Family Psychiatric Treatment Case Study

Presenting Problem: Pt is a 17 year old African American female presenting with PTSD, MDD, moderate with psychosis historically but no psychosis presently. Pt is presently transitioned to Riverside Acute Center due to making statements of self-harm and becoming aggressive towards staff that caused her to be restrained in Riverside Residential Unit. The therapist who has been working with her in residential believes that she is self-sabotaging. She has become increasingly volatile and has lost her temper often. She decided that she didn’t want to be in the program and wanted to leave. She did not reuse to attend therapy, but refused to work on or utilize any skills. She has communicated she does not like her therapist at the facility.

Family
She has been in time out several times over the last month and was a manual hold on 6/28/16. Kayla believes that she does not need certain medication and that medications made her worse and requested to have her Tegretol medication discontinued 6.29.16 thru 7.6.16. Medication was at a therapeutic dose of 5.1. Her Abilify was discontinued on 7.6.16. 7.1.16 she attended court, but before this she became angry at AT staff and threatened to punch the therapist. She soon after was put in a manual hold due to severe agitation. On 7/10 she was banging things in her room, walking on her desk and trying to cause a scene but calmed down after processing with her primary. She defiant when she does not get her way, and requires lots of redirection. She displays loose reality orientation when she became emotionally dysregulated. She barricaded herself in her bathroom. She was hospitalized at the CCCA 9/2015, VTCC 7/2015. She has a history of multiple hospitalizations, aggressive behavior, suicidal ideation and self-harm. She was placed in juvenile detention for 23 days in 2015 due to assaultive behaviors, she transition to a group home for teen mothers, where she threatened to run away. She than was transferred to a foster care