Case PresentationDR IGNAZIO GRAFFEO 02/05/2013

General Informations: RB is a 47 years old lady from Democratic Republic of the Congo, referred to OPD service c/o Markievicz House by her GP.

RB arrived in Ireland about 6 months ago. She lived in Dublin for 2 months, then she was transferred to Sligo.

At the moment she is living in an immigration centre, where she is sharing a room with other 2 ladies.

Reasons for Referral: Tearful

Low mood

Poor sleep

Occasional fleeting thoughts of suicide

Low concentration

Reactive Depression? (Diagnosis made by her GP)

Initial Medication: Escitalopram (Lexapro) 5 mgs od

Zopiclone (Zopitan) 7.5 mgs nocte

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 that from her bed she could not watch the TV, because its position)

Ruminating about her 3 children and her mother situation (they are still living in Africa)

Suffering for her rape, happened in July 2012

Tearful

Poor sleep and low concentration (as referred by her GP)

Worried about her economic condition (“I cannot send money home and I`m living with 19 euros per week”)

History of Presenting Complaint: RB on 11th February 2013 went to her GP describing a two-weeks history of low mood, low self-esteem, initial insomnia, low concentration, mild loss of appetite, tearfulness, suicidal thoughts.

She was not explicit about the beginning of these symptoms, but they probably appeared 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 that time all her symptoms were present except her suicidal thoughts.

She was seen in OPD again on 23rd April: all her symptoms were still present but more attenuated.

She said: “I`ve never felt like this before, in all my life”

Past Psychiatric History: First Presentation

Not Psychiatric issues in her past

Past Medical History: Malaria

High blood pressure (still present)

Drug History: 11/02/2013 Escitalopram 5 mgs od

Zopiclone 7.5 mgs nocte

(2 weeks trial made by her GP)

05/04/2013 Agomelatine (Valdoxan) 25 mgs nocte

23/04/2013 Agomelatine 50 mgs nocte

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, the other 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.

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.

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 her last child) because of jealousy. At that time she was working in a military camp, in the laundry service.

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, she wanted to go to College, but she could not because of economic issues.

Personal History: 18 – Shopping advisor in a shopping centre

20 – Cashier in a frozen food company

31 – Her father passed away. She had to mind to her mother as well, so she worked in a military camp, in the laundry service, and in the same time she was working before in the Ministry of Sport and after in the Ministry of Defence as secretary.

July 2012 – Some military uniforms were missing from the camp, so she was blamed and imprisoned as spy (militaries thought that she was selling their uniforms to rebels, so they could enter the camp without problems).

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 knew before she was imprisoned, and went to Congo Brazaville, waiting to raise some money to pay her trip to Ireland.

October 2012 – RB arrived illegally in Ireland and she was brought to the immigration centre in Dublin .

December 2012 – RB was brought to an immigration centre in Sligo, where she is living now, sharing a room with other 2 women.

Personal History: Before she was brought in prison, she was living with her mother and with her 4 children.

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 Congo Brazaville and told her that the militaries were searching for her children to kill them, 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.

Physical Disabilities: Nil

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 to overcome any kind of difficulty.

Predominant mood: happiness

Character traits: strength, power, gentleness, intelligence

Personal Impression: very resilient

Forensic History: She is still wanted by the police in her own country.

She did not refer any additional legal issue.

Social History: At the moment RB is living in a “small room” she reported shared with other 2 females in an immigration centre in Sligo.

She is also sharing a single bed with another woman (she was very annoyed about this fact, that she kept repeating continuously).

She is receiving food and 19 euros per week from the government, waiting to achieve her VISA or to be rejected from the Republic of Ireland.

She is unemployed at the moment, because she cannot apply for any job without her VISA.

No other incomes. Nobody is working in her family.

No savings.

Financial Problems: She is worried because she is unemployed and then she cannot send money home 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 of shoes, 1 pyjamas.

Substance Abuse: No alcohol misuse

No illicit drugs abuse

Not smoker

Mental State Examination: Appearance

Black African

Casually dressed

Well groomed

Good level of cleanliness

Good general physical condition

No abnormal involuntary movements

Mental State Examination: Behaviour

Appropriate

No anxiety

Good eye contact

Tearful

Good rapport established

Normal posture

No distractibility

Mental State Examination: Speech

Only French speaking. Interviewed with the help of the interpreter

Normal in volume, rate, tone

Normal in quantity and fluency

No abnormal associations

No flight of ideas

Mental State Examination: Mood

Subjectively very low

Objectively moderately low

Good communicability of the mood state

Congruent affect

No anxiety and panic symptoms

No obsessions and compulsions

No suicidal thoughts or passive death wishes

Mental State Examination: Perception

No hallucinations

No depersonalization and derealisation

No illusions

Mental State Examination: Thought

Linear

No formal thought disorders

No delusions

No obsessive thoughts

Preoccupied about her actual state and about her family

No thoughts of harm to others

Mental State Examination: Cognition

Good attention and concentration

Fully orientated to time, place and person

Good level of comprehension

Good short-term memory

Mental State Examination: Insight

Good towards her illness.

Compliant with her treatment and with medical advices.

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, low concentration, poor sleep, preoccupations about her present, her future and about her family, who is living in Democratic Republic of the Congo.

She had in her recent past some traumatic experiences (prison, rape, escape from 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.

Differential Diagnosis:

Depressive Episode

Adjustment Disorder

PTSD (no flashbacks, no hyperarousal, no avoidance conducts detected)

Formulation: Predisposing Factors: history of traumatic life events

Precipitating Factors: job loss

rape

transfer to Ireland

uncertainty about her VISA

Prolonging Factors: loneliness

uncertainty about her family

uncertainty about her VISA

Management Plan: Pharmacological Treatment: Agomelatine 25 – 50 mgs nocte

Supportive Counselling

CBT

Rape Crisis Centre

Regional Counselling Service

Clinical psychologist

Thank you for your kind attention…