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Biopsychosocial Assessment

A client has presented severe mental health symptoms while at an appointment for ongoing HIV care. The client would only be seen for his appointments in his home and refused to be seen in the clinic. Utilizing the biopsychosocial assessment outline from Sands and Gellis (p. 88-89, 2012), a brief report of the client follows (Wooldridge, 2019):

Identifying Information

The client is 50, cisgender male, Caucasian, divorced, not employed due to disability, and identifies as heterosexual. He was referred by case management staff within the local HIV clinic to receive behavioral healthcare. The client has HIV and will not leave his home for any reason.

Presenting Problem

The major problem is the clients unwillingness to leave his home for any reason. This is a barrier to his HIV care and is a manifestation of his fear of being hurt if he leaves. When prompted by asking what would happen if he left the house to attend an appointment, the client became distressed as evidenced by tapping his feet and the speed of his words increasing. He said he would never leave for that and he would be hurt when he walked outside. When asked how he would be hurt, the client said he was unsure, but that he knew something bad would happen. When asked about fear of contracting another disease, the client cried that leaving home is how he got HIV and he wont do something like that again. This inability to leave the home costs the client money for delivery services and limits his options for service providers. He has limited income due to his disability and when paying for delivery and in-home services, he reports not having enough income for food or clothing some months. He also states that his fear of leaving the house restricts his support system. He notes feeling misunderstood with his HIV diagnosis due to a lack of peer support. The isolation away from his family has further increased this gap in his well-being. The client has isolated himself, leading to overdependence on others. The client notes that his quality of care has decreased since needing home-based care. He becomes distressed when discussing or thinking about public transport, open spaces and outside, or finding ways to meet his needs outside of the home. The client has an extreme fear of disease/illness out of his control. This is evidenced by distress upon discussing exposure to the outside and other people. His history of contracting HIV while having an affair outside of his marriage manifests as a larger fear of the disease. He says the HIV causing his immune system to be weakened and causing him to get another disease when exposed to one by a stranger is his biggest fear. He has physical manifestations of this fear, including noted insomnia, shaking, heart racing, and sweating. He has these episodes when faced with leaving or discussing leaving the home. He notes that these also happen without prompting.

Current Situation

The client lives in a rented subsidized home near the city. Equitas Health has a housing program that has helped the client secure this need-based assistance for the foreseeable future. The client lives alone and has no pets. He states that the home is safe and has no infestation of animals or bugs. He moved to this home shortly after his divorce and once in case management, was referred to the housing assistance program noted. He was unable to pay for the home due to the cost of medication and had a pending eviction notice that was resolved once enrolled in the program. He has all his basic needs delivered to the home when he has the money to do so. This includes deliveries of groceries, medications, home goods, clothing, and food from restaurants. If he needs services, the appointments must take place within his home. These include medical, case management, behavioral health, and personal care appointments that would otherwise be in a professionals office. He has these set up during daylight hours and must speak with the person who will be entering the home before their arrival. The client noted attending a non-denominational church in the past and stopped attending after his divorce. He notes having no support system outside of his care team for HIV. When asked how he would improve this, he states that it is not worth leaving his home to be with people. He has limited social interaction in the form of a chat room on a popular video game which he plays approximately 2 times per week for about 1 hour each session.

Previous Mental Health Treatment

The client has had little formal mental healthcare in the past. The only formal care he has received was couples therapy as a newlywed, prior to the affair and HIV diagnosis. He said the clinician was not helpful and would often side with his spouse before listening to his opinion. This caused him to stop speaking much in the appointments, leading to the couple ending their time in therapy because they saw it as a waste of money.

Background Information

The client grew up as an only child with a single mother. His mother worked long hours, leaving the client to occupy his own time while she was gone. He notes that this was often stressful. He is unaware of any medical or mental health diagnoses or cares from his childhood. He notes being kicked out of school several times due to fights related to being bullied by peers. He graduated on time and has an undergraduate degree in business. He mentioned struggling with school attendance and would often skip class to stay home. The client married his high school sweetheart during his time in undergraduate college. He states that they met in class and he liked her easy-going nature. He states that they had their first child after conceiving on their honeymoon. Their second child was born about 2 years later. Their marriage was more difficult after having children, according to the client. He would isolate himself within their home to avoid conflict with his wife or children. Both children are in college and not in contact with their father. The client notes his affair (in which he contracted HIV) began in his 40s. He states that he believed his wife was also having an affair with someone at the time. He notes that this was his first homosexual partner and although they were dating and having sexual intercourse, he has never identified as anything other than heterosexual. He and his wife divorced after his diagnosis exposed his affair. The client states that the divorce was messy and that he no longer has contact with his ex-wife or their two grown children. The client states that this is about the time his symptoms began to affect his quality of life.

Results of Mental Status Exam and Diagnosis

He had an appropriate dress with jeans and a sweater, was well groomed, was cooperative in answering any questions and providing documents, and was guarded while discussing his fears of leaving home, as evidenced by avoiding answering what if? questions. The client had no tremors or tics. He shook and tapped his feet and fingers while distressed. The clients speech was normal and slightly loud. No loose associations or flight of speech. His primary language is English. He reports feeling uneasy. He maintains this and presents in a normal tone. There was no shift in mood. He is not having delusions or hallucinations. There are repetitive phobic thoughts and obsessive thoughts regarding his space and ability to remain in the home. The client is intelligent and expresses himself well. He is orientated to time/place/person. He showed no issue with memory and had a consistent recall. The client is accurate in perceiving sensations. He struggles with body/space orientation and desires more space around him within the home setting. He states while out of the house, everyone seems too close. He expresses no delusions or hallucinations. The client reports no sexual activity and is very controlled with his body and other people. He denies any sexual desires or urges to interact with others. The client is aware of his fear of leaving is not rational. He is aware of how they interfere with his HIV treatment and lack of a support system. With this insight, he still decides to not leave out of the distress leaving brings him. His judgment is influenced by the fear of being harmed or infected.

The client is diagnosed with the client is presenting with the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) defined as anxiety disordered Matchof agoraphobiaEnd Match with panic disorder (AmericanEnd MatchPsychological Association, 2013)

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