The patient (P) is a 62-year-old woman who, after suffering an acute coronary syndrome in January 2003, was admitted to the University Hospital Príncipe de Asturias and presented, during hospitalization, an episode of left hemiparesis.
A neurological study of the patient is carried out in which the following findings refer:
- Normal cortical functions but with verbalized complaints of continuous memory loss since admission.
Left-sided hemiparesis does not manifest as:
• No pyramidal distribution.
• Fluctuations during examination with acceptable manual gesticulation.
• Virtually global anesthesia left hemibody to independent midline.
Therefore, in the neurological examination it is concluded that there are discordant data that suggest a non-organic origin, at least the whole picture would not be explained.
She also had tension-type resistant headache.
Therefore, psychological assessment of the patient is requested.
P. is slightly confused and distressed by the situation of being admitted.
She does not seem to be very worried about the symptoms she presents and verbalizes several times her desire to be discharged.
At the beginning of the first interview, she is reluctant to be evaluated, stating that her problem is exclusively physical and that she does not understand the meaning of a psychological examination.
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Psychological assessment
• Clinical history
Personal History
It was born in a rural environment with the ninth of 11 siblings.
About her childhood she says "have not had childhood because she had to work in the field since she was 9 years old".
This situation prevented him from learning to read and write, a circumstance that gives him great importance nowadays, feeling frustrated by it.
With the exception of boys and one of their sisters, who went to school, the rest of the siblings (women) shared a similar situation.
She points out how sometimes during the intense working hours she could only be absent in case of illness and sometimes she experienced dizziness and weariness.
She acknowledges that, throughout her life, she has suffered these symptoms again in the face of different difficulties (e.g., the fault with the death of her father).
As for social relationships, there were no significant relationships with peers other than those with their siblings.
She is married and describes her relationship with her husband as good, without major conflicts.
She has two daughters of 38 and 30 years old, both married and with children.
She says that her relationship with them has always been "friends" and that they have always told her everything, although she recognizes that sometimes they are overprotective.
1.
Personal History
The patient has not received previous psychiatric or psychological treatment.
Ten years ago he required primary care assistance for insomnia and was prescribed mianserin, which was taking until a year ago, his primary care doctor changed it to paroxetine and bromazepam.
On some occasion, he reported having taken hypnotics, also mentions insomnia from his Health Center.
Also, P. has been diagnosed with hypertension and hypothyroidism and has undergone numerous surgical interventions.
This last aspect is very relevant considering that the patient has had three previous episodes of hemiparesis and all have suffered episodes with periods in which she was hospitalized.
1.
Family history
The only family member who has a psychological personal history of interest is the child of the patient who is currently being treated at the Mental Health Center for episodes of panic attacks.
On the other hand, as shown in Figure 1, there are several antecedents of left hemiplegias in the family.
Firstly, the father, whom P. describes as a very authoritarian and rigid person (it was a dictator), at the same time he apologizes and justifies stating that the hard situation that touched them was very hard to live.
Secondly, two of her sisters, the only ones who, according to the patient, revealed themselves and faced their father and who had a stronger character.
The rest of the sisters were more submissive and accepted the rules of the father although they all married at very early ages to leave the house as soon as possible.
1.
• Evaluation process
Evaluation instruments
For the evaluation of the patient, besides the psychological interview, the following instruments were used:
-Symptoms Scale, SCL-90-R (Derogatis, 1977) (3), allows us a general assessment of psychopathological symptoms.
It is a checklist of symptoms collected in 9 dimensions with Spanish normative data and acceptable psychometric properties (4).
Regarding reliability, it showed good internal consistency in all subscales (ranging from a Cronbach of 0.78 to 0.90), as well as adequate predictive validity (5).
It has also demonstrated adequate discriminative validity, concurrent validity with the IIP-C and GHQ-12 (6).
-MCMI-II (Millon, 1987), is a questionnaire consisting of 175 items of true-false response and reporting on 8 clinical personality patterns, 3 severe forms of personality disorder, 6 clinical syndromes and 3 clinical syndromes.
The scores become base rates, whose cut-off point is at the value of 75, with higher values suggesting some clinical problem.
It has validity and sincerity (7).
1.
Evaluation results
In the interview, P. is a collaborator.
It does not show total indifference due to its hemiparesis, but it remains too important, focusing more on the sequelae of the symptom than on the etiology.
There is a tendency towards somatization in personal and family conflicts, as well as a long response latency and difficulties in recalling their own names and dates, which improve throughout the interview.
Seeks certain feelings of guilt about the concern that your health condition can cause in your family.
As for their personality, the patient is described as a person friendly, anxious, self-exigent and controlling.
It also coincides with the defining characteristics of the type-A behavior pattern (impascience, competitiveness, hostility), taking into account the way it would manifest considering its gender, age and cultural level (8).
On the other hand, she repeatedly manifests that she tries to appear as a strong person and avoids asking for help from family members so as not to worry about them.
For example, when you begin to notice small bowel sounds (pre-infarction symptoms), you do not tell anyone until the situation requires going to the emergency department and the condition requires hospitalization.
This functioning is similar in terms of emotional states.
Paradoxically, it often acts as a very dependent person with those idealized figures.
He does not impress histrionism or theatricality although he does express a seductive attitude in dealing with the therapists whom he tends to idealize, while he puts the other extreme nursing.
With regard to psychopathological variables, among the results of the patient in the SCL-90-R highlights that the highest scores are found in the dimensions of somatization, depression and anxiety.
The scores on the other scales, as well as on the global indexes, are below the average obtained in the Spanish normative data.
This information coincides with the one obtained by the clinical interview and the Mild
1.
Regarding the profile obtained by P. in the MCMI-II, to comment on the following: in the validation scales, it is important to highlight the high value obtained in "desirability", the patient seems to have a healthy image, asking good as possible.
With regard to clinical personality scales, there were significant increases in the scales: "dependent" (B = 98), "trionic" (T = 84), "B = 87), "Bcomplete" (T.
In other words, we are facing a person who constantly needs approval, attention and affection from those around her, this would be achieved on the one hand by behavior in a submissive way, showing little autonomy and a notable "dependent" scale.
On the other hand, by means of a certain tendency to draw the attention of others by means of the Self-dramatization Scale.
The score on the "complete" scale could indicate the patient's self-control when her real wishes and feelings emerge in certain situations (especially those that provoke anger or anger).
1.
As for the scales that indicate clinical syndromes of moderate intensity: we see that P. is tense, nervous and restless (anxiety scale" =109), as well as with a major depression state low mood (92).
In addition, there is a tendency to express psychological difficulties through sound channels (hysteriform scale =105).
Finally, none of the scales that indicate severe personality disorders (schizotypal, borderline and paranoid) and severe clinical syndromes (psychotic base excess, major depression and delusional disorder) were significant.
