Referral for: Evaluation
Date of the Exam: March 16, 2023
Client’s Name: Joshua
Client’s Diagnosis: Persistent Complex Bereavement Disorder
Client Status: Withdrawn and irritable, crying a lot, and has not been interested in playing or doing things he used to enjoy before the diagnosis.
MENTAL STATUS EXAM
Hair- Neat and well kept
Nails- Short and clean
Clothes- Clean and Ironed, Appropriate for the occasion
A little scar on the forehead
Difficult to develop and maintain rapport
Reduced eye contact
Slow and minimal speech
Monotonous and slurred speech
Mood and affect
Apathetic and low mood
Demonstrates flat affect
Abnormally slow thought processing
The patient is well oriented to time, place, and person
He has diminished attention span and concentration levels
He has good short and long term memory
Insight and Judgment
Loose insight and impaired judgment
Joshua is five years old.
A 4th born in a family of five
His parents are both alive
The family believes that generally, pain due to cancer is not reduced by medications. Therefore, they are all worried about the suffering that Joshua undergoes because of his diagnosis.
Current treatment Interventions
The patient is currently undergoing psychotherapy, which is cognitive behavioral therapy for persistent complex bereavement disorder. The patient has been undergoing psycho-education and alteration of grief-related negative automatic thoughts. Through psychoeducation, the patient has learned and accepted that the pain he is feeling has a purpose- it is part of the healing process (Duffy & Wild,2017). He has been able to overcome a few obstacles to the grieving process. Among the obstacles was the patient’s fear of worrying his parents and family when he cries or appears sad. He felt that it was his fault that his family didn’t seem so happy like other families. However, the patient is yet to come to terms with the diagnosis of the terminal illness. Additionally, I have helped the patient adopt positive thoughts to replace grief-related negative automatic thoughts. For example, I provided the patient with a rubber band to wear and snap every time he had a negative thought. In such instances, he replaces the negative thoughts with positive affirmations.
The rubber band technique has been widely used to act as a reminder. We used this intervention to help the patient establish positive affirmations in the conscious and gradually subconscious mind (Duffy & Wild,2017). As of now, the patient has demonstrated a few desired outcomes in the treatment for PCBD. He can verbalize his feelings and concerns. The patient also reports having episodes of negative grief-related thoughts and using the rubber band technique to revert to positive thoughts. However, he reports that he gets frustrated when the negative thoughts keep coming despite using that technique.
I would like to recommend additional psychotherapy for the patient. This might include, and is not limited to homework exposure, goal-oriented activities, and behavioral activation. Despite the current interventions, the patient has clinical manifestations of depression. Therefore, the patient could benefit from medication for depression for improved outcomes.
Local and National Resources
The SOHO center for Mental Health in New York City
Bleuler Psychotherapy Center
Olaolu et al. (2020) present an article analyzing two patients with PCBD. The article begins by denoting how common it is to overlook these conditions, especially when it occurs alongside other psychiatric comorbidities. The report outlines the clinical manifestations, diagnoses, and the treatment of two patients diagnosed with PCBD in the inpatient unit.
The article acknowledges that PCBD is a condition that requires further research as recommended by the DSM-5. the current criteria for diagnosis has 16 symptoms classified into 3 groups: separation distress, reactive distress to the death, and social or identity disruption. For one to be diagnosed with PCBD, “they must have experienced the death of a person with whom they are close, they must have at least one separation distress symptom and six other symptoms” (Olaolu et al., 2020). These symptoms must have persisted for not less than 6 months after the incident for children. While the underlying biological illness in PCBD is idiopathic, various neural mechanisms have been suggested.
The first case is a 41-year old Hispanic female diagnosed with PCBD during her admission in the acute psychiatric inpatient unit. It was during inpatient evaluation that she reported having nightmares, being stressed, traumatized, and hopeless following her son’s death from cancer at 14 years of age. She became hyper-vigilant to cancer and the related topics after the incident. After the incident of her son’s death, she has resorted to unhealthy coping strategies including smoking at least 3 blunts of marijuana per day and at least 7 cigarettes per day, increased alcohol intake till she had three blackouts within 6 months before the time of inpatient evaluation. She has a history of psychiatric hospitalization at the age of 16 when she was diagnosed with major depressive disorder. However, did not adhere to the treatment regimen and the follow-up procedures after discharge.
The second case is a 19- year old male. His mother succumbed to cancer 4 years before the inpatient evaluation. He blames himself for the death, stating that he could have been a better son and done more for her mother. He feels guilty, lost, and sad about the demise. Since the incident, he has had crying spells, triggered by memories of his mother at least six times a week. He also resorted to an unhealthy coping mechanism of smoking marijuana, which led to his other family members abandoning him. This incident plunged him further into depression as his support system weakened. He had been diagnosed with MDD, and PTSD, and hospitalized for suicidal ideation.
The authors highlight the close association of PCBD with MDD and PTSD. They further emphasize the importance of recognizing and managing PCBD appropriately as it manifests with almost similar symptoms to the mentioned disorders. From the above case presentations, the authors conclude that PCBD is also linked with substance use disorder to some degree (SUD). Additionally, there are common factors associated connected to substance use in individuals with PCBD, and they include “discomfort, non-acceptance, loneliness-isolation, and the presence of the deceased, or the ill individual” (Olaolu et al., 2020). They conclude that substance use is a coping strategy used by these individuals to avoid the reality of grief (Masferrer & Caparrós, 2018). The study suggests screening tools, in addition to the DSM-5 in the diagnosis of PCBD. These measures include the use of “Inventory of Complicated grief, the Brief Screen for Complicated Grief, and the Prolonged Grief Disorder Scales” (Olaolu et al., 2020). Finally, the article recommends the use of these screening tools routinely in the care of bereaved patients, particularly those at risk of PCBD. Notably, once recognized, prompt treatment of PCBD should be initiated to reduce morbidity and mortality in these patients.
Duffy, M., & Wild, J. (2017). A cognitive approach to Persistent Complex Bereavement disorder (PCBD). The Cognitive Behaviour Therapist, 10.
Masferrer, L., & Caparrós, B. (2018). Bereavement and substance use disorder. In Drug Addiction. IntechOpen.
Olaolu, O., Tumenta, T., Adeyemo, S., Popoola, O., Oladeji, O., & Olupona, T. (2020). Two Cases of Persistent Complex Bereavement Disorder Diagnosed in the Acute Inpatient Unit. Case reports in psychiatry, 2020.
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