Comprehensive Psychiatric Evaluation

Comprehensive Psychiatric Evaluation

GONZALO BACIGALUPE When I’m asked to do a consultation, one of the first things I ask is, what will be the most benefit for the client and the therapist and in the case that you’re going to see I’m basically asked to have a reflecting team and what we did was first have an interview with the therapist and the family and ask them what they will find useful for the interview and basically to ask them about the history of the therapy and the history of what are the kinds of things that they have been working on. I ask the reflecting team to come in and I instructed them to think of themselves as so let the god mothers of the therapist, who in a way, put them, himself, or in this case herself at risk in front of her peers and another people. So, I wanted them, the reflecting team to address the therapeutic system as a whole not just to address the family, I wanted them to talk also about the therapist and to be protective of them. I also ask the reflecting team not to be too much of clinician, but to really react on a more personal level around the family. I sometimes reflected on what they were saying to clarify or to expand the idea or how I understood it to give voice to other possibilities, but respecting the personal peace, and then, I ask I ask the family to come back to, in a classical way, to respond to those comments what strike them. In the case that we watch, it seems that the family was dealing with sort of like two forms of trauma and/or three forms of trauma; one is, history of battering the domestic violence, child sexual abuse, a history of immigration that in some ways we lay it to that trauma getting away from it and basically the mother of five children deciding that they need to move out of the home, but in the process leaving one behind who is later on sexually, I mean, raped by the father. And then at the present moment mother dealing with a fairly traumatic illness that have her, very disable, unable to walk and to work. So, it’s sort of like the interview trying to address this different forms of trauma and the way in which the young adults are trying to make sense of their bicultural life and how the whole family is trying to make sense of being bicultural and being immigrants. The session doesn’t end with a need or incredible intervention of my part because I feel that this is the part of the therapist to try to decide, this is the family that’s been working this therapist for year and half. Therefore, they have a relationship I feel that I need to respect and so those are the basic intercomments. So tell me how is it that you came out with the idea of having this interview with me? Comprehensive Psychiatric Evaluation

 

00:04:30

Sharleen

 

00:04:30

Patti

 

00:04:30

SANDI Okay. I’m going to go back when Patti came in for the first time. She came in because they were chaos at her household.

 

00:04:45

Sandi – their therapist

 

00:04:45

SANDI She came to this country twelve years ago with her four children and one was left behind, her daughter who was 10 years old at that time, eight years old at that time, was left behind. Just two years back, finally they were able to get her visa and she brought her to United States. So ever since she came here chaos was created inside the household.

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Patti reports that her home has been in chaos for the past two years. Even though she currently resides in the United States, she attributes the chaos to events in Iran. She claims to have been married to an Iranian man, with whom she had five children. Her eldest daughter, Sheela, had a medical condition, and they were forced to seek a medical visa to the United States, where she arrived with four of her children, leaving one (daughter), Shireen, behind due to visa issues. The father did not send financial support after the family immigrated to the United States, and Patti, now a single mother, had to work her way into the custody of the four children. Finally, when Shireen obtained a passport and returned to the United States, she told her mother about her misfortunes in Iran, claiming that her father sexually abused her, physically assaulted her, and abandoned her, leaving her outside the house even at night. Shireen blamed her mother for her suffering in Iran, which caused a schism in the family, which Sharleen, the accompanying daughter, describes as constant fighting, yelling, and cursing at each other as they express their rage at their mother for abandoning Shireen in Iran.

Patti was involved in a road traffic accident, suffered crush injuries, and had bilateral below-knee amputations. Her surgeries rendered her unable to walk (wheelchair-bound) and in a high state of dependency. She also complains of excruciating pain and expresses a desire to be closer to her children. However, as the children grow older, they feel the need to detach from their mother and grow on their own, which has increased tension in the house and increased Patti’s anxiety. Patti reports feeling helpless and hopeless because some of her children have moved out, and she now only lives with the two school-aged boys. Even worse, she visited her older daughter and wanted to spend a night, only to be pulled out, taken to the car, and sent home. She’s been lonely and depressed recently, and her main concern is getting closer to her children and receiving their support. She has also expressed a lack of energy and reports feeling worthless, and she has lost interest in activities that used to bring her joy, such as cooking. She has been attending counseling sessions with some of her children for the past year and a half, an experience she says has helped her understand her relationship with her children. She denies suicidal thoughts, psychotic features (hallucinations, delusions), and elevated or expansive mood.

Past Psychiatric History: No past history of psychiatric illness

General Statement: The patient has been attending counseling sessions with Mr. Sandi for the past year and a half.

Caregivers (if applicable): Her psychotherapist, Mr. Sandi, and her children Comprehensive Psychiatric Evaluation

Hospitalizations: Patti was admitted after undergoing foot surgery on both feet. She had bilateral below-knee amputations, which left her physically disabled.

Medication trials: She has only been on analgesics, taking Ibuprofen 300 mg 8 hourly for her pain. She has not been on any psychopharmacologic agent.

Psychotherapy or Previous Psychiatric Diagnosis: She has been attending counseling sessions with her children for one and a half years. The sessions increased her awareness of the distinction between individualist and collectivist ways of life, as well as her ability to respect and understand the children. She also took her daughter, Shireen, to an Iranian psychologist for $200 per hour to help her deal with the trauma issues she encountered in Iran.

Substance Current Use and History: Denies history of substance abuse or use of any recreational drug

Family Psychiatric/Substance Use History:

Family History: Father alive, mother deceased, none had/have a psychiatric illness

Sibling history: She is the only child

Marital History: Married but separated because of husband’s irresponsibility. The husband has married twice in the last three years since their separation.

Children History: Five children, all alive

1. Firstborn, Sheela, 24-year-old daughter, a professional photographer, asthmatic, no psychopathology
2. Second, born, Sharleen, 23-year-old, the informant daughter, promotional jobs, real estate enthusiast, healthy, no psychopathology
3. Third born, Shireen, a daughter who recently immigrated from Iran, sexually/physically abused by her father, received psychotherapy sessions
4. Brother, 18-year-old, finishing high school next year
5. Brother, 15-year-old, in high school, described as impatient, has a cold relationship with the sister (informant) Comprehensive Psychiatric Evaluation

 

Psychosocial History: The patient was born in the United States and raised by her parents. The mother, however, died in 2020 as a result of Covid19. She is the only child of her parents. “I was 14 years old when my parents chose my husband for me, and we married. And he was a nightmare, a demon from hell.” The patient reports. She spent her married life in Iran with her Iranian husband, but they are now separated, and she has returned to the United States, where she lives in a two-bedroom house with her two school-aged boys. She used to be a caregiver, working 8-12 hours a day and taking care of her family, but she is now disabled due to crush injuries she sustained in a car accident, rendering her unable to work and provide for her family. Her father, a successful investor, provides her with financial assistance. After moving to the United States, her ex-husband stopped financially supporting her and the children. Her premorbid hobby was shopping at the mall, especially on weekends when she was off duty.

Medical History: She had both legs amputated below the knee, rendering her disabled and wheelchair-bound. She was hospitalized for two weeks during this time. Has chronic pain in the lower extremities. Denies any history of diabetes, hypertension, tuberculosis, or PUD. She reports having received four pints of blood transfusions during her hospitalization

Current Medications: Ibuprofen 300 mg 8 hourly

Allergies: No known food and drug allergies

Reproductive Hx:

Gynecologic Hx: Menarche at 13 years; regular menses occurring after every 30 days, light flow, using 3-4 pads/day, no associated dysmenorrhea. Used a five-year Norplant as a contraceptive method but stopped three years ago. Last Cervical cancer screening was negative for intraepithelial lesions. No history of treatment for STDs Comprehensive Psychiatric Evaluation

Obstetric Hx: Para 5+0 non gravida, with five living children

Objective:

Diagnostic results:

Complete blood count: Leukocytosis with predominant neutrophilia

Urinalysis: Trace of blood and nitrites. Urine culture taken results pending

RBS: 110 mg/dl

UECS: No derangement

Assessment:

Mental Status Examination:

A 40-year-old American female patient leading a bicultural life who looks her stated age. She is cooperative with the examiner. She is neatly groomed and clean, and dressed appropriately. Her speech is clear, low in volume and tone, and hesitant.  Her thought process is occupied with thoughts of loneliness. There is no evidence of looseness of association or flight of ideas. Her mood is depressed, and her affect is appropriate to his mood. She denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. She denies any current suicidal or homicidal ideation. Cognitively, she is alert and oriented. Her recent and remote memory is intact. Her concentration is good. His insight is good.

Differential Diagnoses:

Major depressive illness (F33.0): The patient reports being depressed, having low energy levels, losing interest in life, and feeling worthless. The symptoms have lasted for two years and have significantly hampered her social functioning—her relationship with her children. Furthermore, because Patti has no history of substance abuse, the symptoms cannot be attributed to the physiological effects of substance abuse. The DSM 5 diagnostic criteria for major depressive illness include five or more of the following symptoms occurring within the same two weeks: depressed mood, loss of interest, significant weight loss, insomnia, psychomotor agitation, fatigue, feelings of worthlessness, diminished ability to concentrate, and recurring thoughts of death/suicidal ideations (APA, 2013). Furthermore, the symptoms must be severe enough to impair social, occupational, and other areas of functioning, and they must not be attributed to the effects of substance abuse or explained by another mental disorder.

Note: I choose major depressive disorder as my primary diagnosis, with the rational above

Generalized anxiety disorder (GAD) (F41.1): The patient reports feeling anxious about the situation, but she does not meet the symptom threshold for GAD as defined by the DSM 5 criteria. The DSM 5 criteria for GAD require symptoms of excessive anxiety and worry occurring on more days than not for at least 6 months, the individual finding it difficult to control the worry, and it may be associated with motoric and autonomic symptoms (APA, 2013; Munir & Takov, 2022), which Patti does not have.

Mood disorder due to another medical condition: A major depressive episode is the appropriate diagnosis if the mood is not judged based on the individual’s history, physical examination, and laboratory findings to be the direct pathophysiological consequence of a specific medical condition (APA, 2013). The mood symptoms, however, preceded the crush injuries and the consequent foot surgeries and thus cannot be attributed to the patient’s physical illnesses

Urinary tract infection (N39.0): Urinalysis reveals the presence of blood and nitrites, indicating a UTI (Bono et al., 2022). A urine culture is performed to confirm the diagnosis; however, the results are still pending. Comprehensive Psychiatric Evaluation

Reflections:

Gonzalo and his reflecting team interview the patient, her therapist, and her daughter to better understand their journey through psychiatric illness and treatment. Gonzalo’s communication skills are commendable; he attempts to ask open-ended questions to the interviewees and actively listens and allow them to speak. I learned from the case that when dealing with psychiatric patients, their account of illness is important; however, a family member must also be present to assist in providing the history. I have also learned that it’s critical to allow patients to express their ambitions and goals as treatment progresses, just as Patti is allowed to express her goals for the type of relationship she wants to have with her children. One important lesson I’ve learned is that psychiatric patients require close monitoring from someone who can assist them in their daily lives while also being a part of their healing process.

Case Formulation and Treatment Plan:

Case Formulation

Patti, a 40-year-old female American with a bicultural life (American-Iranian), separated from her husband, presents with a two-year history of chaos in her household, leading to her depressed mood, feelings of worthlessness, loss of energy, and loss of interest in previously pleasurable activities. She is physically disabled and wheelchair-bound due to a bilateral below-knee amputation. She also feels lonely and uncared for now that her three daughters have moved out. For the past year and a half, she has attended counseling sessions, which she claims have helped her deal with the situation. On MSE, her speech is clear, low in volume and tone, and hesitant, her thought process is preoccupied with loneliness, and her mood is depressed. She has no prior history of psychiatric illnesses or treatment with psychopharmacologic agents, and she denies any family history of mental disorders.

Treatment Plan

1. Psychiatrist to assess the need for antidepressants
2. Initiation of cognitive behavioral therapy: Attend about 15-20 sessions (Chand et al., 2022)
3. Initiation of individual and family psychotherapy: Attend at least 12 sessions (Varghese et al., 2020)
4. Pain management Comprehensive Psychiatric Evaluation

Referrals

1. Psychiatrist
2. Physician
3. Physiotherapist

Follow-Up:

1. Visit the nearest primary care facility if the pain becomes unbearable
2. See a physiotherapist once a week
3. Visit a psychiatrist if the mood disturbances worsen

 

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425596

Bono, M. J., Leslie, S. W., & Reygaert, W. C. (2022). Urinary Tract Infection. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470195/

Chand, S. P., Kuckel, D. P., & Huecker, M. R. (2022). Cognitive Behavior Therapy. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470241/

Munir, S., & Takov, V. (2022). Generalized anxiety disorder. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441870/

Varghese, M., Kirpekar, V., & Loganathan, S. (2020). Family interventions: Basic principles and techniques. Indian Journal of Psychiatry, 62(Suppl 2), S192–S200. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_770_19 Comprehensive Psychiatric Evaluation