Application of Course Knowledge: Answer all questions/criteria with explanations and detail. Correctly identify your assigned social determinant. Briefly define the determinant and describe how it impacts healthcare outcomes. Select an objective related to your assigned social determinant from the Healthy People website linked above. Identify the status of the objective and the population to whom the objective applies. Include a minimum of two different scholarly sources per week. Cite all references and provide references for all citations. Provide at least three appropriate questions related to the chosen objective that the NP could incorporate into the health history and interview to assess the client and family. Identify at least two online, national, or local resources and explain how the resources could help meet the chosen objective for at-risk clients or families.

 
Week 2-Family Assessment and Psychotherapeutic Approaches
Patients: AB

Gender: Female

Ethnicity: Iranian American

Ages: 40 years

Subjective

Chief Complaint: The mother complains that she is lonely, and this has led to depression. She states that she is in pain after her surgery and wants to spend more time with her family. The daughter, however, states that she wants her mother to lower her expectations and accept children as independent beings who want to live their own lives. She complains that her mother is not allowing her to do her things. She further narrates how she hates her mother’s house because of the dogs that are there. The dogs leave hair on her body, and she does not like it. The dogs make her uncomfortable in her mother’s house.

HPI: The patient is a 40-year-old Iranian American female accompanied by her 23-year-old daughter, whom their therapist has referred for evaluation. The therapist has been treating this family for complex issues that they are facing. The reasons causing trauma to the mother are difficulty adjusting to life in America from Iran and the abusive marriage that she was in with her husband. The husband also raped her daughter, which has destroyed the relationship between her children and her husband. The mother left Iran with her four children but left one behind who was raped by her husband. The chaos started two weeks after the raped child came back from Iran. The child blamed her mothers for her woes. The daughter complains about the lack of privacy. Her mother wants to be all over her business. She wants to control her life. The mother is disabled due to illness, which makes her dependent and hence causes her trauma. The dynamics in this case study are complex. There are many inter-family conflicts present.

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Past Psychiatric History: The mother reports that she gets depression when she is lonely. However, there is no confirmed diagnosis of depression. The patient denies suicidal tendencies. There is no history of any psychiatry or psychiatry hospitalizations.

Hospitalizations: The patient denies any mental hospitalizations.

Previous psychiatric diagnosis: No current psychiatric diagnosis, but the mother is under psychotherapy due to her hopelessness.

Substance Current Use and History: The patient denies tobacco, smoking, alcohol, or illicit drug use.

Family Psychiatric/Substance Use History: There is no history of substance abuse or mental illness.

Psychosocial History: Patients immigrated from Iran 12 years ago. The mother lives with her two sons, while the daughter lives alone. The daughter does promotional jobs. The occupation and education level of the patients are not mentioned. The patient has five children. She left her husband in Iran. The patient has a history of abuse by her husband.

Medical History: The mother had two surgeries done on her foot.

Current medications: The patient is on medications for her hopelessness.

Allergies: Unknown

Reproductive: Mother lives alone. Husband is in Iran. She is not sexually active.

Review of Systems

General: The patient states that she has fatigue and tiredness. The patient denies any night sweats, fever, or chills.

HEENT: Head is autramatic and normocephalic. The patient denies double vision or changes in sight. Both patients deny ear pain, vertigo, and hearing loss. The patient denies sinusitis or nasal congestion. The patient denies throat pain or soreness of the throat.

Skin: The patient denies moles, skin rashes, or any tattoos.

Cardiovascular: Patient denies peripheral oedema or chest pain

Respiratory: Patient denies laboured breathing, wheezing, shortness of breath, and coughing.

Gastrointestinal: Denies abdominal pains, anorexia, nausea, or diarrhoea.

Genitourinary: Denies abnormal vaginal discharge, hematuria, or urinary frequency.

Musculoskeletal: Denies joint pain. The mother has limited mobility due to surgery on both legs.

Hematologic: Denies easy bruising or anaemia.

Lymphatics: Denies swollen lymph nodes.

Endocrinology: Denies heat/cold intolerance, dysuria, or nocturia

Neurologic: Denies tingling sensations, paralysis, ataxia, or vertigo.

Diagnostic Results

Minnesota Multiphasic Personality Inventory (MMPI)

This test will be used to evaluate personality traits, and it can be used to diagnose mental conditions (Kremyar & Ben-Porath, 2020). It is a self-testing report on a scale of 10.

Assessment

The patient is an Iranian-American female referred by her therapist for an evaluation. She is accompanied by her daughter. The mother is forty years while the daughter is 23 years old. The mother is younger than her stated age. The patient is attentive and cooperative during the session. She is neatly dressed. Their dressing is appropriate for the weather. The patient has normal motor activity. The patient was irritable during the session. The patient denies auditory or visual hallucinations. The patient denies suicidal ideations. She has a clear and coherent speech with a normal tone and volume. Her thought process is logical and goal-driven. Her tone is aggressive. She occasionally laughs during the interview. She has good focus and is present-minded. Her short-term and long-term memory is normal. Her mood during the interview is flat. Both patients are A & OX3. Her judgment, abstraction, and concentration are intact.

Differential Diagnosis

Post-Traumatic Stress Disorder (PTSD) 309.81 (F43.10)

PTSD is a mental condition that has several criteria to pass diagnosis. The first criterion is exposure to trauma (American Psychiatric Association, 2013). The patient learned that her daughter was raped by her husband. The patient was also in an abusive relationship with her husband. She has one intrusive symptom (APA, 2013). She has memories of the abuse she faced at the hands of her husband. She has persistent avoidance symptoms (APA, 2013). She tries hard not to remember the trauma she faced back in Iran. She has symptoms of negative alterations in cognition and mood (APA, 2013). She has negative beliefs about her daughter’s boyfriends, and she wants to choose them boyfriends due to fear of them getting an abusive husband. She also blames herself since she left her daughter back in Iran, which led to her being raped (APA, 2013). The other criterion she meets is marked alterations in reactivity associated with the trauma (APA, 2013). She is hypervigilant and does not want her daughters to get married to abusive husbands. She has angry outbursts, as evidenced by shouting in her house with her daughters. The disturbance symptoms have been present for more than a month and are not due to substance effects or medical conditions.

Adjustment Disorders with Depressed Mood

The patient has a predominant low mood and hopelessness. The development of the emotional distress should occur within three days to one month of the identified stressor (APA, 2013). The emotional distress has occurred many years since she left Iran from her abusive husband, which eliminates this diagnosis. Her symptoms are clinically significant since she has a social impairment in a relationship with her daughters (APA, 2013). The other criteria she meets is that the distress is not due to normal grief; it is not a mental disorder (APA, 2013). She does not meet the final criterion in which if the stressor is terminated, symptoms persist for no more than six months (APA, 2013). This diagnosis is ruled out.

Acute Stress Disorders

The patient directly experienced the traumatic event, which was abuse by her husband (APA, 2013). She also has recurrent memories of the trauma. She has a negative in which she is constantly feeling lonely (APA, 2013). She also tries so hard not to remember the traumatic events that occurred in Iran. She is hypervigilant with irritable behavior (APA, 2013). The disturbance has also severely affected her social life, and it is not due to any medical conditions. She does not meet the criterion of duration in which the symptoms have an onset of 3 days to 1 month of the trauma (APA, 2013). This rules out the diagnosis

Case Formulation and Treatment Plan

The patient will be managed through psychotherapy. The form of therapy that will be used is family therapy which addresses the relationship between the trauma survivor and her family members (Watkins et al., 2018). All family members will be present in the therapy, which will occur once every weekend when all family members are present. Nichols (2014) notes that family therapy is better than individual therapy since it allows the conflict to be solved at the source. The patient will be referred to social groups that will allow her to meet other trauma victims, which can help her PTSD. She will also be advised on healthy eating and good coping strategies. The therapy will continue for twelve weeks, and follow-up will be done three months later to assess the effectiveness of the therapy. If not successful, she will be referred to a psychiatrist to prescribe medications.

Reflection

This was a challenging case study. It was hard to come up with a diagnosis for the patients. The symptoms she presented with overlapped between acute stress disorders, PTSD, and adjustment disorders. Any of these conditions can pass as a diagnosis. I utilized the DSM-V manual to help me narrow the diagnosis. The difference between these three conditions is the onset of the symptoms. The symptoms started years later after the mother immigrated to the USA. If I would do this differently, I would invite all the family members into therapy to help resolve the conflict in the family.

Informed consent is essential in therapy (Trachsel & Grosse Holtforth, 2019). The therapist must inform the patient of the type of therapy he wants to do and seek her consent before initiating treatment. The therapist must also consider a law that governs the privacy of patient information. The HIPAA regulation is one of those laws (Cohen & Mello, 2018). She must have structures to protect the privacy of patient information.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®) (5th ed.). American Psychiatric Pub.

Cohen, I. G., & Mello, M. M. (2018). HIPAA and protecting health information in the 21st century. JAMA, 320(3), 231. https://doi.org/10.1001/jama.2018.5630

Kremyar, A. J., & Ben-Porath, Y. S. (2020). Further examining the construct validity of the Minnesota Multiphasic personality inventory-2-Restructured form (MMPI-2-RF) personality disorder spectra scales. Journal of Personality Assessment, 1-12. https://doi.org/10.1080/00223891.2020.1828434

Nichols, M. P. (2014). The essentials of family therapy (6th ed.). Pearson College Division.

Trachsel, M., & Grosse Holtforth, M. (2019). How to strengthen patients’ meaning response by an ethical informed consent in psychotherapy. Frontiers in Psychology, 10. https://doi.org/10.3389/fpsyg.2019.01747