Patient Name: Angela Chukwuma

Date of admission: 02/2/2001

Chief Compliant: Depression, phobia, supernatural and Mysterious feelings,Anxiety, Suicide thoughts, History of Present illness


Angela is an African female with symptoms of Bipolar disorder and depression. Angela has apparently been depressed over the last three months. The condition (depression) Angela struggles with stem from the fact that she was trying to adjust to a new life in a new environment. With no job and support and also beginning her life anew put her on a difficult edge. As a result, Angela became a worry wart. Sequel to anger and worry, Angela demonstrate feelings of separation anxiety and phobia. All effort to calm her inner worries woefully failed. She begins the day with early morning worry which takes her to late evening nightmare and midnight endless replay of obsessive thoughts. Each day seems that there’s one disaster after another where she descends out of the boiling afternoon sky to a restless, sweat-soaked night sleep. Not only does she have to deal with a fastidious husband who forced her to do things she doesn’t want to do. The frustration of abandoning her dream job was marked by a blistering financial spending spree by her husband. In addition to all these are stressful life issues (new environment), illness, financial stress and trouble with in-laws, all created a nightmare of hell to her.

Angela reported persistent symptoms of chronic fatigue, numbness, depressed mood, loss of weight and poor interest in any social activities, hyper-somnina, and diminished concentration. She reported that her symptoms had lasted several months immediately after she had a quarrel with an in-law. She also reported having frequent phone-calls and argument with her father-in-law. In her own house and environment, “life is hard, lonely and tragic.” Initially, it seems she was expressing shock and depression, but symptoms she described were congruent with the diagnosis of depressive disorder, single episode (APA, 2000) and separation anxiety disorder. A major depressive episode is indicated when Angela met the following DSM-IV-TR criteria’s a) a depressed mood most of the day, nearly every day, b) markedly diminished ability to concentrate (APA, 2000) which can be attention-deficit disorder (ADD). Her symptoms stem from mood changes, unemployment and experience with in-laws coupled with the fact that her family were unsupportive. Her distress and her constant mood exacerbated her depressive symptoms, causing her to withdraw from significant social aspects of her life. The continuous stream of negativity and regrets that interrupts her mode of thought late at nights consistently caused her unable to get out of bed in the morning. Angela reports that her thoughts were not focused on one thing but jumps from one negative thought to another. Her depression and worry often drains her energy and make her less likely to make good rational decisions. As a result, Angela would have late night headache, muscle tension, upset stomach, which makes it impossible for her to concentrate on other things. Angela also experienced recurrent episode of aggression due to frustration and sometimes she tore up her cloths and personal belongings. She has been sleeping minimally and has been crying considerably. She admits having feelings of hopelessness, thoughts of death starting on the day before she came to the psychiatric unit for admission. Her last manic episode was last month.


It all began after Angela returned home from work on a brassy rainy evening. On that same evening, there were trembling lightning and thunder storm that engulfed the entire neighborhood that put lights in the living room in total darkness. The sound of the thunder touched the walls and put down pictures hung on the walls. Cups slid back from the dining table and slammed on the floor, and books on the shelves fell down on its own accord. The same strange noise could be heard around the bathroom, living room and the bedroom ceilings. Friends ran to Angela’s house to see for themselves what was going on. Other came to take refuge while others came to see what was amiss. Angela’s husband was terrified as horror events unfolds in his own household. Gripped with fear, friends asked him to hit the alarm system to invite rescue men or to scare off whatever evil that had possessed Angela and overcame the entire household. In a split of seconds, security men arrived and they searched the entire household and found nothing. They found no creature of any kind intruding or inhabiting the household. Five minutes later security officers left, the same noise continued louder than before accompanied by squeaking sounds in the kitchen area. Friends of the family and Angela’s husband began to notice that glasses on the table were turning up and down in the living room.

From time to time, they found Television in the living room turned on and off by itself and plates on the dining table move from its original spot. In all these circumstances, Angela found herself a target of a mysteriously circumstance. In her room, Angela found her own bed cover and mattress shaking randomly obstructing glasses and boxes. The episode continued day after day and night after night. In a maze of fear, Angela’s husband Ekene and few other friends became wild with worry and fear. They suspected that some evil spirit had invaded Angela and had controlled her mind and possessed her body. On a cloudy breezy midnight while Angela was sleeping, her bed began to shake again and she started to scream profusely. Her eyes would stay wild open and fixed and a salivary white substance gushing out from the right side of her mouth. Her pillow was drained and her bed cover were everywhere on the floor as this squeaking sound continued to be heard throughout the household. Ekene quickly rushed Angela into his car and drove her to a nearby Methodist church for prayer and exorcism. Exorcism stems from a Latin word excorismus which means binding by oath. The act of binding by oath is a religious practice of evicting demons or other spiritual entities from a person or place which they are believed to have possessed by causing the entity to swear an oath. This practice is quiet ancient and part of the belief system of many cultures in Nigeria and religions by Christians. The pastor at a local Methodist church John Bosco was a tall lanky man, well known for his long experience in exorcism, deliverance and prayers. John Bosco was called a binder and prayer warrior. Often children and women call him enemy of the dark and of the twilight zone. John Bosco tried earnestly to cast out demons from Angela by hitting her hard like Bakassi boys would beat a thief, but all to no avail. He put Holy Bible on her face, touched her mouth and face with white handkerchief, but her situation was not even better than before. After prayers and long incantation, and after six month of rigorous deliverance without success, he asked Ekene to take her to hospital for psychiatric evaluation and assessment. At the hospital, Angela would laugh at Doctors and Nurses and would throw thing down from their spot making mess in the hospital. Her body would turn pale and take a super human strength. At the end of every routine psychiatric assessment and redirection, Angela would comply to medication and bed rest. Seven days after initial admission in this local psych unit in Nigeria, Angela was believed to be doing better and was discharged and sent home. At home, Angela refused to take her prescribed medications and symptoms of her psych illness came back and took a more difficult form.

A week after her symptoms became worse; Angela was taken to a native medicine man that uses alternative therapy of roots and shrubs to treat chronic mental patients. By night fall after she woke up from her coma, she felt fatigued, footsore and famished. She narrated vivid strange stories of her travel to a strange world killing her husband and children in a dastard battle with the evil one after she was asked to “make a wish.” She narrated how she found a road that led her in what she now knew to be the road to psychiatric hospital in the twilight zone. For her the road was wide and straight as a city street, yet it seemed untraveled and uninhabited. No field bordered it, no dwelling surrounded it. Not so much as the baking of wild dogs or ominous hyena suggested human habitation or animal hibernation. The black bodies of trees formed a straight wall on both sides, terminating on the dead horizon in a point like a diagram dragon in a lesion in life perspective. She narrated that she saw a great wooden but golden stars looking unfamiliar and grouped in strange constellations. Angela expressed that they were arranged in some order which had a secret and harmful outlook. The wood on either side of the forest was full of singular noises of death and human desolation. She narrated that there were something like pain, anguish in their cry and in their limitless tears. As Angela mentioned the word “cry”, she heard a strange unknown voice screamed at her to stop talking to those psycho doctors! Immediately, she stopped talking with a smile of ineffable joy, and an attitude of matchless grace and dignity. Angela really was not possessed but displayed psychiatric tendencies.


Angela has not been diagnosed of any psychiatric condition in the past because she came from a country where psychiatric evaluation and assessment were simply minimal. She reports that she has been hospitalized on 5 different occasions with little or no success. She denies suicide attempts but admits to have overdosed herself of alcohol on many different occasions. Before her admission, Angela has tried Lamictal, Zyprexa, seroquel (orthostatic hypotension), abilify, Zoloft, Lexapro, Cymbalta, Wellbutrin, Remeron, Adderall, Ritalin, Concerta, Vyvanse, Klonopin, Restoril, Ambien and Trazodone.


Eye surgery, Hiatal hernia and appendicitis

ALLERGIES: Cloroqine tablets and dark rooms

SUBSTANCE ABUSE: Binge drinker. Angela reported that she has never abused any hard substance or used alcohol excessively. She recollected that she has been in a situation where she could abuse alcohol but she chooses to stay sober.


Angela is married and has been in a protracted deadlock with her in-laws for the past 7months. She has a degree in Bio-chemistry and was formerly employed as Sales Rep in a multi national cooperation, Enugu Branch, Nigeria. She has a 2year-old son who stays with Dad while she works. Before this time, Angela had worked as Assistant branch manager at Enugu transportation cooperation, Nigeria. The name Angela is Omnipresent in sales and marketing industries and her face was plastered on untold numbers of billboards and posters sent out on an annual basis by Cooperate office. Her work ethic at the transportation office was humbling, that somewhat cause her to remain deliberately aloof to any good and positive mental health condition. Before her sudden illness, her thoughts on personal and emotional stability as well as temperature of fire in her belly largely remain mostly unknown. Despite her aura of inevitability, Angela largely remains an enigma or what therapists or psychologists would call a “problem patient.”


Angela denies that any member of her family has been diagnosed of depression, Bipolar disorder or other mental illness. She denies being treated for psychiatric illness or being put on a prayer spot for exorcism. Angela is an emerging family woman facing myriad domestic and cross-cultural shocks in her new environment.


Lamictal 100mg bid. Pristiq 100mg, Adderall XR 20mg tid, and Ambien CR 12.5mg qhs


General appearance: Adequately groomed Behavior: Cooperative Sensorial: Very alert Mood: Anxious, Sad, and depressed Affect: Congruent with mood Thought process: Circumstantial Denies delusions Perception: Denies hallucinations Memory: Poor for registration and recall. Intact for recent and remote Attention/Concentration: Distractible, lack of focus, often look confused Insight: Poor Judgment: Poor Estimated Intelligence: Average


Angela is an African woman who has a history of bipolar disorder and struggles over internal worry and anger as a result of family conflict with in-laws and the burden of supporting a family of her own. These conditions worsened her mood where she attempted to fight people in a destructive and combatant manner. Regardless whether we chose in the end, the impact of mood changes or the reality of family illusion which resulted in Angela being depressed, one thing is common in this analysis. Angela’s current health condition was as a result of persistent family conflicts, exacerbated by lack of adaptation and limited resources and social support systems. It is not surprising for her to experience shock, confusion and unprecedented display of block-headedness or block-mindedness. It is not surprising for her to feel shy, withdrawn even as her beauty invariably tops the poll ranking as “hottest” or most eligible African queen in her new social environment.


AXIS 1: Bipolar disorder, Type1, Mixed AXIS 11: Deferred AXIS 111: Appendicitis, Hiatal hernia AXIS 1V: Unemployed AXIS V: GAF of 40

ASSETS: No access to medical insurance, Medicaid

Weakness: Depressed, de-compensated coping skills as a result of separation anxiety disorder.

PLAN: Given that Angela has experienced worsening of mood and disposition accompanied by suicidal thoughts, she is expected to be admitted for safety and stabilization. Given that she has experienced loneliness and phobia accompanied by anxiety, as a result of her separation from in-laws, she is expected to have counseling on separation anxiety disorder. She is to be admitted under voluntary status despite hospital unit arrangement. She is to be monitored for safety issues during her initial phase of assessment and treatment. Angela must discontinue the use of Lamictal and Lithium. On the other hand, she is to benefit from individual and group therapy. She may also benefit from family therapy as the case maybe. The goal of the above therapies will center on reducing her intense anxiety or phobia as a result of separation from Husband and children or other loved ones. Attention must center on helping her regain normal behavior and activities.


Angela should not be termed suicidal risk patient or problem patient as therapists would suggest. She would not be termed mad or crazy as family members would opine! Angela should be seen as undergoing psychiatric moment as psychiatrists would suggest. Effort to overcome these moments and anomalies should be made to improve her mood at any given time. Upon inpatient stabilization, she will be recommended to continue outpatient psychiatric follow up. She will consider transitioning to partial hospital program near her place of residence. She will be recommended for a follow-up individual therapy.


The ultimate aim of any psychiatric assessment/treatment or therapy is the recovery of patients such as Angela. It is a grindstone objective of any meaningful therapist that his clients find joy, rejuvenation and fulfillment in the recovery process. To assist patients find fulfillment in their recovery process is the ultimate reason why experimental family therapists and psycho analytic theorists often use the immediacy of therapeutic encounter with patients and family members to help catalyze family’s natural drives towards growth and the fulfillment of individual members’ potentials (Goldenberg et al, 2004). Many of these therapists have succeeded in so many ways and many have equally failed in many different ways in their effort to assist patients experience full recovery. Therefore, the success of any psycho-therapy in health-care profession hinge on prescribing medications, for behavior adjustment and social deviance. These models at different times have helped to alter brain metabolism in the direction of human normalcy.

On one hand, experimental family therapy also has helped OCD, CD patients who experience severe anxiety disorder because of their inability to complete rituals. Behavioral therapy which requires interventions through exposure and response prevention have significantly helped in the recovery of many patients dealing with OCD symptoms, separation anxiety, mood disorder and manic depression. At all times, patients with separation anxiety disorder (SAD), OCD symptoms require family treatment, relaxation training and family counseling in order to clarify communication and troubling discrepancies between family members, patients, pastors, traditional healers and therapists with humanistic effort orientation towards building self-esteem or self-worth in patients. Deep brain stimulation (DBS) from Medtronic is essential here in treating patients like Angela with SAD, and OCD. Exposure/ Ritual prevention is vital for therapists, patients and families in the choice of healing {traditional or psychiatric notwithstanding}. These efforts are geared to present healing transaction and give higher priority to action than insight or book understanding by a social worker. Every behavior, insight, phobia and understanding of symptoms of depression, should be viewed within the therapeutic framework of family structures and values. Therefore, full assessment of family context and structure are essential when prescribing drugs like, placebo, group therapy, cognitive behavioral therapy (CBT) and Stress management therapy. The ultimate goal here must aim at healing patients, satisfaction to families, reassurance to therapists, limited turnover to insurance bureaucrats and finally a healthy human society. In sum, Researchers and Veterinarians have found a surprising link between compulsive behavior in humans and compulsive trial-chasing in dogs and high cholesterol. This finding adds to the growing body of literary evidence-mostly from studies on humans-that high cholesterol maybe marker of behavioral problems such as panic attacks and obsessive compulsive disorder, which could be expressed by frequently tail-chasing in dogs. Bouts of trail-chasing can also occur after a dog experience physical trauma, surgery or illness. This finding was noted by Hasan Batmaz, a member of the faculty of Veterinary Medicine at Turkey’s University of Uludag, who conducted the study along with a team of colleagues (Jennifer, 2008). The reason for a link between humans and animals could be that high cholesterol level glob up cell membranes at the microscopic level affecting the flow of brain hormones such as Serotonin that are involved in mood, anxiety and behavior change as experienced by Angela. Past studies in this light, found that people with panic disorders, separation anxiety disorder and certain phobias as evident with Angela often have higher Cholesterol levels, possibly as a result of increased activity of hormones tied to the “fight or flight” response. Angela is not possessed but undergoing psychiatric fallout. She needs treatment in psychiatry and not prayers in Methodist church. She needs psyche medications and not shrubs from homeopathic healers-utilizing plants, animals and minerals in treatment without assessment.


American Psychiatric Association APA, (2000), Diagnostic and Statistical Manual of mental disorder (4th ed, TR), Washington, DC: Author

DSM-IV-TR, Arlington, VA: American Psychiatric Association 2000

Jennifer, V (2008), Dog Trail-Chasing linked to high Cholesterol, Discovering News @

Goldenberg, I & Goldenberg, H (2004), Family therapy: An Overview(6th Ed) Thomson, Brooks/code

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