L was rushed into the emergency room (ER) by her parents after slitting her right wrist following an argument she had with her money. L’s mother stated that L started being physically violent towards her mother and screaming rapidly before she cut her wrist. L is seventeen years old, in 11th grade at a local public school, a Hispanic female, living with her family members, father, mother, and sister. L’s mother indicated that she had noticed some changes with L in relation to her school work. Generally, L was performing well in school, but she slowly started dropping out most of the activities she enjoyed in the past. The issue began eight months ago when L started having difficulties with her schoolwork. Whenever L became irritated, she exhibited erratic behavior and became explosive, quite defiant. In school, L had been placed in detention several times; she encountered several confrontations with the principle. L had a loving boyfriend though she did not reciprocate the feeling. According to the school counsellor, L was smart, outgoing, and popular, and hen irritated she became someone new.
L had suffered superficial cuts on both the left and right wrists. The cuts appeared few weeks old. On the right wrist, she had cigarette burns, which also appeared one week old. When L was asked about the cigarette burns, responded by saying that she smoked out of curiosity, something expressed through the ideation that she now knew what smoking feels. When L was asked about the old cuts on the wrist, she expressed that she did not want to discuss the issue. The weight and height were taken and recorded as 103 pounds and 5’6’ tall. L’s weight has dropped over the past year, when questioned, she denied dieting or fasting. L does not have a history of substance abuse as she denied using any drugs. L did not relate well with the sister. At home, the mother and father were not in good terms, which might have affected L’s behavior.
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Mental Disorders Assessment
For the past four years, L had been evaluated at the community hospital. Suicide attempts and threatening, violent behavior are risks of depression and being defensive. Therapy had been tried though it was ineffective since L indicated that she was not crazy. L also appears paranoid and in denial, indicating that therapists were experimenting with her, and she was not a bad kid, and nothing was wrong (Severus & Bauer, 2013). These are risks of L suffering from a personality disorder. Other notable symptoms are verbally abusing therapist or not communicating at all, symptoms of mood disorders. Therefore, L has excessive anger issues seen with shoving a desk towards a therapist. When explaining why she did so, L indicates that the therapist asked her to express her feelings, which she did. Laughing at the situation and glancing at her mother shows the possibility of psychotic disorders. The several suicide attempts and running away from home portray possible post-traumatic stress disorder (Savilahti, Haravuori, Rytilä-Manninen, Lindberg, Kettunen, & Marttunen, 2018). L exhibited signs of anxiety disorder, which can be traced back nine years ago when she used to dream of her godmother kidnapping her. When L was eight years old, she was molested by an older man presumed to her friend. The situation can be used to explain why L is defensive and erotic.
To Rule Out
301.83 Borderline Personality Disorder - through L used to be erotic and violent towards other people when offended, she used to calm and popular in school as indicated by her therapist. Therefore, she does not have the Borderline personality disorder mental condition (Martins, Torres, Santos, Teixeira, & Pereira, 2018) .
300.4 Dysthymia Disorder -L was moody from time to time, but happened when she was forced to go for therapy, yet she denied that there was something wrong. When in the jovial mood, she interacted well with her sister. At school, L was popular, indicating she was jolly with others; L did not express low feelings for an extended period, thus ruling out the mental condition.
300.7 Body Dysmorphic Disorder-L has decreased in weight as her mother noted for the past year. However, she denied fasting or avoiding food. At her age, L did not express any issue with physical appearance (Safer, 2009) .
To better diagnose L, I would require additional data that would help establish her mental status. I would ask L regarding fears she dealt with related to the marriage issues the mother and father were passing through. I would let L explain why she felt the need to run away every time faced with a situation she disliked. The reasons L avoided therapy would be necessary, for the determination of the best treatment approach (Curry, 2001). Earlier therapy attempts had all failed, and I would question L why she did not participate, yet it would have been beneficial. The information will be essential in planning for therapy sessions that L would enjoy and feel comfortable to open up, in case I chose the approach for treating her condition.
DSM-IV Multiaxial Evaluation (Final Diagnosis)
Axis I: Mood and anxiety disorder
Axis II: Paranoid Personality Disorder
Axis III: None
Axis IV: School problems and marriage problems
Axis IV: 90: Minimal symptoms with good functioning, seen at school where L was popular and jolly when she was happy. It was also seen at home through the manner in which L related with her sister, but avoided her when angry.
60: Moderate symptoms- School functioning issues, L performed well as her mother indicated that earlier she used to score B+, but she had started failing for the last eight months. L was also suspended from school for assaulting the principle.
30: Behavior is considerably influenced by delusions or hallucinations- L used to dream that her godmother wanted to kidnap her. L also talked about sensing a man who looked forty years but ageless through a haunted mirror.
20: Some danger of hurting self- L was taken to the ER because of cutting her two wrists. L also rushed out on her mother after an argument, the event led to her slitting the wrist. L was termed as violent when she got angry.
Treatment Plan
The previous history indicated that L had undergone therapy several times, and all the cases have failed. Therefore, implementing both medication and therapy would increase the effectiveness of the treatment plan. Assessment will be done through recording data in every therapy session. The therapist will record factors such as willingness to open up, anger spans when discussing pressing issues, rape issues, and evaluating her mood change with topic change. The information will help track L’s performance after every session and determine her progress in school, at home, and suicidal risk levels.
Medication
L is depressed due to her past encounter of rape with an older man; she regarded as her father. Currently, L is having dreams and hallucinations associated with a forty year old man and her godmother kidnapping her. At home, the marriage issues between L’s parents are affecting her, which explains why she runs away from home. Therefore, antidepressants such as Zoloft or Prozac, will be administered (Martins, Torres, Santos, Teixeira, & Pereira, 2018). They will regulate L’s moods and assist with how she handles anger.
Therapeutic Relationship
Planning for effective therapy sessions will consider different factors, noting considerable unsuccessful previous cases. A Hispanic therapist will be best to handle L’s case, someone from the same culture, whom she can relate. The family members have to be involved in therapy so that everyone can learn how to deal with the current situation and leave with it. L's case is severe, and she will commence with four sessions per week. Each session will be one hour long to avoid being monotonous. One of the weekly sessions will involve L’s family, where her father, mother, and sister will attend. Therapy sessions will be adjusted from week three, depending on L’s willingness to participate and her general performance.
Diversity Issues
Culture has a significant role in existence of an individual. It determines the emotional wellness of an individual and how people react when in distress. As a woman, L’s culture has played a part in depression problems. At the age of eight, she was sexually assaulted by an older man, whom she considered her friend. The issue has affected her to the point of not loving her boyfriend the same way he does. L witnesses her parents not getting along has affected her greatly, such as that she does not feel safe when at home and rushes out when there is an argument. L’s extended family lives in Guatemala, which has also affected her since she does not have any close blood relations she can relate.
Recommendations
During therapy sessions, different environments can be considered to make L comfortable. Therapy will also involve signing up L in help groups of girls who have been sexually abused so that she can interact with them, and together, they will help each other overcome the problem. The other option is enrolling L in co-curricular activities such as sports or games, where she can express her anger and engaged instead of being depressed.
References
Curry, J. (2001). Specific psychotherapies for childhood and adolescent depression. Biological Psychiatry, 49, 1091–1100.
Safer, D. J. (2009). Irritable mood and the diagnostic and statistical manual of mental disorders. Child and Adolescent Psychiatry and Mental Health, 3(1), 35. https://doi.org/10.1186/1753-2000-3-35
Severus, E., & Bauer, M. (2013). Diagnosing bipolar disorders in DSM-5. International journal of bipolar disorders , 1 , 14.
Savilahti, E. M., Haravuori, H., Rytilä-Manninen, M., Lindberg, N., Kettunen, K., & Marttunen, M. (2018). High beck depression inventory 21 scores in adolescents without depression are associated with a negative self-image and immature defense style. Psychiatry Research , 263 , 61-68.
Martins, A., Torres, A., Santos, T., Teixeira, R. J., & Pereira, A. (2018). Persistent Depressive Disorder: Personality or Mood Disorder? Implications for Practice. Advances in Mental Health Studies .
