepatitis B. Due to multiple problems
she indulged into drugs and now is abusing Heroin I/V.
Case Scenario
• Asma is a 30 years old lady, single ,graduate and is currently working
as a receptionist in a hotel. She has to support her 4 younger sisters
and one brother as her parents passed away in a road traffic accident
10 years back. Lately she came to know that her brother has started
abusing drugs and he has been caught by the police. Asma is very
caring and sensitive, this event has led to total break-down. She has
stopped going to work and has attempted suicide multiple times .Her
younger sisters were worried and they took her to a doctor where it
was discovered that she has hepatitis B. Due to multiple problems
she indulged into drugs and now is abusing Heroin I/V.
STEPS INVOLVED IN ASSESSMENT
History
❖Demographics and Presenting Complaints
An introduction is necessary to establish the focus of your case and
provide orientation to your reader.
❖Reason for referral and mode of admission
❖Referral source
❖Source of information
❖Presenting complaints
✔ In patient’s and attendants own words (verbatim)
✔ Duration of each complaint
❖History of Presenting Illness
✔ This should be a detailed account of the patient's central problem that
you have already identified in your opening statement. Put details
about the problem and related symptoms in a chronological order.
✔ from the earliest time at which change was noted until admission
✔ precipitating event
✔ Onset: sudden or insidious
✔ Course of illness: continuous or episodic
✔ Behavioural changes
✔ Mood
✔ Biological functions
✔ Functioning
History
❖Treatment History: Part of history of present illness

❖Past Psychiatric History


✔ Details of all psychiatric conditions for which treatment has been received
or not received
✔ Dates and duration of illness
✔ Hospital admissions
✔ Nature of treatment

❖Medical and Surgical History


❖Family History
Include details of:
✔ Parents
• age or age at death and patient’s age at that time, cause of death and patient’s reaction to
death
• Education and occupation
• Relationship with them during childhood
• Periods of separation

✔ Siblings
• Chronological order of birth
• Marital status
• Education
✔ Nature of the relationships between family members
✔ Any family tensions and stresses and family models of coping
✔ Family history of psychiatric illness (incl. drug/alcohol abuse, suicide attempts)
❖Personal history
This portion covers certain areas; include:
✔Birth, Early development, Childhood, School, Adolescence
✔ Education
✔ Occupation
✔ Psychosexual history
✔ Marital history
✔ Drug history
✔ Forensic history

❖Socioeconomic history
Premorbid personality
Description of personality before the illness
❖Predominant mood
✔ stable, mood swings
✔ Optimistic or pessimistic
✔ Anxious, irritable, worrying, tense, lively, apathetic
✔ Ability to express and control feelings of anger, sadness, disappointment

❖Attitude to self
✔ Egocentric, selfish, vain, indulgent, self dramatizing
✔ Critical, self conscious
✔ Attitude to own health, over concerned, neglectful
✔ Realistic or Unrealistic self appraisal
❖Attitude to others/ interpersonal relationships
✔ Ability to trust, make and maintain relationships
✔ Anxious, secure, friendly, warm, reserved, cold, indifferent, dominant,
submissive, sensitive, dependant, quarrelsome

❖Reaction pattern to stress


✔ Ability to tolerate frustration, losses, disappointment and circumstances
arousing anger, anxiety or depression
✔ Evidence of excessive use of particular defense mechanism such as denial,
rationaliztion etc
❖Moral and religious attitudes and standards
✔ Rigid, uncompromising, perfectionist, conforming, rebellious
✔ Religious beliefs

❖Fantasy life
✔ Day dreams, nightmares

❖Leisure activities
✔ Books, plays, pictures, music
✔ Sports and other leisure activities
✔ Spends leisure time alone, with one or two friends or many friends
Mental State Examination
Mental State Examination
Mental State Examination
Mental state examination
Mental State Examination
Mental State Examination
Mental State Examination
Mental State Examination
Mental State Examination
Mental State Examination
Mental State Examination
Mental State Examination
Mental State Examination
Mental State Examination
Mental State Examination
Mental State Examination
Mental State examination
Mental State Examination
Mental State Examination
Diagnosis (ICD 10 )
• Axis 1 :Main diagnosis
• Axis 2 : Functionality
• axis 3 : Contextual factors
● Predisposing
● Precipitating
● Perpetuating
Thank you

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