mother and daughter tale

Week 2: Comprehensive Psychiatric Evaluation

Tolani Ayeni

College of Nursing-PMHNP, Walden University

NRNP 6645: Psychotherapy with Multiple Modalities

Stephanie Smith

September 10, 2021

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NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation

CC (chief complaint): The patient is in for a family psychotherapy session and evaluation due to, “the chaos that began when her daughter who recently arrived from Iran claimed that she was sexually and physically abused her father”. The patient and daughter have, “constant fighting, screaming, and yelling in the home”. The patient also complains about the separation that she feels from her children as they grow up with individualistic ideologies of their host culture, different from her personal upbringing in Iran. She complains of “depression because she feels hopeless, and she has so much pain, and no one can do anything about my pain”.

HPI: Patti is a 40 year old Iranian female who is present for a family psychotherapy session and evaluation. Patti reports feelings of hopelessness, helplessness, and consistent pain. Patti’s 21 year old daughter Shireen has recently came to the United States two years ago, within the past two weeks, she has brought up claims against her father for sexual and physical abuse. Patti reports crying and grieving for months, then attempting to involve her daughter Shireen in counseling, Shireen however refuses. Patti is disabled from failed surgeries and has constant pain, her disability prevents her from taking care of herself. Patti reports feelings of depression when she is lonely, resulting in a strained relationship with each of her children because of her unrealistic and high expectations of their caregiver role in her life.

Past Psychiatric History:

· General Statement: No psychiatric history.

· Caregivers (if applicable): No present care givers

· Hospitalizations: No prior hospitalizations

· Medication trials: No medication trials

· Psychotherapy or Previous Psychiatric Diagnosis: Actively in therapy

Substance Current Use and History: No history of substance abuse or alcoholism

Family Psychiatric/Substance Use History: No psychiatric family history.

Genogram

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Psychosocial History: Patti was born in Iran and raised by her parents, she had an arranged marriage a 14 years old. She was physically abused by her husband, then later emigrated to the U.S twelve years ago with her four children on a medical visa and eventually separated from her husband. She actively worked as a caregiver but had two failed foot surgeries that has recently left her disabled. She currently lives with her two boys and requires consistent personal care.

Medical History: Surgeries: Two foot failed foot surgeries.

· Current Medications:

· Allergies: No known drug allergies

 Reproductive Hx: Gravida 5, Para 5

ROS:

 GENERAL: Generalized obesity, reports of fatigue and weakness.  HEENT: Eyes: no blurred vision, difficult vision, no eye pain. Throat: No sneezing,

runny nose, or sore throat, no difficulty swallowing.  SKIN: Denies rashes, bruises or lesions  CARDIOVASCULAR: Denies chest pain, tachycardia, fatigue, edema  RESPIRATORY: Denies shortness of breath, tachypnea, cough, sputum  GASTROINTESTINAL: Denies abdominal pain  GENITOURINARY: Denies polyuria, incontinence, urgency or frequency  NEUROLOGICAL: Denies visual or auditory hallucinations  MUSCULOSKELETAL: Complains of pain in feet from failed surgeries  HEMATOLOGIC: No anemia, bruising, bleeding.  ENDOCRINOLOGIC: No polyuria or polydipsia

Physical exam: Height: 5ft 7in, 176lb, T: 37.1, HR: 83, BP: 146/73, R:22

 HEENT:

15yo18yo 24yo 23 yo

21yo

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 Head is round and normocephalic, no presence of abnormal lesions or bumps. Pupils are 2mm brisk, equal and reactive. Ears are equal in size, no abnormalities. Dentition is adequate, no lesions or dryness in mouth, moist mucous membranes.

 Neck: Neck is supple with no tenderness. Pt has a full range of motion with no stiffness. No lymph nodes on palpation

 Chest/Lungs: Patients lung sounds are clear and equal bilaterally. No wheezing or rhonchi auscultated

 Heart/Peripheral Vascular: Normal S1 and S2, no clicks or murmurs. No tachycardia No edema, +2 pulses in all extremities, < 2 capillary refill.

 Abdomen: Abdomen is distended, soft, and nontender. No palpable masses, no visible redness/rash/edema on the abdomen. Bowel sounds present in all four quadrants. No presence of abdominal hernia

 Genital/Rectal:.No reports of itching, no presence of rash  Musculoskeletal: Patient has two failed foot surgeries. +Pain, +Tenderness  Neurological: There is full sensation in all extremities, +Pain in BLE  Skin: No apparent rashes. No jaundice. No signs of cutting or burns.  Diagnostic results: None

Assessment

Mental Status Examination: Patti is a 40 year old Iranian female who is present for a family psychotherapy session and evaluation. She has a sad and annoyed tone, she reports feeling hopeless and lonely. She has recently been in individual therapy to reconcile her emotions about her disability and children support level in her life. She is alert and oriented to person, place, time, and situation, she has an appropriate thought process with clear and coherent speech. She is appropriately dressed and appears neatly groomed. Her speech is clear and coherent; no signs of tangent speech. She denies visual or auditory hallucinations, denies suicidal or homicidal ideations. During the interview, Patti identifies the problems that she has with her children, and relates her sadness to her children’s inability to support her in her time of need. Patti continuously becomes enraged by her children’s various inabilities to be cultural and attentive to her needs.

Differential Diagnoses:

1. Adjustment Disorder: Adjustment disorder begins three months within onset of a

stressor and lasts no longer than six months after the stressor as long as the stressor has

ceased. Criteria for a diagnosis of adjustment disorder is having the presence of

emotional or behavioral symptoms in response to an identifiable stressor; the stressor

may be a single event. multiple stressors, or recurrent or continuous stressors. The

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stressor may affect a single individual or entire family (American Psychiatric

Association, 2013). Patti was raised with Iranian values and based on traditional cultural

values attempts to project those expectations on her children. In a study, challenges

associated with sociocultural adjustment in a new country resulting from dissonance

between one’s culture of origin and the host culture (acculturative stress) are of poor

mental health. Family conflict was associated with poorer mental health and

psychological distress for immigrants. (Sangalang et al., 2019). Adjustment disorder is

the primary diagnosis for Patti, Patti consistently expresses her wish to have her children

be in her presence majority of the time, along with a wish for active involvement in her

children’s lives. Patti’s recent disability leaves her unable to engage in personal hobbies

and reliant on her children for companionship. This persistent stressor of having children

grow up and wanting independence causes an adjustment disorder for Patti, her

engagement in therapy with Sandi allows her to realize the cultural shifts occurring in her

family and her need to release control and adjust to the changing times.

2. Major Depressive Disorder: According to the DSM 5, MDD is present when five or

more of the selected symptoms are present during the same two week period. Symptoms

such as : depressed mood (signs of hopelessness, emptiness or sadness), loss of interest or

pleasure, insomnia or hypersomnia, psychomotor agitation or retardation , daily fatigue or

loss of energy the patient experiences, feelings of worthlessness or excessive or

inappropriate guilt, recurrent thoughts of death or suicidal ideations with or without a

plan (American Psychiatric Association, 2013). Patti displays primarily hopelessness, and

helplessness. Although she displays these symptoms, it is evident that she still expresses

interest in different tasks of pleasure, however, the primary issue is her physical disability

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and lack of support from her children. Patients who displays five of the diagnostic

symptoms of MDD, expressing signs of hopelessness, insomnia, fatigue, guilt and

worthlessness, suicidal ideations. This differential diagnosis is ruled out for Patti because

of her resolved underlying depression with individual therapy. Patients that met criteria of

MDD have distinguished levels of severity of MDD such as cognitive dysfunction, age,

psychosis, employment, and suicide ideation. (Tolentino and Schmnidt, 2018).

3. Generalized Anxiety Disorder: The DSM 5 defines GAD as anxiety or worrying about

having difficulty controlling worrying, excessive anxiety and worrying that occurs more

days than not for at least six months, symptoms such as restlessness, fatigue, irritability,

muscle tension, and muscle tension (American Psychological association, 2013). The

patient does not express fatigue, restlessness, or does not have excessive worrying about

her life or children; although she complains, she does not have excessive debilitating

uncontrolled anxiety or worrying over the actual current circumstance. The results of a

study utilizing the GAD-7 as a diagnostic tool referenced points that increased a patients

rating on the scale such as: the inability to sit still, or worrying about too many different

things (Jordan et al., 2017). Patti does not signify excessive worrying, inability to sit still,

or inability to stop worrying; therefore GAD would not be an appropriate primary

diagnosis for the patient.

Reflections: Ethical considerations for this patient is awareness of personal cultural

biases as well as clarification and identification of the client’s cultural biases and

hesitancies. The patient’s perceptions about the effectiveness of mental health services

and potential barriers to achievement of treatment goals should also be identified.

Cultural stereotypes might hinder the utilization of mental health services, due to fear of

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discrimination and devaluation (Bracke et al., 2019). If I were conducting this interview, I

would have had Patti expand on her childhood and explore dependence on other people.

Understanding Patti’s background will give me as the practitioner more insight into

Patti’s understanding of what a family is and how to tailor her individual and therapy

goals.

Case Formulation and Treatment Plan

Initiation of individual therapy for Patti once considering her disability and access to

transportation.

Time was allotted for questions and answers were provided. Provided supportive

listening. Client appeared to understand discussion and reflective team, but remains

hesitant to change. Client agrees to follow treatment regimen as discussed.

Follow up with psychiatrist as needed for medication adjustment, and weekly sessions.

Attend weight watchers sessions as discussed in the interview.

Recommendation for a competition of emotional intelligence testing. Rationale: Patti is

seemingly unaware of how her emotions impact her children. This test will give the client

insight into how to perceive, identify, understand, and manage her emotions.

Return to clinic in two weeks

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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Bracke, P., Delaruelle, K., & Verhaeghe, M. (2019). Dominant Cultural and Personal Stigma

Beliefs and the Utilization of Mental Health Services: A Cross-National Comparison.

Frontiers in sociology. 4, 40. https://doi.org/10.3389/fsoc.2019.00040

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Jordan, P,., Shedden-Mora, M.C,., Löwe B. (2017) Psychometric analysis of the Generalized

Anxiety Disorder scale (GAD-7) in primary care using modern item response theory.

PLOS ONE. 12(8): https://doi.org/10.1371/journal.pone.0182162

Sangalang, C.C., Becerra, D., Mitchell, F.M. (2019). Trauma, Post-Migration Stress, and Mental

Health: A Comparative Analysis of Refugees and Immigrants in the United States. J

Immigrant Minority Health. 21, 909–919. https://doi.org/10.1007/s10903-018-0826-2

Tolentino, J., & Schmidt, S. (2018). DSM-5 Criteria and Depression Severity: Implications for

Clinical Practice. Front Psychiatry. https://doi.org/10.3389/fpsyt.2018.00450

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