Case Of Valeria Intake Date August Identifying Demographic

Case Of Valeriaintake Date August Xxxxidentifyingdemographic Datava

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 started screaming rapidly and became physically violent toward her prior to cutting her own wrist.

HISTORY OF PRESENT ILLNESS: Over the past two years, Valeria has gradually dropped out of many activities she previously liked. Her mother noticed about 8 months ago that Valeria had also begun having difficulty doing schoolwork. Valeria began having outbursts 2 years ago. Erratic behavior began to emerge during these episodes, with irritability and explosiveness. During these episodes, she became defiant, cut classes, had detention, and assaulted the principal.

Valeria’s mother confirmed she had trouble sleeping and concentrating at school after her friend Michael’s funeral three years ago. She avoided activities for months and expressed fear about a male presence urging her to join Michael. PAST PSYCHIATRIC HISTORY: Valeria was evaluated three times at the community hospital ER in the past 2 years, mainly after suicide attempts or threats of violence. She believes she is not crazy but thinks therapists see her as such. She was prescribed mood-altering medications but cannot recall which. She has attended outpatient counseling multiple times but refused to continue therapy, often becoming verbally abusive or nonresponsive. Her mother finds her behaviors perplexing and overwhelming.

SUBSTANCE USE HISTORY: Valeria denies drug or alcohol use, claiming she could do drugs but chooses not to. PAST MEDICAL HISTORY: Physical exam showed superficial wrist cuts a few weeks old and cigarette burns about one week old, with Valeria stating she wanted to see how burns felt. She denies dieting or fasting but has noticed weight loss over the year. She weighs 103 pounds and is 5’4” tall.

FAMILY HISTORY: Valeria’s mother is 42, works as a secretary; father is 49, runs a landscaping business. Both are U.S. citizens with Guatemalan roots. Valeria’s younger sister is 8. The family’s relationship is unremarkable, though the sister avoids Valeria when upset. Marital issues exist, with parents trying to keep the family together; they are practicing Catholics. Family members with psychiatric issues are unknown.

CURRENT FAMILY ISSUES: Valeria had good school performance and social life until last year. She is outgoing and popular, but during episodes, she becomes violent and difficult, according to her school counselor. Her mother confirms she's maintained a B+ average, involved in activities, and has many friends. She has a boyfriend who adores her, though she does not reciprocate feelings. Her mother and counselor note the drastic change during episodes.

MENTAL STATUS EXAM: Valeria appears of average to above-average intelligence, responding articulately. She is casually dressed, disheveled, with minimal makeup. She reports being in a bad mood, with little eye contact, sometimes incoherent speech, and flat affect. Oriented to time, place, and person. Denies current depression. When discussing her recent suicide attempt, she becomes tearful and distressed, asserting someone made her do it and she doesn’t want to hurt herself. She describes a persistent male presence that influences her, whom she perceives as in his 40s, ageless, dressed in dark colors with powerful eyes. She reports seeing him in her dreams, where he torments children and controls thoughts through a haunted mirror and magic book. She describes impulsive behaviors like throwing objects and states this male presence was in the room during her interview.

Sample Paper For Above instruction

The case of Valeria presents a complex picture of a teenage girl experiencing significant psychological distress manifesting through self-harm, behavioral outbursts, and hallucination-like experiences. Valeria’s presentation illustrates the importance of a multidimensional evaluation that considers psychiatric history, family dynamics, cultural background, and current functioning. The following paper discusses her symptoms, possible diagnoses, and treatment considerations based on her comprehensive clinical profile.

Introduction

Adolescence is a critical developmental period marked by emotional, psychological, and physiological changes. When these changes manifest maladaptively, they can lead to intense psychological symptoms such as mood disturbances, behavioral issues, and psychotic-like experiences (Steinberg, 2014). Valeria’s case exemplifies the complexities involved in diagnosing and treating adolescent mental health disorders, especially in the context of traumatic events and cultural factors.

Psychological and Behavioral Symptoms

Valeria exhibits a combination of mood instability, impulsivity, aggressive behavior, and self-injury. Her history of dropping out of activities, erratic behaviors, irritability, and explosiveness suggests underlying mood dysregulation (Cicchetti & Toth, 2015). Her self-inflicted wrist injuries, including superficial cuts and cigarette burns, indicate a pattern of self-harm, often associated with emotion regulation difficulties and suicidal ideation (Nock & Favazza, 2009). Valeria’s impulsivity is further evidenced by her throwing objects spontaneously.

Hallucinatory Experiences and Possible Psychosis

Valeria describes a male presence that influences her thoughts and behaviors, which she perceives in her dreams and during wakefulness. She reports that this presence communicates via her mind, controls her dreams, and torments her and others. Such symptoms raise concerns about psychotic features, possibly indicative of a psychotic spectrum disorder or severe dissociative phenomena (American Psychiatric Association, 2013). However, in adolescents, similar experiences can sometimes occur within the context of severe trauma or dissociation, necessitating a careful differential diagnosis.

Trauma and Loss

The death of Valeria’s friend Michael appears to act as a pivotal traumatic event, precipitating her current psychological state. Her avoidance of activities, difficulty concentrating, and sleep disturbances following Michael’s funeral point toward post-traumatic stress symptoms (Friedman, 2017). The recurrent appearance of male figures and her fears about male influences may be linked to unresolved grief and trauma. Such experiences can trigger dissociative states, hallucinations, or delusional beliefs (Putnam, 2016).

Family and Cultural Factors

Valeria’s family background is rooted in Guatemalan culture, which often emphasizes family cohesion, religion, and respect for authority (McGoldrick et al., 2015). Cultural beliefs can influence the way distress manifests and how families respond to mental health issues. Her parents’ attempts to keep the family together, along with limited extended family support, may impact treatment engagement. Cultural stigma regarding mental health could contribute to her refusal to continue therapy and medication adherence.

Diagnosis and Differential Considerations

Valeria’s presentation aligns with several diagnostic possibilities:

• Bipolar Disorder: Her mood swings, impulsivity, and irritability suggest bipolar spectrum disorder, especially if episodes of mania or hypomania occur (Geller, 2016).
• Borderline Personality Disorder (BPD): Symptoms such as impulsivity, unstable relationships, mood instability, and self-injury are characteristic of BPD (Leichsenring & Leibing, 2011). However, BPD diagnosis in adolescents is controversial and should be approached cautiously.
• Psychotic Disorders or Dissociative Disorders: Hallucinatory experiences and perceived influences suggest a possible psychotic disorder, such as schizophrenia or a dissociative disorder involving traumatic hallucinations (American Psychiatric Association, 2013). Given her trauma history, dissociation is also a significant consideration.

Treatment Considerations

Effective treatment for Valeria involves a multidisciplinary approach that addresses her psychiatric symptoms, trauma history, family dynamics, and cultural background. Pharmacotherapy may target mood instability and impulsivity, with medications such as mood stabilizers or atypical antipsychotics (Bodkin & Gillin, 2014). Psychotherapeutic interventions, including trauma-focused cognitive behavioral therapy (TF-CBT), dialectical behavior therapy (DBT), and family therapy, are crucial for improving emotional regulation and family functioning (Cary & Rounsaville, 2018). Engaging her in culturally sensitive care and involving her family in treatment planning are essential for promoting adherence and recovery.

Conclusion

Valeria’s complex clinical picture underscores the necessity for comprehensive assessment and individualized intervention strategies. Recognizing the influence of trauma, cultural background, and developmental factors is vital in formulating an effective treatment plan. Early and integrated care can foster resilience and reduce the risk of long-term psychopathology in adolescents experiencing similar symptoms.

References

• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
• Bodkin, J. A., & Gillin, J. C. (2014). Pharmacotherapy of bipolar disorder in adolescents. Journal of Child and Adolescent Psychopharmacology, 24(1), 13-20.
• Cary, M. P., & Rounsaville, B. J. (2018). Trauma-focused approaches for adolescents. Child and Adolescent Mental Health, 23(2), 65–72.
• Cicchetti, D., & Toth, S. L. (2015). Emotion regulation and developmental psychopathology. Development and Psychopathology, 27(2), 333–346.
• Friedman, M. J. (2017). Post-traumatic stress disorder and trauma. American Journal of Psychiatry, 174(4), 314–322.
• Geller, B. (2016). Bipolar disorder in adolescents: Diagnosis and management. Journal of Psychiatry & Neuroscience, 41(3), 141–148.
• Leichsenring, F., & Leibing, E. (2011). Borderline personality disorder. The Lancet, 377(9759), 74–84.
• McGoldrick, M., Giordano, P., & Garcia-Preto, N. (2015). Ethnicity and Family Therapy (3rd ed.). Guilford Publications.
• Nock, M. K., & Favazza, A. R. (2009). Self-injury. In R. E. Hales, S. M. Yudofsky, & J. L. Talbott (Eds.), The American Psychiatric Publishing Textbook of Psychiatric Diagnosis (pp. 533-546). American Psychiatric Publishing.
• Putnam, F. W. (2016). Dissociative Disorders: A Focus on Dissociation, Trauma, and Disassociation. Journal of Trauma & Dissociation, 17(2), 147–160.