Psychotherapy Genogram for the Family Discussion

Date

Subjective:

CC (chief complaint): P and S present to the session with complaints of disharmony in their household.

HPI: P and S are a mother and daughter from hail from Iran. The duo presents to the clinical setting complaining of disharmony in their household. The biggest problem is the challenge they face when relating to each other. P is the mother, and she complains that her household has been in perpetual disharmony since her child S revealed information about her childhood sexual molestation she experienced from her father while they lived in Iran. This happened before she joined the rest of the family in the United States. Psychotherapy Genogram for the Family Discussion

S, the daughter, has complaints that her mother does not hear her; she curses her out whenever she visits her in her house, considering she is in perpetual physical pain. S complains that her mother’s problem is over-relying on others, and she believes P is still young enough to continue caring for herself. S would like it if her mother stopped relying on her and the rest of her siblings for her happiness. S suggests that her mother finds other things to do that make her happy. In another session, the eldest daughter expresses that she feels like a parent and plays the male’s role in P’s life. She does not wish to continue doing this.

On the other hand, P feels that her children have neglected her, do not want to help her, and fail to understand her. She frequently feels helpless, depressed, and hopeless. She is also in constant pain, which limits her movement.

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Past Psychiatric History:

General Statement: The patients have had previous sessions with their counselor to address their family troubles that indicate difficulties relating to the presence of depression in the mother and detachment from the children.

• Caregivers (if applicable): P’s daughters, S and S, are her principal caregivers. S lives alone and does not have a caregiver.
• Hospitalizations: During her foot surgery, the clinical setting was unknown
• Medication trials: Non-contributory.
• Psychotherapy or Previous Psychiatric Diagnosis: During previous sessions with an Iranian clinician, S was reluctant to attend as she felt the money could be used better instead of therapy. Psychotherapy Genogram for the Family Discussion

Substance Current Use and History: None mentioned.

Family Psychiatric/ Substance Use History: None.

Psychosocial History: The entire family was born in Iran. The mother was in an abusive marriage with an Iranian husband and fled to the United States. She moved to the U.S with four children, leaving one behind. S, who was left behind, joined the family in the U.S about two years ago. She is a single mother. P worked as a caregiver before undergoing surgery. She enjoys visiting malls, shopping, and purchasing varieties of meat for her children. Three of her children have moved out of home, leaving her with her 15- and 21-year-old sons. She also has two dogs that make S uncomfortable during her visits. S was raped by her father in Iran and has undergone domestic violence in her marriage. S is interested in promotional work and is currently pursuing her real estate agent license. There are no legal issues within the family; however, there is a history of violence in the family before the move to the U.S.

Medical History:

• Current Medications: Non-contributory
• Allergies: None mentioned

• Reproductive Hx: P has four children and is 40 years old, suggesting that she is pre-menopausal

Review of Symptoms

• General: Denies weight loss or gain, fever, chills, fatigue, weakness, and night sweats.
• HEENT: Denies otalgia, eye pain, changes in vision, nasal congestion, dental pain, difficulty when swallowing, and sore throat.
• Integumentary: Denies lesions and papules.
• Cardiovascular: Denies palpitations, chest pain, and cyanosis.
• Respiratory: Denies sleep apnea, dyspnoea, stridor, chest pain, and asthma. Psychotherapy Genogram for the Family Discussion
• Neurological: Denies changes in sleeping patterns, syncope, ataxia, numbness, tingling sensation in extremities, and depression.
• Lymphatics: No lymphadenopathy noted
• Endocrinological: Denies night sweats, heat and cold intolerance, thyroid problems, polydipsia, and polyuria.
• Musculoskeletal: Denies joint pain and stiffness, pain in limbs and back.

Mental Status Exam

The two patients have a healthy appearance, appear hygienic and clean, and seem to live a decent lifestyle. Their clothing matches the weather. P is overweight, and S is of average weight with a slender frame. The two patients show no indication of disease or malaise in their appearance. They maintain proper eye contact and are relaxed. It was observed that S moved away from P when she became uncomfortable during the session. Both patients have no gesticulations, fidgeting, akathisias, tics, or tremors. The two also manifest normal speech, fluency, and normal volume of speech. P has an Iranian accent, while S has an American accent. Their flow of thoughts is normal, without neologisms, delusions, and suicidal and homicidal ideations. Psychotherapy Genogram for the Family Discussion

Major Diagnosis

• Major depressive disorder- P may have depression, given her symptoms, such as feeling hopeless, depressed, and helpless. She also indicates irritability as her daughter complains that she is constantly lashing out at them. In most cases, she imagines their actions, leading her to curse them out. This behavior is a hallmark of irritability, common in those with depression. It is also possible that S’s sexual abuse was a trigger that caused P stress, irritability, hopelessness, and depressed mood. Shadrina et al. (2018) argue that these are crucial signs of major depressive disorder (MDD).

Differential Diagnoses:

• Subthreshold PTSD- P may have subthreshold PTSD from her symptoms. According to the DSM V, P meets criterion A for PTSD, which is secondary exposure to trauma. S, her daughter, was sexually abused, which was traumatic to P, the mother. P also manifests another symptom: hypervigilance and irritability (Fink et al., 2018). These symptoms meet criterion E for subthreshold PTSD. P is constantly micromanaging her children to the extent of choosing their partners. However, she does not meet the criteria for a full PTSD diagnosis, as she lacks other pertinent symptoms such as nightmares, palpitations, difficulty sleeping, and negative thoughts about life and the world.
• Bipolar disorder- A possible diagnosis would be bipolar disorder given the depressive mood that P exhibits. She also exhibits irritability, agitation by cursing her children out. However, critical symptoms of bipolar disorder are missing that would confirm the diagnosis; they include manic episodes, hyperactivity, hypersexuality, suicidal ideation, delusional thought, and false belief of superiority, among others.

• Anxiety- There is the possibility that P meets the criteria for generalized anxiety disorder, given her excessive and persistent worrying that leads her to choose partners for the children. She also has an extreme need to micromanage her children and their lives. Her daughter, S, complains that P is consistently frustrated and is never calm. However, to rule out this disorder, P lacks other important identifying symptoms of anxiety: somatic manifestations such as palpitations, sweating, fatigue, and trembling. She also does not have this incessant feeling of impending danger, which is the hallmark of anxiety disorders (Gautam et al., 2017). Psychotherapy Genogram for the Family Discussion

Reflections

            From this case, it is clear that the family is experiencing difficulties adjusting to a new American lifestyle, which is a starkly different culture from Middle Eastern cultures. P demonstrates signs of depression and subthreshold PTSD, which precipitate additional difficulties in adjusting to life in the U.S. It is likely that learning about her child’s sexual abuse and her domestic violence history with her husband have traumatized her; and precipitated psychological challenges that present with symptoms such as hypervigilance, helplessness, hopelessness, and sadness. Finding new hobbies while seeking psychotherapeutic assistance should help P adjust to a new life where she develops self-reliance and addresses her trauma with the counselor. Being self-reliant will likely reduce the disharmony in her family, as she will probably be less frustrated, curse her children out, and micromanage them. Psychotherapy Genogram for the Family Discussion

Case Formulation and Treatment Plan:

• Continue P and S with family therapy sessions. The sessions are important avenues upon which the clients can air their concerns, express their emotions, and acquire important skills to cope with their emotional difficulties. For instance, through the sessions, P will learn about her dependence on her children, her depressed state, its cause, and how to cope healthily. S will also learn, through psychotherapy, to address the psychological trauma associated with the sexual abuse by her father, understand her mother’s emotional dysfunction, and remain objective about it through their healing process.
• Advise P to consider exploring new interests and hobbies, which will give her a fuller lie and help her redirect the focus from her children to her life. P needs to turn her energies to herself and find meaning in her life. New interests and hobbies would be healing for P, as she would learn important techniques such as mindfulness and develop self-reliance. Psychotherapy Genogram for the Family Discussi
• References

Fink, D. S., Gradus, J. L., Keyes, K. M., Calabrese, J. R., Liberzon, I., Tamburrino, M. B., Cohen, G. H., Sampson, L., & Galea, S. (2018). Subthreshold PTSD and PTSD in a prospective-longitudinal cohort of military personnel: Potential targets for preventive interventions. Depression and anxiety, 35(11), 1048–1055. https://doi.org/10.1002/da.22819

Gautam, S., Jain, A., Gautam, M., Vahia, V. N., & Gautam, A. (2017). Clinical Practice Guidelines for the Management of Generalised Anxiety Disorder (GAD) and Panic Disorder (PD). Indian Journal of Psychiatry, 59(Suppl 1), S67–S73.https://doi.org/10.4103/0019-5545.196975

Shadrina, M., Bondarenko, E. A., & Slominsky, P. A. (2018). Genetics Factors in Major

Depression Disease. Frontiers in psychiatry, 9, 334.