NRNP 6645 ASSIGNMENT WEEK 1: Family Assessment
Family Members
Patti (mother) – 40 years old
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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 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
FAMILY ASSESSMENT
Assessment is as essential to family therapy as it is to individual therapy. Although families often present with one person identified as the “problem,” the assessment process will help you better understand family roles and determine whether the identified problem client is in fact the root of the family’s issues.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
To prepare:
- Review this week’s Learning Resources and reflect on the insights they provide on family assessment. Be sure to review the resource on psychotherapy genograms.
- Download the Comprehensive Psychiatric Evaluation Note Template and review the requirements of the documentation. There is also an exemplar provided with detailed guidance and examples.
- View the Mother and Daughter: A Cultural Tale video in the Learning Resources and consider how you might assess the family in the case study.
THE ASSIGNMENT
Document the following for the family in the video, using the Comprehensive Evaluation Note Template:
- Chief complaint
- History of present illness
- Past psychiatric history
- Substance use history
- Family psychiatric/substance use history
- Psychosocial history/Developmental history
- Medical history
- Review of systems (ROS)
- Physical assessment (if applicable)
- Mental status exam
- Differential diagnosis—Include a minimum of three differential diagnoses and include how you derived each diagnosis in accordance with DSM-5-TR diagnostic criteria
- Case formulation and treatment plan
- Include a psychotherapy genogram for the family
Note: For any item you are unable to address from the video, explain how you would gather this information and why it is important for diagnosis and treatment planning.
BY DAY 7
Submit your Assignment.
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Sample 2
CC (chief complaint): My home is in disarray.
HPI: Patti, a forty-year-old Iranian woman, immigrated to the USA two decades ago with her four children, leaving one behind due to immigration regulations. She worked as a caregiver, with her eldest daughter’s assistance, to support her family. The family dynamics shifted when her third-born daughter, Shireen, joined them in the US, bringing chaos to their household. In Iran, Shireen experienced emotional, sexual, and physical abuse from her father, leading her to blame Patti for leaving her in such an environment. Patti, who is obese, reveals that her husband was abusive, adding trauma to the family’s history. While her three adult daughters have moved out and established independent lives, Patti still resides with her two teenage sons. She is disabled due to a failed foot surgery, experiencing chronic pain. The family’s discord stems from Patti’s adherence to traditional values, while her daughters seek contemporary lifestyles and individual identities. Patti is overwhelmed, feeling helpless and hopeless, as she cannot control her children, and she longs for more frequent visits from them, which they are unable to fulfill. Sharleen, one of her daughters, mentions that Patti desires their presence but remains engrossed in watching TV or her phone, frequently exhibiting cursing, disrespect, impatience, and control. The daughters wish for Patti to become more independent and optimistic, but she insists that their culture dictates children should care for their elderly parents.
Past Psychiatric History:
– General Statement: The patient, an Iranian woman with traditional values, frequently clashes with her US-raised children who seek independent identities.
– Caregivers (if applicable): The patient’s children, three daughters, and two sons.
– Hospitalizations: No hospitalization records, though her history of foot surgery suggests a potential hospitalization.
– Medication trials: No records of past medication trials.
– Psychotherapy or Previous Psychiatric Diagnosis: The family is presently undergoing psychotherapy, with no prior psychiatric diagnoses. This area should have been explored further.
Substance Current Use and History: No records available; this aspect should have been investigated.
Family Psychiatric/Substance Use History: Both Patti and her third-born daughter, Shireen, have histories of emotional, sexual, and physical trauma due to the father. The substance use history should have also been explored.
Psychosocial History: Patti, the children’s mother, immigrated from Iran, is separated from her husband, and has three adult daughters and two teenage sons. She worked as a caregiver since moving to the USA twenty years ago, and her disability followed a failed foot surgery, causing chronic pain and back problems. While her eldest daughter is married, the other two daughters are working and living independently. Patti continues to reside with her two sons, who attend school.
Medical History:
– Current Medications: No documentation of current medications; this information should have been collected.
– Allergies: No known allergies.
Reproductive History: The patient has five children, two sons, and three daughters. She is separated from her husband, who remains in Iran.
ROS (Review of Systems):
– GENERAL: The patient appears alert, oriented, and well-groomed.
– HEENT: Needs assessment according to standard procedures.
– SKIN: Requires assessment as per standard procedures.
– CARDIOVASCULAR: Requires assessment according to standard procedures.
– RESPIRATORY: Needs assessment according to standard procedures.
– GASTROINTESTINAL: Needs assessment according to standard procedures.
– GENITOURINARY: Needs assessment according to standard procedures.
– NEUROLOGICAL: Requires assessment according to standard procedures.
– MUSCULOSKELETAL: Needs assessment according to standard procedures.
– HEMATOLOGIC: Requires assessment according to standard procedures.
– LYMPHATICS: Needs assessment according to standard procedures.
– ENDOCRINOLOGIC: Requires assessment according to standard procedures.
Physical exam: If applicable
Diagnostic results: N/A
Assessment
Mental Status Examination: The patient is appropriately dressed, alert, and oriented. However, she appears worried and stressed. She maintains good eye contact, and her speech is loud and pressured. She is cooperative but irritable, with an anxious, depressed, and irritable mood. Her thoughts are goal-directed, and she denies delusions, suicidal thoughts, ideation, and self-harm. Her long-term and short-term memory are intact, with fair judgment.
Differential Diagnoses:
1. Post-traumatic Stress Disorder (PTSD): This is a potential diagnosis due to the patient’s history of an abusive husband. According to DSM-5 criteria, PTSD results from exposure to traumatic events, including sexual violence, rape, accidents, and death (APA, 2022). The patient reports that her husband was emotionally, sexually, and physically abusive. Additionally, the patient exhibits symptoms such as low energy and a depressed mood, all indicative of post-traumatic stress disorder.
2. Depression: The patient’s household is in chaos, leading to stress. Symptoms of depression include irritability, low energy, and difficulty concentrating (Tolentino & Schmidt, 2018). The patient’s depressed mood may be a result of her strained family relationships, unemployment, separation from her husband, and the feeling of being unable to control her children.
3. Dysthymic Disorder: This condition is characterized by feelings of hopelessness and a reduced interest in life. The patient experiences poor concentration and low energy (Carta et al., 2019). She also feels helpless and hopeless, making this another potential diagnosis.
Case Formulation and Treatment Plan:
The patient requires an intensive psychotherapy plan that combines family therapy and individual therapy. Psychotherapy sessions should be conducted weekly. Medication management is indicated and should be prescribed by a psychiatric specialist. Arrangements for transportation to facilitate the patient’s mobility should be made. Given the patient’s overweight condition, a weight-reducing diet is recommended. The patient should also have a medical assessment of her foot, which underwent surgery.
Reflections:
This case study highlights the importance of patient-family relationships in mental health and overall well-being. The patient has five children, and the family is in turmoil due to her adherence to traditional values, while her daughters seek contemporary lifestyles and their own identities. Additional information could have been sought to better understand the patient’s situation, especially concerning her psychiatric history before immigrating to the USA from Iran. Ethical and safety considerations must be upheld to ensure the patient receives appropriate treatment. One of the Social Determinants of Health (SDOH) that may impact the patient’s outcome is access. The patient is disabled, and arrangements for transportation are necessary for her to attend psychotherapy sessions. Health promotion and education should focus on encouraging her children to lead their lives while providing support when needed. Additionally, the patient would benefit from a diet to manage her overweight condition.
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