NRNP 6645 FAMILY ASSESSMENT

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.”

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:

Major Depressive Disorder (MDD)

MDD presents with a depressed mood or loss of interest in most activities or both. In addition to one of these symptoms, an MDD diagnosis should include at least five of the following symptoms: sleep disturbances, increased/reduced appetite, weight loss/gain, fatigue or low energy levels, psychomotor retardation, feelings of guilt or worthlessness, inability to think and concentrate, indecisiveness, and suicidal ideations (APA, 2013). Patti exhibits symptoms of MDD such as a depressive mood, hopelessness, tearfulness, sadness, and emptiness most of the time, and feelings of helplessness. Besides, she had been referred to a psychiatrist for medication due to feelings of hopelessness and helplessness.

Post-traumatic Stress Disorder (PTSD)

PTSD is a syndrome that develops after an individual sees, hears, or is involved in an extreme traumatic stressor such as a fatal accident, serious injury, or sexual violence. An individual reacts to the stressor with helplessness or fear and avoids being reminded of the event (Watkins et al., 2018). Besides, they develop anxiety symptoms and re-experience the event through recollections in dreams and hallucinatory-like flashbacks (APA, 2013). PTSD impairs social functioning.

Shirleen likely has PTSD after her abandonment, physical and sexual abuse history by her father. She demonstrated PTSD features, including irritable behavior, emotional distress, and reckless behavior when she eloped with a son to her mother’s friend. In addition, Patti and Sharleen may have developed after learning of the traumatic events that their sister went through at the hands of their father. Sharleen has avoidance symptoms since she avoids conversations, thoughts, and feelings connected with the sister’s traumatic event. She also got into a negative emotional state after hearing the sister’s traumatic stories. Patti developed negative alterations in mood and cognition, with a negative emotional state demonstrated by crying for a prolonged period. Furthermore, the elder brother has ceased talking with their father after learning that he physically and sexually abused her sister.

Dependent Personality Disorder (DPD):

DPD presents with a persistent need to be taken care of, resulting in an individual being submissive and developing clinging behaviors. Individuals have challenges in making personal decisions (Ramsay & Jolayemi, 2020). Besides, they demonstrate a persistent need for others to take responsibility in areas of their life (APA, 2013). One feels uncomfortable and vulnerable when left alone and tends to seek relationships so that they can be cared for and supported (APA, 2013). In addition, the individual is absorbed with fears of being left alone.

Patti likely has DPD based on her report of feeling hopeless and helpless since her children do not spend time with her. She seeks to have a relationship with her children for them to support her. In addition, Patti has a constant need to have her daughter take responsibility for nearly all elements of her life. She believes that her children must be available for her because she is disabled.

Reflections:

The case assignment was quite challenging based on the different issues raised by the family members. I have learned that if family members are exposed to the same risk factors for a mental disorder, they are likely to develop the disorder. For example, the family members demonstrate PTSD since they were exposed to Shirleen’s traumatic event through hearing. I have also learned that adults who develop disabilities tend to develop Dependent personality disorder, which makes them fear living alone from their loved ones (Ramsay & Jolayemi, 2020). Legal and ethical factors to consider in this case include beneficence, confidentiality, and obtaining consent. The PMHNP can promote beneficence by conducting psychotherapy to benefit every family member and unite the family (Bipeta, 2019). Besides, the PMHNP should maintain the confidentiality of the family’s history and medical information. The PMHNP should obtain consent from each member before engaging them in psychotherapy.

Case Formulation and Treatment Plan:

The clients demonstrate symptoms of MDD, PTSD, and DPD. Patti will be requested to fill the PHQ-9 questionnaire to measure the severity of depressive symptoms and help diagnose MDD. She will fill a Dependent Personality Questionnaire (DPQ) to help screen DPD (Ramsay & Jolayemi, 2020). If her symptoms meet the MDD diagnosis criterion, she will be referred to a psychiatrist to develop a pharmacological treatment plan.

Treatment Plan

1. MDD: Begin CBT once a week to offer Patti opportunities to identify current life situations that could be contributing to the depressive mood. CBT will aim at helping Patti identify current patterns of thinking or distorted perceptions causing depression (Gautam et al., 2020).
2. PTSD: Begin Family Trauma-focused cognitive-behavioral therapy (TF-CBT) once a week. TF-CBT will seek to help each family member overcome trauma-related difficulties (Watkins et al., 2018).
3. DPD: Family Psychodynamic psychotherapy once a week. The psychotherapy will focus on assessing Patti’s fear of independence and the difficulties she experiences in being assertive (Ramsay & Jolayemi, 2020).

Follow-up: Follow up every week for psychotherapy sessions.

 

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