Case Of Valeria Intake Date August - Identifying Demo 591335

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 slowly has dropped out of many activities she has 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 arise during these episodes when Valeria 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.

Valeria’s mother confirmed that Valeria had trouble sleeping and concentrating at school after the funeral of her friend Michael, three years ago. She did not want to attend activities at that time for months. Valeria’s mother remembered how scared she had become on a few occasions when Valeria stated that a male presence explained that she should join her friend Michael. PAST PSYCHIATRIC HISTORY: Valeria was evaluated three times at the community hospital ER during the past 2 years. Hospital evaluations were usually done after suicide attempts or threatening violent behavior toward 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 in outpatient counseling on at least four occasions. A social worker was even sent for 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 superficial cuts on Valeria’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 Valeria about the cigarette burns, Valeria responded, "I just wanted to see how it felt—now 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 noticed over 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 very worried 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 to being in a nasty mood. There was little 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 even remembering cutting her 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 been a 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 he communicates with her through her mind. She seemed distressed when speaking about him. Valeria reported that during her wake hours she can't see this presence, but she can sense him. She did 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. 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 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." 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.

Paper For Above instruction

The case of Valeria presents complex mental health concerns that require a comprehensive evaluation of her psychological history, current symptoms, and environmental factors. Her presentation suggests possible underlying psychiatric disorders, potentially including mood disorder, psychotic features, or trauma-related symptoms. This analysis aims to explore her background, symptoms, and potential diagnoses, supported by relevant psychological theories and clinical evidence.

Valeria's demographic background is significant for understanding her social and familial context, which can influence her mental health. As a 17-year-old Hispanic female living in Pennsylvania, her familial and cultural background may impact her perceptions of mental health, expression of symptoms, and access to support systems. Her age and developmental stage also suggest she is navigating adolescence, a period characterized by identity formation, emotional regulation, and vulnerability to mental health issues such as depression, anxiety, or behavioral disorders (Shaw et al., 2020).

Her history of presenting with self-harm behaviors, including wrist-cutting and cigarette burns, indicates significant distress and possible underlying psychopathology such as borderline personality disorder (BPD), depression, or post-traumatic stress disorder (PTSD). Self-injurious behavior in adolescents can serve functions such as emotional regulation, self-punishment, or communication of distress (Klonsky, 2007). During her intake, Valeria's claim of knowing she "is not crazy" might reflect insight, albeit limited, typical for adolescents experiencing intense internal conflicts.

Her recurrent assessments at the community hospital ER following suicide attempts or threats highlight the severity of her self-harm and potential risk for suicide, necessitating close monitoring and intervention. The fact that she has refused ongoing therapy and medication compliance complicates her treatment trajectory, indicating resistance possibly rooted in mistrust or lack of insight. Such resistance may also correlate with her perception that mental health providers view her negatively or her struggle with managing her emotions and behaviors (Nock & Prinstein, 2004).

Valeria's history of trauma, notably the funeral of her friend Michael, and her subsequent behavioral changes suggest possible post-traumatic reactions. Her description of hallucination-like male presences that communicate with her through her mind, appear in her dreams, and control her thoughts may signify psychotic features or dissociative phenomena. These symptoms could be indicative of a psychotic disorder such as schizophrenia or schizoaffective disorder; however, in adolescents, such symptoms may also be reflective of severe trauma with dissociative components or a dissociative identity disorder (American Psychiatric Association, 2013).

Her personal account of male presences, including the primary figure described as ageless, dressed in dark colors with powerful eyes, and controlling her thoughts and dreams, aligns with delusional beliefs often seen in psychotic disorders. The secondary male presence, which appears controlled by the primary, may denote paranoid or persecutory themes, common in psychosis, or alternatively, a dissociative manifestation linked to trauma (Mazurek et al., 2018). Her report that during waking hours she cannot see these presences but can sense or see them in dreams indicates dissociative aspects or phenomena related to hallucinations or vivid intrusive imagery.

Behaviorally, Valeria exhibits impulsivity evidenced by throwing objects and her aggressive outbursts toward authority figures, such as assaulting her principal. These behaviors may suggest underlying emotional dysregulation, common in borderline personality pathology or trauma-related disorders (Linehan, 1993). Her flat affect and limited eye contact further suggest emotional blunting, which can be associated with depression, PTSD, or dissociative states.

The familial context adds an important layer to her psychological profile. Her parents' efforts to maintain family stability despite economic and emotional difficulties, combined with her sister's avoidance when Valeria is upset, suggest familial stress and potential limited emotional support at home. Lack of extended family support, especially with relatives in Guatemala, may limit her access to cultural or familial protective factors.

In terms of diagnosis, her symptoms could align with several psychiatric categories. The presence of self-harm, emotional instability, impulsivity, and identity disturbance point toward borderline personality disorder. However, her hallucination-like experiences and paranoid delusions could suggest psychotic episodes. Alternatively, trauma-related disorders, such as PTSD or dissociative identity disorder, could explain her dissociative symptoms and visions linked to her friend Michael's funeral and her subsequent trauma.

Further assessment is vital for an accurate diagnosis, including detailed psychological testing, collateral information from family and school, and ongoing mental status examinations. Treatment approaches should incorporate safety planning, trauma-informed care, psychotherapy targeting emotional regulation (e.g., dialectical behavior therapy), and pharmacological management if necessary. Engaging her in therapy might be challenging given her resistance, hence building rapport and trust is critical.

In conclusion, Valeria's case illustrates the complexity of adolescent mental health and the importance of a multidisciplinary approach. Her symptoms reflect a mixture of trauma, emotional dysregulation, and psychotic features, requiring careful diagnostic evaluation and tailored intervention strategies. Supporting her through therapy, ensuring safety, and addressing her trauma are essential steps toward her recovery.

References

• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
• Clonsky, C. D. (2007). The functions of self-injury: A review of the evidence. Journal of Clinical Psychology, 63(11), 1030–1040.
• Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.
• Mazurek, B., et al. (2018). Dissociative Disorders in Adolescence: Clinical Features and Treatment. Journal of Child & Adolescent Trauma, 11(2), 203–213.
• Nock, M. K., & Prinstein, M. J. (2004). A functional approach to the assessment of self-mutilative behavior. Journal of Consulting and Clinical Psychology, 72(5), 885–890.
• Shaw, D. S., et al. (2020). The Development of Emotional Regulation in Adolescence. Developmental Psychology, 56(10), 1939–1949.