Case Background

A mother calls the pediatric primary care office and wants to bring her daughter, Kara, in to be seen. She says something isn’t right. Kara, age 15, refused to go to school. Lately she has been acting strangely, staying in her room on her computer and not letting anyone in her bedroom. The mother says her daughter used to take good care of herself, had many friends and liked socializing. But lately she has gained weight, stopped going out, and doesn’t care about her appearance. Her mother has even had to tell her to take a shower and wash her hair. Kara was a good student; now her grades are poor. She just doesn’t seem to care.

Recently her boyfriend’s family moved away to seek a job in another state, and Kara hasn’t heard from him. The mother says her beautiful child has turned into someone else, and she is worried. After talking with the mother you ask her to wait in the waiting room. Kara is in the exam room, and you ask her to remove her clothing and put on a gown. At first she refuses, but at your insistence she agrees. She appears very hostile, and you begin to better understand her mother’s concern. When you return to the exam room, Kara opens the gown and exposes cuts she has made with a razor blade on her body— her wrists, thighs, breasts, and hips all have long superficial cuts. She is very angry and says, “There, is that what you want to see?” When you ask her what has happened, she says she hates herself and hates her life. She says her boyfriend told everyone she was a slut and they are making fun of her on Facebook. She doesn’t want to live anymore.

When you ask her if she has thoughts of hurting herself further, she says she is going to hang herself as soon as she gets a chance; she just hopes she has the guts to do it. You call and ask for another staff member to come into the exam room, telling your colleague not to let the girl out of the room and to sit within arm’s length of her. Then you go to the desk and call the Mobile Crisis Unit. You return to the exam room and stay with the patient until the emergency responders arrive. You ask your colleague to take the mother into another exam room and tell her what is happening.

Case Critical Reasoning Questions

1.  What are Kara’s predisposing risk and protective factors?

2.  What behaviors suggest changes in her neurotransmitters?

3.  What is her precipitating stressor and maladaptive coping mechanism?

4.  What would be the goals of her treatment?