Biopsychosocial Assessment

Presenting Problem

Carla is a 54 year-old, single, Hispanic female.  Carla has been having uncontrollable mood swings for the past 6 years.  Initially she was depressed for the first year.   She has had a loss of energy, loss of appetite, and irritability.   She has strong urges of outburst towards her daughter which began several months ago. 

Personal Status    

Carla is the eldest of five siblings. She has one younger brother and four younger sisters.  Carla was born and raised in Colorado.  Carla was forced to drop out of middle school to work and take care of her younger siblings.  Carla had her daughter at the age of 20.  Carla divorced her husband at the age of 46. Upon starting a new single life, she maintained employment at Walmart. Carla admits she is lonely and bitter.  

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Family Dynamic

Carla was raised by her two parents. Her father died when she was 18 years-old.  Her father was an alcoholic, and her mother was verbally abusive.  Carla’s and her ex-husband had a couple domestic disputes ending with Carla arrested.  Carla’s daughter has little to do with her mother.  Carla’s daughter is still in high school and sees her father every other weekend.  Carla rarely speaks to her sibling, and her mother now lives with her.  Carla began working at Walmart after her divorce.  

Positive Support Systems

Carla’s mother is now living with her and granddaughter to help pay the bills.  Carla’s mother is supportive to seek treatment.  Carla has attempted to make friends at her employment.

Crime and Delinquency

Carla was arrested for assaulting her ex-husband and ex-husband’s employee in Colorado.  She was given probation and anger management class for both charges.  Carla stabbed a girl when she was 12 years of age.  She was only given probation due to self-defense and victim survived.  

Mental Health History

Carla experienced physical and verbal abuse from her mother.  Carla’s grew up with an alcoholic father.  Carla has experienced depression off and on throughout her life.  Self- harm was introduced through mixing alcohol with pain killers.  Carla’s primary care physician wanted Carla to be mentally evaluated for Bi-polar disorder. 


Carla dropped out of 8th grade.  She never attended a GED program. She appears to be of an average intelligence.  She reports feeling guilty for never going back to school and resentment towards mother for making her drop out to work.  Carla expresses to go back for her GED.

Medical History

Carla was diagnosed with borderline diabetes two years ago.  She was to control it with exercise and healthier diet.  She had painful and heavy menstruation.  She has had a hysterectomy 1 year ago.  She smoked tobacco off and on in her early adult years.  Carla experimented in her early adult years with cocaine and marijuana.


Carla is currently employed with Walmart.  In the past she has worked mainly as a waitress or cashier.  Her longest place of employment was a grocery store in Colorado.  She worked there for four years.  Carla employment varied from restaurants, bars, and gas stations for the past 20 years.  Over the past five years Carla was fired for becoming combative towards the customers.  

Readiness for Treatment

Carla accepts the fact that she is in need of treatment.  Her work strongly recommends it and furthermore, Probation is requiring that she receives treatment or be sent to a psych award.  Her daughter is also pushing her towards this treatment or she will move out with her father permanently. 

Resources and Responsibilities

Carla is currently receiving Medicaid through the City Welfare System. This will cover the cost of her treatment and monitor her diabetes.  It is her responsibility to provide proof of insurance coverage to the Billing Department and proof of treatment to her Probation Officer.  Carla is tempting to get her GED with the City Welfare System.

Mental Status Exam Narrative

Carla is a fifty- four year old single mother, Hispanic, female.  She appeared to be the stated age.  She was dressed appropriate for the setting and good hygiene.  She wore a light pink blouse with dark blue jeans and brown boots.  Her grooming was adequate.  She hesitated to some of the questions but mostly calm and polite.  Her mood was both defensive and rigid.  

Carla’s affect was appropriate to content; she was reasonably emotional over her history and distressed over her current situation.  Her rate of speech was normal with slight tense in her voice when addressing stressful subjects.  Her tone was normal throughout the session.  Her thought process was logical to her needs; yet did not demonstrate proper regards to her own actions of past and present, how it contributed to his situation with her daughter, and her continued inability to control her acted out impulses of violent outburst.  Her thought content was relevant.

Carla did not demonstrate psychotic symptoms.  She denied any current hallucinations; however, she admitted having graphic dreams and waking up in a sweat.  She admitted she was obsessed with keeping her house immaculate.  She did not deny any compulsions.  Carla was oriented to time, place, and person.  Her intelligence was estimated to be around average.  Her judgment and impulse control were fair.  She denied both suicidal and homicidal ideation.  


AXIS I: Post-Traumatic Stress Disorder

AXIS II:Borderline Personality Disorder

AXIS III: Border Line Diabetes

AXIS IV: Problems related to interaction with the legal system (probation)

Relationship problems with her siblings

Health Problems

Financial problems

AXIS V: GAF = 60 on admission

Treatment Plan


DSM-IV Diagnosis


Posttraumatic stress disorder due to child abuse; with borderline diabetes. 




Attention to Detail



Short tempered 


Low intelligence


To enable Carla to accept that her past and present are related.

To improve her social relationships.

To manage her temperament.


Refer her to a relationship psychologist.

Referral to a gym membership.

Refer her to a social group within her community

Ask her employer to organize a social corporate event to enable her interact with her colleagues

Talk with Carla’s mother and grandchildren on how to live well with her.

Talk with Carla’s siblings in order they can make an effort to interact with her better.  


Family Counseling once weekly

Individual Counseling Twice weekly

Client’s Personal Values and Attitudes 

Being a single mother, Carla prefers to work with female therapist with children who can relate having raising them.

Counselor’s Personal Values and Attitudes

The therapist could relate to having to start working at a young age, and reminded her lot of herself.  The therapist’s value system is such that she is not biased to any of her situations and can be judgmental free to all her criminal incidents.

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