The Case Of L Presenting Problem Client Presented In The Eme

The Case of L Presenting ProblemClient presented in the emergency room

The case involves a 17-year-old Hispanic female, referred to as L, who was brought to the emergency room following self-injurious behavior, specifically cutting her wrist, after an argument with her parents. Her psychological profile includes episodes of irritability, explosive behavior, defiance, and violent conduct, coupled with a history of self-harm, substance refusal, and complex family dynamics. She has a history of multiple hospital visits for suicidal threats and attempts, inconsistent engagement with mental health treatment, and a history of trauma including childhood sexual abuse. The goal of this paper is to develop an accurate DSM-5 diagnosis, explore differential diagnoses, recommend validation assessments, and formulate a culturally sensitive treatment plan tailored to L's presenting problems and strengths.

Paper For Above Instruction

Introduction

Adolescence is a critical developmental stage marked by significant emotional, psychological, and social changes. For some youth, these changes are accompanied by the onset of mental health disorders, which require careful diagnostic assessment and tailored intervention. In this case, L presents with complex symptoms including self-harm, emotional dysregulation, impulsivity, and trauma history. Given her multifaceted clinical picture, a thorough differential diagnosis process substantiated by DSM-5 criteria is essential to establish an accurate diagnosis and guide treatment. This paper aims to articulate a comprehensive diagnostic profile for L, evaluate plausible alternative diagnoses, recommend suitable assessment tools, and propose culturally competent, evidence-based interventions that leverage her strengths.

Diagnostic Evaluation

Full DSM-5 Diagnosis

Based on the comprehensive clinical presentation, L’s symptoms align with several DSM-5 diagnoses. The primary diagnosis is Borderline Personality Disorder (BPD) (ICD-10-CM: F60.3), given her history of emotional instability, impulsivity, unstable interpersonal relationships, identity disturbance, chronic feelings of emptiness, intense anger, and self-injurious behavior. The pattern of recurrent suicidal acts, self-mutilation, and affective dysregulation also supports this diagnosis.

Additional diagnoses include Post-Traumatic Stress Disorder (PTSD) (ICD-10-CM: F43.10), considering her history of childhood sexual trauma and ongoing trauma-related symptoms, such as mistrust and hyperarousal. Her episodes of irritability, explosive behavior, and persistent mood variability can also be indicative of Bipolar II Disorder (ICD-10-CM: F31.81), particularly if a pattern of hypomanic episodes is observed, though current evidence points more strongly to BPD as the primary diagnosis.

Furthermore, given her history of substance refusal and no current substance use, a primary diagnosis of No Substance Use Disorder is appropriate, although vigilance for comorbidities remains important.

Supplementary codes include Z-codes such as Personal history of childhood sexual abuse (Z63.8) and Other problems related to primary support group (Z63.5), to address her trauma and familial issues in treatment planning.

Matching Symptoms to DSM-5 Criteria

According to DSM-5 criteria for Borderline Personality Disorder, a pervasive pattern of instability of interpersonal relationships, self-image, and affects, as well as marked impulsivity beginning in early adulthood, is evident. Conditions such as frantic efforts to avoid real or imagined abandonment, unstable and intense interpersonal relationships, identity disturbance, impulsivity in areas that are potentially self-damaging (e.g., self-harm), recurrent suicidal behavior, and chronic feelings of emptiness are present. L reports numerous impulsive and self-injurious behaviors, emotional volatility, and identity issues, fulfilling DSM-5 criteria (American Psychiatric Association [APA], 2013).

Her PTSD diagnosis aligns with criteria including exposure to traumatic events in childhood, intrusive symptoms, hyperarousal, and avoidance behaviors. Her self-injury, trauma, and history of sexual abuse substantiate this diagnosis (Reus et al., 2018).

For potential Bipolar II, the episodic mood shifts, including irritability and impulsivity, may resemble hypomanic episodes if persistent but do not reach full manic criteria, warranting further longitudinal assessment (Helm, 2016).

Differential Diagnoses Considered and Ruled Out

  1. Major Depressive Disorder (MDD): Considered due to her sadness, weight loss, and self-harm; however, her episodic impulsivity and identity swings are more characteristic of BPD than MDD, which lacks pervasive pattern of instability.
  2. Conduct Disorder (CD): Raised due to her most recent aggressive behaviors and defiance; but the affective instability, self-harm, and unstable relationships point more towards BPD rather than conduct disorder, which primarily involves violation of societal norms and rules without pervasive affective instability.
  3. Bipolar Disorder (particularly BP I): While mood episodes are present, the pattern of instability is more consistent with BPD. The lack of clear manic episodes and mood cycling suggests BPD as more fitting.

These alternative conditions were considered based on her symptoms but were ruled out due to the prominence of affective instability, identity disturbance, and self-harming behaviors characteristic of BPD, supported by her trauma history and pattern of relational instability.

Assessment Recommendations

To validate the diagnosis and monitor clinical progress, specific assessments are recommended. The Borderline Evaluation of Severity over Time (BEST) tool can measure severity trends for BPD symptoms (Gowin et al., 2017). The Childhood Trauma Questionnaire (CTQ) can quantify trauma history, critical for trauma-informed care (Hom et al., 2016). The Beck Depression Inventory-II (BDI-II) and the State-Trait Anxiety Inventory (STAI) are useful for periodically evaluating mood and anxiety levels.

Furthermore, the Structured Clinical Interview for DSM-5 (SCID) should be employed to confirm Axis I and II diagnoses comprehensively. Cultural and linguistic adaptations are essential; translated versions or culturally sensitive tools should be used to ensure accuracy (Helm, 2016).

Culturally Sensitive Resources and Treatment Strategies

Given L’s cultural background (Hispanic, Guatemalan roots), a culturally competent approach is critical. Incorporating culturally relevant psychoeducation, involving family members in therapy, and respecting familial values align with the models articulated by Best et al. (2016).

Initial treatment should focus on building rapport, establishing safety, and addressing trauma through trauma-focused cognitive-behavioral therapy (TF-CBT) and dialectical behavior therapy (DBT), which is evidenced as effective in BPD (Reus et al., 2018). These modalities help with emotional regulation, distress tolerance, and identity development. Inclusion of culturally adapted interventions increases engagement and efficacy (Gowin et al., 2017).

Client Strengths and Utilization in Treatment

Despite her complex presentation, L demonstrates notable strengths: intelligence, articulateness, cultural pride, social skills, and insight into her own behaviors. These can be leveraged to foster motivation, resilience, and therapeutic alliance. For example, her intelligence facilitates cognitive restructuring, while her social skills can be used to practice interpersonal effectiveness.

Her awareness, although limited, about her trauma and behaviors provides a foundation for engagement. Strength-based interventions should cultivate her self-efficacy, emphasizing her potential for recovery and growth.

Skills and Knowledge Acquisition for Effective Treatment

Clinicians working with L should pursue specialized training in DBT, trauma-informed care, and cultural competence to adequately address her needs (APA, 2013). Learning about Hispanic cultural values such as familismo, respeto, and simpatía is essential for effective engagement. Ongoing supervision, consultation, and self-education in adolescent trauma and personality disorders are necessary to enhance clinical skills.

A multidisciplinary approach including case management and family therapy is recommended to support her comprehensive needs. Regularly reviewing literature and participating in continuing education ensure adherence to best practices (Helm, 20116).

Conclusion

In sum, L’s presentation suggests a primary diagnosis of Borderline Personality Disorder, substantiated by her history, symptoms, and clinical criteria. Differential diagnoses like Major Depression, Conduct Disorder, and Bipolar Disorder were carefully considered and ruled out based on symptom pattern and clinical judgment. Validating assessments, culturally competent interventions, and strength-based treatment plans are crucial for her recovery trajectory. Addressing her trauma, emotional regulation deficits, and familial context within an evidence-based framework offers the best path toward stabilization and growth. Clinicians must continually adapt interventions to suit L's cultural and developmental needs, ensuring a holistic, respectful approach that fosters resilience and healing.

References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
  • Gowin, J. L., Sloan, M. E., Stangl, B. L., Vatsalya, V., & Ramchandani, V. A. (2017). Vulnerability for alcohol use disorder and rate of alcohol consumption. American Journal of Psychiatry, 174(11), 1094–1101. https://doi.org/10.1176/appi.ajp.2017
  • Helm, P. (2016). Development and psychometric analysis of the Brief DSM-5 Alcohol Use Disorder Diagnostic Assessment: Towards effective diagnosis in college students. Psychology of Addictive Behaviors, 31(7), 797–806. https://doi.org/10.1037/adb
  • Hom, M. A., Lim, I. C., Stanley, I. H., Chiurliza, B., Podlogar, M. C., Michaels, M. S., & Joiner, T. E., Jr. (2016). Insomnia brings soldiers into mental health treatment, predicts treatment engagement, and outperforms other suicide-related symptoms as a predictor of major depressive episodes. Journal of Psychiatric Research, 79, 108–115. https://doi.org/10.1016/j.jpsychires.2016.05.008
  • Reus, V. I., Fochtmann, L. J., Bukstein, O., Eyler, A. E., Hilty, D. M., Horvitz-Lennon, M., & Hong, S.-H. (2018). The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. American Journal of Psychiatry, 175(1), 86–90. https://doi.org/10.1176/appi.ajp.2017
  • Best, D., Beckwith, M., Haslam, C., Haslam, S. A., Jetten, J., Mawson, E., & Lubman, D. I. (2016). Overcoming alcohol and other drug addiction as a process of social identity transition: The social identity model of recovery (SIMOR). Addiction Research & Theory, 24(2), 111–123. https://doi.org/10.3109/.2015
  • Petrakis, I. L. (2017). The importance of identifying characteristics underlying the vulnerability to develop alcohol use disorder. American Journal of Psychiatry, 174(11), 1034–1035. https://doi.org/10.1176/appi.ajp.2017

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