Biopsychosocial Assessment
Demographics
The patient is a 23-year-old white woman, not married, does not have children. Currently lives with her parents in their own house in a calm neighborhood.
Biological Health
At present, the patient does not report any significant health problems. She had a closed malleolar fracture and cerebral concussion as a result of a car accident three years ago, but she has fully recovered. Organs and systems are functioning within normal age limits. The patient only complains of headaches which usually appear as a result of insomnia which bothers her once or twice a month.
Psychological Health
The patient experienced panic attacks during half a year after the accident. They appeared after she attempted to drive a car, but there have been no attacks for more than two years. However, the patient experiences nightmares which make her paranoiac. She currently complains of feeling stressed and the lack of motivation. The patient frequently has no appetite, rarely experiences insomnia, which results in headaches and the feeling of hopelessness. She reports being often in despair.
History of the Problem
The patient was in a car accident three years ago. Her injuries were not so dangerous but demanded about half a year for physical recovery. The health condition did not let the young women finish her education which made her even more depressed. Her boyfriend graduated and moved to another state. They had to break up because she could not follow him. This fact caused more severe depression.
She was seeing an analyst for three months and the therapy helped to remove the symptoms of depression. She returned to college and graduated a year later with a degree in business administration. She has been looking for a job for nine months already and refused some suitable positions because of the necessity to drive to work. The situation increases her depression and the feeling of uselessness.
Social Components
The patient is the younger of two daughters in the family. The elder daughter is married and lives separately. The patient has been living with her parent since the accident because she needed care. The relationships in the family are warm and friendly; they live in love and understanding and are always eager to support each other. However, she is planning to move as soon as she finds a job and earns her living. The family does not object to her living in the house. They gather together during the holidays.
Her social life is not active. The lasting depression is characterized by the loss of interest in her previous hobbies. Her sports activities within the past three years were limited to posttraumatic rehabilitation. Despite the successful recovery, the young woman did not return to doing a sport which was a part of her life before the accident. She does not see her friends often. Most of them are busy with their jobs and career development and they have less in common than they had when they were in college. This situation also intensifies her depressed condition. She is not in a relationship at the moment. The patient has an admirer, but she is not ready to trust another person yet.
The patient did not report any substance abuse. As a teenager, she smoked, but then stopped. She does not drink alcohol. She could drink a glass or two of wine as a student, but she stopped after the accident. Her history of drug use is limited to the prescribed painkillers after the accident and antidepressants as a part of complex therapy to treat depression two and a half years ago.
Mental Status Assessment
The patient is dressed casually and neatly. She is cooperative although sad and calm. There are no signs of tremors or other neurotic reactions. She responds adequately and eagerly, but she is in a depressed mood. She speaks logically, the speech is organized and associative. She does not complain of and there are no evident signs of delusions or hallucinations. Her behavior and mental condition correspond to her history and can be explained by her previous experiences. There is also no evidence of aggressive behavior. There are no signs of suicidal ideation.
Diagnosis
The most probable diagnosis according to DSM-V is F43.10 Posttraumatic stress disorder. It is one of the “Anxiety disorders.” The patient meets the criteria of this diagnosis because she directly experienced the traumatic event which was a car accident. She experiences such intrusion symptoms which started after the traumatic event as repeated involuntary distressing memories of the traumatic event, repeated distressing dreams, intense or prolonged psychological distress while facing internal or external clues that represent or resemble the situation of the traumatic event. Moreover, she avoids stimuli associated with the traumatic event (she cannot drive a car anymore).
Also, the patient demonstrates negative changes in moods. For example, she exaggerates negative beliefs and expectations concerning herself and feels detachment or estrangement from others, mostly her friends. Finally, the young woman demonstrates a lack of ability to experience positive emotions and be satisfied with her condition. Her experience of insomnia also confirms the diagnosis of posttraumatic stress disorder.
Differential Diagnosis
Before the final diagnosis, there were some differential ones. Thus, there was a possibility of traumatic brain injury as a result of concussion during the car accident. It has symptoms similar to posttraumatic stress disorder. It is important to differentiate the two conditions because they can occur simultaneously. However, in the case of the patient traumatic brain injury is less probable because the concussion was not severe and the accident happened three years ago, thus traumatic brain injury would have been revealed earlier.
Another possible differential diagnosis was a personality disorder. They could be conditioned by the break-up with a partner, impossibility to graduate with friends, and other personal problems. However, the major factor which stimulated these events was the car accident. Consequently, the patient’s symptoms and conditions are not the signs of personality disorders but refer to the posttraumatic stress disorder.
Finally, medication-induced bipolar disorder could be the reason for the patient’s current condition. She used painkillers after the accident and antidepressants as a part of the therapy for depression. Nevertheless, the thorough examination did not reveal any signs of drug abuse or any dependence on drugs. Thus, medication cannot be a reason for a patient’s disorders.
Cultural and Social Justice Issues
The patient comes from a common middle-class family. Thus, there are no cultural norms or customs that can prevent her treatment. She did not face any discrimination on religious or racial background. Her current condition and the trauma are not connected to her cultural issues. The full range of healthcare services is available in the community they live in.