Psychiatric Core Rotations

Psychiatric case report on Patient X.

By Jessica Prince
All Saints University School of Medicine

Demographics
NAME: X
AGE: 14
SEX: Female
POB: Dominica
ETNICITY: Afro-Caribbean
MARITAL STATUS: SINGLE
OCCUPATION: Unemployed
RELIGION: Christian
LANGUAGE: English

Chief compliant
Attempted suicide, disruptive behavior at school and at home.
History of Present Illness
This is a fourteen year old female patient referred from the A&E department. She was
brought in by Welfare officers in handcuffs with a history of:

Running away from a welfare holding facility

Attempted suicide by drowning
Aggressive behavior
Drug Abuse

Prior to this incident, she had been involved in a group where members would engage in
satanic rituals, prostitution and illicit drug distribution and use, including marijuana,
cocaine, crack and alcohol. X claimed she was Satans daughter, at the time of admission
and later stated that she had engaged in sexual acts with other members of the group.
Also, X. has ran away from home on four different occasions, with the reason being that she
wanted to avoid being physically abused by her Step-father, there was a social gathering
she wanted to attend and a group members bash.
Past psychiatric history
There is no past psychiatric history
Substance abuse history

Alcohol
Marijuana
Cocaine
Crack

Family psychiatric history

No known family history of Psychiatric illness
Medical History
No chronic illnesses

Social History

X was born in Dominica but migrated to another Caribbean island at the age of
20months.
While abroad, she lived with her Fathers family, where at the age of 7yrs, a family
friend sexually abused her.
At 9yrs X migrated back to Dominica, where she currently resides with her mother,
step-father and five siblings all under the age of 18, including a four month old baby
brother.

X now has a poor relationship with her biological father who lives in abroad. At home X
frequently sees conflict between her mother and step-father, the family is burdened with
financial constraints, and X frequently assumes an adult role by doing many chores around
the house. Also, X reports physical abuse by her step-father, including him using a piece of
wood to hit her with in public.
At home X.:

Lies
Runs away on a weekly basis
Verbally and physically abused her 16 year old sister

Education
After migrating back to Dominica at 9 yrs. X. presented with developmental delays
including being illiterate and was placed in Grade II at primary school.
At the age of ten she improved and performed satisfactory at school, but she also began
displaying dysfunctional behavior such as:

Non-adherence to rules
Stealing

X. lost interest in academics around the age of 11 but was able to pass the National
assessment exams and received a scholarship, from a local church, to attend high school. At
high school she presented with:

Defiant behavior towards staff

Decreased academic performance
Inappropriate behavior on the school compound including:
Kissing a male student in the hallway for which she was suspended
Dancing on a pole structure at the school auditorium

Occupation and Financial support:

She is currently unemployed and is financially supported by:

Her Step-father works at a bakery

Welfare/ Social services provide a $250 Family package

Religion
Christian
Habits

Crack
Cocaine
Alcohol
Marijuana
X. engages in prostitution and the trading of illicit substances

Relationships

X. Commenced sexual relations, at the age of 11 with her classmate who she refers
to as her boyfriend.
X. has a boyfriend who is 18 years old, and she engages in sexual activities with
other members of her group.

Physical Examination
No abnormalities detected on P.E. and Vital signs were stable
Lab Investigations
CBC, U&Es, and HIV I & II were done and no abnormalities detected

Mental Status Examination on Admission

Untidy
Poor eye contact
Cooperative with interview
Alert and Oriented
Speech: Clear and Coherent
Mood: Sad
Affect: Inappropriate
Suicidal Ideations: Present
Suicidal Plan: Drown herself
Judgment: Fair

X. Stay on the ward

X. spent six weeks on the ward. In her first week of arrival, she was defiant towards staff
and she was easily agitated. She had negative feelings about being on the ward, once she
stated that anyone who tells her she was in the mad house she will fight them. On one
occasion she damaged a tap in the bathroom, and had also engaged in verbal altercations
with other patients, she also complained of having to wake up and go to sleep too early.
X. also began displaying disinhibited behavior and interacted with male patients on the
ward inappropriately, engaging in kissing a male patient.
Occasionally, during ward rounds X. would seem angry, distant and uncooperative; and
staff reported feeling a sense of ambivalence from her but after four weeks of admission,
she improved.
She became remorseful of her defiant behavior, became well behaved on the ward and
interacted with staff more cooperatively; she was given the responsibility of keeping the
ward tidy for a week and fulfilled her responsibilities well. X. also began verbalizing her
desire to change her bad habits, to improve her grades and she also expressed her goal of
becoming a doctor or lawyer in the future.

Multiaxial Assessment
AXIS I- Conduct disorder
Substance abuse
AXIS II- Deferred
AXIS III: Deferred
AXIS IV: Psychosocial and environmental factors affecting her current psychiatric and
treatment outcome:

Problems with primary support group

Biological father is absent
Step-father physical abuses her
Mother is primary disciplinarian of six children at home, has
increased stress levels
Economic problems: Parents are unable to provide financially

AXIS V- Childrens Global assessment Scale.

On Admission her CGAS 35
40-31 Major impairment of functioning in several areas and unable to function in at home,
at school, with peers, or in society at large, persistent aggression without clear instigation;
markedly withdrawn and isolated behavior, suicidal attempts with clear lethal intent; such
children are likely to require special schooling and/or hospitalization or withdrawal from
school
On Discharge her CGAS - 71
80-71 No more than slight impairments in functioning at home, at school, or with peers;
some disturbance of behavior or emotional distress may be present in response to life
stresses these are brief and interference with functioning is transient; such children are
only minimally disturbing to others and are not considered deviant by those who know
them.
Diagnosis
Conduct Disorder
Substance abuse

DSM IV Criteria for Conduct Disorder

Conduct Disorder
A. A repetitive and persistent pattern of behavior in which the basic rights of others or
major age-appropriate societal norms or rules are violated, as manifested by the presence
of three (or more) of the following criteria in the past 12 months, with at least one criterion
present in the past 6 months:

Aggression to people and animals:

often bullies, threatens, or intimidates others
often initiates physical fights
has used a weapon that can cause serious physical harm to others
(e.g., a bat, brick, broken bottle, knife, gun)
has been physically cruel to people
has been physically cruel to animals
has stolen while confronting a victim (e.g., mugging, purse snatching,
extortion, armed robbery)
has forced someone into sexual activity
Destruction of property:
has deliberately engaged in fire setting with the intention of causing
serious damage
has deliberately destroyed others property (other than by fire
setting)

Deceitfulness or theft:

has broken into someone elses house, building, or car

often lies to obtain goods or favors or to avoid obligations (i.e., cons others)
has stolen items of nontrivial value without confronting a victim (e.g., shoplifting,
but without breaking and entering; forgery)
Serious violations of rules:
Often stays out at night despite parental prohibitions, beginning before age 13
years
Has run away from home overnight at least twice while living in parental or
parental surrogate home (or once without returning for a lengthy period)
Is often truant from school, beginning before age 13 years

B. The disturbance in behavior causes clinically significant impairment in social, academic,

or occupational functioning.

Differential Diagnosis

Oppositional Defiant Disorder

Attention Deficit Hyperactivity Disorder

Major Depression

Bipolar Disorder

Intermittent Explosive Disorder

Management of X.
Multimodal approach was used:
Medication: Tegretol (Carbamazepine) 200mg
Social intervention
Family Therapy
Parent Management Training
Cognitive Behavioral therapy
Psycho-education
Individual Therapy
Social skills
Academic and Community Support
X.s participation in Occupational Therapy
X. was cooperative, but did not take the activities seriously in the beginning. However, she
improved and began actively participating, and interacting with patients during these
activities.
Prognosis
X.s prognosis is fair

Positives:

X. improved on the ward

X. understood that her deviant behavior is wrong and non-beneficial to her
X. was placed in a home with her Aunty

Negatives:
Substance abuse
Discharge:
A session was held with the Psychiatric team along with Welfare officers, to inform her
mother of the decision to discharge X. to her Aunts care. X. and her mother were both
tearful and sobbing during the session. X. also informed her Aunty, that she is hoping she
receives, Attention, love, care and Rules from her.
Post Discharge Plan:
Follow up at the end of the week
Tegretol 200mg PO BD for one month

Post Discharge
X. returned to the ward accompanied by her Aunt at the end of the week. She was
dressed provocatively; her facial expressions seemed sad and X. expressed her
desire to see a female friend she had made on the ward. PMT was initiated with her
Aunt, and X. is scheduled to return as an outpatient client this week.