Introduction
Mrs. Alana Abidi, is a 24-year-old married Pakistani-American female client who was referred for further evaluation and possible psychotherapy from her current PCP-OB. She is currently 8 months pregnant with her first child. She identifies as Muslim and notes that she observes her religion and culture.
Chief Complaint: Client presents with recent trouble concentrating and feeling down with some excessive worry increasing over the last few weeks.
Vitals:
- Height: 62”
- Weight: 157lbs
- BP: 128/68
- P: 72
- R: 18
- O2 sat: 98%
- Pain: 0 on a 0-10 scale
Interview Findings:
Her dress, appearance and behavior appear to be culturally appropriate. At the initial interview she speaks willingly about her current issues and feelings. The client believes that she is suffering from psychiatric mental illness. The client complains of and states the following: lack of concentration, lack of self-confidence, and indecisiveness. She also complains of depressed mood, feelings of guilt, lack of pleasure, anger and hopelessness with recent increase in worry, anxiety and panic. She feels irritability and fear constantly. She avoids social gatherings with friends and sometimes she states that cries without reason. The client complains of headaches, and palpitations upon waking with worry about her upcoming birth and worry about her marriage relationship changing. She also complains that family members usually irritate her especially her eldest brother. She is motivated and interested to work collaboratively with therapist .
History
Exploration of history reveals that the client grew up in a middle-class family in a rural area of Pakistan with three brothers and three sisters. She is number 6 in birth order. Her father is now 63 years old and he owns and operates a small tailor business. Her mother is 45 years old who has been a stay-at-home mom and “housewife”. She expressed that during her childhood the relationship between her parents was not and is not good still. Her oldest brother maintains everything for the family; finance control, health care decisions, etc... Throughout her childhood, her oldest brother was very dominating over her and her siblings as well. She had to abide by his suggestions for her daily activities. Though she was a straight A student she was always ridiculed and underestimated instead of being encouraged. Her older brothers always used to apply pressure on her for increasing her studies. They were not happy with the results she obtained and therefore her parents were not pleased. She recalled that during any bad occurrence in her family if she protested or even posed questions, she had been termed as “disobedient”.
Coping Strategies
She states that she likes reading and listening to music. She recalls these have always been outlets for her feelings, but she was discouraged from either activity by her oldest brother when she was younger. She notes that she was physically tortured several times for listening to music as a teenager when her oldest brother did not approve.
Additional Trauma History
During discussion of past traumas, she disclosed that she was sexually abused several times. When she was in “class seven” her cousin tried to sexually abuse her with a group of his friends. During college, she was called home when her father was in a car accident. Her uncle was sent to pick her up and he tried to abuse her before taking her home. She recalls fighting him and he stopped but threatened her to stay silent. She felt she could not tell her family of these events for fear of receiving disbelief from them and possibly being sent away.
Current Situation
She is recently married and expecting her first child. She reports her husband is patient and caring and understands her past as a block in their relationship. She reports being hopeful for the future and wants a better life for her children. She currently works as an assistant advocate at the local college in the cultural and community center helping minority women navigate the college experience. She does worry that her marriage may turn into one like her parents after her child is born and more household stresses are a part of daily life.
History of Present Illness
Onset: 8 weeks ago with increasing symptoms of worry, trouble concentrating and depression over last 3 weeks
Location: distracted at work and at home
Duration: worries most of day, feels down “more days than not”, trouble concentrating at work, Depression and Anxiety diagnosed at PCP 2 weeks ago.
Characteristics: Mrs. Abidi reports that she has been experiencing excessive worry about relationship, upcoming birth of child, family relationships, trouble concentrating on work, crying more frequently “with no apparent cause”. She currently sees a PCP-OB provider who diagnosed her with depression and anxiety at her last visit 2 weeks ago with an onset related to the perinatal period. However, she notes she has struggled with “getting over her past” for some time. She has difficulty falling asleep and staying asleep as she wakes most nights in middle of the night 9some due to increased urination frequency with pregnancy, some due to worry). Her appetite is “the same” but she has a great deal of trouble concentrating on tasks and has an increase in poor memory throughout the day. “I just keep forgetting what I am doing in the middle of thing. I forgot to turn the water off in the sink when I was cooking and filled the pot.”
Aggravating: talking to family; older brother, parents, worrying about birth of child, after conversations about future with husband
Relieving: reading a book in bed, walks with husband in evening after dinner
Timing: symptoms occurring daily, symptoms present more often at night before bed and in mornings upon waking
Severity: “it’s not terrible, I just feel like I am not myself and that I am bring drawn back to my past”
Psychiatric Review of Systems:
Mood: “just ok” “worried and sad at times then anxious” Admits to low mood at time. Denies suicidal or homicidal ideations.
Sleep: Admits insomnia, difficulty falling asleep, some middle-night awakening, and disruption of 24-hour sleep cycle. Does report “wanting to sleep much more” and “low energy in the morning”.
Feelings of: Denies feelings of hopelessness, helplessness, hostility, low self-esteem, guilt or shame.
Interests: Admits loss of interest or pleasure in activities, or social isolation however, notes she wants to stay safe during the Covid-19 pandemic since she is pregnant. “I choose not to attend activities to stay safe but I also have no motivation to stay in touch with friends right now.
Energy: Denies: increased energy, but does occasionally feel fatigued
Concentration: Has noticed that she has some difficulty concentrating; stopped watching TV and is very forgetful at times.
Appetite: Denies: increased or decreased appetite.
Self-Harm/Suicide Risk: Denies: self-inflicted injuries, no frequent thoughts of death, lack of desire to continue living, suicidal tendency
Homicidal thoughts: Denies homicidal thoughts
Other Mania Symptoms: Denies: pressured speech, impulsive behavior, feelings of grandeur, inflated self-esteem; not easily distracted
Other Anxiety Symptoms: Denies: racing thoughts, phobia, obsessive-compulsive behavior, school/work absenteeism due to anxiety. Does note some panic feelings in Am and before bedtime and some thoughts of general worry about baby and marriage.
Psychosis: Denies: delusions, hallucinations, feelings of persecution, hearing sounds which seem to be voices, preoccupation with religion
Eating Disordered Behavior: Denies: disordered eating, excessive diet restriction, secretive binges, inability to limit intake of foods followed by purging, excessive exercising, use of laxatives for weight control
Attention and Behavior: Denies: lack of organization, lack of goal-direction, hyperactive behavior, over activity, impulsive behavior, vandalism, setting fires, initiation of fights, running away, aggression towards parent(s), torturing animals, verbal disruptions, oppositional behavior, discipline problems, yelling, bullying, use of foul language.
Does note stopping some activities in middle to rest and forgetting to go back to them (like cleaning out fridge, or prepping dinner)
Precipitating Factors: Denies: family problems, poor school/work performance, recent separation, job loss, legal problems; not under stress other than worrying about increased anxiety and feeling overall worse
Histories:
Past Medical History:
Chicken pox age 7
Past Surgical History:
Denies
Psychiatric History:
Diagnosis(es): recent diagnosis (2 weeks ago by PCP-OB) MDD, GAD
Treatments: Medications only
Medications: Zoloft 50mg PO QD
Previous Medication Trials: none
Therapy: referred to CBT by PCP-OB 2 weeks ago
Previous Therapy Trials: none
Outcomes: N/A
Developmental History:
Developmental delays? none
How were they managed? N/A (pronounced not applicable)
What therapies were used, and did they help? N/A
Social history
Mrs. Abidi is the 6th child born to biological parents who raised her in Pakistan. Completed HS and college (social work degree). Came to the US as teenager at age of 14. Received Green Card and then became a US citizen 6 years ago. Recently married 2 years ago. No history of alcohol or drug use., 8 months pregnant currently with first child.
Family history:
Father: 63 alive, HTN
Mother: 45 alive, HTN
Paternal and maternal grandmother: DMII, HTN
Maternal Aunts (2): unknown
Paternal Uncles (3): unknown
Older Brother 1: alive, no known health issues
Older Brother 2: alive, no known health issues
Younger Brother 1: alive, no known health issues
Older Sister 1: alive, endometriosis, anxiety, depression
Older Sister 2: alive, no known health issues
Preventive health care: Last Gyn exam and PAP – normal 3 year ago. Last PCP-OB visit – 2 weeks ago. OB-Maternity care up to date.
Medications and Allergies:
Medications:
PNV, Zoloft 50mg PO QD (started 2 weeks ago)
Allergies:
Medications: Sulfa (rash)
Food: none known
Environmental: none known
Immunizations & travel:
Last immunization: Flu vaccine, 1 year ago, recent Covid vaccines (2)
No recent travel outside of US within last 2 years
Mental Status Exam:
General: A&Ox3 Appropriate dress and neat appearance. No spontaneous speech, but answers questions when asked.
Behavior: No: noted hypervigilence, heightened startle reflex, abnormal mannerisms, uncommunicative/disinterested/hostile/inattentive attitude
Movement: No: tremor or tics; normal gait and stance; no involuntary movements;
Speech: No: refusal to speak, loosening of association on word salad; not slowed, rapid, difficult; normal rhythm of speech, speech tone, speech volume
Mood: Does not appear: anxious, dysphoric, euphoric, elevated, expansive, irritable, angry at visit
Affect: Full-ranging, Not: blunted, constricted, flat, incongruent with mood, inappropriate, labile, sad, tearful
Language: No: language abnormalities; speech fluent; no dysphonia; no stuttering; language fluent and intact for naming, normal sentence structure.
Cognition: Patient oriented x 3, No: disorientation, short term memory impairment, reduced abstraction ability, diminished cognitive functioning
Thought Process: No: deficiency on evaluation of connectedness, organized
Thought Content: No: thought content impairment; no suicidal ideation, homicidal ideations, paranoid ideations, poverty of thought, thought insertions, obsessions, irrational fears, delusions, hallucinations
Insight and Judgment: No: impaired insight, impaired judgment, poor problem solving
Consider what psychotherapy plan you would develop for this client. Incorporate additional therapy modalities with CBT if you feel they are valid in this case.
In your psychotherapy plan you will include the following:
- Differentials: List your diagnosis for the client
- Develop a plan of care for each diagnosis including the following:
- What additional subjective and objective data would you obtain?
- Diagnostic testing/screening tool/instrument you would use
- Non- Pharmacologic interventions, including modality, and frequency
- Education, including health promotion, maintenance, and psychosocial needs
- Safety Plan
- Referrals required
- Follow-up, including return to clinic (RTC) in what time frame and reason.
- Psychotherapy plan: objectives, interventions, long-term goals and short-term goals
