Comprehensive Psychiatric Evaluation
Age: 40 years
Residence: West Virginia
Marital status: Separated
Informant: Patient and accompanying daughter
CC (chief complaint): “My home is in disarray.” The patient reports
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
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
- Firstborn, Sheela, 24-year-old daughter, a professional photographer, asthmatic, no psychopathology
- Second, born, Sharleen, 23-year-old, the informant daughter, promotional jobs, real estate enthusiast, healthy, no psychopathology
- Third born, Shireen, a daughter who recently immigrated from Iran, sexually/physically abused by her father, received psychotherapy sessions
- Brother, 18-year-old, finishing high school next year
- Brother, 15-year-old, in high school, described as impatient, has a cold relationship with the sister (informant)
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
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
Obstetric Hx: Para 5+0 non gravida, with five living children
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
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.
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.
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:
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.
- Psychiatrist to assess the need for antidepressants
- Initiation of cognitive behavioral therapy: Attend about 15-20 sessions (Chand et al., 2022)
- Initiation of individual and family psychotherapy: Attend at least 12 sessions (Varghese et al., 2020)
- Pain management
- Visit the nearest primary care facility if the pain becomes unbearable
- See a physiotherapist once a week
- Visit a psychiatrist if the mood disturbances worsen
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 Instructions
- Carlat, D. J. (2017). The psychiatric interview(4th ed.). Wolters Kluwer.
- Chapter 31, “Assessing Personality Disorders”
- Chapter 32, “How to Educate Your Patient”
- American Psychiatric Association. (2022). Sexual dysfunctions Links to an external site.. In Diagnostic and statistical manual of mental disorders(5th ed., text rev.).
- American Psychiatric Association. (2022). Personality disorders Links to an external site.. In Diagnostic and statistical manual of mental disorders(5th ed., text rev.).
- American Psychiatric Association. (2022). Paraphilic disorders Links to an external site.. In Diagnostic and statistical manual of mental disorders(5th ed., text rev.).
- Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry(11th ed.). Wolters Kluwer.
- Chapter 17, “Human Sexuality and Sexual Dysfunction”
- Chapter 22, “Personality Disorders”
- Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
- Objective: What observations did you make during the interview and review of systems?
- Assessment:What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
- Reflection notes:What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.