Quick Guide to Biopsychosocial Assessment | NCE & Addiction Counselor Exam Review

Hey there, everybody, and welcome to this presentation on biopsychosocial assessment, part of the NCMHCE and addiction counselor exam review. I'm your host, Dr. Donnellice Snipes. In this presentation, which is brief, we're going to learn how to conduct a biopsychosocial interview and why it's important. And then we'll go through each domain that you want to assess and we'll talk about why we want to ask about each one of those things. I've created mnemonic devices for each domain in order to make it a little bit easier. So we'll talk about those as we go through. The first thing that you're going to start out with on any assessment, any paperwork, is the demographics. You're going to identify somebody's culture, their race, ethnicity, age, marital status, and biological, as well as identified gender. Why? Because people's identified gender is very important in tailoring treatment strategies, identifying proper pronouns, that sort of thing. But their biological gender is going to impact some of the functioning of their body and what may alter their neurotransmitters, because people, people who are biologically female, experience different neurotransmitter reactions to hormones than people who are biologically male. So we do want to recognize that biology does play a part. Let's start with the physical aspect. What are we going to assess regarding their biological or physiological underpinnings? And the mnemonic for this is Camp Shape chant. Whenever I went to camp, we did a lot of chanting and we did a lot of physical activity. So that's kind of how I remember this. The first part, camp stands for circadian rhythms and sleep addictions, including behavioral ones, medications and supplements and pain. Why do we need to assess for circadian rhythms and sleep? Well, your circadian rhythms are involved in regulating your hormone levels. They're involved in regulating your cortisol levels. They're involved in just about every aspect of your being, including your immunity, and which results in inflammation when that gets kind of out of whack. Hunger, satiation, blood sugar levels, all kinds of things are involved in your circadian rhythms. So somebody who doesn't have a solid circadian rhythm pattern. Circadian pattern may be experiencing hormone and neurotransmitter imbalances that are contributing to their mood issues or their physical symptoms like fatigue and apathy. Sleep is important, and it's not the same as circadian rhythms. Circadian rhythms do help control sleep and the release of melatonin and that sort of thing. But good quality sleep is also a time when people's bodies rebalance, restore, repair, and clear out a hormone called adenosine that builds up during the day. Adenosine contributes to what they call sleep pressure and makes it difficult to focus and to function. You get kind of groggy when you go to sleep. Your brain clears out that adenosine to get you ready for the next day. It's kind of like in a factory when during the. During the day, the factory makes all kinds of byproducts and waste products and stuff. And the cleaning crew goes in overnight, cleans everything up. The maintenance crew comes in, tunes up all the machines so everything is ready to go first thing in the morning. Now, if the factory doesn't shut down overnight, then that can't happen. And eventually too much stuff is going to build up and it's going to start clogging up the works. And the same thing is true for our body and our brain. We want to assess addictions, including behavioral ones. Now, behavioral ones haven't fully made it to the DSM 5 or, you know, whatever the upcoming versions are going to be, but they've started to make inroads into the ICD 11. So we do want to be aware that even behavioral addictions will alter neurotransmitter levels, causing increases and surges of things like dopamine. So the person may start to become dopamine tolerant and experience fatigue and apathy and difficulty concentrating when they are not engaged in that behavior because their brain needs the extra surge in order to function. What is normal for that person. We also want to look at chemical addictions because those obviously also impact a person's physiology and neurobiology, medications and supplements. We want to ask about those. Not just so we fill in the block, but so we can assess if there's anything the person's taking that might be contributing to their mood symptoms, or if we identify that they may have a problem or an issue and they're not taking anything for it, we can make a referral to a physician. For example, cbd. A lot of people are taking CBD oil now. And, you know, that's a whole different. Actually, multiple presentations I've got. But CBD interacts with Cytochrome P450, which is the enzyme that breaks down and clears a lot of medications and toxins and other things from the body. So CBD can actually alter the levels of just about every other medication, from anticoagulants to NSAIDs to, you know, antipsychotics. So it's really important if somebody's taking CBD oil and they're taking any other medication that they consult with their physician to make sure that the levels are right. We also want to find out about psychotropics that they're taking. We want to find out if they're on anything for their presenting symptoms or for other issues. Other medications like statins for example, are also associated with some mood symptoms. So one of the things that you can do is go to drugs.com and look for the symptoms checker and they have an entire database of symptoms that are reported with various different medications. If you're not familiar with the medication, you can double check to see if that might be contributing to their presenting mood issues. And finally, other supplements, you know, if they're taking guarana or I don't know, you know, any sort of over the counter supplement, including pre workout supplements, post workout supplements, creatine. We, we need to get information about those because all of those things can interact. Sometimes it's in a positive way, but other times they, it may interact with medications they're already taking or it may be something that is contributing to their presenting issues. We are not physicians, we are not nutritionists or registered dietitians, so we can't make recommendations about medications or supplements. But if we think that there's something that might need to be addressed, then a referral is imperative. And finally, pain. Pain is so important to address because it impairs people's ability to get quality sleep. When their sleep gets impaired, it starts to affect their circadian rhythms. When they are in pain, it generally means that there's inflammation somewhere. Inflammation, when it becomes systemic contributes to mood symptoms including anxiety and depression. The research is very clear about that. So addressing pain is going to be really important. Also addressing what helps that pain go from a strength set based perspective to help people identify what is working to help them control the pain, ensure that they are under a doctor's care if they are experiencing chronic pain in order to ensure that they are experiencing the highest quality of life possible. So that's the camp part. CHANT stands for cardiovascular disease, disease, hormones, gonadal and thyroid, autoimmune issues, including diabetes. Didn't know that that was autoimmune, did you? And nutrition and hydration and traumatic brain injury, cardiovascular disease. You're like, why do I assess for that? You know, I'm not a doctor. But when people's cardiovascular system is not working effectively, then their body cannot effectively get oxygen to important places like the brain. When the brain is not getting enough oxygen, people will feel fatigued, they May feel apathetic. If it's deprived of enough oxygen, it can contribute to the development of dementia. So cardiovascular disease is really important to assess and that includes high blood pressure. And some of those blood pressure medications will affect people, people's symptoms, you know, and maybe may present or cause symptoms that may be common among certain mood disorders. So you do want to be aware of cardiovascular disease in your clients. Additionally, if they've got cardiovascular disease, just like if they've got pain or addictions, that's also going to potentially be a treatment target. Because living with a chronic condition can involve a grieving process, an adjustment process. There's a lot of stuff that may go along with getting a particular diagnosis. In terms of hormones, gonadal hormones, your estrogen, progesterone, testosterone. It's important to know about those because they affect the availability of neurotransmitters in the brain. They also are rebalanced when people are under chronic stress. They obviously affect libido, which often affects people's self esteem. And estrogen, for example, is neuroprotective. So when people have adequate levels of estrogen in their body and, and people who are both biologically male and biologically female have estrogen in their system, it helps protect the neurons from stress and from neurotoxic assaults. Testosterone, low testosterone, for example, in men is associated with apathy and lack of energy and depressive type symptoms. So it is important to identify if people have had their gonadal hormones assessed in their annual physical, because as we age, our body unfortunately starts reducing its production of those hormones. So if you're working with somebody who is middle aged or older, they may have a gonadal hormone deficiency. And thyroid hormones can either be too high or too low. But our thyroid is intimately involved in the HPA axis, our fight or flight response, and our energy levels and our metabolism. So when people are experiencing a imbalance in their thyroid hormones, it impacts their HPA axis, it impacts their energy levels, and it impacts the availability of neurotransmitters. Gonadal and thyroid hormones can easily be measured in blood tests. So as well as we'll talk in a minute. Vitamin D and iron, those are things that a doctor can identify as potential contributors to people's mood issues, especially depressive type symptoms. Autoimmune diseases, including diabetes. Now, diabetes type 1 has really clear autoimmune connections. Diabetes type 2, they're just now starting to see where there might be an autoimmune component to it. However, it is important to assess for diabetes because Blood sugar alterations in and of themselves, autoimmune issues aside, can contribute to mood issues and a whole bunch of other things. And autoimmune issues, by their very definition, involve inflammation. And what did I say earlier? Systemic inflammation has been clearly identified in the literature to correlate very strongly with depressive and anxiety symptoms. We know that as stress, depression, anxiety go up, autoimmune symptoms also tend to be exacerbated. And it's a bi directional relationship. Nutrition and hydration, these are the building blocks that your body uses to make the hormones and the neurotransmitters and the tissues and everything else that are important to the body factory functioning. And there are certain things that your body just cannot manufacture on its own. So like tryptophan, there are certain proteins, amino acids that, that you have to get from your diet, hydration, all of your neurochemical reactions take place within a fluid environment, basically. And when people are dehydrated, even 1%, it starts impacting their reaction time. By the time they're dehydrated, 2%, it started to impact their cognitive functioning. But they don't even really realize they're dehydrated until they're at least 3% dehydrated. So it is important that people continue to hydrate throughout the day and not just wait until they're parched. Dehydration contributes to difficulty of those neurotransmitters doing their job, which can contribute to lethargy, mood symptoms, fatigue, and things like dry skin and other physical symptoms. Omegas, especially Omega 3s, are painfully low in in the American diet and are essential for brain functioning as well as they are powerful anti inflammatories and antioxidants. So are people getting enough omega 3s in their diet? Most Americans aren't. Creatine also can serve as an anti inflammatory and it helps tissues repair itself that comes from muscle tissue. So if people are omnivores, they're probably getting plenty. If they are vegetarians or vegans, they may not be getting enough. We can't recommend that they start taking any sort of supplement, but it is important to suggest that they talk about it with their physician or a registered dietitian. Calcium is important in the construction, if you will, or of serotonin. Calcium is needed in the chemical reaction that breaks down tryptophan and eventually makes serotonin. Most of your neurotransmitters take place in calcium channels or neurotransmitter reactions take place in calcium channels. So if people do not have Adequate levels of calcium, it's going to potentially make it more difficult for their nervous system to function. Now, calcium, yes, your body can get it from, you know, leaching it out of the bones and everything. But calcium deficiency can be an issue, especially for people who don't eat dairy. There are a lot of people who are lactose intolerant and a lot of people who have sworn off milk. They're like, as soon as I turn 18, I'm not drinking milk again. Well, all right, that's fine. And you can get calcium from a lot of other things, like green leafy vegetables. But a lot of people don't eat dairy and they don't eat green leafy vegetables. So they just don't have a calcium source. B vitamins help your body convert food to energy, basically, and do some other things. Vitamin D. There are tons of vitamin D receptors in those areas in the brain that are also responsible for emotion. We know that low vitamin D levels are associated with seasonal affective disorder. Most doctors, as a matter of course, when they do, do a blood panel, check vitamin D levels as well as iron levels. Iron helps your body carry oxygen throughout. The red blood cells carry oxygen throughout the body. People who are anemic have difficulty with oxygenation, so they often feel extremely fatigued and weak. Magnesium and zinc are two other important nutrients for people to have because they are also essential components in the chemical reactions that help turn food into usable products like serotonin and dopamine and, you know, your other neurotransmitters. And finally, traumatic brain injury. Now, a concussion often is not a huge, big deal. Sometimes it can be multiple concussions, and blast concussions can have a progressive effect. And some people can develop traumatic encephalopathy at years after they've had multiple traumatic brain injuries. So we see this in boxers, we see this in football players. It is important to assess if somebody was in a situation like in the military, some sort of sport where they were getting repeatedly getting their bell rung, as they say, if they are starting to have mood issues or erratic behavior, TBI can contribute to mood symptoms even many, many years later. In terms of the affective or cognitive dimension. Now, a lot of these are going to be things that you've heard, affect and emotional dysregulation. Does somebody go from 0 to 200 like that? If they do, that's often an indication of HPA axis dysfunction, oftentimes related to adverse childhood experiences or trauma, but sometimes related to other sources of chronic stress that have led to HPA axis DYSREGULATION we want to assess for trauma, trauma that they identify, like victimization, for example, but also those adverse childhood experiences. Remember, those are abuse or neglect, abandonment from a caregiver, mental health or addictive issues within the nuclear family. So if somebody living in the household had mental health or addictive issues, those are the three main categories that a lot of the aces fall into. Now, people can experience ACEs without necessarily developing traumatic injury if they have sufficient support and they are cognitively able to process it and everything at the time. It may not continue to be an issue for them when they're seeing you. However, for a lot of people it does cause traumatic injury and it is an issue. You want to make sure that they are oriented to person, place and time. You want to assess for memory issues and you can do that by asking them, you know, who's the president? You can ask them where they are, you can ask them a variety of different questions. But it is important to make sure they have a fund of recent memory as well as remote memory. You also should ask them to remember three words. You know, cat, bus and kite. Whatever three words you choose, tell them you're going to ask them about those words later and then, you know, 20 minutes later or something ask them what the three words were. And that just helps see what their, you know, short term memory is really capable of doing at that point in time. Insight and judgment is important because if people are not aware of what their needs are, they may not exercise effective judgment. So do they understand what they're needing right now? Do they see the problem? Are they willing to explore options for addressing the issue? So those are the things that you're going to look at for insight and judgment. Now people who are starting to have difficulty with orientation, memory or insight and, or insight, especially if it is sudden onset, definitely need to be referred to a neurologist for an evaluation. This is especially true if they are in early recovery from addiction. If they've have anorexia, or if they have had gastric bypass surgery, it can be associated with something called Wernicke Korsakoff syndrome. Now that's probably not going to be on the ncmhce, but it is important to know if somebody has a sudden onset. It could indicate an extreme thiamine deficiency, which is a medical emergency. So they need to be assessed right away. C stands for concentration. Can people focus? Now if your intake process is two hours long, yeah, it's going to be difficult for them to keep focus the whole time. But are they able to focus in Small chunks. You ask them a question, they can respond appropriately. Chipper stands for cognitive ability, hallucinations and delusions, Impulsiveness, problem solving and coping skills. Psychiatric diagnoses, esteem of self and relatives, history of mental health issues. So up to cognitive ability and educational issues. We know that low educational attainment is associated with low socioeconomic status and often is a risk factor for the development of a variety of mental health and addictive issues. We want to assess that, but we also want to assess their cognitive ability. If you have somebody who is not able to read or write, or if they have fetal alcohol spectrum issues where they're able to talk at a very high level, but they're not able to receive information at that same level, then they are going to need different treatment placements than someone who has, you know, an age appropriate cognitive ability, Hallucinations and delusions and going back up to cognitive ability. People who have a cognitive ability below their chronological age as well as people who have a cognitive ability that is higher than the norm, may need social support and may need to address some of those issues. Because when you don't fall right in the middle of that bell curve, sometimes it's hard to feel like you fit in. Or sometimes day to day life can be challenging in a variety of different ways. Hallucinations and delusions. You know, obviously we want to screen for that to assess whether they may have a psychotic disorder or if they may have depression with psychotic features. We need to recognize that psychotic features can appear in major depressive disorder, but those hallucinations and delusions are often an indication of, you know, a much bigger problem. We want to assess for impulsiveness and problem solving and coping skills. And I kind of put these together. How do people cope with stress? How do people cope with distress when something happens? What are their strengths? How do they keep from being impulsive? Psychiatric diagnoses. What have they been diagnosed with in the past or, or what psychiatric diagnoses do they think they have and what are their symptoms? They say they're depressed. Tell me what that looks like for you. They say they're anxious or bipolar or whatever they think their diagnosis is. Let's talk about that. What is their self esteem like? People with low self esteem often tend to have problems in multiple dimensions including mood, which can impact their health. Low mood, high anxiety, contributes to HPA axis dysregulation, contributes to increased inflammation and a whole cascade of stress related health problems. So we do want to ask about self esteem and their family history, their relative history of psychiatric diagnoses we want to look at first generation and maybe second second generation. We can look at grandparents and parents. Once you get past that, you're probably not going to see as much connection. But we do know that there is a genetic component to a lot of mental health as well as physical health issues. By asking about family history of diagnoses, we can also find out what has worked and what hasn't worked, what for those people, because again, a lot of people have a genetic component. So what worked for mom may work for junior. And things that really didn't work for mom may not be first line treatments for junior. Environmental SS ship Now, my most relaxing place in the world, I think is, is, well, maybe not in the world, but I love being on the water, I love being on the ocean. So when I think of a relaxing environment, I think of being on a cruise ship. So SS ship. We want to look at sensory sensitivities and triggers. People with adhd, schizophrenia, autism spectrum disorder, and a variety of other issues often have sensory sensitivities. So things that sound average to you may sound very quiet or very, very loud to them. Things that feel lukewarm to you may feel not warm at all or very, very hot to them. So it's important to recognize if they have sensory sensitivities to sounds, to smells, to sights, and to tactile sensations. Because all of these things, especially if things are more acute, if things feel hotter, louder, you know, it can be painful, it can be distressful, and as an infant, they still had these sensory sensitivities and nobody probably recognized it. So as an infant, they probably experienced trauma because nobody knew they were what was causing their distress or how to make it stop. We do want to recognize the impact of sensory sensitivities and sensory integration issues. But we also want to recognize that our senses are some of our main triggers for memories and emotions. We want to encourage people to examine what triggers sights, smells, sounds, you know, tactile, are positive in their environment. What do they like to see, hear, smell, and how can they increase that in their environment, as well as what things in their environment are stressful, what things trigger their anxiety, their anger, their depression, and you know, remember, smells are there as well. It's not just what they smell in order to help them identify strategies that they may be able to use in order to create a safer environment. People who've experienced trauma have an overwhelming sense of disempowerment and unsafeness, and we want to help them feel empowered and figure out what they need to do to Feel safe, which takes us down to safety. Their perception of safety in their own skin. You know, some people, I had one client that I worked with who had schizophrenia and he did have command hallucinations that told him to cause himself bodily harm. And they were ego dystonic. You know, he didn't want them. He knew that that's not what he wanted to do. But he felt very unsafe in his own body because it was like he had another person living in there. So we do want to explore their perception of safety in their own skin. Do they feel like they can trust themselves to keep themselves safe? Their safety when they're trying to sleep, when they're at home, when they're at work, when they are traveling. Know some people feel very unsafe, especially if they've had a bad experience like a carjacking or something, or maybe they've been in a bad car accident and they feel very unsafe when they're driving, but they have to drive to and from work. Okay, so we want to explore some of those times when they don't feel safe and strategies that they might be able to consider to help them feel safer. Housing, is it stable? We all need stable housing. Think of Maslow's hierarchy here. You know, that baseline is our basic biological needs. And one of those things is, guess what? Housing. Safe, stable housing. So do they have that? And that is basically what we're talking about, is a roof over your head and one that you're not in jeopardy of being evicted or foreclosed on or something like that. The next question is, with whom do you live? And if they live with people who are supportive and is a wonderful environment, that's great. If they live with people who are threatening in some way or they feel are dangerous in some way, that can be a problem. Sometimes it's not that the people are threatening or dangerous, but they live in an overcrowded environment. Whether it is, you know, four people living in an apartment together in college and three of them are out partying all night long and they come home and make all kinds of noise or, you know, it could just be overcrowding. And that can contribute to anxiety and depression. There's lots of research that shows that the living environment, overcrowding can contribute to high stress levels. We want to find out about their income, you know, what is their financial situation right now. Not to be nosy, but to figure out if they might be able to tap into some of the resources that are in the community to help them with a variety of their needs. Personal space, this kind of goes along with housing. Do they have enough personal space? How much do they need? Some people, you know, extroverts tend to like to be around other people and they may not need as much. Introverts tend to need some quiet downtime in order to regroup. And they really treasure their personal space. And this is true in recovery environments too. I remember the residential program that I ran. One of the facilities, we had people eight to a room, and you can imagine nobody had any personal space. It was very, very crowded. And that can get exhausting, especially if you've got people sleeping in the same room and some of them snore like a freight train. That impacts their rhythms and sleep and stress levels and everything else. But just in a general sense, do people feel like they have got a space that they can call their own where they can put stuff that's private and not have it gone through or violated in some way? So that's SS Ship. And finally, relationships. And this one I don't have a cute mnemonic device for. It's just A, B, C, D, E, Fs. And relationships are one of the basic needs that we have. So if you want to think about it that way, it's alphabetical. Attachment issues. We do want to assess for their attachment style. Secure, insecure, insecure, avoidant, insecure, disorganized. You know, what are we looking at? We want to examine abandonment issues that they may have. I have seen a super significant increase in abandonment issues over the past five years in the clients that I see. So we do want to look at attachment style and attachment issues, starting with their primary attachment figures and including their adult attachments. Boundaries. How able are they to set them emotional and physical and keep them. And for a lot of people, it's important to explain what boundaries really look like. You know, are you able to set a line, set a wall between you and someone else where you can be happy even if they're upset? You can empathize with them, but their emotions don't overwhelm you. Communication skills. How effective are they at being assertive, or do they have difficulty with that? They tend to struggle with anger and aggression issues or passivity. They feel like nobody hears them. What dysfunctional relationship patterns do they have, if any? And I think most of us have one or two that we could stand to become aware of and work on at some point in our lives. But we do want to explore prior relationships because social support is so important in the recovery process. We want to help them develop and nurture healthy relationships. Empathy and emotional intelligence. How effective are they at identifying their own emotions and regulating them, as well as empathizing with others and being able to respond appropriately to other people's emotions? Now remember, you know, there's that boundary there. They don't have to take other people's emotions on, but they have to be able to recognize them and respond appropriately. Family of origin and current nuclear family. Family. This is when you talk about, you know, what was life like growing up. Tell me about your relationship with your parents, with your siblings, with your best friend from elementary school, whatever, and then let's talk about your current nuclear family. What are those relationships like? And look for parallels as well as divergences between the family of origin and the current family. And identify what things in those families in those situations felt good and what things that they struggled with. And finally, social support. Social support is not always family. And for a lot of people it's anybody but family. So where do they find their social support? Where do they find acceptance and validation and, and respect from others? Where do they feel like they are understood to a certain extent? And some people have none, you know, so that can be a early therapeutic target as well. Obviously, if they're struggling with something like social anxiety or low self esteem, you know, telling them to go out and make friends ain't going to be right up there on the top of the list because they've got other issues to deal with first. But social support is important and that's where support groups can be super helpful. Finally, spirituality. I love birds and I feel very happy in the morning when I see the sun rising and the birds coming to the feeders and chirping. So chirp Spirituality. Think about the dove that chirps. Chirp stands for connection to others. Higher power. Influence of culture, reason for current condition and purpose in life. We want to assess their connection to others and the universe. Where do they feel they fit in? How do they feel that the universe or other people impact them? And likewise, how do they see themselves impacting others? If they see themselves as disconnected or feeling powerless, you know, that's gonna be something to talk about. Higher power. Not everybody believes in one, but if they do, then assessing the impact of their belief in their higher power on their life and on their how they perceive the best way to handle their current condition is I stands for influence of culture. People may identify as being from a particular culture, but that doesn't mean that they're 100% acculturated. It doesn't mean that they embrace 100% of the values and behaviors and customs of that culture. So we want to explore that with them, Talk about how did they define themselves culturally and what does that look like? What does that mean? What are the most important points of or important parts of that culture in their life? You can use their sense of spirituality and their culture too to explore their perception of the reason for their current condition. Why do you think this is happening to you? And some people may feel like it is punishment from a higher power. Other people may feel like it is negative energy from the universe. Other people may say, it has nothing to do with my current condition. But it's one of those things that we need to explore because a lot of people do have ideas about what might be causing their current condition that are culturally informed. And finally, what is their purpose in life? And sometimes it's, you know, what do they want to do? But, you know, why are they here on this earth? Some people haven't thought about it. Some people have thought about it a lot. But they have found that there is a strong correlation between depression and suicidality and a sense of a lack of purpose. So we do want to assess people's perception of their purpose in life in order to potentially identify a treatment target, but also to again help inform the development of the treatment plan. So to go back over really quickly, Physical assessment, camp chant, circadian rhythms and sleep, addictions, medications and supplements and pain, cardiovascular disease, hormones, autoimmune issues including diabetes, nutrition and traumatic brain injury. Affective and cognitive dimensions. Atomic Chipper. We want to assess their affect and emotional dysregulation, trauma history, their orientation, memory issues, insight and judgment and concentration. Chipper stands for cognitive ability and educational issues, hallucinations and delusions, impulsiveness, problem solving, psychiatric diagnoses, esteem that self esteem and their relatives. History of psychiatric diagnoses. For the environmental assessment, it's SS ship. Look for their sensory sensitivities, if they have any. You know, do things tend to bother them more than other people. Sites, smells, sounds, et cetera. As well as help them start being aware of and identifying their triggers, both positive and negative emotional triggers that are sensory based. So sensory sensitivities, safety, housing, income and personal space, relationships, back to basics. A, B, C, D, E, F, S. So we want to look at attachment issues, boundaries, communication skills, dysfunctional relationship patterns, empathy and emotional intelligence, family of origin and social support. And last but not least, spiritual cultural dimensions. This is chirp. Just like the birds outside your window or the dove that we often see. Associated with spirituality, connection to others, higher power influence of culture, their reason for their current condition, or their perceived reason and their purpose in life. A variety of different things can cause or worsen behavioral health symptoms. A complete biopsychosocial assessment can help identify possible issues which can be synthesized and into your comprehensive summary, like pieces of a puzzle. So again, in your comprehensive summary, you're not just going to say Jane has an autoimmune issue or Jane has fibromyalgia. You're going to talk about why that's important and how that contributes to her current presentation.