Biopsychosocial Assessment of Asha Green_Provisional Bipolar Disorder Diagnosis CBT Theory and Treatment

The document presents a clinical assessment of Mrs. Asha Green (age 37, African American, widowed) who is seeking help for symptoms including constant fatigue, withdrawal, lethargy with distressing thoughts, racing heart, and excessive sweating11. She reports episodes of anhedonia, trouble sleeping, and lost appetite, contrasted with periods of being elated, full of life, and active12.Key Components:Identifying Information & History: Mrs. Green is an employed barista with a diploma in social work. She has a history of anxiety with symptoms of depression, delusions, and palpitations, but did not complete previous treatment due to financial issues14. She is an active user of alcohol and is cutting down on marijuana15. She is dealing with two recent legal issues16.Provisional Diagnosis: The report suggests a possible diagnosis of mild-stage Bipolar Disorder ($text{F}31.61$) co-occurring with depressive symptoms 17, based on the presentation of both manic (e.g., grandiosity, racing thoughts, distractibility, hyperactivity, irritability, delusions ) and depressive symptoms (e.g., lethargy, anhedonia, trouble concentrating/forgetfulness ).Treatment Plan: A structured plan is proposed addressing three issues: manic episodes, depressive episodes, and client safety20. The provider's tasks include talk therapy using Motivational Interviewing (MI) and providing medication, while the client's tasks include medication compliance, communication, and attending sessions21.Theoretical Framework & Evidence Base: The endorsed technique is Cognitive Behavioral Therapy (CBT) 22, based on the theory that thoughts, emotions, body sensations, and behavior are connected and influence each other23. Research confirms the efficacy of CBT combined with medication in treating bipolar disorder24.Unanswered Questions & Ethics: The report lists critical missing information, such as past medication history, symptom duration, family genetic history, living conditions, and childhood experiences. It also outlines ethical dilemmas, including costs vs. benefits, discussion about money, informed consent and autonomy, and termination of therapy.