To prepare:  Use a differential diagnosis process and analysis of the Mental Status Exam in "The Case of L" to determine if the case meets the criteria for a clinical diagnosis. Questions: Provide the full DSM-5 diagnosis. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may need clinical attention). Explain the full diagnosis, matching the symptoms of the case to the criteria for any diagnoses used. Identify 2-3 of the close differentials that you considered for the case and have ruled out. Concisely explain why these conditions were considered but eliminated. Identify the assessments you recommend to validate treatment. Explain the rationale behind choosing the assessment instruments to support, clarify, or track treatment progress for the diagnosis. Explain your recommendations for initial resources and treatment. Use scholarly resources to support your evidence-based treatment recommendations. Explain how you took cultural factors and diversity into account when making the assessment and recommending interventions. Identify client strengths, and explain how you would utilize strengths throughout treatment. Identify specific knowledge or skills you would need to obtain to effectively treat this client, and provide a plan on how you will do so. These questions are based on the following case: The Case of L Presenting Problem Client presented in the emergency room (ER) having been brought in the previous night by her parents. Following an argument with her parents, L cut her right wrist. L's mother reported that L started screaming rapidly and became physically violent toward her prior to cutting her own wrist. Psychological Data L is a 17-year-old Hispanic female who resides in Pennsylvania with her mother, father, and older sister. She is in 11th grade at the local public school. L 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. 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. L slowly dropped out of many activities she liked in the past. Her mother noticed about 8 months ago that L had also begun having difficulty doing schoolwork. Erratic behavior arose during episodes when L 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. L 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 L is outgoing, popular, and smart; but during these episodes she became another person, one who is very ...

1. To prepare:
Use a differential diagnosis process and analysis of the Mental
Status Exam in "The Case of L" to determine if the case meets
the criteria for a clinical diagnosis.
Questions:
Provide the full DSM-5 diagnosis. Remember, a full diagnosis
should include the name of the disorder, ICD-10-CM code,
specifiers, severity, and the Z codes (other conditions that may
need clinical attention).
Explain the full diagnosis, matching the symptoms of the case
to the criteria for any diagnoses used.
Identify 2-3 of the close differentials that you considered for
the case and have ruled out. Concisely explain why these
conditions were considered but eliminated.
Identify the assessments you recommend to validate treatment.
Explain the rationale behind choosing the assessment
instruments to support, clarify, or track treatment progress for
the diagnosis.
Explain your recommendations for initial resources and
treatment. Use scholarly resources to support your evidence-
based treatment recommendations.
Explain how you took cultural factors and diversity into account
when making the assessment and recommending interventions.
Identify client strengths, and explain how you would utilize

2. strengths throughout treatment.
Identify specific knowledge or skills you would need to obtain
to effectively treat this client, and provide a plan on how you
will do so.
These questions are based on the following case:
The Case of L Presenting Problem Client presented in the
emergency room (ER) having been brought in the previous night
by her parents. Following an argument with her parents, L cut
her right wrist. L's mother reported that L started screaming
rapidly and became physically violent toward her prior to
cutting her own wrist. Psychological Data L is a 17-year-old
Hispanic female who resides in Pennsylvania with her mother,
father, and older sister. She is in 11th grade at the local public
school. L 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. 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. L slowly dropped out of many activities
she liked in the past. Her mother noticed about 8 months ago
that L had also begun having difficulty doing schoolwork.
Erratic behavior arose during episodes when L 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. L 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 L is
outgoing, popular, and smart; but during these episodes she
became another person, one who is very violent and difficult.
Medical History A physical examination by a staff doctor

3. revealed superficial cuts on L'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 L about the cigarette burns, L responded, "I just
wanted to see how it felt—now I know." Whe 2 a high school
education. L's sister is considerably younger, aged 8. Their
relationship is described as unremarkable, although L's mother
noted that the younger sister stays away when L 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 L have been an additional difficulty for the family, but
they said they are very worried about L's lack of self-control
and discipline. Extended family are far away and mostly still in
Guatemala. L's parents were not aware of any other family
members with psychiatric problems. Psychiatric History L was
evaluated three times at the community hospital ER during the
past 4 years. Hospital evaluations were usually done after
suicide attempts or threatening violent behavior toward others.
L thought that the clinicians trying to diagnose her only had
book skills and no people skills. She assumed that no one will
ever know what is wrong with her; she did not plan to tell them
because she doesn't like them. L said she knows she "is not
crazy," but she was convinced that the therapist thought she is
crazy or a "bad" kid. "They're just experimenting with me," L
said. L 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; nothing is wrong with me." L's
mother reported that L was involved in outpatient counseling on
at least four occasions as well as being placed in a shelter once
after school truancy, running away from home, and threatening
to assault her. A social worker was even sent for home visits for
a 3-month period. Each time, L would abruptly end therapy by
becoming verbally abusive or totally noncommunicative toward
the therapist and would adamantly refuse to continue therapy.
She even admitted to shoving a desk toward a therapist and

4. threatening her with a pencil. When questioned about this
behavior, L responded, "Well she told me to express myself and
let my true feelings out, so I did." (L also laughed and glanced
at her mother during this exchange.) L's mother was particularly
perplexed and overwhelmed by these behaviors. She stated that
her husband is completely frustrated and angry. Both admitted
that L's behavior is part of the considerable strain on their
marriage. L denied being under any continued psychiatric care
even though it was recommended numerous times. She refused
to go, stating, "The therapists are the ones who are crazy." L
was first seen in outpatient counseling 9 years ago after she
began to have nightmares and experienced tremendous anxiety
after her godmother threatened to kidnap her. Her godmother
became obsessed with L when L was 6 years old, first
threatening to kidnap her then. Her godmother had to be
institutionalized after exhibiting bizarre behavior. Recently, the
godmother started threatening to kidnap L again. Three years
ago, L was sent for counseling after she ran away from home
after getting a bad report card and also discovering that her
parents were considering a divorce. L requested therapy, as she
reported that at 8 years of age she was sexually molested by an
older man in the community (who is now deceased). She
expressed having mixed emotions, because she viewed her
perpetrator as her friend. By pretending that nothing 3
happened, she could think of him as a nice old man, and she
didn't have to deal with the thought of something this bad
happening to her. L's mother reported that she herself was raped
at 8 years old and that L had knowledge of this. Two years ago,
L and the entire family again became involved in outpatient
counseling after L's godmother accused L's mother of child
abuse. L's mother thought this was largely done out of spite. An
investigation by Child Protective Services revealed no abuse.
Mental Status (1 day after she had been evaluated at the ER) L
presented casually, disheveled, in shorts and a tee shirt, and
with minimal makeup. L admitted to being in a nasty mood.
There was little eye contact, and conversation was difficult.

5. Thought and speech patterns were clear. Affect was flat. She
was oriented to time, place, and person. L denied feeling
depressed. 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." L denied even
remembering cutting her wrist, saying, "He must have done it or
made me do it." L was questioned about the person she was
talking about. She related that there has been a male presence in
her life since she was 6 years old 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. L said he communicates with her through her
mind. She seemed distressed when speaking about him. Her
mother appeared distressed and fearful as well. L's mother
confirmed that L had trouble sleeping and concentrating at
school after the funeral. She did not want to attend Girl Scouts
anymore, because the uniform had gotten tight and the male
presence was laughing at her. L's mother remembered how
scared she had become on a few occasions when L attempted to
run out into traffic. Every time L's mother yelled at L for doing
that, L stated that the male presence explained that this was how
she could join her friend Michael. L's mother took L to a
therapist. When L entered the third grade, L's mother took her
out of therapy. L reported that during her awake hours she can't
see this presence, but she can sense him. She said she does 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. L 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." L was asked
why she never shared this information before. She stated,
"Because I would be put in the hospital and medicated—and I
told you, I'm not crazy. I know you don't understand, but I am

6. him and he is me, and he eventually wants to totally control
me." She admitted to acting out impulsively at times, such as
throwing things for no reason. L 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." L also mentioned
that during the past 4 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. L ended the session by saying, "I know this sounds
weird, but this is what is happening to me. If you tell any other
therapist, I'll deny it, because I don't want to be put away."