Section 1 of Utilizing the DSM-IV-TR outlines a general, initial approach for patient diagnostic and assessment. For the purposes of this assignment, which is to establish an initial assessment plan for a patient, we will assume the following details about the patient: The patient is a 22 year-old, African-American woman who is demonstrating symptoms of depression, anxiety and significant life stress. Using Section 1 of Utilizing the DSM-IV-TR as a guide, what follows is a discussion of how I would assess this patient.
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According to Section 1 of Utilizing the DMS-IV-TR, “assessment involves ‘determining the nature, cause, progression, and prognosis of a problem and the personalities and situations involved’ as well as understanding and making changes to minimize or resolve it” and requires “thinking and formulating from the facts within a client’s situation to reach tentative conclusions regarding their meaning.” (p. 17) Therefore, I would begin by gathering as much information as possible from the patient before drawing conclusions and recommending changes to resolve the issue. This means asking questions to gather information while providing opportunities for the patient to guide the conversation, gleaning information from what the patient chooses to discuss, in order to gain a holistic understanding of the patient’s situation and make effective recommendations to alleviate the problem.
In order to determine the nature of the problem (which is suspected to be depression, anxiety and life stress), I would ask the patient a series of questions pertaining to her mood, feelings and attitude. How would she rate her overall happiness level, on a scale from 1-5? Does she often feel sad? Do things upset her more frequently than usual? How often does she find herself worrying about things? What does she worry about? Is she having trouble sleeping or concentrating? Is she often tired? Is she experiencing a lack of interest in the things that she used to enjoy?
Next, I would look for information pertaining to any possible causes, exacerbation and progression of these symptoms in order to provide an effective service plan for the patient. What does she do for a living? Has she recently lost her job or does she perform psychologically impactful or stressful work such as animal rescue or law enforcement? Has she been at odds with a family member recently or has an unexpected expense? Does she have a family history of these symptoms? I would ask her to also describe her childhood, any significant experiences she’s had, as well as her present daily life in order locate possible causes. I would attempt to walk the patient through a guided recollection of when these symptoms started becoming noticeable to the patient in order to detect when and why these symptoms may have progressed.
In accordance with Section 1 of Utilizing the DMS-IV-TR, I would pay vigilant attention to other factors that may inform both the responses that the patient has shared and those she may not have. For example, Section one cautions to be aware of how forthcoming or reluctant the patient may be to share information, and to consider how accurate the information shared may be. (p. 19) Has the patient reported child abuse? If so, she may be ashamed or it may be too painful for the patient to describe with accuracy the nature and details of the abuse. If the problem relates to illegal activity, the patient may withhold information out of fear of being persecuted. Informing the patient of her confidentiality rights and comparing her responses to the DMS manual will help me to determine the significance of her responses in relation to her symptoms. While gathering and evaluating information, I would also keep in mind that both the patient’s and my own opinions, beliefs, culture and world views may influence how the problem is being perceived. The patient, for example, may have cultural or religious beliefs about marriage that are contributing to her feelings of anxiety over her mother’s Jewish fiancé, or perhaps my own unawareness of African-American culture may prevent me from seeing the importance of a particular experience or issue that is not prevalent in Spanish heritage. It is important to remember that my own convictions have the potential to create a bias that can affect the accuracy of my assessment. By keeping this in mind, I will be less likely to misinterpret my own beliefs or attitudes as valid assessment.
Upon establishing that the patient is experiencing depression, anxiety and stress, I would begin to determine a service plan for the patient to eliminate or alleviate the issues causing her symptoms. But as Section 1 of Utilizing the DMS-IV-TR warns, it is essential to focus on the patient’s strengths and autonomy or ability to independently address the issues at hand for continued resolution and maintenance. (p.20) In order to foster a sense of strength, ability to overcome and a sense of hope for resolution within the patient, I would keep the focus positive and motivating through an emphasis on the patient’s own strengths and capabilities. Reminding the patient of her available resources, past accomplishments and abilities while encouraging her to take time to praise or reward herself for her own strengths and achievements will enable her to see a light at the end of the tunnel, believe in herself, commit to her own recovery and actively work toward better mental health with clear and manageable goals in mind.
I would also be careful to observe the patient’s current biomedical and psychological states. Does the patient have any physical disabilities or illnesses that may relate to the issue or inhibit a particular recovery approach? What is the patient’s mental functioning and status? What is her ability to think and reason? How does she perceive the issues at hand? Most importantly, I would be vigilant in continually assessing the patient’s safety in terms of her likeliness to hurt herself or someone else and would institute a service plan accordingly.
Lastly, but continually throughout my assessment, I would consider any social or environmental factors that may relate to or influence the patient’s symptoms or recovery plan. Does the patient have the appropriate social, familial or occupational support systems in place? If not, how might the lack thereof pertain to or inform her symptoms? Will a plan for intervention have to be established? Where will patient support come from in the future? These questions are essential to an effective, post-assessment service plan.
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