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Diagnostic Worksheet - Pychosocial History (from Sommers & Flanagan, p 234)

I Identifying Information
Amanda, age 16, female

II Behavioral Observations/MSE
MSE (from Sommers & Flanagan, p 252)
Appearance

Speech and Thought

N/A

N/A

Behavior/ psychomotor activity

Attitude towards examiner

Risky behaviors Jumping off high objects,


punching/pinching self, running into walls

N/A

Affect and Mood

Perceptual Disturbances
Auditory and visual halluncinations

N/A
Orientation (x3) and Consciousness

Memory and Intelligence

N/A

High IQ, seems to have some memory,


concentration, and processing deficits

Reliability, judgement and Insight


N/A

III History of present problem


MK 2011 revised EK 2013

Diagnostic Worksheet - Pychosocial History (from Sommers & Flanagan, p 234)


-

Difficult baby to settle, would cry and could not be soothed, never took naps

Was thought to have separation anxiety until age 9

Began hearing voices at night at age 6she was also hyper in class

Symptoms at age nine included extreme moods, suicidal ideation, visual hallucinations,
and insomnia

Panic attacks occurred from 7th 9th grade (still occurring), as well as self harming
behaviors, anxiety, and depression

IV Past Treatment
-

Past medications have included Seroquel, Zoloft, Prozac, Risperdal, Zyprexa, and
quentiapine but had a bad experience with the latter (joint pain) and stopped taking it and
refused medication

V Relevant Medical History


-

See medications above

MK 2011 revised EK 2013

Diagnostic Worksheet - Pychosocial History (from Sommers & Flanagan, p 234)

VI Developmental history
-

Seems to have memory, concentration, and processing deficits

VII Social and Family history


-

unknown

VIII Current situation and functioning


-

disruptive behavior

experiences panic attacks on downward end of cycling

experiences manic episodes

reported visual/auditory hallucinations

MK 2011 revised EK 2013

Diagnostic Worksheet - Pychosocial History (from Sommers & Flanagan, p 234)


-

struggles to sit still and concentrate in classroom

IX Diagnostic impressions
List/grouping of symptoms by diagnosis
disorder

Sx that fit diagnosis

Bipolar I

A Criteria met for manic


episode
B not better explained by
schizophrenia-related
disorder

Sx that do not fit


diagnosis

Information needed?

MK 2011 revised EK 2013

Diagnostic Worksheet - Pychosocial History (from Sommers & Flanagan, p 234)

Diagnostic code based on DSM 5


296.43

X Case formulation and treatment plan (ETinterventionstoaddressSxasappropriate)


Physiological

Physical

Behavioral
decreaseimpulsiveandunsafebehaviors

Interpersonal/relational
increasesafeandhealthysocialinteractionsinamusictherapygroup

Affect/Mood
usetempoofmusictoinfluencemoodortoreflectmood

MK 2011 revised EK 2013

Diagnostic Worksheet - Pychosocial History (from Sommers & Flanagan, p 234)


Cognitive

Cultural/environmental

Creative
- writemusicwithmusictherapistwillgiveAmandaanoutletandcontrol

Spiritual

MK 2011 revised EK 2013