Heidi is a 15 year old who is ambitious and has a lot of strong personality traits. Heidi is outgoing and enjoys being around meeting people. Heidi comes from a troubled family background and has had a lot of interpersonal problems with her mother. She has overcome being homeless and has struggled to be able to manage life on her own at a young age.
Heidi has blonde hair and blue eyes and was neat in appearance. She had clean clothes on and was dressed in a neat and appropriate manner.
Presenting Problem and History of the Problem—
Heidi has had some difficulty with meeting new people and has had problems with being taken advantage of by men in her life. Heidi is overly sexual and has been in a lot of situations where she could have been harmed or been in trouble based on the fact that she has not taken a lot of precautions when she has had sexual intercourse with men. She has put herself in a lot of risky situations. She has a lot of self blame and has problems with feeling as though she doesn’t deserve for things to be good for her based on her issues with the past and problems that she has had.
Heidi is prone to mood swings and tends to “freak out” at times yelling at those who are around her. Heidi does not have many friends and has a hard time with getting along with others that are around her. Her interpersonal problems carry over into her place of employment. Heidi has recently moved back into her mother’s home after having left over guilty feelings of kissing her mother’s boyfriend. Heidi and her mother are working on their relationship but Heidi continues to harbor self blame for incidents from the past.
Multi-axial DSMV IV Diagnosis—
Axis I—Bipolar Disorder I
Axis II—Borderline Personality Disorder
Axis III V71.09/no diagnosis
Axis IV—housing issues
Axis V—GAF 45
Discussion of Differential Diagnosis—
The diagnosis of Bipolar Disorder I was chosen as Heidi tends to be manic most of the time. She reacts in an overly sexualized way and tends to try to gain attention from those who will show her attention whether or not the attention is positive. She experiences some very real versions of mania and problems with being overly sexual which are problems in themselves. She also was experiencing symptoms of emotional involvement when she freaked out and yelled at those who are around her. She was losing control of her temper and unable to control her emotional outburst. These are all symptoms of bipolar disorder. Some other symptoms that she had of bipolar disorder were the symptoms of being depressed. She also talked a lot about self guilt and had a lot of self blame for issues. She had a continued lack of insight and also had emotional barriers that kept her from being able to react in a calm and organized manner. She had loose thought associations as well as some problems with being able to relate to the environment that she was in.
As for her Axis II diagnosis of Borderline Personality Disorder, she had many of the symptoms of BPD. She was very emotionally outraged and she tended to have some problems and freaking out as needed. Another issue was that she acted out in many ways that were considered to be attention seeking behaviors including the issues of freaking out and having a lot of sexual intercourse with various members of the opposite sex. She also seemed to have little insight into what was going on. She was not concerned with the reactions for her actions or how they affected other people. When she was kissing her mom’s boyfriend, she had little thought about what it would do to her relationship with her mother. Further when she was going home with various men from the bar or hanging out with men in different places. She did not think about the dangers that could happen or the trouble that she get involved with in these places or in these situations. She didn’t think about what was going on with those around her either as far as her sexual health was concerned, she had no insight into the problems that could occur from her not being more careful with who she was having sex with.
There were no known medical conditions mentioned so she did not have an Axis III diagnosis.
As for her Axis IV diagnosis, well she was having some significant problems with her housing throughout the movie. The housing was due to various problems. When she was caught making out with her mom’s boyfriend she then found herself to be homeless and this was one of the things that were available to her. She then ended up living in a hotel but did not have the most stable living environment. At the end of the movie she was moving back in with her mother however the possibility of there being problems in the future is likely without her getting treatment and therefore housing problems could still be an issue.
Another Axis IV diagnosis is that she was having financial problems. Being that she is 15 and is trying to earn enough income to support herself would explain why she is having problems financially. She would have a hard time finding stable enough employment at her age in order to be able to live and find the things that she needed without having continued problems. The last problem area that I identified on the Axis IV was interpersonal problems/conflict. The problems that were occurring with her mother were a prime example of the lack of insight into interpersonal relationships. The other problems were that she had few friends and did not seem to get along with others well. She also had poor choices in her relationships with men during the movie and this too could be fofr many various reasons, most of which were stemmed from her lack of ability to have successful interpersonal relationships.
Heidi’s Axis V diagnosis or GAF was 45. She had some serious areas of diminishment and would not have been able to maintain her life on her own without the outside support of someone. She was fortunate to have found the outside support of the cook at the hotel and her boyfriend as well as having her mother when she was back in her mother’s home. She would have had a hard time maintaining on her own without outside supports.
It was ruled out that she had Bipolar II disorder (she was not recently and most recently in a depressed mood) and Schizoeffective Disorder (although she had the mood swings and lack of insight there was little to show any symptoms of parnoia or any halleucinations). For Axis II there were no rule outs and it was clear that she was having symptoms and problems that could be associated with Borderline Personality Disorder. As for Axis III there were no medical problems so there were no rule outs. For Axis IV there was the rule out of employment problems as there were problems with employment however she was able to find employment on her own. For her GAF, it was questionable about how high her abilities to care for herself were.
Other Concerns and/or Problems—
A majority of the extra concerns and problems are due to the lack of knowledge and insight, much of which is simply based on her age as she is a very young adult/teenager. There are a lot of concerns and issues about her sexual health and the lack of insight into her sexual activity. It was clear that she was not concerned with having protected sex or with being sure to participate in a safe sexual relationship. There were many problems with her needing sexual education and to also be sure to check with an MD to ensure that she has positive sexual health at this time. She would need to have a full gynecological exam and pap smear to ensure that she has not been infected with any STD’s or that she is not currently pregnant.
There are many treatment options for someone who is diagnosed with Bipolar Disorder I. The first suggestion for Heidi would be that she begin seeing a psychologist and that she begin to see a therapist and be part of an outpatient mental health program. This way she would be able to see people on a regular basis who were trained to monitor her mental health. The outpatient staff could assist her in learning and utilizing some basic ADL’s (activities of daily living) and could also help them to be able to manage her mental health through learning how to live on her own. Some other activities that could be worked on with the outpatient staff are learning how to utilize a journal for recovery management and also learning about groups that would be available to Heidi.
Some further services for Heidi could be advanced DBT (dialectic behavior therapy). This would help Heidi to realize how to control her emotions and her behaviors that were a part of her Borderline Personality Disorder. These include many things like her attention seeking behaviors. With these behaviors there are definite things that could happen to cause Heidi to need specific therapy for these things and the need to learn how to control herself.
Through the psychiatrist Heidi would be able to get medication treatment and have medications to help her manage her moods and stabilize her behaviors. Heidi’s theraptist could work with her on responsibility and her learning how to manage her emotions through emotional management. The two could work together through a clinic or separate as could the outpatient services provider. The outpatient services provider could be either a Recovery Specialist or a Case Manager.
Heidi could also get assistance through a payee or budgeting assistant in her being able to manage her mental health and her finances.
Some other services that might be useful are groups ranging in involvement. There could be an anger management group, this could help her to be less spirited when she is upset and would help her to be able to manage her mental health in a better way. Another group could be a friendship or basic interaction group where Heidi could meet others as well as a young adult or teenage group where she could learn how to become friends with those around them.
American Psychiatric Association. Diagnostic and Statistic Manual of Mental Disorders
DSM-IV-TR. Washington DC: American Psychiatric Association, 2000.
Sue, David; Derald Wing Sue and Stanley Sue. Understanding Abnormal Behavior.
New York: Wadsworth Publishing, 2008.