Biosocial-Psychological Assessment

I. Introduction

Sarah Jenkins (DOB: 14/05/1989, Medicare: 2849 18273 1) is a 35-year-old female referred by her GP under a Mental Health Treatment Plan on 24/10/2023. She presents with a 4-month history of escalating generalised anxiety, low mood, and initial insomnia following a workplace redundancy.

II. Biological Factors

• Family History: Maternal history of Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD). Paternal history of alcohol use disorder.
• Medical History: Hypothyroidism diagnosed in 2019, currently stable on levothyroxine (Oroxine®) 100 mcg PO daily. Recent thyroid function tests (10/10/2023) were NAD. No history of head injury or neurological conditions.
• Substance Use: Consumes 10–12 standard drinks of wine per week, increased from 2–4 per week prior to redundancy. Uses alcohol to assist with sleep onset. Denies illicit drug use or tobacco smoking. Consumes 3–4 cups of coffee prior to 12:00.
• Sleep Patterns: Chronic initial and middle insomnia; sleep onset latency > 90 mins, averaging 5 hours of fragmented sleep per night. Reports waking unrefreshed.

III. Social Factors

• Family Dynamics: Married for 6 years. Relationship is generally supportive, though recent financial strain has caused increased marital friction and communication breakdown.
• Social Supports: Has a small network of close friends in Sydney, though she has been socially withdrawing over the past 2 months due to embarrassment regarding unemployment.
• Employment and Education: Holds a Bachelor of Commerce. Worked as a senior marketing manager for 8 years until her position was made redundant in June 2023.
• Living Circumstances: Lives with her husband in a mortgaged apartment in Parramatta, NSW. Stable housing, though mortgage repayments are a primary stressor.
• Life Events: Sudden job loss in June 2023; two unsuccessful final-round job interviews in September 2023, which precipitated a sharp decline in mood.
• Social Participation: Ceased attending her local running club 6 weeks ago; spends most days isolated at home applying for jobs.
• Financial Concerns: High financial stress due to reliance on a single income and rising interest rates.

IV. Psychological Factors

• Mental Health History: Subclinical anxiety during university exams; no formal prior diagnoses.
• Current Symptoms: Meets DSM-5 criteria for Adjustment Disorder with mixed anxiety and depressed mood. Symptoms include pervasive worry, anhedonia, fatigue, feelings of worthlessness, and somatic tension. DASS-21 scores: Depression 22 (Severe), Anxiety 16 (Severe), Stress 26 (Severe). Denies suicidal ideation, intent, or plan.
• Cognitive Functioning: Alert and oriented. Reports subjective difficulties with sustained attention and short-term memory, likely secondary to sleep deprivation and anxiety. Intact problem-solving capacity.
• Coping Strategies: Relies on maladaptive coping mechanisms including rumination, experiential avoidance, and evening alcohol use. Protective factors include high psychological insight and strong motivation for recovery.
• Behavioural Patterns: Procrastination regarding job applications followed by periods of compulsive over-preparing; social withdrawal.
• Emotional Regulation: Experiencing heightened emotional lability, tearfulness, and irritability.
• Self-Esteem and Identity: Self-worth is heavily enmeshed with professional identity and financial contribution; currently experiencing a significant loss of identity and perceived competence.
• Previous Interventions: Attended 3 sessions of Employee Assistance Program (EAP) counselling in 2021 for work stress, which she found moderately helpful for learning basic boundary-setting.

V. Summary of Findings

Sarah is a 35-year-old female presenting with severe adjustment-related anxiety and depressive symptoms precipitated by sudden unemployment and subsequent financial strain. Biologically, she has a genetic predisposition to mood/anxiety disorders, and her presentation is compounded by poor sleep architecture and increased alcohol consumption. Socially, the loss of workplace structure and withdrawal from her running club have reduced her positive reinforcement, while mortgage stress strains her primary relationship. Psychologically, rigid core beliefs linking self-worth to productivity are driving rumination and avoidance behaviours. Key strengths include high insight, intact cognitive baseline, a supportive spouse, and prior positive engagement with therapy.

VI. Recommendations

• Therapy: Commence individual psychological therapy (10 Medicare-rebated sessions) utilising Cognitive Behavioural Therapy (CBT) and Acceptance and Commitment Therapy (ACT) frameworks.
• Medication Management: Liaise with referring GP regarding potential short-term pharmacotherapy (e.g., SSRI) if symptoms do not improve after 4–6 sessions of psychotherapy.
• Strengthening Social Supports: Re-engage with at least one social contact per week and recommence local running club attendance to counter behavioural withdrawal.
• Behavioural Interventions: Implement cognitive restructuring targeting catastrophic thinking around finances/employment, alongside graded task assignment for job applications.
• Lifestyle Changes: Institute strict sleep hygiene protocols (stimulus control, ceasing caffeine after 10:00) and alcohol reduction strategies (aiming for < 4 standard drinks/week with at least 4 alcohol-free days).

VII. Conclusion

Sarah agreed to the proposed treatment plan. Next appointment is scheduled for 31/10/2023 at 10:00. Immediate goals for the coming week include completing a sleep diary, implementing a 30-minute daily window for job applications, and scheduling a walk with a friend. A GP review letter will be sent following Session 1, with a formal review planned at Session 6. Crisis contact numbers (Lifeline 13 11 14, Mental Health Line 1800 011 511) were provided.