Ms. "R"

DATA: Client is a 3 year old Caucasian female, self-referred to clinic, with a chief complaint of what she described as “my tummy is not happy.” Ms. R declined to elaborate upon further inquiry, but instead sucked her left thumb and leaned her head upon the co-therapist. From this point on, she responded only to close-ended questions. The interviewer was able to gather that Ms. R did not feel physically well at the time of the interview, and that she did not want to use the “potty.” The co-therapist offered Ms. R some refreshment, and several minutes later, Ms. R vocalized discomfort, placed a hand at her midsection, and vomited. She reacted with crying, and requested to be embraced by the co-therapist, which was permitted. After she was composed, Ms. R spent the remainder of the session lying on the couch, sucking her thumb, and watching videos of talking/singing puppets. Later in the day, Ms. R was found passed out asleep on her kitchen floor. Upon waking she was unable to recall how long she had slept, but witnesses estimate that she was unconscious for approximately 2 hours (see below).

ASSESSMENT: Ms. R was alert and oriented to person and place at the time of the interview, but was unable to estimate the time of day, month, year, and could not name the current or any former president of the United States. She was unable to describe her mood, but appeared dysthymic. A review of her file revealed that she has slept approximately 11 to 12 hours nightly for the last year. She denied a history of substance abuse or head trauma, and stated that she had never been treated for mental health issues previously, although her file indicates that she has been prescribed hugs and kisses daily for various psychological symptoms. There is even documentation that she has been placed in timeout for inappropriate behavior. No criminal history is noted. Her speech was staggered, eye contact was appropriate, and her thought process was fixated (on her “unhappy tummy”). Thought content was concrete, though peppered with anthropomorphic statements, usually applying emotional characteristics to some section of her bowels. She denied symptoms of psychosis, however, considering her disoriented state, her staggered speech, practice of thumb sucking, and ascribing human characteristics to non-human things, psychosis cannot be ruled out as of yet.

Possible diagnoses at this time include (a) traumatic brain injury, (b) drug induced psychosis – perhaps explaining the vomiting as well, (c) other psychotic disorders, (d) somatoform disorder with vomiting resulting from internalizing outside stressors – perhaps work or personal relationship struggles, or (e) being 3 years old and sick.

PLAN:

1. Build therapeutic and parental rapport throughout indefinite remaining sessions.

2. Encourage use of client’s “words” to describe her emotional/physical discomfort.

3. Encourage periodic intakes of low impact, nutritious foods until vomiting behavior subsides.

4. Encourage napping as needed.

5. Cuddle client when requested.

6. Cuddle client when not requested.

7. Kiss client’s soft little cheeks until therapists’ lips are chapped and sore.

#Happenings #Humor