Question: Part 1
XXXXXXX is a 17-year-old female brought in for an evaluation by her mother, XXXXXXX Even before you XXXXXXX them, you hear the commotion in the waiting room, which concludes with XXXXXXX calling XXXXXXX a "XXXXXXX" and kicking a chair across the room.
Once in your office, the contrast between them is striking. The family lives in one of the pricier suburbs, and XXXXXXX works as an advertising executive. She is successful and well regarded, as is her husband, XXXXXXX father, who works in international banking. XXXXXXX says that he regrets not being present, but there was a sudden meeting in Barcelona that required his attention. XXXXXXX is well-dressed, poised, and soft-spoken.
XXXXXXX on the other hand, is quite gaunt, surly, noticeably unwashed, and dressed in full anarchist punk regalia. You count 11 piercings, some quite large, involving her tongue, lower lip, both nostrils, one eyebrow, and both ears; there may be more hidden by her dramatically dyed and styled hair.
XXXXXXX gives the following account as XXXXXXX shreds a Styrofoam cup, dropping the small pieces on the carpet, sighing loudly, scowling, and mumbling, "Bullshit XXXXXXX
XXXXXXX notes that she and her husband have "bent over backwards" to accept XXXXXXX "lifestyle choices" and her friends. XXXXXXX has not been appreciative, but they understand that adolescence is a difficult time. In the past few months, however, XXXXXXX has lost 25 pounds and has become verbally abusive. She also displays dramatic mood swings and is physically violent, and she is completely disengaged from school, family, and her old friends. She has also taken to hoarding strange objects, and XXXXXXX has noticed strange burns on XXXXXXX arms.
XXXXXXX has concluded that XXXXXXX has developed an eating disorder and is perhaps engaging in self-mutilation. XXXXXXX fears for XXXXXXX health and for the loss of educational opportunity that will occur if XXXXXXX continues nonparticipation in the expensive private school she attends. When you ask XXXXXXX her view on her mother's concerns, she says, "Whatever XXXXXXX
You take some initial background information. XXXXXXX has one sister, four years older, who attends an Ivy League school on the East coast. Her sister had "eating disorder issues" in her freshman year in college, but worked through them in therapy and is now doing well. XXXXXXX reports that XXXXXXX was without problems until last year, when she began hanging around "a rougher element XXXXXXX XXXXXXX and her friends often spent weekends in a cabin in an isolated rural area, and XXXXXXX initially discounted the dangers of these rougher companions, thinking, "How bad can they be if they are into nature?"
When questioned, XXXXXXX says that XXXXXXX has been hoarding all sorts of odd flasks and containers, "just junk XXXXXXX but XXXXXXX has not otherwise examined them because they smell bad. "They must be filthy; I wonder if she got them out of a dumpster XXXXXXX She also reports that XXXXXXX has broken furniture, driven one of the family sports cars through the XXXXXXX garden in a rage, and very recently physically threatened the housekeeper when she attempted to clean XXXXXXX room, to the extent that the housekeeper quit.
XXXXXXX has spoken to her other daughter's therapist, who suggested that as the eating disorder worsens, XXXXXXX self-esteem is plummeting, and as a result she associates more with "degrading people and objects XXXXXXX The therapist speculated that XXXXXXX might be giving herself cigarette burns. XXXXXXX also notes that XXXXXXX has taken up cigarette smoking in this period, and "smokes like a chimney XXXXXXX

Here is my diagnosis or I'm I off again???

Axis I:     296.6x     Bipolar I Disorder Most Recent Episode Mixed
Axis II:     301.83     Borderline Personality Disorder
     301.4     Obsessive Compulsive Personality Disorder
AXIS III:      None
AXIS IV:      None
AXIS V:     20

1. What further diagnostic evaluation do you believe is warranted?
2. What other psychological measures or evaluations/medical data that you would recommend to assist in your diagnosis?

Okay, based on the prior diagnosis….The axis would be….I wasn’t clear…

Axis I:     307.50     Eating disorder not otherwise specified
     295.90 Undifferentiated type
Axis II:     301.83     Borderline Personality Disorder
AXIS III:      None
AXIS IV:      None
AXIS V:      20

I’m I correct on this?

What if we found this new information during a second interview with the patient….

Part 2

• XXXXXXX asks to speak to you privately. She reports that a local pharmacist called her recently to inform her that last week XXXXXXX attempted to purchase a large supply of cold tablets.
• XXXXXXX looked through the trunk of XXXXXXX car and found a good-sized canister of anhydrous ammonia. She has also found a cache of batteries.
• XXXXXXX has learned from neighbors in the community that XXXXXXX has been seen around town with large sums of cash. She notes that she has been very careful to not disrupt XXXXXXX fragile self-esteem by depriving her of her allowance, which has always been generous. But the amounts reported were thousands of dollars. Despite the best efforts of XXXXXXX and her husband, XXXXXXX has never learned money management. It is very unlike her to have accumulated this much cash.
• XXXXXXX tells you that she thinks XXXXXXX is planning suicide, whether by overdose of over-the-counter medication, chemicals, or electrocution. She believes that XXXXXXX is spending all her money as a final fling before killing herself. XXXXXXX has been reading up on eating disorders and has learned that there is an increased risk of suicide in this group. XXXXXXX wants XXXXXXX hospitalized immediately.
• You interview XXXXXXX alone. She is again unresponsive to questions, but her physical appearance is somewhat different. She is very much on edge, seems to have difficulty concentrating, and is quite nervous and twitchy.

1.     What would the new diagnostic AXIS hypotheses would be just for this scenario?

Axis I:     296 Major Depressive Disorder
Axis II:     301.83     Borderline Personality Disorder
AXIS III:      None
AXIS IV:      Environmental
AXIS V:      5

I just not understanding…I guess if I’m not on the right track



2. What further diagnostic evaluation do you believe is warranted?
3. What other psychological measures or evaluations/medical data that you would recommend to assist in your diagnosis?