Family Assessment
Evaluation Note Template
CC (chief complaint): I would like to learn to live my life alone and take care of my things. I depend on my kids a lot because in our customs when the parents get old and can’t walk or take care of themselves, the are always there. But here they have their own life, I expect them to be all the time but they can’t
HPI: Patti is a 40-year-old Iranian woman who presented to the clinic with problems after her daughter was finally reunited with her family at home for the first time in 10 years. Patti is lonely, depressed, hopeless, and in severe pain. She is the mother of five children. Sheela, 24 years old female, Sharleen, 23 years old female, Shireen, 21 years old female, Armin Jr., 18 years old male, Sam, 15 years old male. Sharleen is currently undergoing her family therapy. They are of Iranian descent and have been in individual and family therapy for 18 months. The family was happy at first, but after a few weeks, Shireen told her mother and siblings about the emotional, physical, and sexual abuse she suffered from her father. She felt abandoned by her mother. Patti injured both of her legs, leaving her with a disability and chronic pain before she required surgery. Her surgery and disability added to the tension and stress at home. She is in constant pain and is unable to take care of herself. Patti lives with her two sons and her daughter lives alone. Shireen recently left her mother’s home and married a stranger to her family, and she now has little contact with her family. Her mother sees Sheila every day. She thinks Patti would like her daughters to stay and spend time with her. She was referred to a psychiatric healthcare provider for treatment.
Past Psychiatric History:
· General Statement: Patti denies any psychiatric history. Patti started therapy with her children a year and a half ago. Her daughter Shireen reunited with her family after being separated for 12. She told her family that Shireen suffered emotional and sexual abuse from her biological father. She has her feelings because she is experiencing trauma from her blame, guilt, shame, and increasing pressure from her family. She denies past drug abuse. Patty denies suicide or attempted murder.
· Caregivers (if applicable): Her 18-year-old son.
· Hospitalizations: Patti denies past psychiatric hospitalization. She has had past bilateral foot surgeries due to arthritis, hammer toe, and severe plantar fasciitis with no relief for two years. For each surgery, she was hospitalized overnight.
· Medication trials: Takes Lexapro 10mg every morning for depression and there is minimal relief. Lexapro 20mg was administered orally daily 4 weeks ago. She reported no side effects from Lexapro.
· Psychotherapy or Previous Psychiatric Diagnosis: Patti and her family have been receiving individual and family therapy for the past 18 months. Shireen came once but she stopped coming and she now refuses to remain part of it. The family came together to therapy five times. The stressor is that Patti has had foot surgery in the past six months and due to her disability, she is unable to work.
Substance Current Use and History: Admits daily consumption of caffeinated beverages. Denies drinking alcohol or smoking.
Family Psychiatric/Substance Use History: Denies alcohol or substance use. Patti denies knowledge of a family history of alcohol abuse or substance use. Patti’s husband drinks alcohol every day but has not received any treatment for alcoholism. Denies any past psychiatric treatment of her family or herself.
Psychosocial History: Patti was born in Iran and grew up with her parents. she is an only child. At the age of 14, Pati’s parents arranged her marriage to Armin, a prominent Iranian car executive. She Pati moved to Tehran, where she gave birth to five children. She stayed home and raised her children while her husband worked and took care of her family. When her two daughters, Sheela and Sharleen, were 11 and 12 years old, their family doctor discovered that they had health problems that required treatment in the United States. Patti came to the United States with her four children. Patti leaves behind one of her daughters, Shireen. Her husband Amir came later with Shireen. After many years, Patty did not want to return to Iran. She found it difficult to leave Shireen behind and worried that if she returned to Iran, she would not be able to return to the United States to care for her other children. During Patti’s marriage to Amir, she suffered mental, physical, and sexual abuse from her husband. She struggled for several years to bring Shireen to the United States. She was finally able to give birth to an 18-year-old daughter, Shireen. A few weeks after her arrival in the United States, Shireen began talking about the mental, physical, and sexual abuse she suffered at the hands of her father. Patti was traumatized when she heard that information. Shireen was angry and blamed her mother Patti for leaving her with her father in Iran. Patti sought therapy help to process and deal with the shame and guilt her trauma caused her.
Medical History:
· Current Medications:
Lexapro 20 mg daily for depression and anxiety.
Tramadol 100 mg PO TID PRN for severe pain
Ibuprofen 800 mg PO BID PRN for mild or moderate pain.
Trazodone 50 mg or 100 mg PO PRN for sleep at night.
· Allergies: NKDA, seasonal and food allergies
· Reproductive Hx: Patti has been pregnant and has given birth five times. Denies any abortion or miscarriage. Has abstained from any sexual activity since she got to the United States. Denies any STI. Patti reported regular menstruation, which started at the age of fourteen.
ROS:
General: Alert and oriented x 4. Calm and cooperative during examination. No recent weight changes. No fever or chills. No weakness, or fatigue,
Head: symmetric, Normocephalic, and atraumatic
Eye: Eye lids are normal. Appropriately aligned gaze, with intact extraocular movements. Normal conjunctive, equal and round pupils, reactive to the right.
Ears: symmetry. Symmetric, eardrum and outer ear are normal. No hearing loss was observed.
Neck: Full ROM, No JVD,.
Cardiovascular: Normal heart rate and regular rhythm. No murmur was heard.
Lungs: Normal pulmonary effort, no shortness of breath. Breath sounds are normal, no wheezing or rattles.
Abdomen: Large and round. Bowel sounds are present in all four quadrants. No tenderness.
Genital/Rectal: No abnormality. No painful urination was reported. Regular monthly. Menstruation reported.
Musculoskeletal: Muscle weakness resulting from physical inactivity. Walking slowly and unsteadily due to pain. Normal ROM
Neurological: No dizziness or headaches.
Skin: No clubbing, rashes, or cyanosis. No bruises.
Toes: Arthritis, Hammertoes, already healed bilateral incisions noted.
Physical Exam: N/A. Physical examination information can be obtained using a couple of techniques, including; inspection, palpation, auscultation, and percussion. Properly assessing a patient’s physical health can also help personalize medication intake and reduce the risk of side effects (Garden, 2005).
Diagnostic results: CBC: within normal range. Anxiety assessment using the GAD-7 scale; Depression Assessment using the Hamilton Rating Scale.
Assessment:
Mental Status Examination: The 40-year-old Iranian woman appeared to be of the stated age. Appearance is neat and tidy with casual clothes. Normal posture and actions within normal ranges. Patient makes good eye contact. Speech rate, rhythm, and volume are normal. The thought process is logical and goal-oriented. Thoughts are normal, with no hallucinations, flight of ideas, or delusions. The patient’s mood is depressed and anxious. Emotions temporarily subside, and the patient now denies suicide or murder. The patient’s memory is intact. He has excellent insight and is able to make decisions with concentration. The patient has no legal issues and no arrests or pending charges.
Differential Diagnosis
Adjustment disorder
Patty’s children are grown and now Patti feels alone. She reported feeling hopeless and helpless when she is alone. She wants her kids to be with her because she’s having a hard time getting used to them not being home much. She has also had surgery in the past four months and is adjusting to the fact that her limited mobility and severe pain will no longer allow her to be as independent as she used to be. She is experiencing grief and anxiety due to her three specific stressors: her recent surgery, her children’s move out of the home, and her feelings of sadness and guilt over her daughter’s past tragedies. She is experiencing a feeling of hopelessness. Patti met the criteria (APA, 2013). In adjustment disorders, stressors can vary in severity and may not meet the criteria for PTSD. According to DSM-5 criteria, a person is diagnosed with adjustment disorder if the person develops a PTSD symptom pattern in response to a stressor that is not consistent with PTSD.
Major Depressive Disorder
After the surgery, Patty became more depressed, developed pessimistic thoughts, and developed a desire for her daughter. Her independence in her patty faded and she became indifferent to anything that affected her athletic performance. Changes in family relationships can lead to family discord. Individuals may feel sad due to family tensions and have more difficulty controlling their discomfort (Boone & Kim, 2019). Although Patti does not meet some of the DSM-5 diagnostic criteria for the disorder, she enjoys spending time with her children, friends, and dogs. People can be affected positively or negatively depending on how much emotional support they receive. The clinical picture is dominated by a marked and persistent phase of depressed mood or a significant decrease in interest and enjoyment in all activities. Decline in social, professional, or other important areas of functioning, or the primary reason is clinically significant stress. If a mood disorder is a common illness, physicians must first determine the presence of a known illness (APA, 2013).
Generalized Anxiety Disorder
According to the DSM-5, GAD may be defined as excessive anxiety or worries that occur on multiple days in conjunction with a series of events or activities over a period of at least 6 months (Anxiety and the DSM-5, 2015). The DSM-5 chapter on anxiety disorders reflects a developmental approach, with disorders grouped by typical age of onset. Additionally, the six-month period for these disorders, including specific phobias and social anxiety disorders, has now been extended to all age groups. Panic attacks can now be cited as a specifier that applies to all DSM-5 disorders, not just anxiety disorders. Separation anxiety disorder and selective mutism are classified as anxiety disorders (Anxiety and DSM-5, 2015). Patty is extremely afraid of her children not helping around the house. She wants her daughter to stay and be with her. GAD is the most common disease in primary care. It affects 8% of the population and is statistically related to age and gender (Jordan et al., 2017). Comorbidities include depression and somatization.
Case Formulation and Treatment Plan:
Patients with thyroid disorders are more likely to develop symptoms of depression, and depression can be associated with a variety of subtle thyroid abnormalities (Kafle et al., 2020). For this reason, I would order a thyroid panel check. Next, I will order a vitamin D level test for depression or anxiety. This is because vitamin D has been shown to improve UCMS-induced anxiety and depression by reducing oxidative stress in the brain and suppressing neuroinflammation (Bakhtiari-Dovvombaygi et al., 2021).
The patient is then referred to a local behavioral health outpatient clinic for treatment, including medication management with a psychiatrist and group, and art therapy with the clinic’s specialists. Collaboration with a primary care physician is also necessary for ongoing treatment. Referral to physical therapy is recommended to promote mobility and prevent decompensation. Introducing a nutritionist to help Patti with weight management increases self-esteem and promotes community involvement. An appointment will be made with a psychiatrist.
The patient should be encouraged to call her children, a crisis hotline, emergency medical services, or the nearest emergency room if she feels she may have future self-harm, suicidal, or homicidal thoughts. The concerns of the patient should also be addressed. She will be made to understand and freely sign the treatment plan.
Reflections
Family psychotherapy sessions resulted in conflicts between the patient and the children. Patti suffers from depression due to various factors. This includes her disability and feelings of loneliness and isolation from children. But the family is trying to recover and move on. Children want to have independent lives and lead independent and productive lives. It is also important to respect family beliefs and differences. The goal is to find a common ground for both Patti and her adult children. It is also important to be aware of cultural differences when providing care. Cognitive behavioral therapy, interpersonal therapy, and psychodynamic therapy are also good approaches. The patient is also advised to be active and exercise, try to improve their sleep quality, avoid unhealthy coping strategies, and reduce stress.
Patti’s Family Genogram
Patti
Amir
Sheela
F. 24
Sharleen
F. 23
Shireen
F. 21
Armin Jr.
M. 18
Sam
M. 15
References
American Psychiatric Association.. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5). [MBS Direct]. https://mbsdirect.vitalsource.com/#/books/9780890425572/
Bakhtiari-Dovvombaygi, H., Izadi, S., Zare Moghaddam, M., Hashemzehi, M., Hosseini, M., Azhdari-Zarmehri, H., Dinpanah, H., & Beheshti, F. (2021). Beneficial effects of vitamin D on anxiety and depression-like behaviors induced by unpredictable chronic mild stress by suppression of brain oxidative stress and neuroinflammation in rats. Naunyn-Schmiedeberg’s Archives of Pharmacology, 394(4), 655-667. https://doi.org/10.1007/s00210-020-02002-0
Boone, D., & Kim, S. Y. (2019). Family Strain, Depression, and Somatic Amplification in Adults with Chronic Pain. International Journal of Behavioral Medicine, 26(4), 427-436. https://doi.org/waldenulibrary.org/10.1007/s12529-019-09799-y
Garden G. (2005). Physical examination in psychiatric practice. Advances in Psychiatric Treatment. 2005;11(2):142-149. doi:10.1192/apt.11.2.142
Kafle, B., Khadka, B., & Tiwari, M. L. (2020). Prevalence of Thyroid Dysfunction Among Depression Patients in a Tertiary Care Centre. JNMA; Journal of the Nepal Medical Association, 58(229), 654-658. https://doi.org/10.31729/jnma.5296
Mondal, S., & Mugesh, G. (2017). Novel thyroid hormone analogues, enzyme inhibitors and mimetics, and their action. Molecular and Cellular Endocrinology, 458, 91-104. https://doi.org/10.1016/j.mce.2017.04.006
Mother and Daughter: A Cultural Tale., directed by Anonymous. (2003). Masterswork Productions [Video]. Alexander Street. https://video.alexanderstreet.com/watch/motherand-daughter-a-cultural-tale