NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Template

CC (chief complaint):

The mother reports feelings of isolation, chronic pain, and depression. She reports frustration with the battle between herself and her children, mainly her daughter Charlene, regarding time spent together and differences in cultural expectations: NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Template.

HPI:

Patty is a middle-aged Iranian immigrant, probably in her late 50s to early 60s, who comes with complaints of ongoing psychosocial distress stemming from strained familial relationships and unresolved trauma. She is the mother of several adult children, including Charlene, who is in her mid-20s. Patty reports profound emotional distress, chronic back pain, and feelings of loneliness exacerbated by perceived abandonment as her children assert independence.

About 20 years ago, Patty immigrated to the U.S. with most of her children but was forced to leave one behind due to visa restrictions. She says she feels a lingering sense of guilt about that and what it led to: the child was abused while in her father’s custody. Patty describes her role as a caregiver and protector but now feels disconnected as her children grow into adulthood.

Charlene, raised in the U.S., points out conflicts arising from cultural expectations and her mother’s high demands for time and attention. She describes feelings of overwhelm about her mother’s control, which she attributes to cultural differences and her mother’s unresolved trauma. While both have been to therapy, they acknowledge that many of these issues are not resolved. Their interaction presents a complex interplay between cultural identity, intergenerational conflict, and emotional needs.

Past Psychiatric History:

• General Statement: Patty has a history of untreated trauma stemming from her abusive marriage and migration experiences.
• Caregivers (if applicable): N/A
• Hospitalizations: Not reported.
• Medication trials: Not mentioned
• Psychotherapy or Previous Psychiatric Diagnosis: Previous therapy for family conflict and cultural transition issues not resolved had in prior therapy of comparable sort of conflicts.

Substance Current Use and History: Patty and Charlene reported no history of substance use.

Family Psychiatric/Substance Use History:

• Patty’s former husband was emotionally abusive and neglectful.
• No family history of substance use disorders or psychiatric diagnoses reported.

Psychosocial History: Patty came to the U.S. with some of her children. She was forced to leave one of her daughters in Iran because of visa issues. At the same time, she cared for her children back in the U.S., working as a caregiver.

The family dynamic involves some form of both origin cultural conflict, such as how Iran and America differ in how they function as societies. Charlene has a dilemma on how much she should respect her mother’s traditional ethnocentrism and have individualism simultaneously.

Medical History:

• Current Medications: Not reported
• Allergies: None mentioned

• Reproductive Hx: N/A

ROS:

• GENERAL: Chronic back pain and fatigue.
• HEENT: No reported concerns.
• SKIN: No concerns have been reported.
• CARDIOVASCULAR: No reported concerns.
• RESPIRATORY: No issue raised
• GASTROINTESTINAL: No concern was raised
• GENITOURINARY: No concern was raised
• NEUROLOGICAL: No concern was raised
• MUSCULOSKELETAL: Reports of chronic back pain.
• HEMATOLOGIC: No issue raised
• LYMPHATICS: No complaints mentioned
• ENDOCRINOLOGIC: No concern was raised

Physical exam: This session was not conducted. Patty reports significant physical limitations due to chronic back pain.

Diagnostic results: No diagnostic tests were conducted during the session. Consider imaging or physical evaluations for chronic back pain.

Assessment

Mental Status Examination:

Patty appeared her stated age, cooperative, and appropriately dressed. She maintained good eye contact. Her mood was described as depressed, with a constricted affect. The speech was clear but occasionally tearful.

Thought processes were logical, with some ruminations about past trauma. She denied hallucinations, delusions, or suicidal ideation. Insight and judgment were moderate. Cognition and memory appeared intact.

Charlene appeared engaged but frustrated, with an irritable mood and congruent affect. She denied psychiatric symptoms and articulated her concerns clearly.

Main Diagnosis:

1. Adjustment Disorder with Depressed Mood (F43.21)

• Justification: Symptoms are tied to chronic stressors from family conflicts and life transitions (O’Donnell et al., 2020).

Differential Diagnoses:

1. Persistent Depressive Disorder (Dysthymia) (F34.1)

• Justification: Prolonged emotional distress spanning years (Patel & Rose, 2023).
• Exclusion: Lacks pervasiveness of depressive symptoms in multiple domains.

1. Post-Traumatic Stress Disorder (F43.10)

• Justification: History of trauma, including abuse and guilt over past decisions (Mann & Marwaha, 2022).
• Exclusion: Does not meet full DSM-5-TR criteria for avoidance and hyperarousal.

1. Major Depressive Disorder (F33.1)

• Justification: Some of Patty’s symptoms, including persistent low mood and anhedonia, could overlap with the criteria for a depressive episode (Marx et al., 2023).
• Exclusion: Symptoms are not severe enough or pervasive enough across domains to meet the criteria for Major Depressive Disorder.

Case Formulation and Treatment Plan:

Case Formulation:

Patty and Charlene present with unresolved familial conflict compounded by cultural differences. Patty’s trauma and guilt over her migration decisions influence her high expectations and controlling behaviour. Charlene seeks independence, leading to tension. This dynamic reflects broader struggles between dependence, independence, and interdependence.

Treatment Plan:

1. Psychotherapy:
   • Engage in family therapy focused on boundary setting and communication.
   • Cognitive-behavioral therapy (CBT) for Patty to address guilt and depressive symptoms (Sp et al., 2020).
   • Individual sessions for Charlene to explore assertiveness and coping strategies.
2. Support Resources:
   • Connect Patty with social support groups for Iranian immigrants.
   • Explore physical therapy or pain management for Patty’s chronic back pain.
3. Psychoeducation:
   • Educate the family on cultural adjustment and intergenerational conflict resolution (Sarkhel et al., 2020).

Reflections:

This case underscores the complexities of intergenerational and cultural conflicts in immigrant families. Cultural competence and sensitivity are critical for addressing both individual and collective needs. Therapy should focus on fostering a balance between autonomy and familial connection, acknowledging each member’s perspective.

References

Mann, S. K., & Marwaha, R. (2022). Posttraumatic Stress Disorder. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/32644555/

Marx, W., Penninx, B. W. J. H., Solmi, M., Furukawa, T. A., Firth, J., Carvalho, A. F., & Berk, M. (2023). Major depressive disorder. Nature Reviews Disease Primers, 9(1). https://doi.org/10.1038/s41572-023-00454-1

O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2020). Adjustment disorder: Current developments and future directions. International Journal of Environmental Research and Public Health, 16(14), 2537. https://doi.org/10.3390/ijerph16142537

Patel, R. K., & Rose, G. M. (2023, June 26). Persistent Depressive Disorder (Dysthymia). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541052/

Sarkhel, S., Singh, O., & Arora, M. (2020). Clinical Practice Guidelines for Psychoeducation in Psychiatric Disorders General Principles of Psychoeducation. Indian Journal of Psychiatry, 62(8). https://doi.org/10.4103/psychiatry.indianjpsychiatry_780_19

Sp, C., Dp, K., & Mr, H. (2020, January 1). Cognitive Behavior Therapy (CBT). PubMed. https://pubmed.ncbi.nlm.nih.gov/29261869/

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