Case of VALERIA

Intake Date: August xxxx

IDENTIFYING/DEMOGRAPHIC DATA: Valeria is a 17-year-old Hispanic female who resides in Pennsylvania with her mother, father, and younger sister. She is in 11th grade at the local public school.

CHIEF COMPLAINT/PRESENTING PROBLEM: Valeria presented in the emergency room (ER) having been brought in the previous night by her parents. Following an argument with her boyfriend,Valeria cut her right wrist. Valeria's mother reported that Valeria startedscreaming rapidly and became physically violenttoward her prior to cutting her own wrist.

HISTORY OF PRESENT ILLNESS: Over the past two years, Valeria slowly has dropped out of many activitiesshe has previously liked. Her mother noticed about 8 months ago that Valeria had alsobegun having difficulty doing schoolwork. Valeria began having outbursts 2 years ago. Erratic behavior began to arise during these episodes when Valeria also becameirritable and explosive. During these repeated episodes, she became quite defiant, cut classes, had to be placed in school detention, and had evenassaulted the principal. Valeria's mother confirmed that Valeria hadtrouble sleeping and concentrating at school after the funeral of her friend Michael, three years ago. She did notwant to attend activities at that time for months. Valeria's mother remembered how scared she had become on a few occasionswhen Valeria stated that a male presenceexplained that she should join her friendMichael.

PAST PSYCHIATRIC HISTORY: Valeria was evaluated three times at the community hospital ER duringthe past 2 years.Hospital evaluations were usually doneafter suicide attempts or threatening violent behaviortoward others. Valeria said she knows she "is not crazy," but she was convinced that the therapist thought she is crazy or a "bad" kid. Valeria 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, did not take them, nothing is wrong with me."

Valeria's mother reported that Valeria was involved inoutpatient counseling on at least four occasions.A social worker was even sentfor home visits for a 3-month period.Each time,Valeria would abruptly end therapy by becoming verbally abusive or totally noncommunicative toward the therapist and would adamantly refuse to continue therapy. Valeria's mother was particularly perplexed and overwhelmed by these behaviors since the social worker had no evidence of depression at the time. She stated that her husband is completely frustrated and angry.

SUBSTANCE USE HISTORY: Valeria denied any drug or alcohol use. When she was questioned regarding such, her response was "I could do drugs if I wanted to. I don't want to, because it's dumb."

PAST MEDICAL HISTORY: A physical examination by a staff doctor revealed superficialcuts on Valeria's left and right wrist. The cuts appeared to be a few weeks old. There werecigarette burns on her rightwristthat looked to be approximately one week old. In questioning Valeria about the cigarette burns, Valeria responded, "I just wanted to see how it feltnow I know." When questioned about old cuts on her left wrist, she responded, "I don't want to talk about it." Valeria weighs 103 pounds and is 5' 4" tall. Valeria denied any dieting or fasting, but her mother noticedover this past year that her weight has dropped.

FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: Valeria's mother is 42 years old and works as a secretary for a large telephone company. Her father is 49 years old and operates a small landscaping business. Both are U.S. citizens, with a cultural background from Guatemala of which they are proud. Both have a high school education. Valeria's sister is considerably younger, aged 8. Their relationship is described as unremarkable, although Valeria's mother noted that the younger sister stays away when Valeria 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 Valeria have been an additional difficulty for the family, but they said they are veryworried about Valeria's lack of self-control and discipline.Extended family are far away and mostly still in Guatemala. Valeria's parents were not aware of any other family members with psychiatric problems.

CURRENT FAMILY ISSUES AND DYNAMICS: 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.Valeria 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 Valeria is outgoing, popular, and smart,but during these episodes she becomes another person, one who is very violent and difficult.

MENTAL STATUS EXAM: Valeria 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. Valeria presented casually,disheveled,in shorts and a tee shirt, and with minimal makeup. Valeria admitted tobeing in a nasty mood. There waslittle eye contact, and conversation was difficult and incoherent at times).Affect was flat.She was oriented to time, place, and person. Valeria denied feeling depressed currently. 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." Valeria denied evenremembering cuttingher wrist, saying, "He must have done it or made me do it."

Valeria was questioned about the person she was talking about. She related that there has beena male presence in her life over the last few years 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. Valeria said hecommunicates with her through her mind. Sheseemed distressedwhen speaking about him. Valeria reported that during her wake hours shecan't see this presence, but she can sense him.She said she doessee him in her dreams, andhis 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. Valeria 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." She admitted to acting out impulsively at times, such as throwing things for no reason. Valeria reported that thepresence 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."Valeria also mentioned that during the past 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.

Submit your diagnosis for the client in the case. Follow the guidelines below.

Code + Name + Specifier (appears on its own first line) Z code (appears on its own line next with its name written next to the code)

• Explain how you support the diagnosis by specifically identifying the criteria from the case study.
  • Describe in detail how the client's symptoms match up with the specific diagnostic criteria for the disorder (or all the disorders) that you finally selected for the client. You do not need to repeat the diagnostic code in the explanation.
• Identify the differential diagnosis you considered.
• Explain why you excluded this diagnosis/diagnoses.
• Explain the specific factors of culture that are or may be relevant to the case and the diagnosis, which may include the cultural concepts of distress.
• Explain why you chose the Z codes you have for this client.
  • Remember: When using Z codes, stay focused on the psychosocial and environmental impact on the client within the last 12 months.