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Case presentation

  1. 1. Case PresentationDR IGNAZIO GRAFFEO02/05/2013
  2. 2. General Informations:RB is a 47 years old lady from Democratic Republic of the Congo, referred toOPD service c/o Markievicz House by her GP.RB arrived in Ireland about 6 months ago. She lived in Dublin for 2 months, thenshe was transferred to Sligo.At the moment she is living in an immigration centre, where she is sharing aroom with other 2 ladies.
  3. 3. Reasons for Referral:TearfulLow moodPoor sleepOccasional fleeting thoughts of suicideLow concentrationReactive Depression? (Diagnosis made by her GP)Initial Medication: Escitalopram (Lexapro) 5 mgs odZopiclone (Zopitan) 7.5 mgs nocte
  4. 4. Presenting Complaint:RB at the time of the interview was feeling low in mood since last 3 months.She was feeling uncomfortable in her accommodation (she was repeating thatfrom her bed she could not watch the TV, because its position)Ruminating about her 3 children and her mother situation (they are still living inAfrica)Suffering for her rape, happened in July 2012TearfulPoor sleep and low concentration (as referred by her GP)Worried about her economic condition (“I cannot send money home and I`mliving with 19 euros per week”)
  5. 5. History of Presenting Complaint:RB on 11th February 2013 went to her GP describing a two-weeks history of lowmood, low self-esteem, initial insomnia, low concentration, mild loss ofappetite, tearfulness, suicidal thoughts.She was not explicit about the beginning of these symptoms, but they probablyappeared one month after the patient was transferred to Sligo.She was seen in OPD at Markievicz House for the first time on 5th April; at thattime all her symptoms were present except her suicidal thoughts.She was seen in OPD again on 23rd April: all her symptoms were still present butmore attenuated.She said: “I`ve never felt like this before, in all my life”
  6. 6. Past Psychiatric History:First PresentationNot Psychiatric issues in her past
  7. 7. Past Medical History:MalariaHigh blood pressure (still present)
  8. 8. Drug History:11/02/2013 Escitalopram 5 mgs odZopiclone 7.5 mgs nocte(2 weeks trial made by her GP)05/04/2013 Agomelatine (Valdoxan) 25 mgs nocte23/04/2013 Agomelatine 50 mgs nocte
  9. 9. Family History:Father: passed away in 1996 because of a car accident. He was 43 years old.Mother: still alive, aged 73 years old. History of arthritis and malaria.RB also has 3 brothers aged 42, 39, 37: the oldest one is living in Angola, theother 2 are living in Congo Brazaville. They do not have any health problem.No psychiatric issues in her native family.No history of substance abuse or alcohol misuse.Good quality of relationships.
  10. 10. Family History:RB also has 4 children:1 girl aged 30 (first man)3 boys aged 13, 7, 3 (second man)RB never got married.No health problems.
  11. 11. Family History:RB had 2 partners:1 for 3 years.1 for 10 years. He broke up their relationship 3 years ago (after the birth of herlast child) because of jealousy. At that time she was working in a military camp, inthe laundry service.
  12. 12. Personal History:No problems during her pregnancy and delivery.She grow up e lived until August 2012 in Democratic Republic of the Congo.She reached development milestones normally.No childhood illnesses.She said that her childhood was happy.Very good at school, RB reached her Leaving Certificate at the age of 18, shewanted to go to College, but she could not because of economic issues.
  13. 13. Personal History:18 – Shopping advisor in a shopping centre20 – Cashier in a frozen food company31 – Her father passed away. She had to mind to her mother as well, so sheworked in a military camp, in the laundry service, and in the same time she wasworking before in the Ministry of Sport and after in the Ministry of Defence assecretary.July 2012 – Some military uniforms were missing from the camp, so she wasblamed and imprisoned as spy (militaries thought that she was selling theiruniforms to rebels, so they could enter the camp without problems).
  14. 14. Personal History:While she was in prison, she was continuously sexually abused by militaries.After 2 weeks she escaped from the prison, helped by a military that she knewbefore she was imprisoned, and went to Congo Brazaville, waiting to raise somemoney to pay her trip to Ireland.October 2012 – RB arrived illegally in Ireland and she was brought to theimmigration centre in Dublin .December 2012 – RB was brought to an immigration centre in Sligo, where she isliving now, sharing a room with other 2 women.
  15. 15. Personal History:Before she was brought in prison, she was living with her mother and with her 4children.When she was in prison, they went to live with their cousins.After RB escaped from the prison, one of her brothers met her in CongoBrazaville and told her that the militaries were searching for her children to killthem, to reach their revenge towards her.At the moment she does not know if they are still alive, where they are living,how they are surviving without money.
  16. 16. Physical Disabilities:Nil
  17. 17. Premorbid Personality:At the interview, RB said that she was happy when she was young.“Normal personality” she said.No hobbies or interests in particular.She liked to play with other kids.She also said that her parents described her as a strong person, able toovercome any kind of difficulty.Predominant mood: happinessCharacter traits: strength, power, gentleness, intelligencePersonal Impression: very resilient
  18. 18. Forensic History:She is still wanted by the police in her own country.She did not refer any additional legal issue.
  19. 19. Social History:At the moment RB is living in a “small room” she reported shared with other 2females in an immigration centre in Sligo.She is also sharing a single bed with another woman (she was very annoyedabout this fact, that she kept repeating continuously).She is receiving food and 19 euros per week from the government, waiting toachieve her VISA or to be rejected from the Republic of Ireland.She is unemployed at the moment, because she cannot apply for any jobwithout her VISA.No other incomes. Nobody is working in her family.No savings.
  20. 20. Financial Problems:She is worried because she is unemployed and then she cannot send moneyhome to her family.She is also disappointed because she cannot buy anything for herself(clothes, etc.).She stated that she has only 1 sweater, 1 jacket, 1 pair of trousers, 1 pair ofshoes, 1 pyjamas.
  21. 21. Substance Abuse:No alcohol misuseNo illicit drugs abuseNot smoker
  22. 22. Mental State Examination:AppearanceBlack AfricanCasually dressedWell groomedGood level of cleanlinessGood general physical conditionNo abnormal involuntary movements
  23. 23. Mental State Examination:BehaviourAppropriateNo anxietyGood eye contactTearfulGood rapport establishedNormal postureNo distractibility
  24. 24. Mental State Examination:SpeechOnly French speaking. Interviewed with the help of the interpreterNormal in volume, rate, toneNormal in quantity and fluencyNo abnormal associationsNo flight of ideas
  25. 25. Mental State Examination:MoodSubjectively very lowObjectively moderately lowGood communicability of the mood stateCongruent affectNo anxiety and panic symptomsNo obsessions and compulsionsNo suicidal thoughts or passive death wishes
  26. 26. Mental State Examination:PerceptionNo hallucinationsNo depersonalization and derealisationNo illusions
  27. 27. Mental State Examination:ThoughtLinearNo formal thought disordersNo delusionsNo obsessive thoughtsPreoccupied about her actual state and about her familyNo thoughts of harm to others
  28. 28. Mental State Examination:CognitionGood attention and concentrationFully orientated to time, place and personGood level of comprehensionGood short-term memory
  29. 29. Mental State Examination:InsightGood towards her illness.Compliant with her treatment and with medical advices.
  30. 30. Synopsis:RB is a 47 year old Congolese lady, arrived in Ireland about 6 months ago.She is presenting at the moment low self-esteem, tearfulness, low mood, lowconcentration, poor sleep, preoccupations about her present, her future andabout her family, who is living in Democratic Republic of the Congo.She had in her recent past some traumatic experiences (prison, rape, escapefrom her country, economic issues).She had a diagnosis of reactive depression by her GP.Suicide risk reported by her GP, but not detected at time of the interview.
  31. 31. Differential Diagnosis:Depressive EpisodeAdjustment DisorderPTSD (no flashbacks, no hyperarousal, no avoidance conducts detected)
  32. 32. Formulation:Predisposing Factors: history of traumatic life eventsPrecipitating Factors: job lossrapetransfer to Irelanduncertainty about her VISAProlonging Factors: lonelinessuncertainty about her familyuncertainty about her VISA
  33. 33. Management Plan:Pharmacological Treatment: Agomelatine 25 – 50 mgs nocteSupportive CounsellingCBTRape Crisis CentreRegional Counselling ServiceClinical psychologist
  34. 34. Thank you for your kindattention…