Shaine Case Summary

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Presenting Problem: Shaine is a 17 y/o male who has a chronic and persistent danger to self by demonstrating self-mutilation, with unmanageable behaviors (i.e. anger outburst/ aggression) which he has presented these behaviors greater than 6 months. The symptoms began 2 years ago according to mother and have recently escalated significantly. He has anger outburst, several x/week since 2014, that range from yelling and verbal abuse to aggressive behaviors (i.e. shoving, hitting holes in wall/door, suicidal threats, cutting self and sister with knife). He does not response to parent redirections. He claims not remember the details of his actions an feels no control over them. He isolates frequently in his room and has no friends other than one “girlfriend” he met online with whom he has had no face to face contact. Substance Use Hx: The pt denies drinking alcohol or use of any drugs. He is a nonsmoker. Medical Hx: Pt has a past medial history of ear surgery. He also had two fracture injuries …show more content…

Shaine resides with his biological mother, stepfather, and step sister. He has three sisters and two brothers. His parents got divorced when he was 5 years old. Inside the home the pt does not respond to interventions, discipline or redirection. Medication does not seem to be effective (mother reports he taken it regularly). Per report the mother recent behaviors would include 12/11 the pt was physically and aggressive towards her and the family, where he became belligerent toward her and assaulted her. The pt grabbed a knife and stated he was going to kill himself, than cut himself with the knife (not requiring stitches). On the 12/12 stepfather told him “stop” which cause him become aggressive by throwing an astray at him, which mother was able to calm him down. Yet when she left, he was in a verbal altercation with stepsister that transistion to physical altercation that York Co. sheriffs came out to de-escalate the

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