NRNP 6635: Psychopathology and Diagnostic Reasoning

Subjective

This paper examines the case of a single-parent immigrant family facing several challenges. Firstly, a larger part of the family relocated from Iran to the United States for treatment, leaving behind one sibling her parent later abused. Moreover, the mother (the family’s sole breadwinner) is disabled, unemployed, and highly dependent on her children. Lastly, some of her children feel that their mother is increasingly dependent and does not allow them to live their lives and do as they please.

CC (chief complaint): The client stated that the family lived in peace until the child left Iran and arrived in the United States. Although they initially celebrated and related well, trouble began when she revealed that she was mistreated and raped by her father when the family left her behind in their home country. Since the revelation, the family has had constant fights and arguments. Again, the mother complained that the children had become somehow insensitive to her suffering, although she would want them to spend time and care for her since she is disabled and in constant pain. The children think their mother expects too much, interfering with their personal lives and ambitions.

HPI:  The parent revealed that she was also brutalized and abused by her husband back at home. During such episodes, she would persevere violence and humiliation to protect her children. When the parent learned that one of her children was raped by her spouse, she confronted him, but he denied it vehemently. Regardless, she moved on and accepted that she was helpless. Since she became disabled, the parent has become hopeless and increasingly dependent on her children to the extent she chooses friends and partners for her daughters. With time, the children have grown wary of such behaviour and would like their mother to relax and give them time to grow and explore their dreams.

Past Psychiatric History:

• General Statement: The parent stated that she felt lonely and hopeless most of the time. She wishes the children could visit her during such periods, spend time with her, and assist her because of her condition. Since the children are young and often busy with work or school, they cannot meet most of their parent’s demands. This situation creates a conflict between them all the time.
• Caregivers: Single parent of five.
• Hospitalizations: The parent was hospitalized and underwent surgery. The surgery failed, and she is currently disabled.
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis: The family had briefly undergone psychotherapy. However, no member has ever experienced a psychiatric diagnosis.

Substance Current Use and History: The family does not have a substance use history.

Family Psychiatric/Substance Use History: the family does not have a psychiatric/substance use history, although one of the spouses was abusive.

Psychosocial History:  The clients have undergone adverse events involving physical, verbal, and sexual abuse. Besides, they have lived in poverty for many years. Their challenges have created a rift in the family, with each party striving to fulfil their physical and psychological needs.

Medical History:

• Current Medications: None
• Allergies: One of the clients stated that she dislikes dogs.
• Reproductive Hx: Other clients besides the parent do not have a considerable reproductive history.

Objective:

Physical examination: Considering the nature of the complaint, a physical exam was ruled out. Nevertheless, the clients answered some questions to establish organic conditions, often mistaken for a mental illness.

Diagnostic results: The clients’ answers indicated needing a mental status examination to establish the problem.

Assessment:

Mental Status Examination: The clients appeared well-groomed, normal, with good memory and straightforward speech. Besides, they seemed willing and prepared to participate in the session and answered all the questions well and as required. Nevertheless, the clients seemed obstinate and failed to agree with one another on restoring their relationship.

Differential Diagnoses:

• Major depressive disorder

Major depressive disorder describes a mental illness in which patients experience extreme sadness, hopelessness, and mood changes for an extended period (Ote et al., 2016). Over time, such feelings adversely affect physical, emotional, and psychological wellness. In this way, patients experience both physical and mental turmoil, creating intense feelings of worthlessness. According to the DSM-5 criteria, the most common symptoms linked to depression include persistent feelings of hopelessness, irritability over trivial issues, guilt and self-blame over past events, troubled/ distorted thinking, extreme fatigue and lack of energy to accomplish minor tasks, and inexplicable physical complications including back and joint pains (2013). In older adults, depression manifests as personality changes, increased desire to stay at home, and suicidal ideation. Like other mental illnesses, there is no established cause of the major depressive disorder. However, a broad range of genetic and environmental causes are linked to depression (Kupfer et al., 2012). Such factors include biological differences, brain chemistry, family history, and hormonal changes. The risk factors linked to major depressive disorder include substance use, other psychological conditions, low/negative self-perception, family history, and chronic illnesses. Based on the client’s case, I selected depression as one of the differential diagnoses since she expressed intense and persistent sad feelings and loneliness.

(ii) Dependent Personality Disorder

According to Disney (2013), Dependent Personality Disorder (DPD) refers to a personality disorder in which patients experience an overwhelming need to be cared for by others. DPD patients loathe being left alone and exceedingly rely on other people for physical and psychological support in this state. This condition renders DPD patients clingy, needy, and helpless since they do not believe in the ability to take care of themselves. According to the DSM-5 criteria, a patient is diagnosed with DPD if they are indecisive and rely on others to make decisions, experience difficulties being alone, lack self-confidence, avoid personal responsibilities, and feel hopelessness stemming from abandonment (2013). The most significant causes linked to DPD include anxiety and other mental illnesses, abusive relations, family history, cultural/religious traditions, and childhood trauma. DPD patients can develop depression and other severe mental conditions (Simonelli & Parolin, 2017). I selected DPD as a differential diagnosis because one of the clients could not bear staying alone and insisted on having others around her most of the time.

• Narcissistic Personality Disorder

Narcissistic personality disorder describes a personality disorder in which a person develops an exceeding sense of self-importance, lacks empathy or consideration for other people’s feelings and desires admiration (Yakeley, 2018). The DSM-5 criteria identify various symptoms linked to Narcissistic personality behaviour, including a sense of entitlement, preoccupation with fantasies about riches, money, and success, arrogant behavior, inability to consider other people’s needs, and excessive self-importance (2013). Due to such symptoms, people with NPD cannot contain their emotions, become impatient, and are easily offended. NPD stems from environmental, neurological, and genetic factors like other mental illnesses.

Reflections:

Family issues intersecting with mental health require broader perspectives found in family therapy. In such cases, family therapy is the most suitable approach to enhancing communication and resolving differences between family members. Although it is ideal for all members, it is most practical when those involved are willing to participate. The family examined in this paper faces several challenges, most initially seeming to stem from a particular member. Nevertheless, throughout the session, it became clear that most problems were linked to unresolved issues and traumatic experiences that often triggered arguments and conflict in the family. Such cases include domestic violence, parental separation, and child abuse. In such a scenario, family therapy helps the family members learn how to express themselves, resolve their differences, discover their strengths and weaknesses, support one another, and play their respective roles. Since resolving family issues is complex, family therapy should involve the family therapist and other resource persons to provide the best ways of treatment.

Reference

Disney, K. L. (2013). Dependent personality disorder: a critical review. Clinical Psychology Review, 33(8), 1184-1196.

Edition, F. (2013). Diagnostic and statistical manual of mental disorders. Am Psychiatric Assoc, 21.

Kupfer, D. J., Frank, E., & Phillips, M. L. (2012). Major depressive disorder: new clinical, neurobiological, and treatment perspectives. The Lancet, 379(9820), 1045-1055.

Simonelli, A., & Parolin, M. (2017). Dependent personality disorder. Encyclopedia of personality and individual differences [Internet]. Cham: Springer.

Simonelli, A., & Parolin, M. (2017). Dependent personality disorder. Encyclopedia of personality and individual differences [Internet]. Cham: Springer.

Yakeley, J. (2018). Current understanding of narcissism and narcissistic personality disorder. BJPsych advances, 24(5), 305-315.

Yakeley, J. (2018). Current understanding of narcissism and narcissistic personality disorder. BJPsych advances, 24(5), 305-315