Housatonic Adolescent Hospital
CASE#: 920,623 NAME: Samantha Frankel Page 1
DISCHARGE SUMMARY
October 24, 1990
Date of Admission: July 6, 1989
Date of Discharge: October 10, 1990
Initial Diagnosis: DSM III-R
Axis I 309.00 Adjustment Disorder with
Depressed Mood
312.39 Atypical Impulse Control Disorder
Axis II 301.83 Borderline Personality Disorder
Axis III No Diagnosis
Final Diagnosis: DSM III-R
Axis I 309.00 Adjustment Disorder with
Depressed Mood
312.39 Atypical Impulse Control Disorder
Axis II 301.83 Borderline Personality Disorder
Axis III No Diagnosis
Reason For Admission
Samantha Frankel is an 18 year old, single, Caucasian female who was admitted on July 6, 1989 on a Physician’s Certificate form the Park City Hospital Emergency Room. The precipitant was a several day history of multiple self-abusive actions involving cutting and scratching of her wrists and forearms and incising the word “hate” on her arm, etc. Samantha had been living at home for the three weeks prior to her evaluation in the emergency room. As Samantha had a long history of psychiatric hospitalizations, including a prior admission to Housatonic Adolescent Hospital, she was viewed as being a continued risk for self-harm and was transferred to the Brief Treatment Unit.
Samantha had been discharged from Housatonic Adolescent Hospital in January of 1988 following a lengthy hospitalization which included treatment on both the Brief Treatment Unit and the ADAM House Unit. She attended Valleyhead School from January, 1988 until April, 1989. Her mother reported that Mandy adjusted fairly well to Valleyhead and developed some positive peer relationships. She was able to spend relatively lengthy passes at home and seemed to generally enjoy attending the Valleyhead School. She never completely ceased either cutting or scratching herself even during periods or relatively stable behavior. Her self-abusiveness became more severe in September, 1988. Her behavior continued to be erratic and , at times, self-abusive, necessitating several trips to a local emergency room over the course of several months. In March of 1989, a sexual incident with girls at the Valleyhead School was a significant stressor for Mandy. On Easter Sunday (March 26, 1989) Mandy overdoses on Tylenol and was admitted to the intensive care unit of Hillcrest Hospital for three days. It was at this point that the staff at Valleyhead School felt they could not provide Mandy an appropriate living arrangement which would meet her needs and provide her with an element of structure and safety. They indicated that they would be looking toward discharging Mandy once another arrangement could be obtained. On April 28, 1989, she was admitted to Elmcrest hospital where she remained until June 14, 1989. At Elmcrest she was unable to cut herself as sharp objects were kept from her. During this period, she scratched herself with her fingernails rather than cutting herself. While at Elmcrest she received day passes home and only acted out of control on one occasion. This included screaming, ranting, and raving. She was discharged on June 14, 1989 to the home of her mother. Outpatient therapy was set up, as was a work study program. She reportedly did not like her outpatient therapist and decided not to see him after only a few visits. On July 1, 1989, Samantha engaged in some minor cutting. She also locked herself in the bathroom and then carved the word “hate” in her arm. Her behavior continued to be self-abusive and erratic over the next few days and she was brought to the emergency room at Park City Hospital and eventually transferred here.
PROBLEM LIST
Four problems were identified for treatment.
1. Self-abusive Behavior
Samantha had a lengthy history of cutting and scratching her arms and hands. She also had demonstrated two serious suicide attempts by overdosing on medications within six months prior to hospitalization.
2. Personality Difficulties
Samantha had a long standing history of conflicted and ambivalent relationships stemming from her unpredictable and self-abusive behavior. She had a very low self-esteem with periods of dysphoria and resorted to impulsive acting out.
3. Affective Disturbance
Samantha presented with chronic low self-esteem and sadness. She also presented with significant guilt around father’s death for which she felt as if she deserved some blame.
4. Family Conflict
Samantha had an ambivalent and conflictual relationship with her father prior to his death. Reports indicated that he was verbally possibly physically abusive to both Mandy and her mother. Mandy also had a lengthy history of conflict with her older sister. Mandy’s behavior seemed to be most self-defeating when she was at home. Her attempts to live at home have ended in failure inspite of the involvement of the family in family therapy in the recent past.
COURSE OF TREATMENT
On admission, Samantha was cooperative, amiable, not particularly distraught nor depressed, and free of apparent self-destructive impulses. She was placed on a routine q 15 minute check. The following day, On July 7, 1989, she began complaining of not wanting to be in the hospital. That morning she scraped her arm on a screen. A treatment plan for self-abuse was re-instated which had been effective with Samantha during her previous hospitalization. Samantha manifested considerable emotional lability, impulsivity, attention seeking behavior, and limit tested with respect to self-abusive actions. The implementation of the treatment plan seemed to be helpful as no self-abusive behavior was noted for several weeks thereafter.
The admission physical examination revealed Samantha to be mildly undernourished with multiple self-inflicted lacerations and abrasions on her hands and arms. Mild dorsal scoliosis, error retraction and slight involuntary tremor of both hands were identified. A complete blood count, urinalysis, blood chemistries, thyroid studies have been essentionally unremarkable. Serium Lithium and Tegretol levels had been in therapeutic range. An EKG demonstrated mild non-specific changes. Over the first month of hospitalization medications included Lithium 900 mg. Per day, Tegretol 600 mg. Per day, and Mellaril in daily doses ranging from 25 mg. to 100 mg. The latter was used during periods of some emotional tension.
Problem #1- Self-Abusive Behavior
Throughout her hospitalization, Samantha engaged in self-abusive behavior. This included a severe scratching of her wrist on October 9, 1990 which necessitated a discharge from Housatonic Adolescent Hospital and an admission to Fairfield Hills Hospital. However, this was progress in this area as the pattern of self-abusive behavior changed remarkably over time. Over the first three months of hospitalization, Samantha engaged in either cutting or scratching behavior at least once per month. In August she used a plastic serrated knife and made a laceration on her left arm which required five stitches. In September she had two minor instances of scratching behavior. Samantha was transferred to ADAM House for long term treatment on October 30, 1989. Within the next three weeks, Samantha cut herself twice. Samantha was then able to go for a period of four months with no evidence of self-abusive behavior. She was having passes home and in May, 1990, Samantha continued to be vulnerable to self –abuse as an expression of her emotions. At this point she was involved in scratching her wrists following an argument with her mother. However, the self-abusive episodes were much less frequent, less intense and were of a much shorter duration than earlier. She rebounded very quickly. On May 22, 1990, Samantha scratched both sides of her face with a piece of glass, feeling overwhelmed by a conflictual relationship with a female peer. However, during the week of June 12 she called the unit from home while on pass stating she had felt that she wanted to hurt herself after having conflicts with her sister. She did not engage in self-abusive behavior, but returned to the unit early and was on close observations for a period of time. She began to show that she was able to handle anger and frustration by seeking out peers and staff to talk rather than becoming self-abusive. Samantha continued to make gains in her self-control and general adjustment over the summer of 1990. She had some emotional upset on while on pass, but she did not resort to self-abuse as a way of handling her emotions. However, as discharge and treatment disposition was becoming more and more imminent (as Samantha reached her 18th birthday), Samantha’s emotional lability increased. She asked to be transferred to the Brief Treatment Unit as she felt she was losing control of her ability not to be self-abusive. This request was granted two days prior to her 18th birthday on September 6, 1990. At first Samantha appeared relieved to be on the Brief Treatment Unit, spoke fairly openly to staff about her concerns concerning going to Fairfield Hills Hospital and slept well. However, on the evening of September 9, 1990, she acted inappropriately in group, superficially scratched her arm and ultimately had to be placed in restraints. This incident appeared to have relieved Samantha of pent up anxiety and she soon was in better spirits. As all discharge plans were being met with roadblocks, Samantha’s emotional lability increased to the point that on October 9, 1990 she scratched her wrist severely. Generally, Samantha has shown some ability and motivation to control her self-abusive behaviors. However, in the face of ongoing and increased frustrations she is likely to resort to self-abuse as a means of relieving her pent up anxieties.
Problem #2- Personality Difficulties & Problem #3- Affective Disturbance
During the first several weeks of hospitalization where she demonstrated rapid mood swings, at several times she was quite friendly and engaging and quickly would become angry and rejecting. She was very resistive to discussing appropriate ways of expressing her anger or her sad feelings. She quickly became friends with a female peer on the unit, however, there interactions tended to be of a negative quality towards the program and towards other residents. Over the second month of hospitalization, Samantha worked in individual therapy and milue therapy on personal issues of a very serious nature: feelings about her father’s death, her sexual orientation, her victimization, and despair about her symptom behaviors and her future. While she was acting in a nervous manner, she was reported to be doing fairly mature work on these issues and allowed herself to experience painful feelings without losing control and acting out. There were other signs of maturation, as well. Samantha took it upon herself to speak with her mother in a calm and appropriate manner about her (Samantha’s) sexual orientation. Mother appeared to have handled the information well and had not shown the anger or rejection Samantha feared. Samantha also made a decision not to request a visit home for her birthday, but to ask for a few hours with her mother here. She stated that she knew she would think about acting out and hurting herself if she were at home which would probably ruin her birthday for everyone. Over the next four months, Samantha continued to have intense feelings about issues of relationships, anger towards her father, AWOL’s, and continued to struggle mightily with appropriate ways to express her feelings. Mandy stated once she reached a critical level of anxiety or anger, it is difficult for her not to react with temptations of self-abuse. Samantha expressed a sense of despair and hopelessness after her acting out behaviors. She was aware that most places would not consider her and that her family would not take her in. She stated that Fairfield Hills Hospital would be the only option for her. By March 1990, Mandy demonstrated remarkable growth in most modalities. In activity therapy she had had more patience with herself and had attempted to develop more mature and age-appropriate interactions with peers and with staff. In addition she had the ability to be an excellent member of activity groups by being energetic and helpful and acting as a leader. She occasionally behaved in an immature manner (e.g., silly, agitated, sucking her thumb, being augmentative or temperamental with a peer or staff). But for the most part, Mandy had interacted well with a select group of peers. However, she seemed to be testing staff a great deal. She became moody to the point of abrasiveness, at times, when she did not get her way. At this point she felt unappreciated as a person by her family and by some staff and residents. She had a difficult pass home on one weekend and wanted to cut herself. She brought in a razor blade to the hospital, but turned it over to the milue staff. In group therapy Mandy had shown strength in speaking about her issues. She became silly and giddy because of nervousness, but she believed her feelings were genuine and valid. She treated herself much more seriously and she struggled to overcome her feelings of low-self-esteem. In individual therapy Mandy utilized sessions to express her feelings of anger, anxiety, and depression in appropriate ways and had been largely successful. She recognized the self-defeating nature of much of her behavior and had been able to discuss her feelings with staff as a means of self-control. Over the next two months Samantha continued to ___ treatment. Signs ____ her ____ of self-esteem raised include1) She was much more direct in groups and did not allow others to speak for her:2) She was willing to discuss topics of sexual abuse more openly, although with a great deal of anxiety and : 3) she was able to demonstrate consistent high levels of motivation in activity therapy. At times within the milue, Samantha demonstrated her sense of sadness and hopelessness. She acted silly and refused to comply with some of her criteria for her life skills tasks. She seemed to be afraid of going outdoors and occasionally demonstrated an “I don’t care attitude”.
By July 1990, discharge issues were becoming more prominent for Mandy. Although somewhat erratic, Mandy improved her affective expression and problem-solving skills. She was more open about her fear of separation from the hospital and her lack of confidence in her ability to manage herself in the community. She discussed the options that she had, the ways to manage stress, and the ways of solving problems she encountered in the community and at home. She also discussed her graduation from high school and the significance it had for her as a milestone in her life. Overall, staff found Samantha to be considerably more stable and optimistic than she had been for several months. She interacted appropriately, maturely, and maintained good social interactions. As Samantha’s 18th birthday approached and discharge plans remained unsettled, her behavior began to decline. However, she continued to demonstrate maturity and growth that she had developed over the past year. She very appropriately expressed her feelings of anxiety about leaving Housatonic Adolescent Hospital and she attempted to offer support and feedback to others in a mature fashion. Even her transfer to BTU was a manifestation of growth. She was transferred because she experienced anxiety coupled with fears that she would hurt herself and therefore made the request. However, the emotional tension was so great that eventually Mandy had to resort to her old methods of self-abuse in order to relieve them. Her ability to rebound quickly from these incidents and be able to work on her issues in a more appropriate fashion was remarkable.
Problem #4- Family Conflict
As this family had been in traditional psychotherapy for quite some time and appeared to be well aware of many of the psychodynamic issues, the focus of family therapy at this hospital was oriented toward the goal of transitioning Samantha back into the community. Samantha would not be able to live at home with her mother and sister for an extended period of time because she would eventually resort to self-abusive behavior. Samantha’s passes home varied in the degree of success. There were times when she would put a great deal of effort into getting out of the house and doing “normal adolescent” things such as calling friends or going to the beach or going to a local game room, etc. There were other times she would be in marked conflict with her sister. As the time of discharge approached a plan was developed in which Samantha would spend her days at a day treatment program and her nights at home and weekends at Housatonic Adolescent Hospital. However, as Samantha was being interviewed for placements and programs, she engaged in some self-abusive behavior on Tuesday, August 21, 1990 which required her to be placed in restraints and to receive a prn medication. The decision was made to transfer Samantha to Fairfield Hills Hospital after her 18th birthday. The family discussed their feelings around expectations for placement and the feelings of failure that the family had around Samantha making this transfer and the transfer took longer than was expected, the family put forth a great deal of effort to try to get her placed elsewhere. However, once again Samantha engaged in self-abusive behavior.
Medical Findings
On 7/6/89 Samantha, a 17 year old white female was admitted to BTU on a Physicians Certificate. She was seen at Park City Hospital emergency room after cutting her arms. She had a long history of self-abusiveness and psychiatric hospitalizations.
Samantha had been transferred to ADAM House for treatment and periodically death with her emotions through self-abuse, she turned 18 and on 9/8/90 and due to anxiety of placement was transferred to BTU on q 15 minute checks. On 10/9/90 she scratched her wrist and was placed on q 15 minute checks and today was discharged and sent to Fairfield Hills Hospital on a physicians Certificate.
Last dental exam- 4/2/90- work completed- to return 4-6 months:10/26/89-eye exam- no glasses required; 7/16/90- ECG- normal:8/10/90- CBC, platelet count, profile T- T3, T4, thyroid function, thyroid antibodies and urinalysis all within normal limits; 8/30/90- Tegretol level (2.1)- below normal, all others within normal limits; 7/6/90- hearing screen- passed: no known allergies.
Presently Mandy is on Tegretol 200 mg.b.i.d., Mellaril 25 mg. p.o. q 5 hours prn and benedryl 25 mg. q.h.s. prn. She will appropriately request Mellaril when feeling anxious, but does not overuse this medication. During her stay, Mandy had also been on various antidepressants. When placed on Desipramine on 8/23/90, Mandy complained of G.I. distress, headache, and a rash on her neck. This was discontinued on 8/27/90. She also complained of headache when on Doxipin. Complaints of sleeplessness were alleviated with Benedryl at times. Thorozine was used when in an agitated state.
Discharge and Aftercare
Samantha Frankel was discharged from Housatonic Adolescent Hospital on October 10, 1990 and was transferred to Fairfield Hills Hospital. The transfer was required due to a recent self-abusive gesture on October 9, 1990 when she scratched her wrist severely with a thumbtack. All treatment and aftercare considerations will be developed by Fairfield Hills Hospital.
Signed: Director of Psychology
Signed: Co-Clinical Director
