INTEGRATIVE REPORT
Name: Mrs. A.
Date of Birth: 39/03/1990Age: 29 years 6 months
Interview Date: 1st October 2019
REASON FOR REFERRAL:
Mrs. A. reported that she was suggested to seek help by her family physician after she found that there were bruises on left arm which indicated a possibility of domestic violence. The client reported that she was mistreated by her husband and the marks were linked to that. On suggestion of her general physician she approached for assessment.
IDENTIFYING INFORMATION:
Mrs. A. is twenty nine years and six months old married woman who happens to be a homemaker.
She identified herself as a Muslim (Shi’ite sect) belonging to a Punjabi family. She can fluently speak Punjabi, Urdu and English. She lives in a bungalow situated in a posh locality of Islamabad with her husband who she said has a thriving family business of logistics and her husband belongs to an upper middle class family. The interview was conducted after she personally approached the private clinic on suggestion of her family physician.
She said that her physician suggested her to consult a psychologist and had presented her with two or three options when she asked where she should go. She chose the option herself.
PRESENTING PROBLEM:
The client reported that she is experiencing domestic abuse, she said, I get beaten up and my husband spares no chance to belittle me. When asked further to elaborate what she meant by belittling she said that she gets to listen negative remarks on her appearance and personality. She also mentioned that she has been married for six years now and right from the beginning her husband used to violate boundaries (engaged in domestic violence). According to her, he used to slap me but now sometimes when he is angry he pulls my hair. She used the word ‘jalal’ to describe his anger saying that wo kehta hai meray khandan main sab ko jalal ata hai. She also went on to add that she is afraid of his anger, her verbatim was mujhay bohat dar lagta hai kion k wo pehlay aisay bhi nahi , ab bohat ziada barh gai hai ye cheez Client reported that she was experiencing elevated heart beat so she was taken to her family physician by her cousin. The physician saw bruises on her arm during measurement of blood pressure and asked her about those bruises. Initially she denied violence and told the physician that those were random injuries but after a while she says when the doctor insisted she told her that meray shohar ne meray baazo pakra tha zor se is liay hua hoga. She narrates that the physician then asked her to consult a psychologist and presented her with three or two options when she asked where she should go. According to her she knows that her circumstances are affecting her life and there are issues that need to be addressed.
Since there was no direct referral it cannot be stated how her family physician viewed her issues.
HISTORY OF PRESENT ILLNESS:
It is reported by that client that she gets mistreated and physically abused by her husband, she says to cope up with that she has been consuming Lexotan (Bromazepam) from past four months. She was introduced to it by a friend and initially she took one pill (of 1.5 mg) daily but now she takes two and a half pills (3.75mg). According to her she feels drowsy and all day she rests on the couch. It is also reported that she feels tired most of the time. She reports that hath uthana is a thing in practice on part of her husband ever since they got married however, over the time it has become more frequent such that now he does it on daily basis. She has shared this with her mother who then shared it with her father but although her mother now insists that she should go for a separation from her husband her father doesnt want her to. Her father insists that she should let things be. According to her she is confused about leaving her husband since she still loves him and feels that he will start treating her well someday. She reported that her use of Lexotan is linked to the fact that when her husband turned more aggressive she used those pills to cope up with that. She switched from one pill in evening to two and a half tablets. Presently, she thinks that her husband abuses her verbally and physically but will not kill her as she believes that after all both of them love each other. She blames business struggles as a factor contributing to his husbands recent bouts of anger which are more intense than his previous bouts of anger. She reports that she takes tablets only to feel better and is not experiencing sleep issues. When asked to elaborate if she craves those tablets, she denied that altogether. Other than that there is no history of substance use. There is no history of suicidal ideation.She has never been to any psychologist before and there is no history of psychotropic treatment.
Early social and developmental history:
The information related to the birth and developmental milestones was not provided by the client. She however mentioned that her childhood was good. Her father was a class A Government officer and her mother assumed the job of a homemaker after her marriage and had quite her job as a translator at a well known research institute. Born and raised in Islamabad, she has a sister (aged 36, married with two kids) and a brother (26, unmarried), and she is the middle child. She reported that she is more closer to her mother compared to her father; with her mother she can share things. Her relationship with her siblings was unproblematic and friendly throughout but both of them now live abroad so there is lack of communication (they call or message once or twice a month). As a child she reported that she was a good girl who was compliant and never caused trouble. She attained puberty at the age of twelve, it was somehow traumatic for her because her mother she says hadnt conveyed what was about to happen. She got married to her husband when she was twenty three years old six years ago; it was an arranged marriage and he belongs to the same sect and ethnicity but a different family. She stated that financially they are well to do and he owns the home. Her husband is a last born and has three sisters, all settled abroad. Her husband is aged thirty six and is seven years older than her. Both of his parents were alive when they got married but passed away within the first three years, with his mothers death preceding that of his father by an year. Her relationships with her in-laws were reported to be strained, she demanded a separate home but that earned her animosity (she said they disliked means were too critical) on part of her in laws. She moved in an independent home after few months of marriage. She reported that initially her husband used to hit me twice or thrice a year whenever there was some big fight between us. She reported that the first incident happened after six months of marriage ( he slapped me after a big fight over finances). She recalled that it numbed her for a while and she did not share it with anyone. During first four years it was a twice yearly incident. But after that it became a practice that used to happen almost every month. This year it has turned into a daily practice. She stated that she has a love-hate relationship with her husband. She was reluctant in sharing details.
She also reported that her mother was always reticent about topics related to sexuality so even when she was getting married she had lots of misconceptions. She was otherwise not really expressive about her relationship with her husband and her sexual life. Moreover, she reported that ever since her childhood she has always had a few friends although there is a female cousin of same age as her with whom she shares a close bond. She is close to her friends but after marriage she no longer meets them but is in contact with them through social media and phone.
Educational and occupational history:
Mrs. A. holds a Bachelors degree in Education, she reported that she was never studious and she earned the degree only upon insistence of her mother. She went on to describe herself as a student by saying, I never rote learned and was only good at tasks involving creativity. She shared that she knows four languages namely Urdu, English, German and Punjabi. She said that she has an aptitude for learning languages and writing. She never sought a job because she was not encouraged at home to seek one but she continued on to mention that I was just not interested , it was never like that they discouraged me but they didnt encourage either.
Health and Medical History:
The client reported that from past two weeks she has been experiencing palpitations and her heart beat gets very irregular and feels like it will just burst. The client reported that she has never had any significant major health related issue in past. She has never conceived and that is because her husband (and she too) dont want to have children. She reported that husband engages in domestic violence but it has never resulted in an injury beyond bruising. As reported earlier she takes two and a half tablets of Lexotan daily in the evening. She takes it despite that she said she doesnt have sleep problems however the tablets make her feel good and calm. Each tablet is of 1.5 mg so she consumes 3.75 mg of Lexotan daily. There is no personal and family history of diabetes, hypertension or any metabolic dysfunction. She is currently using no other medications and her physician has asked her to immediately decrease the dose of Lexotan to half.
Psychiatric/counseling history:
The client reported that she has no family or personal history of psychiatric issues. She had never been to a psychologist or a psychiatrist or a counselor before. Nobody in her family and in laws have ever consulted any of the above as well. It is the first time she had realized her problems and has sought help.
Strengths and coping skills:
She reported that she has tried to communicate her feelings related to domestic violence to her husband in spite of the fact that she fears his anger. It shows that she is willing to deal with this situation actively. She has mentioned that she has shared her domestic issues with her family and with some of her friends so there isnt absence of communication which is a good factor. However, nowadays she is engaging in avoidance coping strategies as she believes that if we will interact less, we will fight less. Her primary strength lies in the fact that she wants to change herself and realized that she can manage to learn how to cope with her situation.
BEHAVIORAL OBSERVATIONS:
The clients grooming habits appeared to be adequate and there was nothing unusual about the appearance. Her eyes appeared to be swollen but one could see that she had applied some makeup although the swelling underneath was visible.. She was wearing a full sleeved baggy dress which was clean and well ironed, nothing unusual for the weather or occasion. She appeared to be a little nervous as was evident from a slight trembling of her hands whenever she tried to clasp them. Initially she was guarded about her circumstances and tried to use small sentences to describe her situation and kept repeating mujhay maloom nahin k apko batana chahiye k nahin. It appeared that she was concerned whether she should share information related to her situation or not. She appeared to be sad and her posture was sitting in a slightly rigid posture with little movement of limbs until later on in the session when she adopted a comparatively relaxed (open) posture and she rested her back on the chair. It was evident from her statements that she had a flow of self defeating thoughts as she used sentences like mujh as nahin hoga , main baat karnay ki koshish tou karti hoon magar shayad meri baat ki ehmiat nahin hai or shayad theek ho jaen magar lagta bhi nahin. She claimed that she keeps on brooding whether she still loves her husband or not.
MENTAL STATUS EXAMINATION:
The client appeared to be well groomed as is apparent from her well combed hair arranged in braids, neatly trimmed nails (finger as well as toe nails), well brushed teeth and clean attire. She looks healthy (no pallor, appropriate body mass for her height), however her eyes appeared to be a little swollen.
Initially, she appeared to be guarded but as the interview continued it diminished and she appeared to be more cooperative. Good rapport was established as she expressed herself more.
She was responding normally to the cues given by interviewer but her speech was hesitant initially. Throughout the interview the speech was low pitched and there was no change of tone (monotonous) even when later on she started to talk openly about emotional topics of her life lie domestic violence.
The mood was reported to be dysphoric and there was an element of fright as expressed by her verbatim like mujhay dar lagta hai ab. The affect appeared to be constricted, she appeared to be sad but her facial muscles were not really mobile indicating how exactly she was feeling. However they were not immobile so it was not flat affect.
Form of thought seemed to be coherent and logical. Apparently no formal thought disorder appeared to exist. All of the events were logically connected and central idea was expressed with coherence.
It appeared that there wasnt any disorientation as to time, place or person. She was well oriented and her past and present memory appeared to be intact as she was recalling the events from her childhood easily and there was no disruption or difficulty in recall of present life events.
Her judgment appeared to be adequate as she acknowledged the factors contributing to her condition and also highlighted that if she wont take any measures she will suffer, she said mujhay andaza hai k ye cheez mujhay nuqsan pohncha rahi hai and mujhay pata hai k tablets ki waja se meri heart beat ka masla ho gaya hai. It also appeared that she had adequate insight (intellectual insight) and is aware of the nature of her issues and the consequences as well. She was found to be extrapolating where her current situation might lead her (said,mujhay pata hai k mujhay dawa ki craving nahi hoti magar agar main khati rahi tou main aadi ho jaon gi). She chose to approach a psychologist herself and selected an option independently from the ones her physician presented her with which indicates towards adequate judgment and insight as well.
DIAGNOSIS:
The clients assessment shows that she is using anxiolytic Bromazepam sold under the trade name of Lexotan (total dose of 3.75 mg daily) from past four months, she doesnt crave those tablets. The normal dose of Bromazepam for adults ranges from 6 mg to 8 mg so it can be established that this is not a case of overdose or abuse. However it should not be used for prolonged periods of time as it is known to cause dizziness, drowsiness, irregular heart beat, pounding heart and breathlessness. The client does not qualify the DSM 5 criterion for Sedative, Hypnotic or Anxiolytic use disorder (DSM 5, pp. 550-554). But her use of Lexotan needs attention as she is experiencing two of the side effects that are drowsiness (I feel sleepy and lay on couch when awake) and elevated heart beat (which is the primary reason she sough medical help from the physician who referred her). Since her sleep problems are linked with the use of Lexotan probably as it is known to cause drowsiness it is essential to rule out if it is the primary cause of it or not which will require further interviewing. More information I required to check if low mood and self defeating thoughts are symptoms of depression. The dynamics of her relationship with her husband require more exploration. She has no suicidal ideation and is not at risk of harming herself or others. However from her verbatim it is evident that she is at risk of physical and verbal abuse but she has reported that her husband will not harm her in a critical way.
ETHICAL CONSIDERATIONS:
The client has informed parents about physical violence in the past but they want her to continue living with her husband. But since the situation has intensified and she reports fear of getting hurt it is inevitable to bring this matter into the consideration of her family. Here it is important that the dissemination of the information should not cause any harm to the client instead.
CULTURAL CONSIDERATIONS:
The clients apparent reluctance related to discussing her marital life may be due to the fact that she probably feels that she cannot just start sharing personal details of her marital life, as she reported that her mother did not discuss puberty with her it can be said that there is a possibility that she doesnt feel discussing her marital life in detail at this moment. This could be due to the above mentioned reason. This area can be explored later as more rapport gets built.
SUMMARY AND CONCLUSIONS:
It can be established from the interview of the client that although she probably doesnt have an anxiolytic use disorder but her use of anxiolytic (Lexotan) is related to domestic violence as indicated by her. The side effects of using Lexotan which she is experiencing, namely drowsiness and elevated heart beat need to be investigated to rule out other possibilities. Her basic coping strategy is avoidance and even the intake of Lexotan is related to that. Her general appearance doesnt indicate any unusual feature although she appears to be in a low mood and sounds slightly guarded (like she has avoided talking about many aspects of her marital life and talks about abuse but not about the content of verbal abuse or her sexual relationship with her husband). The kind of environment she is currently living in is the cause of her low mood according to her so evidently she doesnt lack an insight; understands how her circumstances are affecting her and realized where the problem lies. She should be further interviewed for other symptoms which might help in developing an understanding of her issues.
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders
(DSM-5).(pp. 550-554).