100%(4)4 out of 4 people found this document helpful
This preview shows page 1 - 3 out of 10 pages.
CASE STUDY TREATMENT PLANBIOPSYCHOSOCIAL ASSESSMENT FORMCultural Background:Name:RosalynAge:59Gender:femaleRace:Rosalyn is identifies as being BlackEthnicity:Rosalyn is an African AmericanReligious Issues:Christian Baptist, Rosalyn reports that she is a member of her church however, she doesattend church weekly but states she attends maybe one or twice a month.Sexual Orientation:Rosalyn identifies as being a heterosexualRelevant Cultural Norms:Relevant cultural norms are, Rosalyn is a 59 year old widow who was married for 31 yearsuntil he passed away from a massive heart attack and now four years later she is questioningher understanding about starting a new relationship, she wants to make sense of her sexualdesires.Other Relevant Cultural Norms:Other relevant cultural norms are, Rosalyn being concerned and needing some helpfuldirection in moving forward in a relationship at her age and after being married for 31 years to
a man that took care of her and a relationship she had been happy in for so long, and now tobe sexually attracted to another man and wanting him to meet her expectations.Current Symptoms:Reason for Visit Listed as DSM-5 Symptoms:Unspecified Sexual Disorder 302.70 (F52.9), Rosalyn does not fit in any of the categories forsexual dysfunctions, however, Rosalyn felt discomfort due to vaginal dryness (may be due tomenopause but not enough information yet).Rosalyn is still trying to get used to not having her husband and states that she feels acombination of emotions after having a sexual encounter after 4 dates with Matthew. Rosalynwas not satisfied sexually with Mathew as she was with her husbandAdjustment disorder diagnostic criteria A with anxiety 309.24 (F43.22)Rosalyn could be in need of counseling attention to have some focus directed to towardRelationship Distress With Spouse or Intimate Partner code # V61.10 (Z63.0), the sexualencounter was not what Rosalyn anticipated. Rosalyn stated that she experienced pain duringintercourse due to vaginal dryness and Mathew was not in tuned to her sexual needs only hisneeds seemed to matter.Rosalyn could be in need of counseling attention due to the death of her husband of 31 yearswhich would be in the DSM-5 category of Uncomplicated bereavement code # V62.82 (Z63.4)âÂ€ÂƒFamily Background:Family of Origin Issues:Rosalyn lost her husband of 31 years from a heart attack 4 years ago. She was introduced toMatthew and is unsure whether or not to continue the relationship after having a sexualencounter and was not satisfied. Rosalyn wants to learn how to live again but questions herability to select the right intimate partner.Family Environment in Childhood/Adolescence:Rosalyn stated that she struggled early in life to accomplish her goals and takes much pride inher efforts. Rosalyn has not yet gone into detail in regard to her child hood.