NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Template

NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Template

CC (chief complaint): Conflict between mother and adult daughter regarding differing expectations, cultural assimilation, and mother’s recent disability.

HPI:

Patti, a 40-year-old Iranian immigrant mother of five children, is seeking therapy to address the chaos and tension in her household. The primary source of conflict is the differing expectations and cultural assimilation between Patti and her adult children, particularly her 23-year-old daughter, Sharleen. Patti immigrated to the United States 12 years ago with four of her children, leaving her then 8-year-old daughter Sharleen behind with her abusive husband. Two years ago, Sharleen was finally able to join the family, and upon her arrival, she revealed the physical and sexual abuse she had endured from her father. This revelation led to a significant increase in family conflict and tension. Additionally, Patti recently underwent two unsuccessful surgeries on her feet, leaving her disabled and in constant pain. This has further exacerbated the tension within the family, as Patti feels hopeless, helpless, and unable to fulfill her traditional caregiving role. She often expects her adult children, particularly Sharleen, to spend more time with her and assist her with daily tasks.

Past Psychiatric History:

General Statement: No previous psychiatric history

Caregivers (if applicable): Not applicable

Hospitalizations: None

Medication trials: Patti has been referred to a psychiatrist for medication due to feelings of hopelessness and helplessness related to her disability.

Psychotherapy or Previous Psychiatric Diagnosis: Patti and her daughters, Sharleen and Sheela, have been in therapy with Sandi for about 1.5 years, focusing on family conflicts, cultural differences, and Patti’s adjustment to her disability.

Substance Current Use and History: None

Family Psychiatric/Substance Use History: History of domestic violence and child sexual abuse perpetrated by Patti’s ex-husband.

Psychosocial History: Patti is an Iranian immigrant of 12 years. She raised her children as a single parent after leaving an abusive marriage. Cultural clashes arise between her traditional values and her children’s American individualism. Her recent disability intensifies tensions as she grapples with dependency and expectations of familial care.

Medical History:

• Current Medications: None
• Allergies: None
• Reproductive Hx: Patti has five children.

ROS:

• GENERAL: No significant weight loss, fever, or fatigue was reported.
• HEENT (Head, Eyes, Ears, Nose, Throat): No visual or hearing changes, no headaches.
• SKIN: No rashes, lesions, or itching.
• CARDIOVASCULAR: No chest pain or palpitations.
• RESPIRATORY: No shortness of breath or cough.
• GASTROINTESTINAL: No nausea, vomiting, diarrhea, or abdominal pain.
• GENITOURINARY: No urinary frequency, urgency, or changes in urinary habits.
• NEUROLOGICAL: Reports hopelessness
• MUSCULOSKELETAL: Chronic pain and disability due to failed foot surgeries and inability to walk for long distances.
• HEMATOLOGIC: No bleeding disorders.
• LYMPHATICS: No swollen lymph nodes.
• ENDOCRINOLOGIC: No excessive thirst or urination, no heat or cold intolerance.

Physical Exam: Not applicable

Diagnostic Results: No specific diagnostic results were provided.

 Assessment:

Mental Status Examination: Patti is a 35-year-old Caucasian female who appears her stated age. She presents as frustrated, hopeless, and depressed at times, likely due to her disability and family conflicts. She is cooperative with the examiner and maintains appropriate grooming and cleanliness. There is no evidence of abnormal motor activity. Her speech is normal in rate, volume, and clarity. Her thought process appears rigid and inflexible, particularly regarding her expectations of her children. There are no delusions or hallucinations present. Perception cannot be assessed based on available information. Cognitively, Patti demonstrates intact functioning based on the conversation. However, she exhibits limited insight into the impact of her expectations and behavior on her children, potentially influenced by her cultural beliefs and values. Judgment may be impaired by these cultural factors as well.

Differential Diagnoses:

1. Adjustment Disorder with Depressed Mood (F43.23):
   • Patti is experiencing depressed mood, hopelessness, and difficulty adjusting to her chronic pain, disability, and changing family dynamics.
   • Her symptoms appear to be a maladaptive reaction to these identified stressors.
   • Criteria A, B, C, D, and E of the DSM-5-TR diagnostic criteria for Adjustment Disorder with Depressed Mood are potentially met (American Psychiatric Association, 2013).
2. Major Depressive Disorder, Single Episode, Moderate (F32.1):
   • Patti exhibits symptoms of depressed mood, hopelessness, and functional impairment.
   • The transcript does not establish the duration and severity of her symptoms.
   • Criteria A and C for Major Depressive Disorder may be met, but more information is needed to confirm the presence of other criteria American Psychiatric Association, 2013).
3. Persistent Complex Bereavement Disorder (ICD-11):
   • Patti may be experiencing persistent grief and difficulty accepting the loss of her role as a caregiver and the changing relationships with her children.
   • Her symptoms of preoccupation with loss, emotional pain, and functional impairment could potentially meet the ICD-11 criteria for Persistent Complex Bereavement Disorder (Wheeler, 2020).

Case Formulation and Treatment Plan:

Patti’s case involves a complex interplay of cultural factors, trauma, family dynamics, and adjustment to her chronic pain and disability. The family’s immigration history, exposure to domestic violence, and the sexual abuse of Sharleen have left significant emotional scars. Patti’s traditional Iranian values and expectations of filial piety clash with her children’s acculturation to American individualistic values, leading to intergenerational conflicts.

Patti’s recent disability and chronic pain have exacerbated these tensions as she struggles to accept her children’s growing independence and adjust to her newfound dependency. Her feelings of hopelessness and helplessness may be indicative of an adjustment disorder or depressive episode, further complicated by unresolved grief over the loss of her role as a caregiver and provider.

Treatment should involve a multi-pronged approach addressing individual, family, and cultural factors:

1. Individual Therapy for Patti:
   • Cognitive-behavioral therapy (CBT) to challenge rigid beliefs, manage expectations, and develop coping strategies for chronic pain and disability.
   • Grief counseling to process the loss of her previous roles and independence.
   • Exploration of cultural values, acculturation stress, and identity issues (Wheeler, 2020).
2. Family Therapy:
   • Strengthen communication, promote understanding of different perspectives, and negotiate boundaries and expectations.
   • Address intergenerational conflicts, unresolved trauma, and attachment issues.
   • Facilitate the family’s transition to a new dynamic that respects individual autonomy while maintaining cultural values and connections (Nichols & Davis, 2020).
3. Group Therapy:
   • Engage with others facing similar challenges related to chronic pain, disability, or cultural adjustments.
   • Provide a supportive environment for sharing experiences and gaining new perspectives (Petiprin, 2016).
4. Psychopharmacological Intervention (in consultation with a psychiatrist):
   • Antidepressant medication may be considered to alleviate depressive symptoms and hopelessness and improve overall functioning.
   • Careful monitoring and management of potential side effects and drug interactions (Petiprin, 2016).
5. Referrals and Community Resources:
   • Physical therapy and occupational therapy to improve functioning and independence with daily activities.
   • Support groups or organizations for individuals with chronic pain or disabilities.
   • Cultural organizations or community centers foster a sense of belonging and cultural identity (Petiprin, 2016).
6. Psychoeducation:
   • Provide education on chronic pain management, disability adjustment, and coping strategies.
   • Educate the family on acculturation and cultural differences and promote healthy family dynamics (Petiprin, 2016).

Reflections:

Patti’s case highlights the complex challenges immigrant families face navigating the acculturation process and the intergenerational conflicts that can arise. Patti’s disability and the family’s history of trauma further compound the difficulties they face. As the therapist, one must maintain cultural humility and sensitivity while facilitating open communication and understanding between Patti and her adult children. Striking a balance between respecting traditional values and promoting healthy adaptation to the host culture will be crucial.

Addressing Patti’s feelings of hopelessness and helplessness related to her disability is also a priority, as these emotions can exacerbate the existing tensions within the family. Encouraging her to find meaning and purpose beyond her caregiving role may help alleviate some of her distress and promote personal growth (Nichols & Davis, 2020). Ultimately, the goal should be to foster a supportive and harmonious family dynamic where Patti and her adult children can find a middle ground that respects their cultural differences while promoting mutual understanding and respect.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.

Nichols, M., & Davis, S. D. (2020). The Essentials of Family Therapy (7th ed.). Pearson.

Petiprin, A. (2016). Psychiatric and mental health nursing. Nursing Theory. https://www.nursing-theory.org/theories-and-models/psychiatric-and-mental-health-nursing.php

Wheeler, K. (Ed.). (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer Publishing.

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Physical assessment (if applicable)

Mental status exam

Differential diagnosis—Include a minimum of three differential diagnoses and include how you derived each diagnosis by DSM-5-TR diagnostic criteria

NRNP-PRAC 6645 Comprehensive Psychiatric Evaluation Note Template

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.