FAMILY ASSESSMENT AND PSYCHOTHERAPEUTIC APPROACHES 1

Family Assessment and Psychotherapeutic Approaches

Walden University

NRNP – 6645 Psychotherapy with Multiple Modalities

June 13, 2021

FAMILY ASSESSMENT AND PSYCHOTHERAPEUTIC APPROACHES 2

Family Assessment and Psychotherapeutic Approaches

Historian: Mother and daughter (Self)

Language: English

Name: Non- listed

Gender: Both female (mother and daughter)

Age: 40 years old and 23 years old.

Chief complaint — “I am in so much pain, nobody can help me and nothing is helping

me manage the pain. I want my mom to be more peaceful, I want her to lower her expectations

and accept a lot of things about life, I have a sense that my mom is holding me back from all I

could be doing”. I just want them to spend time with me, I am very lonely, and I get depressed

when I am lonely. I hate spending time with my mother, I hate her house, she has two dogs and I

do not like those at all, I do not like their hair on my body and I do not like touching them. Do

you believe I cannot even eat in her house, everything smells like dog, and it is very

uncomfortable for me”.

History of present illness (HPI) — This patient is a 40-year-old Iranian American

female. She is here today to be seen for complex family dynamic issues as it relates to her and

her five children. She was seen with her 23-year-old daughter who detailed the multiple issues as

it relates to her relationship with her mom and siblings. They are here for evaluation of trauma

related issues as it relates to abuse by her husband and their father. Mom is currently struggling

with trauma related issues from being married and also struggling with adjusting to the norms

and principles of America which can be called Adjustment disorder at this time

Per self report, one of her daughters was raped and abused by her biological father and

this has left a dent in the way the family relates with their dad. There has been difficulties

FAMILY ASSESSMENT AND PSYCHOTHERAPEUTIC APPROACHES 3

relating to one another, difficulties relating to their father, difficulties relating to the issues of

traditional Iranian family becoming “Americanized”, issues with spending time with their

mother, their lack of privacy and distrust overall. Overall, this is a complex family unit and there

are multiple conflicts active and ongoing at the same time. The biggest issue has to do with the

mother of the house becoming sick, and having multiple surgeries to fix her foot which has left

her almost dependent. The second issue is the rape allegation. One of the daughters alleged that

her biological father raped her., this has left the family traumatized and unforgiving.

Thirdly, there is the issue of the of a mother desperately trying to hold unto her traditional

Iranian beliefs and traditions. For example, in Africa and the Middle East, it is believed that

children are to stop their lives to care for their parents if they need that help. In America, the

tradition is to employ a capable nursing facility or a private nurse to do the caring. These are very

different standards. In this case, her children are urging her to do more for herself and for her

health, to not solely depend on them or wait on them. Overall, there are major unresolved

conflicts going on that are trauma related, depression, physical health etc.

Some physical signs noted during the assessments were fidgeting, excited. There are also

signs of hyperactivity, impulsivity, irritability, lack of restraint, and persistent repetition of words.

There is no notice of difficulty focusing, issues with paying attention or short attention span.

Past psychiatric history — In the scenario, mom mentioned depressive episodes, there

was however no mention of medically diagnosed psychiatric conditions like depression. They

denied suicidal ideations. They also denied the use of illicit drugs/ alcohol, prior serious mental

or psychiatric breakdown, or mania. No prior reports of psychiatric inpatient hospitalizations to

report either.

FAMILY ASSESSMENT AND PSYCHOTHERAPEUTIC APPROACHES 4

Hospitalizations- No inpatient psychiatric hospitalizations reported nor are there any

reports for active Pyschotherapy medications listed for these patients.

Psychotherapy or previous psychiatric diagnosis — No current psychiatric diagnosis,

no Psychotherapy “therapy” is documented for this patient. Note however that the patient said

she “gets depressed when she is alone”. It was not reported that depression was medically

diagnosed or that it is currently being managed by any medication.

Pertinent substance use- Patients deny alcohol or abusing any substances at this time.

They also deny any chronic substance use/abuse.

Family psychiatric/substance use- Patients deny any family psychiatric/ substance use.

Psychosocial history/Developmental history — These patients are 40 and 23-year-old

Iranian immigrants that are currently struggling with adjusting their traditional beliefs with the

Americanized way of life. They are here today for mental assessment/ possible diagnosis of

trauma related issues including adjustment disorder. They were referred by their current

psychiatrist who has tried multiple dimensions to manage the patient and her children. Of note,

she was present for the assessment and answered pertinent questions as it relates to the patients,

their past and their overall issues.

Mom is currently living on disability but her daughter that came with her for the

evaluation lives by herself. Of note, it was reported that she is currently in school, but her social

life was not discussed during assessment. It is always vital to know your patients, for this

evaluation., there was no concrete data collected or reported. For example, knowing what school

the daughter attends, her sexual orientation, understanding her full social life is important in

treatment plan. Questions like does she have a boyfriend and does she live with him? Is she

bisexual? What kind of friends does she have? How many drinks does she drink during nights

FAMILY ASSESSMENT AND PSYCHOTHERAPEUTIC APPROACHES 5

out? What kind of alcoholic beverages does she drink? Collecting, collating and analyzing these

informations can create a well-rounded scenario and can help in creating a full treatment plan for

targeted intervention.

Knowing our patient’s lifestyle and if they indulge in high risk behaviors can assist in

creating a plan of care that can address the specifics for high risk behaviors like testing

periodically for STDs, liver functions, and sometimes suicide. As we all know, alcohol and drug

use can contribute to unintentional injuries and sometimes violence. Tobacco use, unhealthy

dietary behaviors, physical inactivity and sexual behaviors can all contribute to unintended

pregnancy and sexually transmitted infections. It is therefore imperative to assess these functions

and tailor care to fit the assessment (Kelley, T., 2016)

For these patients and the family as a whole, there was no mention of past or current

medical history. From what I could deduce from the assessment, mom recently had surgery of

her bilateral foot. The reason for this surgery or what prompted it was not reported. To

understand this patients whole health history, it is imperative to ask some vital questions.

Considering her physical weight, I would want to know is she diabetic? Does she suffer from

hypertension? What medications does she take daily to manage these ailments? These are vital

information because we would know how to vigorously manage her wounds and how well she

may heal after surgery. (Kelley, T., 2016). Unmanaged diabetes can lead to necrotic wounds that

may not heal which can lead to sepsis. It is therefore vital to have a clear picture of your patient

during assessment (Kelley, T., 2016)

Work History — None on file/ assessed

Legal history — None on file/ assessed

Medical History- No head injuries to report, no seizures, no developmental concerns.

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Current Medications- None listed

Allergies — Unknown

Medical Diagnoses — none listed

Reproductive Hx — Post 6 children for mom, unknown for the children.Relationship

— Mom is separated from her husband and the father of her children, no relationship status

posted or reported for her children

Educational Level — None listed for everyone involved in this assessment

Occupation — None listed or reported

Hospitalizations — None reported or found in the chart.

Family Medical History —None reported or assessed from previous visits

Review of Systems (ROS)

General- mom reports fatigue and tiredness, denies night sweats, fevers, chills. Daughter

reports being fine but just overwhelmed by her moms demands and unaware of how to manage

the situation.

HEENT- No visible head injuries or trauma noticed on both patients, patients deny

change in vision, hearing, no ear pain, blurred or double vision, or yellow sclerae. Ears, Nose,

Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat

Skin — No skin issues or concerns to report or noted.

Cardiovascular — No chest pain, heart palpitations, syncope, or edema noted on both

patients.

Respiratory — No cough, wheeze, or diminished breathe sounds noted, occasional

dyspnea with exertion noted, perhaps related to anxiety and depression.

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Gastrointestinal — No abdominal pain, constipation, diarrhea, nausea, constipation. No

anorexia noted.

Genitourinary — No flank pain, dysuria, burning on urination, hematuria etc.

Musculoskeletal — No myalgias, no joint pain.

Hematologic — No anemia. No easy bruising or bleeding.

Lymphatics — No lymph nodes issues to report. No enlarged nodes. No history of

splenectomy.

Endocrinology — No diabetes, no thyroid disorders. No polyuria, polyphagia, or

polydipsia, or polyphagia.

Neurological — No headaches, dizziness, syncope, paralysis, ataxia, numbness, or

tingling in the extremities. No change in bowel or bladder control.

Physical Exam (Done by PCP)

T- 98.3 R 16 106/72 Ht 5’7 Wt 117lbs

Average build

Vital signs

RR:16 bpm,

BP: 106/72,

O2: 98%

Temp — 98.3 F,

P- 69

Weight — 117 lbs.

Height — 5’7, and 5’11 respectively

Head — atraumatic

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Eyes — white sclera bilaterally, pink conjunctiva

Ears — patent, no discharge, grey pearl TM bilaterally.

Nose — pink mucosal membranes bilaterally, no congestion and intact turbinates

Throat — red mucosal membrane. No exudates.

Neck — no swelling and bruits. ROM is full.

Lungs — symmetrical chest, symmetry in expansion, and resonant sound in all areas.

Cardiovascular — S1, S2 clear, and no murmurs. Peripheral pulses 3+ and no edema.

Abdomen — flat and symmetrical, no tenderness, no masses, & normoactive sounds

Musculoskeletal — 5/5, no disuse/atrophy/hypertrophy.

Neuro — intact from CN I up to XII

Lymph/skin — no edema, no swelling.

Mental Status Examination

Mom is a 40-year-old Iranian female and her daughter is a 23 Americanized Iranian

female. Mom looks older than her stated age perhaps due to stress from being married young and

in an abusive marriage. Her daughter here today looks her stated age with no concerns. He is

cooperative with the examiner. They are both neatly groomed and clean, they are also dressed

appropriately for the weather and times. There is no evidence of any abnormal motor activity.,

They both however present with significant anxiety, restlessness and irritation.They deny any

visual or auditory hallucinations, delusions, tangentiality/mood. Their speeches are clear, stressed

and loud but coherent and normal in volume and tone. Thought process is goal driven and

logical.

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There is clear evidence of annoyance, excitability, fidgeting, hyperactivity, impulsivity,

irritability, medium restraint and persistent repetition of some words in a forced and aggressive

tone. They seemed present-minded when spoken to, there is no difficulty focusing, no lack of

memory recall/ forgetfulness, no issues paying attention, and no issues with short attention span.

Their moods are gloomy and affect is appropriate to presented moods (flat). They deny any

auditory or visual hallucinations. They also deny any current suicidal or homicidal ideations.

Cognitively, they are alert and oriented to themselves, the situation and recent and remote

memories are intact. Concentration is normal, insight is average, there is no difficulty in

memories recollection. Abstraction, attention, insight, and judgment are all reasonable and intact.

Eye contact- Good

Speech — Normal rate and volume.

Behavior — Anxious (for both patients)

Psychomotor — No involuntary movements.

Mood — gloomy

Affect — Flat.

Thought Process: logical, goal-directed and organized.

Thought Content: no delusions. — no suicidal ideations, — no homicidal, or self-harm

ideations noted.

Perception: Minimum reaction to external stimuli.

Attention/ Concentration: Sustained attention and concentration observed.

Cognition: Alert, and oriented X 4.

Memory: No issues with recall

Insight: Fair.

FAMILY ASSESSMENT AND PSYCHOTHERAPEUTIC APPROACHES 10

Judgment: Average

Fund of Knowledge: Average.

Intelligence: Average

Post Traumatic Stress Disorder Diagnosis and Screening in Adults.

Previously, PTSD was simply called a “soldier's heart,” “shell shock,” or “combat

fatigue.” The terminology of post-traumatic stress disorder (PTSD) arose immediately after the

Vietnam War. It was observed that traumatic events lead to a complex psychobiological

presentation during and after the Civil War (Patra, B. N.,2018).

This disorder was first described by ABR Myers (1838–1921) in 1870, it was described

as a multifaceted disorder with complex factors and presentation combining acute fatigue,

dyspnea, a sighing respiration, palpitation, sweating, tremor, an aching sensation in the left

pericardium, utter fatigue, an exaggeration of symptoms upon efforts and in severe cases syncope

that can happen suddenly (Iribarren, J., 2015).

Differential Diagnoses

POST- TRAUMATIC STRESS DISORDER- PTSD; ICD-10 CODE: F.43

PTSD can occur after a traumatic event such as military combat, a violent physical

assault, or a natural disaster. While stress is usual after a trauma, people with PTSD often relive

traumatic events in their minds countless times. They may also begin to feel distant from friends

and family. They may also start to experience various emotions and experience anger that does

not go away over time, or perhaps even get worse.

This disorder usually affect individuals who have experienced a wide range of life-

threatening occurrences. According to research, approximately 8% of the American population

FAMILY ASSESSMENT AND PSYCHOTHERAPEUTIC APPROACHES 11

will experience PTSD at some point in their lives. In Veterans, PTSD is commonly associated

with combat trauma. According to the National Center for PTSD, the prevalence of PTSD is not

fixed on race, sexual orientation or physical features, it can happen to both men and women in

various capacities.

The stress that results from traumatic events bring about a spectrum of psycho-emotional

and physiopathological consequences. Post-traumatic stress disorder (PTSD) is a psychiatric

disorder that expresses itself as a result of an experience or of a witnessing of really traumatic or

a life-threatening episode. Post Traumatic Stress Disorder has a profound psychological

correlation with generalised physical impairments. These symptoms can profoundly impair an

individual’s daily life functions and can be life and mind-altering. This disorder is common in

extended combat, terrorism, exposure to certain environmental toxins etc. Overall, per recent

research, there is expected to be a rise in individuals with Post Traumatic Stress Disorder

diagnosis is expected in upcoming decades

Overall post-traumatic stress disorder (PTSD) is a disorder that develops in certain

individuals who have experienced a shocking, scary, and or a dangerous experience that has left

scars too fearful to forget. As we all know, fear triggers many split-second changes in the body to

help defend against danger scenarios and propel certain actions that it deems fit would cause

rescue from the situation. This episode known simply as “fight-or-flight” response is a typical

reaction meant to shield an individual from harm in frightful circumstances

Of note., 95% of individuals will experience a variety of reactions after a life- altering

trauma episode, but most people will recover fully from initial symptoms without any external

help or re-direction. The individuals who keep experiencing trauma as a result of an experience.,

FAMILY ASSESSMENT AND PSYCHOTHERAPEUTIC APPROACHES 12

will be diagnosed with PTSD. People who have this disorder usually feel stressed or frightened,

even when there is no danger lucking around.

All criteria met : Some signs of PTSD are persistent thoughts about a past event,

persistent negative emotional thoughts, extreme thoughts of fear, fear, horror, anger, guilt, or

shame. “Markedly diminished interest or participation in significant activities” (Adler et al.,

2006; Glind et al., 2013). These patients are currently experiencing chronic signs of PTSD, from

being married to an abusive man and from having a sister that was sexually abused by their

father.

Another significant factor of PTSD verbal aggression, unsanitary home, and

economically depressed lifestyle. These factors are current in “moms” behaviour. Her verbal

aggression has also contributed significantly to her estrangement from her children.

ADJUSTMENT DISORDER — ICD-10-CM Code F31

Adjustment disorder refers to an unexpected strong behavioral or emotional reaction that

occurs as a result of an identifiable stressful life change or that occurred within the past three

months. It can present in multiple forms and behaviors, these can include the feeling of

hopelessness, sadness or persistent stress. This can also include physical symptoms occurring

after one undergoes through a stressful event in life. Overall, adjustment disorder primarily deals

with mood, while acute stress disorder deals with environmental stimulation (Harvard Medical

School, 2017). Psychological symptoms such as anxiety, low mood, irritability, emotional ups

and downs, poor sleep, poor concentration, wanting to be alone etc are some symptoms.

Fundamental issues coping with daily activities, mental abilities and general day-to-day activities

are some challenges of having this disorder.

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As at the time of this assignment, there is no known cause of this disorder.(Brüne, 2015).

However, the disorder is thought to be as a result of life’s stressors and experiences, interaction

of genetics, temperament and altered levels of some chemicals in the brain. Over the years,

research has revealed that certain events can increase the chances of developing this disorder.

These events can range from daily challenges to school functions. In the psychiatry community,

there is a belief that genetics is again believed to play a significant role in the formation, while

the environment is assumed to play an aggravating factor in its activation and symmetry. Overall,

a combination of genetics, the environment, and sometimes a “modified” brain structure and

chemistry may play a significant role.

Significantly, management for this disorder can be lifelong and treatment revolves around

intricate combination of medications, psychotherapy and other kinds of therapies. Psychiatric

Mental Health Nurse Practitioners diagnose Adjustment disorders after reviewing the patient’s

symptoms, overall history, life experiences plus family history etc. As we all understand in

Mental illnesses, it is vital to diagnose adjustment disorders early enough for a targeted

intervention and expected outcome to occur promptly.

“The Outcome of Depression International Network (ODIN) project shows adjustment

disorder in less than 1% of population. Another recent study of the general population found the

prevalence of adjustment disorder to be about 0.9%. Note that when the criterion of clinically

significant impairment was considered. A further 1.4% of the sample was diagnosed with

adjustment disorder without fulfilling the impairment criterion” (Patra, B. N., 2018).

All criteria not met: The diagnostic criteria is not met due to the time frame for the

diagnosis which ranges between 0-3 months. Some symptoms of adjustment disorder are feeling

sad, hopelessness or lack of enjoyment. Adjustment disorders do share some symptoms with

FAMILY ASSESSMENT AND PSYCHOTHERAPEUTIC APPROACHES 14

depression and some Practitioners have diagnosed depression in place if this disorder. Frequent

crying, worrying or feeling anxious, nervous, jittery or stressed out, trouble sleeping, lack of

appetite, difficulty concentrating, feeling overwhelmed, and lastly difficulty functioning overall

(Ustun, B., 2017)

ACUTE STRESS DISORDER— 2021 Acute Stress Disorder DSM-5 308.3 (F43.0)

Acute Stress Disorder (ASD), unlike Adjustment disorder, develops within the first

month after an individual develops/ witnesses an event that involves a threat or actual death.

Overall, these patients respond to these events with excessive feelings of helplessness, dread and

horror. ASD was introduced as a diagnostic procedure to help in identifying persons that would

ultimately develop post-traumatic stress disorder (PTSD). However, PTSD and ASD differ in

two major ways (Brüne, 2015).

The obvious difference between ASD and PTSD is the onset and duration of symptoms.

The effects of ASD present immediately and last up to a month, while PTSD symptoms present

slower and last longer, up to several years if not treated. Psychological symptoms such as

anxiety, low mood, irritability, emotional ups and downs, poor sleep, poor concentration, wanting

to be alone are all signs and symptoms that point to ASD.

All Criterias not meet;- Based on the accepted time frame for diagnosing this ailment, it

is highly impossible for these patients to be suffering from acute stress disorder. This is a

possibility but not a diagnosis at this time. PTSD as a result of a traumatic marriage and abuse is

the more possible choice at this time.

Case Formulation and Treatment Plan

FAMILY ASSESSMENT AND PSYCHOTHERAPEUTIC APPROACHES 15

The main treatments for people with PTSD are medications, psychotherapy, or both.

Everyone is different, and PTSD affects people differently, so a treatment that works for one

person may be ineffective for another. It is important for patients with PTSD to be managed by a

licensed mental health provider that is experienced and knowledgeable with this disorder. Some

people with PTSD may need to try different treatments to find what works for their symptoms.

This is where an experienced practitioner comes in.

The complicating factor in mental heath is the factor of co-occuring mental illnesses. It is

vital to treat illnesses from their root course. For example, if my patient is going through PTSD

as a result of an abusive and physical relationship, it is important to stop that trigger and that may

usually mean ending the relationship and charting a new course of rehabilitation. Like I pointed

out prior, if depression is related to the root cause of a patients PTSD presentation, that

depression has to be treated with first class SSRI and psychotherapy, or possibly group therapy

depending on the trigger and aggravating factor. Other ongoing problems that can co-occur are

panic disorder, depression, substance abuse, and suicidal ideation.

Mom in this scenario is exhibiting signs and symptoms of socialization skills and has

noticed an increase in her depressive issues. Linkage to community resources, assistance with

medical appointments, psychotherapy, and problem-solving with issues related to activities of

daily living.

Treatment Plan

Prozac 20mg daily

Buspar 15mg BID

Seroquel 50mg po QHS

Psychotherapy with Cognitive Behaviour Therapy to be followed up in four weeks.

FAMILY ASSESSMENT AND PSYCHOTHERAPEUTIC APPROACHES 16

Stress management

Diet and Nutrition specialist

Medications side effects and overall expectations.

Reflections /Legal and Ethical Implications

As I began to study the scenario and the topics for this assignment, I was intrigued by the

spectrum and the many factors that set each mental illness factor apart. PTSD is a complex

disorder that most folks incorrectly relate to veterans. Many neurotransmitters are associated in

the formation and sustainability of PTSD. So far Glutamate and Dopamine are said to be the

largest contributor in this class. The prefrontal cortex is also implicated in the roles in attention

and regulation of impulse control in impulse control. EEG studies found elevated beta activity in

their electroencephalography studies (Sadock, B. J., 2015).

Considering that patients with PTSD have a predisposition to obesity, it is imperative that

these patients understand the detriments of having excess body weight as it predisposes them to

acute and chronic illnesses like diabetes mellitus, hyperlipidemia, obstructive sleep apnea,

cardiovascular disease, chronic obstruction pulmonary disease, rheumatoid arthritis etc. “Post

Traumatic Stress Disorder is associated with an increased risk of type II diabetes mellitus,”

(Brüne, 2015). Across the lifespan, there is a correlation between PTSD and complex

health complications. Including behaviors that can trigger high risk behaviour regardless of their

consequences. Some high risk behaviors that can be activated as a result of PTSD are substance

abuse, binge-eating, obesity, and improper/unsafe sexual behavior etc. It is therefore imperative

to educate these patients on the importance of safe sex practices, healthy food options and

FAMILY ASSESSMENT AND PSYCHOTHERAPEUTIC APPROACHES 17

exercises. Practitioners and their patients may discuss healthy habits, healthy meals and exercises

with this patient to promote good health and prevent diseases and complications (Sadock, B. J.,

2015).

In ethical implications, confidentiality in practice has always been the strongest

contender. Mental illness has continued to be a source of stigmatization and mockery in our

communities today. It is therefore important to maintain HIPPA laws to the full extent the law

permits. Lastly, the principle of autonomy, justice, beneficence, and nonmaleficence must be

maintained throughout the interaction with the patient and thereafter. Legal and ethical

implications have to be considered during every patient/ provider encounter. Patients and their

families must be given accurate and up to date information, and given the options to either seek

care or decline.

References

“Mother and Daughter: A Cultural Tale.” , directed by Anonymous., Masterswork

Productions, 2003. Alexander Street, https://video.alexanderstreet.com/watch/mother-and-

daughter-a-cultural-tale.

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of

psychiatry (11th ed.). Wolters Kluwer.

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American Psychiatric Association. (2013). In Diagnostic and statistical manual of mental

disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596.dsm05

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Rajan P. (2017). Community physiotherapy or community-based physiotherapy. Health

promotion perspectives, 7(2), 50–51. https://doi.org/10.15171/hpp.2017.10

Patra, B. N., & Sarkar, S. (2018). Adjustment disorder: current diagnostic status. Indian

journal of psychological medicine, 35(1), 4–9. https://doi.org/10.4103/0253-7176.112193

Brüne, M. (2015) Textbook of Evolutionary Psychiatry and Psychosomatic Medicine:

The Origins of Psychopathology. OUP Oxford.

http://www.ptsd.va.gov/professional/treatment/early/acute-stress-disorder.asp

Iribarren, J., Prolo, P., Neagos, N., & Chiappelli, F. (2015). Post-traumatic stress disorder:

evidence-based research for the third millennium. Evidence-based complementary and

alternative medicine : eCAM, 2(4), 503–512. https://doi.org/10.1093/ecam/neh127

Kelley, T., Docherty, S., & Brandon, D. (2016). Information needed to support knowing

the patient. ANS. Advances in nursing science, 36(4), 351–363.

https://doi.org/10.1097/ANS.0000000000000006

International meta-analysis of PTSD genome-wide association studies identifies sex- and

ancestry-specific genetic risk loci. Nievergelt CM, et al. Between 5% and 20% of PTSD risk can

be identified to inherited genes, with heritability higher in women than men. In addition, a gene

previously linked to Parkinson’s disease is also associated with PTSD. Nat Commun. 2019 Oct

8;10(1):4558.