NRNP 6645 ASSIGNMENT WEEK 1: Family Assessment

Family Members:
Patti (mother) – 40 years old
Sheela (1st born) – 24 years
Sharleen (2nd born) – 23 years
Shirleen (3rd born) – 21 years
Son (4th born) – 18 years
Son (5th born) – 15 years

Subjective:

CC (Chief Complaint): “My household is full of chaos from my children.”

Family Assessment Overview:

In this family assessment, the focus is on psychiatric evaluation, the psychiatric diagnosis, and how family dynamics contribute to the mental health struggles of each member. The primary concern is the family conflict within the household, impacting both the mental and emotional health of the children and the mother, Patti. In assessing these relationships, it’s important to integrate the psychosocial history, psychiatric care, and nursing interventions required to improve family function. Furthermore, the family must be understood in a cultural context, particularly given the immigrant background and the clash between traditional family roles and modern societal expectations.

History of Present Illness (HPI):

Patti, a 40-year-old woman, reports that her household is chaotic, and she feels unable to cope with her children’s behaviors and her own emotional distress. Patti immigrated to the U.S. from Iran 12 years ago, bringing her four children along. The fifth child, Shirleen, joined the family two years ago after significant family trauma, including Shirleen’s disclosure that their father sexually abused her. This disclosure caused deep emotional distress and has contributed to the family dysfunction.

The family’s culture, religious values, and traditional roles add complexity to the family dynamic, where family roles in therapy need to be addressed to bring about positive change. Patti’s struggle with hopelessness and helplessness seems to stem from a combination of cultural conflict, her disability, and the fallout from her family’s trauma. The family therapy in this case needs to navigate these cultural and individual challenges to foster better mental health for everyone. This case calls for both psychiatric treatment plans for individuals and family-centered therapy to address the multiple layers of mental health concerns.  

Past Psychiatric History:

Patti has a documented history of mental health issues. She has been referred to psychiatric care due to feelings of overwhelming hopelessness and depression, which she attributes to her disability and strained family relationships. She has not been formally diagnosed with a specific psychiatric disorder, but her symptoms align with Major Depressive Disorder (MDD) and Post-Traumatic Stress Disorder (PTSD).

Her children do not have a significant psychiatric history, though family dynamics suggest that unresolved trauma and family conflict have led to increased stress. For example, Shirleen’s trauma and subsequent struggles might point to PTSD, especially considering the sexual abuse she endured. A psychiatric evaluation will help clarify the appropriate psychiatric diagnosis for each family member, especially for children like Shirleen, who may be suffering from secondary trauma as a result of the family’s past history.

Substance Use History:

At present, there is no information indicating any substance use history among the family members. However, it is important to investigate potential substance use by any family member, as it can contribute to psychiatric disorders such as depression and anxiety, and may impact treatment adherence. Substance abuse could also be a contributing factor in family conflict and the mental health of adolescents. This should be assessed in subsequent interviews, especially in light of the family’s emotional strain.

Family Psychiatric and Substance Use History:

No substantial psychiatric or substance use history has been reported for the family as a whole, though individual family members may experience mental health challenges that have yet to be addressed. Psychiatric history in families can provide critical insight into the genetic components of mood disorders like MDD, bipolar disorder, or even personality disorders such as Dependent Personality Disorder (DPD) or Borderline Personality Disorder (BPD).

The cultural stigma associated with seeking psychiatric help in many immigrant communities may also play a role in the family’s reluctance to engage fully with mental health professionals, complicating the assessment and treatment process.

Psychosocial History:

Patti and her children relocated to the U.S. from Iran, where traditional family roles shaped their initial family dynamics. The family has undergone significant challenges in adjusting to American life, experiencing cultural tension between the traditional Iranian family structure and the more individualistic American culture. Shirleen, the most recent immigrant, has faced emotional difficulties after sexual abuse and abandonment by her father. Her arrival in the U.S. marked a significant period of trauma, leading to family dysfunction.

Patti’s chronic pain and disability have contributed to her depression and feelings of being overwhelmed by family dynamics. She has become increasingly reliant on her children, exacerbating the co-dependent relationship and inhibiting their growth toward independence. Family therapy can help unravel these issues, providing space for healing and fostering a healthy family structure.

Medical History:

Patti’s medical history includes two foot surgeries, one of which was botched, leading to chronic pain and disability. This disability has had a profound effect on her mental health, contributing to feelings of hopelessness, helplessness, and inability to participate in daily life fully. It also complicates her role as a mother, as she struggles to balance the physical limitations of her condition with her responsibilities to her children. A review of Patti’s medications, particularly pain management and any potential antidepressants, is needed for a comprehensive psychiatric treatment plan.

Review of Systems (ROS):

Given the family’s complex history, it’s essential to explore any physical conditions that could be contributing to mental health symptoms. Patti’s chronic pain and disability need thorough assessment, as conditions like hypothyroidism or fibromyalgia can sometimes present with psychiatric symptoms similar to depression or anxiety. Further assessment through a physical examination will ensure that medical conditions that could affect mental health are not overlooked.

Mental Status Examination:

During the assessment, Patti and her daughter Sharleen are well-groomed, appropriately dressed, and demonstrate clear speech. However, their speech rate and tone fluctuate, which may suggest underlying emotional distress. Both individuals are oriented to person, place, time, and event. Their thought processes appear logical and coherent, though some emotional dysregulation is evident in the form of irritability and anxiety. Neither exhibits signs of psychosis (e.g., delusions, hallucinations), and there are no immediate indications of suicidal ideation or self-harm behavior.

Shirleen, the youngest, may show symptoms indicative of trauma, which could suggest an emerging Post-Traumatic Stress Disorder (PTSD) diagnosis. Cognitive Behavioral Therapy (CBT) and Trauma-Focused CBT (TF-CBT) would likely be beneficial interventions for her.

Differential Diagnosis:

The psychiatric evaluation should consider the following possible diagnoses:

1. Major Depressive Disorder (MDD): Patti’s pervasive symptoms of hopelessness, helplessness, and inability to find joy in everyday activities are consistent with MDD, according to the DSM-5.
2. Post-Traumatic Stress Disorder (PTSD): Shirleen’s exposure to sexual trauma and subsequent emotional distress points to a potential diagnosis of PTSD.
3. Dependent Personality Disorder (DPD): Patti’s significant reliance on her children for emotional support and fear of being abandoned could align with a diagnosis of Dependent Personality Disorder (DPD).
4. Adjustment Disorder: This diagnosis could apply to the children’s struggle to adjust to life in the U.S. and the transition from Iranian cultural norms to American societal norms.

Treatment Plan and Nursing Interventions:

The treatment plan will include:

1. Cognitive Behavioral Therapy (CBT) for addressing depression and anxiety in both Patti and Sharleen.
2. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for Shirleen, focusing on addressing trauma-related symptoms like avoidance, emotional numbing, and hypervigilance.
3. Family Psychotherapy to improve communication and family dynamics. This will help resolve underlying family conflicts and address cultural differences between traditional family roles and the needs of a modern, Americanized family.
4. Psychiatric Medication may be indicated for managing depression, anxiety, and pain, including possible prescriptions for antidepressants or anxiolytics.

Nursing interventions will focus on improving family communication, supporting self-care strategies for mental health, and encouraging culturally competent care throughout the process. The ultimate goal is to improve the family’s mental health, reduce conflict, and foster a supportive, cohesive family system.

Ethical Considerations:

Throughout the family’s therapy, it’s important to consider ethical principles such as confidentiality, informed consent, and ensuring that each member’s voice is heard. The therapist must maintain a balance between addressing the individual’s mental health needs and the collective family dynamic, ensuring that all members feel safe and supported.

References:

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
• Gautam, M., Tripathi, A., Deshmukh, D., & Gaur, M. (2020). Cognitive Behavioral Therapy for Depression. Indian journal of psychiatry, 62(Suppl 2), S223–S229.
• Ramsay, G., & Jolayemi, A. (2020). Personality Disorders Revisited: A Newly Proposed Mental Illness. Cureus, 12(8), e9634.
• Watkins, L. E., Sprang, K. R., & Rothbaum, B. O. (2018). Treating PTSD: A Review of Evidence-Based Psychotherapy Interventions. Frontiers in Behavioral Neuroscience, 12, 258.

NRNP 6645 ASSIGNMENT WEEK 1: Family Assessment

Family Members

Patti (mother) – 40 years old

Sheela- (1^st born) 24 years

Sharleen- (2^nd born) 23 years

Shirleen- (3^rd born) 21 years

Son- (4^th born) 18 years

Son- (5^th born) 15 years

Subjective:

CC (chief complaint): “My household of full of chaos from my children.”

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HPI:

Patti is a 40-year-old female client who first presented for psychotherapy with reports of her household being in chaos from her children. She comes for psychotherapy today together with her 23-year-old daughter, Sharleen.  Patti reported that she immigrated to the U.S 12 years ago alongside her four children. However, one daughter, Shirleen, was left in Iran. Patti obtained a visa for Shirleen two years ago, but since she joined them in the U.S, chaos has gradually increased in the family. According to Patti, the chaos began when Shirleen reported that she was and sexually abused their father, and he would abandon her in the house. As a result, she constantly blamed Patti for leaving her back in Iran, where their father constantly abused her.

Patti states that the chaos is demonstrated by unceasing fights, yelling, screaming, and cursing each other. Besides, the fights have been worsened by the daughters detaching from their mother because she still follows their traditions. They wish to live independently, identify, and embrace their individuality. However, the family has a lot of tension and anxiety because Patti became immobilized after a botched surgery. The disability left her hopeless and helpless, and she feels that the children are uncontrollable. Patti perceives that she is not in control of her children, and they do not need her any longer. She gets into frequent disagreements because she wishes that they spend more time with her. However, the children want to live their lives separately. Patti states that she feels depressed when they do not spend time with her. Both Patti and Sharleen deny having obsessive thoughts, compulsions, phobias, delusions, hallucinations, or suicidal/ homicidal thoughts or ideations.

Past Psychiatric History:

• General Statement: Patti has a history of referral to a psychiatrist. The children have no significant psychiatric history.
• Caregivers (if applicable): None
• Hospitalizations: No history of psychiatric admission
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis: The family is on family psychotherapy.

Substance Current Use and History:

The video did not include the family members’ past and current substance use. I would acquire this information by asking each family member if they currently or in the past smoked tobacco, used alcohol, or other drug substances and for how long they used them. The information is crucial because alcohol and drug substances are linked with various psychiatric disorders, including depression and psychosis.

Family Psychiatric/Substance Use History:

The video did not address psychiatric and substance use history among the family’s close relatives. The information would be obtained by inquiring if any relatives have a history of using illicit drugs or excessive alcohol consumption. I would also enquire about the presence of relatives with a history of mental disorders. Psychiatric and substance use history is essential in identifying disorders associated with genetic factors such as schizophrenia, Huntington’s disease, and substance use disorders.

Psychosocial History:

Patti and her four children relocated to the U.S from Iran 12 years ago.  Shirleen immigrated to the U.S two years ago. Patti lives with her two sons, 18 and 15 years old, and the three daughters live independently. Patti worked as a caregiver before she became disabled. Her daughter, Sheela, is studying and working. Sharleen is into promotional jobs and is currently working on obtaining a real estate license. Shirleen is married and lives with her spouse. Their father remarried twice after leaving him in Iran. The sons are currently in high school. The family has a cousin who relocated with them and lives in LA.

Medical History:

Patti had two feet surgeries. One was a botched surgery that left her incapacitated and with constant pain. Sheela had a medical problem in her childhood. Patti has been referred to a psychiatrist for pharmacologic treatment secondary to reports of hopelessness and helplessness.

• Current Medications: Not provided. The information would help in determining drugs to prescribe when developing the treatment plan.
• Allergies: Not provided. I will collect the allergy information by inquiring if any family member has a drug, food, or environmental allergy. Allergy information is essential in planning treatment to avoid prescribing drugs that would cause an allergic reaction.

• Reproductive Hx: No history of gynecologic or obstetric disorders.

Objective:

A physical exam was not conducted in this session. A full physical exam is important to identify signs of underlying abnormalities that present signs similar to mental disorders such as hypothyroidism, which present with depressive symptoms.

Diagnostic results:

No diagnostic tests were requested during the session.

Assessment:

Mental Status Examination:

Patti and Sharleen are well-groomed and appropriately dressed for the event and weather. Their speech is clear, but their volume and rate fluctuate during the interview. They demonstrate a coherent thought process. No obsessions, compulsions, phobias, delusions, or hallucinations were observed. Both Patti and Sharleen are oriented to person, place, time, and event. Both their short-term and long-term memory are intact.

Differential Diagnoses:

1. Major Depressive Disorder (MDD)

Major Depressive Disorder (MDD) manifests with a persistent depressed mood or loss of interest in most activities. To diagnose MDD, the presence of at least five of the following symptoms is required: sleep disturbances, changes in appetite or weight, fatigue or low energy levels, psychomotor retardation, feelings of guilt or worthlessness, difficulty concentrating, and suicidal thoughts (APA, 2013). Patti displays several symptoms indicative of MDD, such as a pervasive depressed mood, hopelessness, tearfulness, sadness, emptiness, and feelings of helplessness. She has even been referred to a psychiatrist due to her overwhelming feelings of hopelessness and helplessness.

2. Post-traumatic Stress Disorder (PTSD)

Post-traumatic Stress Disorder (PTSD) is a condition that develops after exposure to a severe traumatic stressor, such as a life-threatening accident, serious injury, or sexual violence. Individuals with PTSD respond to the traumatic event with feelings of helplessness and fear, and they often avoid reminders of the event (Watkins et al., 2018). Additionally, they may experience anxiety symptoms and re-experience the trauma through flashbacks and nightmares (APA, 2013). PTSD can significantly impair social functioning.

It’s likely that Shirleen has developed PTSD due to her history of abandonment, physical, and sexual abuse by her father. Her behavior displays PTSD characteristics, including irritability, emotional distress, and reckless actions, such as eloping with her mother’s friend’s son. Moreover, Patti and Sharleen may have developed PTSD after learning about their sister’s traumatic experiences at the hands of their father. Sharleen exhibits avoidance symptoms, as she avoids conversations and thoughts related to her sister’s trauma, and her emotional state becomes negatively affected when she hears about her sister’s traumatic experiences. Patti, on the other hand, has displayed negative alterations in mood and cognition, marked by prolonged crying. Furthermore, their elder brother has severed communication with their father after learning about his physical and sexual abuse of their sister.

3. Dependent Personality Disorder (DPD)

Dependent Personality Disorder (DPD) is characterized by a persistent need to be taken care of, leading to submissive behavior and clinginess. Individuals with DPD struggle to make personal decisions and exhibit a constant need for others to assume responsibility for various aspects of their lives (APA, 2013). They may feel uncomfortable and vulnerable when left alone and tend to seek relationships where they can be cared for and supported.

Patti likely has DPD, as she expresses feelings of hopelessness and helplessness, particularly because her children do not spend time with her. She seeks to maintain a relationship with her children so that they can provide her with support. Additionally, Patti consistently relies on her daughter to take responsibility for various aspects of her life, believing that her children must always be available because of her disability.

Reflections:

The case assignment proved to be quite challenging due to the myriad issues presented by the family members. It became apparent that family members exposed to the same risk factors for mental disorders were at higher risk of developing those disorders. For example, the family members are exhibiting symptoms of PTSD due to their exposure to Shirleen’s traumatic event, which they learned about through hearing her story. It also became evident that adults who develop disabilities may develop Dependent Personality Disorder, resulting in a fear of being alone without their loved ones (Ramsay & Jolayemi, 2020). Legal and ethical considerations in this case encompass principles such as beneficence, confidentiality, and obtaining consent. The PMHNP can promote beneficence by conducting psychotherapy to benefit each family member and foster family unity (Bipeta, 2019). Confidentiality of the family’s history and medical information must be strictly maintained. Additionally, the PMHNP should seek consent from each member before involving them in psychotherapy.

Case Formulation and Treatment Plan:

The clients exhibit symptoms of MDD, PTSD, and DPD. To ascertain the severity of depressive symptoms and diagnose MDD, Patti will be asked to complete the PHQ-9 questionnaire. She will also complete a Dependent Personality Questionnaire (DPQ) to screen for DPD (Ramsay & Jolayemi, 2020). If her symptoms meet the criteria for an MDD diagnosis, she will be referred to a psychiatrist to establish a pharmacological treatment plan.

Treatment Plan:

1. MDD: Commence Cognitive Behavioral Therapy (CBT) on a weekly basis to provide Patti with the opportunity to identify current life situations contributing to her depressive mood. CBT will focus on helping Patti recognize distorted thought patterns that may be causing her depression (Gautam et al., 2020).

2. PTSD: Implement Family Trauma-focused Cognitive-Behavioral Therapy (TF-CBT) once a week. TF-CBT will aim to assist each family member in overcoming trauma-related difficulties (Watkins et al., 2018).

3. DPD: Engage in Family Psychodynamic Psychotherapy on a weekly basis. This psychotherapy will concentrate on evaluating Patti’s fear of independence and the challenges she faces in asserting herself (Ramsay & Jolayemi, 2020).

Follow-up:

Conduct follow-up sessions weekly to monitor the progress of psychotherapy. These follow-up sessions are vital to ensure that each family member receives the necessary support and interventions.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19

Gautam, M., Tripathi, A., Deshmukh, D., & Gaur, M. (2020). Cognitive Behavioral Therapy for Depression. Indian journal of psychiatry, 62(Suppl 2), S223–S229. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_772_19

Ramsay, G., & Jolayemi, A. (2020). Personality Disorders Revisited: A Newly Proposed Mental Illness. Cureus, 12(8), e9634. https://doi.org/10.7759/cureus.9634

Watkins, L. E., Sprang, K. R., & Rothbaum, B. O. (2018). Treating PTSD: A Review of Evidence-Based Psychotherapy Interventions. Frontiers in behavioral neuroscience, 12, 258. https://doi.org/10.3389/fnbeh.2018.00258