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To prepare: Use a differential diagnosis process and analysis of the Mental Status Exam in “The Case of L” to determine if the case meets the criteria for a clinical diagnosis.
These questions are based on the following case:
The Case of L Presenting Problem Client presented in the emergency room (ER) having been brought in the previous night by her parents. Following an argument with her parents, L cut her right wrist. L’s mother reported that L started screaming rapidly and became physically violent toward her prior to cutting her own wrist. Psychological Data L is a 17-year-old Hispanic female who resides in Pennsylvania with her mother, father, and older sister. She is in 11th grade at the local public school. L appeared to be of average to above-average intelligence, as she was able to respond to numerous questions in an articulate and intelligent manner. She was well versed about world history and current affairs. Her mother confirmed that she has done well in school, maintaining a B+ average and participating in various school activities (e.g., chorus, school paper) until last year. L slowly dropped out of many activities she liked in the past. Her mother noticed about 8 months ago that L had also begun having difficulty doing schoolwork. Erratic behavior arose during episodes when L also became irritable and explosive. During these repeated episodes, she became quite defiant, cut classes, had to be placed in school detention, and had even assaulted the principal. L has numerous friends and believed she can relate to all types of people. She has a boyfriend who adores her, but she said she doesn’t feel the same about him. The school counselor confirmed that L is outgoing, popular, and smart; but during these episodes she became another person, one who is very violent and difficult. Medical History A physical examination by a staff doctor revealed superficial cuts on L’s left and right wrist. The cuts appeared to be a few weeks old. There were cigarette burns on her right wrist that looked to be approximately one week old. In questioning L about the cigarette burns, L responded, “I just wanted to see how it felt—now I know.” Whe 2 a high school education. L’s sister is considerably younger, aged 8. Their relationship is described as unremarkable, although L’s mother noted that the younger sister stays away when L is upset. Marital circumstances are uncertain, although the parents admitted that they are trying to keep the family together for their children, and they are of the Catholic faith. Treatment costs for L have been an additional difficulty for the family, but they said they are very worried about L’s lack of self-control and discipline. Extended family are far away and mostly still in Guatemala. L’s parents were not aware of any other family members with psychiatric problems. Psychiatric History L was evaluated three times at the community hospital ER during the past 4 years. Hospital evaluations were usually done after suicide attempts or threatening violent behavior toward others. L thought that the clinicians trying to diagnose her only had book skills and no people skills. She assumed that no one will ever know what is wrong with her; she did not plan to tell them because she doesn’t like them. L said she knows she “is not crazy,” but she was convinced that the therapist thought she is crazy or a “bad” kid. “They’re just experimenting with me,” L said. L indicated that she had been prescribed medications to alter her mood, but she couldn’t recall what it was, as she stated, “I don’t need those; nothing is wrong with me.” L’s mother reported that L was involved in outpatient counseling on at least four occasions as well as being placed in a shelter once after school truancy, running away from home, and threatening to assault her. A social worker was even sent for home visits for a 3-month period. Each time, L would abruptly end therapy by becoming verbally abusive or totally noncommunicative toward the therapist and would adamantly refuse to continue therapy. She even admitted to shoving a desk toward a therapist and threatening her with a pencil. When questioned about this behavior, L responded, “Well she told me to express myself and let my true feelings out, so I did.” (L also laughed and glanced at her mother during this exchange.) L’s mother was particularly perplexed and overwhelmed by these behaviors. She stated that her husband is completely frustrated and angry. Both admitted that L’s behavior is part of the considerable strain on their marriage. L denied being under any continued psychiatric care even though it was recommended numerous times. She refused to go, stating, “The therapists are the ones who are crazy.” L was first seen in outpatient counseling 9 years ago after she began to have nightmares and experienced tremendous anxiety after her godmother threatened to kidnap her. Her godmother became obsessed with L when L was 6 years old, first threatening to kidnap her then. Her godmother had to be institutionalized after exhibiting bizarre behavior. Recently, the godmother started threatening to kidnap L again. Three years ago, L was sent for counseling after she ran away from home after getting a bad report card and also discovering that her parents were considering a divorce. L requested therapy, as she reported that at 8 years of age she was sexually molested by an older man in the community (who is now deceased). She expressed having mixed emotions, because she viewed her perpetrator as her friend. By pretending that nothing 3 happened, she could think of him as a nice old man, and she didn’t have to deal with the thought of something this bad happening to her. L’s mother reported that she herself was raped at 8 years old and that L had knowledge of this. Two years ago, L and the entire family again became involved in outpatient counseling after L’s godmother accused L’s mother of child abuse. L’s mother thought this was largely done out of spite. An investigation by Child Protective Services revealed no abuse. Mental Status (1 day after she had been evaluated at the ER) L presented casually, disheveled, in shorts and a tee shirt, and with minimal makeup. L admitted to being in a nasty mood. There was little eye contact, and conversation was difficult. Thought and speech patterns were clear. Affect was flat. She was oriented to time, place, and person. L denied feeling depressed. When questioned about her suicide attempt the previous day, she suddenly became quiet and teary eyed. She lowered her head and responded, “You don’t understand, he made me do it. I don’t want to hurt myself.” L denied even remembering cutting her wrist, saying, “He must have done it or made me do it.” L was questioned about the person she was talking about. She related that there has been a male presence in her life since she was 6 years old and that he makes her do things that she doesn’t want to do or things she can’t even remember. This presence showed up after the funeral of her best friend, Michael. L said he communicates with her through her mind. She seemed distressed when speaking about him. Her mother appeared distressed and fearful as well. L’s mother confirmed that L had trouble sleeping and concentrating at school after the funeral. She did not want to attend Girl Scouts anymore, because the uniform had gotten tight and the male presence was laughing at her. L’s mother remembered how scared she had become on a few occasions when L attempted to run out into traffic. Every time L’s mother yelled at L for doing that, L stated that the male presence explained that this was how she could join her friend Michael. L’s mother took L to a therapist. When L entered the third grade, L’s mother took her out of therapy. L reported that during her awake hours she can’t see this presence, but she can sense him. She said she does see him in her dreams, and his appearances in them have intensified within the past year. In her dreams, he torments children, and he controls people through a haunted mirror and a magic book. He reads and controls thoughts. L described him this way: “He looks in his 40s, but is really ageless. Always dressed in dark colors, but I can’t tell the exact colors he wears. I know his eyes are powerful, but I never really look at his eyes.” L was asked why she never shared this information before. She stated, “Because I would be put in the hospital and medicated—and I told you, I’m not crazy. I know you don’t understand, but I am him and he is me, and he eventually wants to totally control me.” She admitted to acting out impulsively at times, such as throwing things for no reason. L reported that the presence was in the room during this interview. When questioned about why he doesn’t influence her now or make her do something, she replied, “He’s too smart, he wouldn’t do that.” L also mentioned that during the past 4 couple of months another male presence has been with her. This new presence seems to be controlled by and intimidated by the primary presence. The two males communicate with one another about how to hurt the children in her dreams. L ended the session by saying, “I know this sounds weird, but this is what is happening to me. If you tell any other therapist, I’ll deny it, because I don’t want to be put away.”
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