The British Journal of Psychiatry (2003) 182: s62-S66
© 2003 The Royal College of Psychiatrists
IGDA. 11: Illustrative clinical case
IGDA WORKGROUP, WPA
 |
DEMOGRAPHIC IDENTIFICATION, SOURCES OF INFORMATION AND REASONS FOR
EVALUATION
|
|---|
Ms Y is a 28-year-old monolingual Spanish-speaking woman of Mexican origin
living for 2 years in the USA and married to a Mexican man self-employed in
the construction business. She presents for care to the emergency room
accompanied by a female friend, complaining of ‘nervios’,
feeling guilty for not being able to perform her duties as a wife, and
concerned that there may be some type of imbalance in her body. The
interviewer is a female psychiatrist, born in South America and trained in the
USA.
|
|
HISTORY OF PSYCHIATRIC AND GENERAL MEDICAL ILLNESS
|
|---|
Ms Y reports that she has been having ‘nervios’ for
the past few months. She describes this condition as feeling desperate,
‘like having a knot in my throat’. Upon further questioning, she
acknowledges feeling sad for the past 6 months. She attributes her sadness to
feelings of loneliness. Additionally, she acknowledges frequent crying,
usually in relation to remembering her family in Mexico. She has been
experiencing insomnia and decreased appetite, with a 5-kg weight loss. Her
energy has decreased, and she has to make an effort to complete her daily
routine, which includes doing all the household chores. She verbalises some
anger towards her husband for expecting her to have a full meal prepared by
the time he gets home. At the same time, she is proud to explain that she
makes her own masa for her tortillas. She denies having had homicidal
or suicidal thoughts. She has also complained of headaches, occasional
palpitations and generalised muscle aches for the past 2 weeks. These symptoms
occur throughout the day and are usually relieved by rest and non-prescription
non-steroidal anti-inflammatory agents. She denies having had any
manifestations of psychotic disturbances, alcohol or drug use. She has been
taking oral contraceptive medication for 2 years.
|
|
FAMILY, DEVELOPMENTAL AND SOCIAL HISTORY
|
|---|
Ms Y was born in a small town in Mexico. She was the eldest and only girl
in a sibship of three. Her father left the family when she was 6 years old and
her mother took them to live with grandparents. She has not had any contact
with her father since then. Her brothers and mother still live in Mexico. She
reports good memories from her childhood and that her grandparents were very
supportive.
She grew up in a lower middle-class neighbourhood and was raised as a
Catholic, attending church every Sunday with her family. Her mother had to
work hard in order to support all the children and was therefore often absent
from home, but devoted all her available time to her children.
Ms Y completed high school and then went to work as a secretary for a large
company in town. She assumed increasing responsibilities within the company
and achieved the position of supervisor for a whole floor. She stayed with the
company for a total of 6 years.
Ms Y met her husband through her job while he was doing business with her
company. They dated for 2 years and finally decided to marry when the company
went bankrupt after the devaluation of the Mexican peso in 1994. Her family
approved of the marriage, following which the couple moved to the USA.
Ms Y lives with her husband in a rented house. Her husband is self-employed
and works in the construction business. She describes her husband as
hard-working and very ‘traditional’ in his views of marriage, and
denies any type of abuse from him. She states that she is happy with her
marriage although she recognises that they have some problems. She feels that
marriage is forever, and that she needs to work on making it better. She is
taking oral contraception but has been discussing with her husband the
possibility of having children. They are currently saving all the money they
can to buy a house.
Ms Y has been working as a maid for a family for the past year and she
enjoys her job, stating that her employer is very supportive and encourages
her to learn English. However, she has been unable to attend any classes
‘because of lack of time’. She keeps contact with her family in
Mexico, but has not made them aware of her job situation because she is
concerned that they would be upset if they knew that she was working as a
maid. She misses her family, particularly because they were very close to each
other, and remembers fondly getting together every Sunday.
Her current social relations are limited (restricted to the friend who
accompanied her to the emergency room), owing to her inability to drive. She
does not have a driver's licence because her permit to stay in the USA has
expired and she is afraid of detection by the immigration service. Her husband
is a legal resident in the USA and she wants him to volunteer to take the
steps to make her stay legal. He has not offered to do this so far, and she
has not explicitly requested it because she does not want him to think that
all she wants is a ‘green card’. They have no health
insurance.
|
|
SYMPTOMS AND MENTAL STATE EVALUATION
|
|---|
Ms Y is a young-looking and attractive Mexican woman who wears a long,
simple dress. She has no make-up on and her hair is combed in a ponytail. She
is pleasant in her interactions, initially inhibited but becoming more
talkative as the interview progresses.
Her speech is spontaneous and somewhat slow. Her thought processes are
coherent, logical and goal-directed. There is no evidence of hallucinations,
delusions, flight-of-ideas or loose associations.
Her mood is moderately depressed and she expresses multiple worries. She
does not voice any homicidal or suicidal ideation. She moves her hands
nervously.
She is alert and oriented to place and time. Her concentration and memory
are somewhat impaired. Her intellectual functioning is in the average range as
suggested by the vocabulary she uses. Her judgement and insight on having
clinical problems are good.
|
|
PHYSICAL EXAMINATION
|
|---|
The results of this examination appear to be within normal limits, except
that the patient looks pale, and her skin is cold and dry.
|
|
SUPPLEMENTARY ASSESSMENTS
|
|---|
The patient's blood cell count shows mild microcytic anaemia. Iron studies
show that the level of serum ferritin is decreased, the iron-binding capacity
of the serum is increased, and total iron concentration is decreased.
Thyroid-stimulating hormone concentration is mildly elevated.
|
|
DIAGNOSIS AND TREATMENT
|
|---|
The diagnostic formulations and treatment plan for Ms Y are given in
Appendices 1-3.
This article has been cited by other articles:
|
|
|
|
 
IGDA. Introduction
The British Journal of Psychiatry,
May 1, 2003;
182
(45):
s37 - s39.
[Full Text]
[PDF]
|
|
|
|
|
|
|
IGDA. 7: Standardised multi-axial diagnostic formulation
The British Journal of Psychiatry,
May 1, 2003;
182
(45):
s52 - s54.
[Full Text]
[PDF]
|
|
|
TOP
DEMOGRAPHIC IDENTIFICATION,...
HISTORY OF PSYCHIATRIC AND...
