NRNP 6635: Comprehensive Psychiatric Evaluation

Subjective: This paper examines the case of a middle-aged female patient experiencing various problems. Firstly, she was involved in a deadly shooting that left her disabled and unemployed. Although her former employer compensated her for terminating their contract, all the funds paid for multiple surgeries she underwent after the incident. As a single mother of three and the family’s sole breadwinner, the patient has lost hope, feels unable to carry on with her current situation, and thinks she has lost control of her life and family.

CC (chief complaint): According to the client, her life took a tragic turn when she was attacked by several masked gunmen one morning on her way to work. After surviving the ordeal, she could not believe that she would remain disabled for the rest of her life. Much worse, she felt betrayed when her former employer dismissed her instead of giving her a less demanding position. Since the incident, the patient has become hopeless and lives in extreme uncertainty over her life and family.

HPI: The patient mentioned that she was abused and brutalized by her former husband and the father of her children. When she reported the matter to the police and moved out to start a new life with the children, she received several death threats from her husband but took the issue lightly. However, later, she learned that the attack was retaliation for standing up against abuse. Due to her current situation, the patient has lost hope, avoids people, and sees no need to reorganize her life.

Past Psychiatric History:

• General Statement: The patient often feels hopeless, purposeless, and helpless because she is not in a position to take care of and protect her family due to her disability. During such periods, she feels increasingly sad and contemplates suicide.
• Caregivers (if applicable): Single parent of three children.
• Hospitalizations: The patient was hospitalized and underwent several major surgeries that left her disabled.
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis: The patient has never undergone a psychiatric diagnosis or psychotherapy.

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

Family Psychiatric/Substance Use History: Although her former husband was abusive, the patient’s family does not have a psychiatric substance use history.

Psychosocial History: The patient has undergone many adverse experiences in her life. Her former marriage was abusive, and the attempt on her life has shattered her family’s prospects of peace, success, and prosperity. The patient has lost hope and worries about her children’s lives and future.

Medical History:

• Current Medications: None
• Allergies: None
• Reproductive Hx: The patient has a considerable reproductive history since she is a parent.

Objective:

Physical examination: Considering the patient’s complaint, a physical exam WNL was recommended. The test consisted of a series of questions and a neurological exam.

Diagnostic results: The physical examination yielded no considerable outcomes. However, the neurological examination findings suggested that the patient had suffered Traumatic Brain Injury (TBI). These findings were obtained using the Glasgow Coma Scale, which is widely used in examining trauma-related brain injury (Clark et al., 2021). As per the scale, the patient scored 5 out of 15, indicating that she possibly had TBI.

Assessment:

Mental Status Examination: The client was alert and had a relatively good memory, although she was not well-groomed. Again, she answered all the questions as required and was willing to participate in the sessions. Notwithstanding, the client showed signs of hopelessness, fear, and despair. For instance, she often questioned the relevance of our interactions and doubted whether she would recover from her physical and psychological situation.

Differential Diagnoses:

• Major depression

According to Bentely et al. (2014), major depression denotes an illness in which patients persistently feel sad, hopeless, and experience mood changes. As time passes, the negative feelings interfere with the patient’s physical and psychological well-being, resulting in a deep sense of worthlessness. According to the DSM-5 manual, major depression symptoms include irritability over petty matters, self-blame, distorted thinking, tiredness, lack of enthusiasm for activities, restlessness, and unexplainable physical illnesses like joint pains and backache (2013). Major depression manifests as irritability, suicidal ideation, and personality changes in adults. Although no organic causes cause major depression, extensive studies point out that major depression stems from environmental factors like physical abuse and genetic causes like biological variations (Otte et al., 2016). The risk factors that trigger major depression include traumatic incidents, history of depression and other mental illnesses, alcohol and substance use, low self-esteem, chronic illnesses, and specific medications. As Otte et al. (2016) pointed out, major depression is more prevalent among women due to their biological vulnerability. Considering the client’s case, I selected major depression as one of the differential diagnoses because she exhibited most of the symptoms highlighted in the DSM-5 manual.

• Persistent depressive disorder

Persistent depressive disorder refers to a less severe but long-term type of depression. Patients experience sadness, develop negative self-perception and inadequacy, lose interest in activities and feel hopeless. Like major depression, such feelings eventually interfere with the patient’s functioning, relationships, and physical health. According to Melrose (2019), Dysythamia leads to fatigue, low self-esteem, pessimistic self-perception, indecisiveness, reduced appetite, and guilt. As per the DSM-5 criteria, Dysythamia diagnosis involves physical examinations, laboratory tests, and psychological evaluation (2013). Like other mood disorders, persistent depressive disorder stems from genetic and environmental causes like traumatic life events and inherited traits. The risk factors linked to Dysythamia include family history, traumatic or stressful incidences, personality attributes, and other mental disorders (Schramm et al., 2020). In this patient’s case, I selected Dysythamia as a differential diagnosis because she persistently felt sad and hopeless.

• Depression due to another medical condition

Depression due to another medical condition is an illness marked by prolonged feelings of sadness and loss of interest in activities due to the effects of another medical issue (Cosci et al., 2015). Like other mood disorders, the primary cause of DDDAMC remains unknown. However, specific illnesses like viral infections, cancer, heart attacks, and neurological disorders are linked to the condition. As per the DSM-5 criteria, the most prominent symptoms of DDDAMC include extended periods of sadness and depressed moods and reduced interest in activities. Other indicators include laboratory findings linking the depression to other medical conditions, lack of any other psychological disorder which explains the illness, and interference with physical and mental functioning (2013). The risk factors associated with DDDAMC include chronic diseases and traumatic brain injury. I selected DDDAMC as a differential diagnosis in this patient’s case because the patient had not experienced depression before the attack, which potentially triggered the condition.

Reflections:

Individual therapy is more practical in dealing with intricate issues. In this case, the client faced numerous problems requiring keen attention to create meaningful solutions. Regardless of her resigned personality, I was amazed that she was willing to participate in the sessions and air out her predicaments. Even though she had lost hope and doubted the effectiveness of the treatment process, I admired her for standing firm for her family despite facing severe challenges like domestic abuse and the attempt on her life. Since she is vulnerable to self-pity and hopelessness, it would be more helpful also to employ family therapy to feel supported, loved, appreciated, and protected.

References

Bentley, S. M., Pagalilauan, G. L., & Simpson, S. A. (2014). Major depression. Medical Clinics, 98(5), 981-1005.

Clark, A., Das, J. M., & Mesfin, F. B. (2021). Trauma neurological exam. StatPearls

Cosci F, Fava G, A, Sonino. (2015). Mood and Anxiety Disorders as Early Manifestations of Medical Illness: A Systematic Review. Psychother Psychosom.

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

Melrose, S. (2019). Persistent depressive disorder or dysthymia: An overview of assessment and treatment approaches. Sherri Melrose Publications: A Virtual Memory Box.

Otte, C., Gold, S. M., Penninx, B. W., Pariante, C. M., Etkin, A., Fava, M., … & Schatzberg, A. F. (2016). Major depressive disorder. Nature reviews Disease primers, 2(1), 1-20.

Schramm, E., Klein, D. N., Elsaesser, M., Furukawa, T. A., & Domschke, K. (2020). Review of dysthymia and persistent depressive disorder: history, correlates, and clinical implications. The Lancet Psychiatry, 7(9), 801-812.