​Week 2: Family Assessment and Psychotherapeutic Approaches
A family’s patterns of behavior influences [sic] the individual and therefore may need to be a part of the treatment plan. In marriage and family therapy, the unit of treatment isn’t just the person—even if only a single person is interviewed—it is the set of relationships in which the person is imbedded.
—American Association of Marriage and Family Therapy, “About Marriage and Family Therapistsâ€
When issues arise within a family unit, the family often presents with one member identified as the “problem.†However, you will frequently find that the issue is not necessarily the “problem client,†but rather dysfunctional family patterns and relationships. To better understand such patterns and relationships, and develop a family treatment plan, it is essential that the practitioner appropriately assess all family members. This requires you to have a strong foundation in family assessment and therapy.
This week, you practice assessing and diagnosing client families presenting for psychotherapy.
​Assignment: 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.
​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 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.
That is the link to the video;
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/mother-and-daughter-a-cultural-tale
Mother and Daughter: A Cultural Tale – Alexander Street, a ProQuest Company (openathens.net)
TAMPLETS
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignments. After reviewing full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
- Chief complaint
- History of present illness (HPI)
- Past psychiatric history
- Medication trials and current medications
- Psychotherapy or previous psychiatric diagnosis
- Pertinent substance use, family psychiatric/substance use, social, and medical history
- Allergies
- ROS
- Read rating descriptions to see the grading standards!
In the Objective section, provide:
- Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
- Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
- Read rating descriptions to see the grading standards!
In the Assessment section, provide:
- Results of the mental status examination, presented in paragraph form.
- At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
- Read rating descriptions to see the grading standards!
Reflect on this case. Include what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)
Template
EXEMPLAR BEGINS HERE
CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why they are presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication, and referral reason. For example:
N.M. is a 34-year-old Asian male who presents for psychotherapeutic evaluation for anxiety. He is currently prescribed sertraline by (?) which he finds ineffective. His PCP referred him for evaluation and treatment.
Or
P.H. is a 16-year-old Hispanic female who presents for psychotherapeutic evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her mental health provider for evaluation and treatment.
Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. This section contains the symptoms that is bringing the patient into your office. The symptoms onset, the duration, the frequency, the severity, and the impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders. You will complete a psychiatric ROS to rule out other psychiatric illnesses.
Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP.
General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.
Caregivers are listed if applicable.
Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?
Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)
Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. (Or, you could document both.)
Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.
Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information (be sure to include a reader’s key to your genogram) or write up in narrative form.
Psychosocial History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include:
- Where patient was born, who raised the patient
- Number of brothers/sisters (what order is the patient within siblings)
- Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?
- Educational Level
- Hobbies
- Work History: currently working/profession, disabled, unemployed, retired?
- Legal history: past hx, any current issues?
- Trauma history: Any childhood or adult history of trauma?
- Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)
Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
Assessment
Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudo hallucinations, illusions, etc.), cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.
He is an 8 yo African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.
Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.
Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s treatment of the patient and why or why not. What did you learn from this case? What would you do differently?
Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Case Formulation and Treatment Plan.
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions with psychotherapy, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *see an example below—you will modify to your practice so there may be information excluded/included—what does your preceptor document?
Example:
Initiation of (what form/type) of individual, group, or family psychotherapy and frequency.
Documentation of any resources you provide for patient education or coping/relaxation skills, homework for next appointment.
Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)
Reviewed hospital records/therapist records for collaborative information; Reviewed PCP report (only if actually available)
Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (This relates to informed consent; you will need to assess their understanding and agreement.)
Follow up with PCP as needed and/or for:
Write out what psychotherapy testing or screening ordered/conducted, rationale for ordering
Any other community or provider referrals
Return to clinic:
Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care OR if one-time evaluation, say so and any other follow up plans.
References (move to begin on next page)
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
RUBRICS
​Rubric Detail
Select Grid View or List View to change the rubric’s layout.
​Name: NRNP_6645_Week2_Assignment_Rubric
Excellent 90%–100%
Good 80%–89%
Fair 70%–79%
Poor 0%–69%
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)
18 (18%) – 20 (20%)
The assignment includes an accurate, clear, and complete description of the subjective and objective information for the client family. The response addresses each of the required elements and demonstrates thoughtful consideration of the client family’s situation and culture.
16 (16%) – 17 (17%)
The assignment includes an accurate, clear, and complete description of the subjective and objective information for the client family.
14 (14%) – 15 (15%)
The assignment includes a description of the subjective and objective information for the client family but is somewhat general or contains small inaccuracies.
0 (0%) – 13 (13%)
The assignment includes a description of the subjective and objective information for the client family but is vague or contains many inaccuracies. Or, several of the required elements are missing.
• Mental status exam • Differential diagnoses—Include a minimum of three differential diagnoses and include how you derived at each diagnosis in accordance with DSM-5 diagnostic criteria
18 (18%) – 20 (20%)
The response thoroughly and accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the family in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.
16 (16%) – 17 (17%)
The response accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected.
14 (14%) – 15 (15%)
The response documents the results of the mental status exam with some vagueness or innacuracy. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vaguess or innacuracy.
0 (0%) – 13 (13%)
The response provides an incomplete or inaccurate description of the results of the mental status exam and/or explanation of the differential diagnoses. Or, assessment documentation is missing.
• Case formulation • Treatment plan that includes psychotherapy interventions
23 (23%) – 25 (25%)
Case formulation is thorough, thoughtful, and demonstrate critical thinking. The assignment includes an accurate, clear, and complete treatment plan for the client family that includes psychotherapy interventions. The response demonstrates thoughtful consideration of the client family’s situation and culture.
20 (20%) – 22 (22%)
Case formulation demonstrates critical thinking. The assignment includes an accurate, clear, and complete treatment plan for the client family that includes psychotherapy interventions.
18 (18%) – 19 (19%)
Case formulation is somewhat general or does not demonstrate critical thinking. The assignment includes a treatment plan for the client family that includes psychotherapy interventions but is somewhat general or contains small inaccuracies.
0 (0%) – 17 (17%)
The assignment provides a vague and/or inaccurate description of the case formulation and treatment plan for the client family. Or, many of the required elements are missing.
• A psychotherapy genogram for the family
18 (18%) – 20 (20%)
The assignment includes an accurate, clear, and complete genogram of the client family. The documentation style is consistent and a key is provided.
16 (16%) – 17 (17%)
The assignment includes an accurate genogram of the client family. The documentation style is consistent and a key is provided.
14 (14%) – 15 (15%)
The assignment includes a genogram of the client family but is somewhat limited or contains factual inaccuracies or inconsistencies in documentation style.
0 (0%) – 13 (13%)
The genogram provided is vague or contains many inaccuracies. Or, the genogram is missing.
Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided which delineate all required criteria.
5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.
0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity <60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
4 (4%) – 4 (4%)
Contains 1 or 2 grammar, spelling, and punctuation errors.
3 (3%) – 3 (3%)
Contains 3 or 4 grammar, spelling, and punctuation errors.
0 (0%) – 2 (2%)
Contains many (≥5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.
5 (5%) – 5 (5%)
Uses correct APA format with no errors.
4 (4%) – 4 (4%)
Contains 1 or 2 APA format errors.
3 (3%) – 3 (3%)
Contains 3 or 4 APA format errors.
0 (0%) – 2 (2%)
Contains many (≥5) APA format errors.
Total Points: 100
EXAMPLE
College of Nursing-PMHNP, Walden University
NRNP 6645: Psychopathology and Diagnostic Reasoning
Dr. Loraine Fleming
March 14, 2021
Introduction
This case study involves a 40-year-old female who is an Iranian immigrant. She came to the United States 12 years ago with four of her five children. Her husband would not allow the youngest daughter to leave to ensure the woman’s return to Iran. Two years ago, she was able to bring the daughter she left behind to live with her. The patient sought therapy for the family due to the chaos that was introduced into the home when the daughter arrived.
The purpose of this paper is to complete a comprehensive psychiatric evaluation of the patient with differential diagnosis and to complete a case formulation and treatment plan for family therapy. A reflection of the case study will discuss missing information and how the information may be obtained.
NRNP/PRAC 6645 Comprehensive Psychiatric
Evaluation Note Template
CC (chief complaint): The family is experiencing chaos in the home.
HPI: This is a 40-yr-old female Iranian immigrant who came to the United States 12 years ago. The mother of five children with ages ranging from 15-24, presenting for a consultation after being in therapy for approximately two years, had to leave one of her children in Iran when she left. The child was eight years old when she left her behind. Two years ago, the mother was able to bring the child, who is now an adult, to the United States to live with her. The family reports a chaotic situation within the family occurred when the child moved in. Family arguments began to happen more frequently. The daughter who had moved in reported to the family the father had physically and sexually abused her and abandoned her during the time she was living with him apart from the rest of the family. The daughter blames the mother for the abuse causing a strain on the relationship. Another trauma compounding the family issues include the declining health of the mother who has had two failed surgeries leaving her disabled and unable to work or care for herself completely. Due to the mother’s poor health, she feels as though the children should be more helpful and comply with the Iranian tradition of taking care of their ailing parent. This causes increased discord within the family as three of the five children have moved out of the house leaving only the two younger male children in the household. The daughters report via the 23 year old, who is their spokesperson, that they feel the mother should be more independent and not pressure them to spend time with her and help her with things she should be able to do for herself. The detachment and inability of the three daughters to be with the mother daily has the mother feeling helpless, hopeless, and feeling the children are out of control. The mother was referred to a psychiatrist for pharmacological treatment to help manage these feelings. The mother also reports she has a lot of problems with her 15-year-old son and does not†get along†with him.
Past Psychiatric History:
- General Statement: The patient entered family counseling approximately two years ago. He has been referred to a psychiatrist for medication management of symptoms of hopelessness and helplessness.
- Caregivers (if applicable): The patient is disabled and requires help from her children.
- Hospitalizations: Inpatient hospitalizations is not determined. However, she has had two surgeries.
- Medication trials: Unable to assess
- Psychotherapy or Previous Psychiatric Diagnosis: The patient has been in family psychotherapy for approximately two years. She reports therapy is helping her. Previous diagnosis is unknown.
Substance Current Use and History: Unable to assess
Family Psychiatric/Substance Use History: Unable to assess
Psychosocial History: This is a 40-yr-old divorced female who was born in Iran. She immigrated to the United States 12 years ago at age 28 after leaving a physically abusive marriage. The patient lives in a single-family home with the youngest two of her five children. She has three daughters ages 21, 23, and 24 and two sons ages 18 and 15. She worked as a caregiver until becoming disabled due to two failed surgeries. She is unable to read or write. The patient denies having any hobbies but endorses cooking and shopping for her daughters outside the home. The patient endorses no safety concerns in the home but does report frequent family arguments. The patient has a past history of domestic violence prior to coming to the United States. She owns a car and is still able to drive. She has access to healthcare.
Medical History:
- Current Medications: Unable to assess
- Allergies: Unable to assess
- Reproductive Hx: Unable to assess
ROS:
- GENERAL: Unable to assess
- HEENT: Unable to assess
- SKIN: Unable to assess
- CARDIOVASCULAR: Unable to assess
- RESPIRATORY: Unable to assess
- GASTROINTESTINAL: Unable to assess
- GENITOURINARY: Unable to assess
- NEUROLOGICAL: Unable to assess
- MUSCULOSKELETAL: Unable to assess
- HEMATOLOGIC: Unable to assess
- LYMPHATICS: Unable to assess
- ENDOCRINOLOGIC: Unable to assess
Physical exam: Unable to assess
Diagnostic results:
No diagnostic studies are discussed in case study.
Assessment
Mental Status Examination: This is a 40-yr-old female who looks her stated age, presenting with her 23 yr.-old daughter who also looks her stated age. The individuals are sitting calmly and comfortably next to each other. They are dressed appropriately for the situation with good hygiene noted. Information is gathered from both participants and appears reliable. Both participants are respectful toward each other and the interviewer. The mother and daughter both appear sad with a congruent affect. The mother is alert and oriented x4. She displays no evidence of abnormal motor activity. Her speech is clear, coherent with normal volume. Her thought process is goal oriented and logical. She shows no evidence of loose association or flight of ideas. There is no evidence of hallucinations or delusional thinking. Recent and remote memory is intact. Concentration is good. Judgement and insight are poor. The daughter is alert and oriented x4. No evidence of abnormal motor activity. Speech is clear, coherent, normal volume. She displays a goal-oriented thought process with no evidence of hallucinations or delusional thinking. Her recent and remote memory appears intact. Her concentration is good, and she appears to have good judgement and insight.
Differential Diagnoses:
- Persistent Depressive Disorder (Dysthymia)
Patti meets the DSM-5 criteria as evidenced by depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years (American Psychiatric Association, 2013b); feelings of low self-esteem and hopelessness while depressed (American Psychiatric Association, 2013b); During the 2-year period of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time (American Psychiatric Association, 2013b); Criteria for a major depressive disorder may be continuously present for 2 years. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder (American Psychiatric Association, 2013b); The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder (American Psychiatric Association, 2013b); The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g. hypothyroidism) (American Psychiatric Association, 2013b); The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (American Psychiatric Association, 2013b).
Patti reports onset of symptoms was two years ago, and these feelings have been persistent (Mother and daughter, 2003). During the interview Patti endorses feelings of hopelessness and indicates she experiences destress in important areas of functioning (Mother and Daughter, 2003). There was no evidence of substance use, psychotic disorder, or manic episodes (Mother and Daughter, 2003).
- Post-Traumatic Stress Disorder (PTSD)
Patti meets the DSM-5 criteria as evidenced by exposure to actual or threatened death, serious injury, or sexual violence by directly experiencing the trauma and learning that the traumatic event occurred to a close family member or close friend (American Psychiatric Association, 2013c). Further criteria include recurrent, involuntary, and intrusive distressing memories of the traumatic event and persistent avoidance of stimuli associated with the traumatic event, beginning after the traumatic event occurred, as evidenced by avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event (American Psychiatric Association, 2013c). Patti also meets criteria D which includes negative alterations in cognitions and mood associated with the traumatic event, beginning or worsening after the traumatic event occurred, as evidenced by persistent negative emotional state and persistent inability to experience positive emotions (American Psychiatric Association, 2013c). Further criteria include marked alterations in arousal and reactivity associated with the traumatic event, beginning or worsening after the traumatic event occurred, as evidenced by irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects and reckless or self-destructive behavior (American Psychiatric Association, 2013c). Patti has had symptoms more than one month, the issue has caused clinically significant distress or impairment in social, occupational, or other important areas of functioning and is not attributable to substance abuse (Mother and Daughter, 2003). Patti was physically abused by her husband and her daughter was physically and sexually abused by the father (Mother and Daughter, 2003). Although Patti states she is “over itâ€, the family turmoil suggests otherwise (Mother and Daughter, 2003). Patti appears to be in a persistent negative emotional state even when her children comply with her request to spend time with her (Mother and Daughter, 2003). Patti has an increase in verbal altercations with her children and her behaviors have been self-destructive (Mother and Daughter, 2003).
- Generalized Anxiety Disorder (GAD)
Patti meets DSM-5 criteria for GAD as evidenced by excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (American Psychiatric Association, 2013a); difficulty with controlling the worry (American Psychiatric Association, 2013a); The anxiety and worry are associated with being easily fatigued and irritability (American Psychiatric Association, 2013a); the anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (American Psychiatric Association, 2013a); the disturbance is not better explained by another mental condition or substance use (American Psychiatric Association, 2013a). Patti displays excessive worry regarding her inability to control her children (Mother and Daughter, 2003). This presents as irritability and fatigue causing increased issues with her children (Mother and Daughter, 2003). Patti’s worry regarding her children’s actions causes distress in important areas of functioning (Mother and Daughter, 2003).
Case Formulation and Treatment Plan:
Refer Patti to a psychiatrist for medication management for persistent depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder.
Discuss the benefits of psychopharmacological therapy.
Discuss current medication regimen.
Discuss substance use history and any current use.
Screening for depression (i.e. Hamilton Depression Rating Scale (HDRS), Beck Depression Inventory (BDI))
Psychological evaluation.
Lab tests such as Vit D, TSH, HGB, A1c, LFT to rule out physiological issues that may cause symptoms.
Discuss the importance of continued treatment for chronic pain.
Initiate Solution-Focused therapy developing goals with the family’s input.
Discuss plan to interview all family members who will be involved in therapy.
Allow time for questions. Provide information regarding therapy modality. Provide information regarding expected participation and goals for therapy.
Provide emergency crisis line information.
Reflections:
The therapist did a good job in identifying the issues within this family. However, this case study is lacking much information. The missing information can be obtained by reviewing Patti’s medical records and interviewing the patient as well as all the family members involved. Current treatment of the medical issues will have a bearing on the mother’s mental state and should be considered when planning treatment.
The attitudes and beliefs of the mother and the children should be investigated due to the views of traditional versus more modern ways of living. The mother obviously wishes to live more traditionally. However, the children are attempting to break away from many of the traditions. Understanding the needs of each individual will help to create more attainable problem-solving goals for therapy.
The case study video talks about the chaos beginning when the 21-year-old daughter is brought into the home. However, the mother’s medical issues seemed to begin at that time as well. This possible correlation to the chaos should be investigated further. The mother’s independence was interrupted by the new onset medical issues. Losing independence and depending on the children can cause increased tension between the mother and children.
The attitudes of the family regarding the 21-year-old daughters abuse appears to be an issue as well. The daughter blames the mother for placing her in the situation. The mother and 23-year old daughters view are they are “over itâ€. However, the trauma the daughter has suffered is obviously still a problem for her. A focus of therapy should be to help the family to come to terms with their feeling surrounding the abuse (i.e. guilt, blame). Resolving these feelings could help to improve the relationship between all family members.
Finally, the issues between the mother and the 15-year-old son was brought up in the interview. The information was vague but seemed important and could add to the chaos. Understanding the problems between mother and son will help to focus therapy goals.
Conclusion
In conclusion, this case study has several issues that should be focused on. The family’s different views on traditional living, trauma and abuse, dependency, medical issues, and the relationship between the mother and her children should be addressed. Solution-focused therapy with goals decided upon by the family will help to improve the issues and bring them back to the post-chaotic state they are hoping for.
references
American Psychiatric Association. (2013a). Anxiety disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. https://doi-org.ezp.waldenulibrary.org/10.1176/appi.books.9780890425596.dsm05
American Psychiatric Association. (2013b). Depressive disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. https://doi-org.ezp.waldenulibrary.org/10.1176/appi.books.9780890425596.dsm04
American Psychiatric Association. (2013c). Trauma- and stressor-related disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. https://doi-org.ezp.waldenulibrary.org/10.1176/appi.books.9780890425596.dsm07
Mother and Daughter: A Cultural Tale. . (2003).[Video/DVD] Masterswork Productions. https://video.alexanderstreet.com/watch/mother-and-daughter-a-cultural-tale
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