Diagnosis: Borderline Personality Disorder
- Outline the major symptoms of this disorder.
- The DSM – V describes Borderline Personality Disorder (BPD) as a disorder that manifests in early adulthood as a pattern of instability in “relationships, self-image, and affects, and impulsivity” (p. 663). Criteria for BPD includes, the individual portrays aggressive effort to avoid real or imagined abandonment, convey an identity disturbance, reveal suicidal ideation or self-mutilating behaviors, and maintain feelings of emptiness (American Psychiatric Association, 2013). Additionally, an individual exhibits patterns of instability in interpersonal relationships via extreme devaluation and idealization, and affect due to reactivity of mood (American Psychiatric Association, 2013). Individuals must portray two potentially self-damaging impulsive behaviors such as sex, spending, or substance abuse as well as exhibit intense anger or the inability to control anger (American Psychiatric Association, 2013).
- Briefly outline the client’s background (age, race, occupations, etc.).
- Becky is a 24-year-old college student who lives with her father, who was diagnosed with muscular dystrophy when she was three, in a one-bedroom apartment and sleeps in the dining room. She lives with her father while trying to attain financial and emotional stability so she can support herself better. She currently takes two medications (600mg/day) and has never thought of herself as mentally well. Becky is the oldest of five children born over six years. Raised in a Mormon Church, she now repudiates, she left the church at 15 years old and began attending a Baptist church with her friends searching for a sense of belonging. However, she claims she was not her “true self.” She expresses self-doubt and feels as if others are dishonestly praising her. She also deals with a personal internal conflict which manifests through self-mutilation. Becky experiences severe panic attacks if she becomes the center of attention or separated from a person. Upon uniting, she exhibits verbal rage. However, she recognizes her irrational behavior and apologizes after she calms down (McGraw Hill Higher Education, 2007).
- Becky experiences severe anxiety attacks relieved through “cutting”, self- mutilation practice that has progressively worsened over time. Her first experience of cutting came about when she was left home alone for the weekend in the home she shared with a roommate. The episode was triggered by a television program that made her cry due to sadness. She attempted to distract herself and accidently sliced her arm which brought pain and further distraction. She now uses the technique as a way to punish herself for irrational behavior. Although Becky claims she is intelligent and possesses the good work ethic and empathy for others, her perception of self is negative as she views herself as unworthy of love and fake to society. She fears if others find out her true self, they will abandon her (McGraw Hill Higher Education, 2007).
- Becky has found peace with her therapist and views him as a positive and understanding support in her life. She is proud to say she has had a male friend for five years, the longest ever, leading me to believe her friend is her therapist as she did not expose any further information about the friend or time in therapy. Becky maintains a negative view of the world claiming the human race is stupid, mean, horrible and cruel. Due to this and biological factors, Becky does not want children (McGraw Hill Higher Education, 2007).
- Although Becky claims to experience panic when she is in the limelight, she volunteered to do the interview to help her overcome her troubles, which seems contradictory. She claims she wants to finish college and be free of medication and therapy and use her personal experience to help children like her (McGraw Hill Higher Education, 2007).
- Describe any factors in the client’s background that might predispose him or her to this disorder.
- According to the DSM, premature parental loss, neglect, and violent conflict are two features associated with BPD (American Psychiatric Association, 2013). Although Becky has not experienced a parental loss, per se, she is coping with a father who is terminally ill and has been since she was only three years old. She does not expose how ill her father is or if he suffers from limitations, but she has been living with the possibility of losing him. Additionally, the violent altercations between her and her family members also support this feature of the DSM. Becky shared that she did not receive the love and attention she needed in childhood. She claims that she cried for attention and affection and even went to extreme measures to gain it, but she never received it which implies feelings of neglect. Additionally, Becky claimed in the interview that mental health problems run in her family, which creates a predisposition to mental illness (Nolen-Hoeksema, 2013). Another thing that stood out in the interview was Becky claiming that her mother would take all of her frustrations out on her and use her as her confidant even for inappropriate conversation. Her mother’s behavior in conjunction with possible feelings of spousal abandonment or neglect, and dealing with childhood sexual abuse memories may be symptomatic of an undisclosed or undiagnosed mental health issue that predisposed Becky to her disorder. In high school. Becky fell in love with a guy who made her feel as if here was potential in a relationship between them. However, he married her best friend. The incident seems as if it reinforced her unworthiness of love she felt from her mother which holds the potential to cause Becky to exhibit the inability to maintain interpersonal relationships and continually “phase out” relationships she deems as having the potential to leave her feeling abandoned (McGraw Hill Higher Education, 2007).
- Throughout the course of the interview, Becky often looks away, making little eye contact, and many facial expressions. She also takes long pauses between thoughts. Becky talks with her hands and smiles often. When speaking of sleeping arrangements, she snickers as if embarrassed at having to admit her arrangement. At the beginning of the interactive, the narrator stated his crew thought she was not genuine, but he disagreed. The pauses imply that she had to think about a response, at some points, she paused for an extended period which seemed as if she was fabricating a scenario or thought. However, other times she was clear and concise right to the point, leading one to believe she was speaking truth. She rarely made eye contact specifically during the pauses; rather her eyes wandered, and she talked to the side. Assuming the interviewer was in front of her, this implies dishonesty or simply shame of the events she recalled. It was noted her thoughts remained mostly consistent and attentive to the question at hand.
- Describe any symptoms that you have observed that support the diagnosis. You can include direct quotes or behaviors that you may have observed.
- Becky recalled a trip to the grocery store in which she and her friend became separated. The separation created a severe panic attack that caused her to lash out yelling at her friend. Her behavior is consistent with avoiding abandonment criteria listed in the DSM. Additionally, Becky disclosed she practices cutting to punish herself for irrational behaviors and rubs the scars as a reminder of the pain she endured from her behavior. She views herself as worthless and fake to the general public and fears people will not like her if they learn who she is. Her negative self-perception is evident when speaking interpersonal relationships. Becky feels she needs to break up by two years because by then people will learn how she actually deals with life and it is better to be unhappy by losing a friend she chose to cut off than feeling abandoned because they discovered the “real” Becky. Additionally, Becky disclosed she had had impulsive spending behaviors in the past (McGraw Hill Higher Education, 2007).
- Describe any symptoms or behaviors that are inconsistent with the diagnosis.
- Becky claims that she did not get mean towards her friends, rather would turn cold and phase them out of her life or just never talk to them again when she began to fear that the individual would learn her unmasked identity. The behavior is inconsistent with the DSM claiming devaluation and idealization as the cause of the dissociation of relationships (American Psychiatric Association, 2013). For Becky, I believe it was the fear of the potential outcome of abandonment.
- Provide any information that you have about the development of this disorder.
- According to the National Alliance on Mental Illness (NAMI) website, genetic factors such as first degree relatives support hereditary as a factor in the development of BPD (2016). Although Becky did not disclose anyone in her family has the same illness, she did state that her family has a history of mental illness. She also recalled hearing of her mother’s traumatic childhood, the dysfunction within her household as a child, her parent’s separation, and her father’s terminal disease. The “NAMI” website claims childhood trauma increases the risk for developing BPD (2016). Brain function, specifically the centers that control emotions and decision making may have a communication barrier that produces extreme behaviors and thoughts in individuals (“NAMI”, 2016).
- Did you observe any evidence of general medical conditions that might contribute to the development of this disorder?
- Becky did not disclose any medical conditions that may contribute to the development of her disorder. However, it seems as if her disorder is attributed to biological and environmental factors.
- Did you observe any evidence of psychosocial and environmental problems that might contribute to this disorder?
- Becky claims her manipulative mother is the root of her problem established through therapy. Becky’s mother learned of her childhood sexual abuse via flashbacks after a traumatic experience. Her mother discussed in detail the sexual abuse her sisters endured from their father when Becky was a young child of 5 years. Additionally, Becky claims she was her mother’s confidant, and she would take her frustrations out on Becky. In the interview, Becky often reverted to the conversation surrounding some sexual abuse which caused for questioning if she fabricated her experience from conversations shared with her mother or if she was genuine in her personal experience. Her parents didn’t talk to each other. However, the NIH website reports that individuals with BPD are more likely to subject themselves to violence and rape (“NIH”) causing one to believe that she is speaking from experience. Additionally, Becky recalled physically violent altercations with family which resorted to her breaking dishes as she threw them screaming until she could calm down which implies that her family was dysfunctional and correlates with the National Institute of Mental Health’s report that she is at risk of developing BPD (“NIH”).
- As per your observations, what is the client’s overall level of safety regarding the potential harm to self or others (suicidality or homicidality)?
- Becky exhibits progressive self-mutilation. She began on her arms, abdomen, and currently on her thighs as she has so much scarring from her actions. Cutting is Becky’s coping skill for anxiety and panic triggered by minor experiences such as being called on in a class or a television program (McGraw Hill Higher Education, 2007).
According to the National Institute of Mental Health, eighty percent of individuals with BPD experience suicidal ideations and four to four percent commit suicide (“NIH”) placing Becky in a bracket of suicide risk. Although she claims she is not suicidal, self-mutilation rituals have become a typical and expected behavior of Becky and the wounds created have potential to become life threatening. Therefore, Becky’s safety should be regarded as highly at-risk to herself.
- What cross-cultural issues, if any, affect the differential diagnosis?
- According to the DSM, individuals exhibiting identity problems including existential dilemmas, emotional instability, and anxiety-provoked decisions, among others may mislead a diagnosis of BPD, especially when substance abuse is involved (American Psychiatric Association, 2013). The three symptoms are identified in Becky. However, there is no evidence of substance abuse outside of her prescription medications. Dependent Personality Disorder is clarified by the individual becoming submissive and appeasing and immediately seeks replacement relationships when things turn negative (American Psychiatric Association, 2013) is also consistent with Becky’s description of her abandonment dilemmas and therefore holds potential for co-occurring disorders. However, the DSM also reports that BPD is established by a pattern of intense and unstable relationships (2013) indicative of Becky’s recorded history.
- In your opinion, what are the appropriate short-term goals of this intervention?
- Self-mutilation seems to be overtaking Becky at this point. It is imperative that she learn skills to cope with stressful events that cause anxiety and panic. Self-mutilation can become deadly and should be the top priority. Becky also needs to learn that she is worthy of positive relationships and should be treated as if she has a place in the world. Additionally, Becky has only spoken of her therapist as a positive support. She needs to develop a support system or reinstate her familial ties as they are not spoken about outside of childhood. It seems as if she only has her father, but embracing her family in its entirety may prove beneficial in her circumstance.
- In your opinion, what are the appropriate long-term goals of this intervention?
- Becky appears to have unresolved issues with her mother. It is important for Becky to acknowledge and work through these issues to achieve peace with her past and move on to live in the present. Becky has a very negative worldview that needs to be turned around. As she realizes her self-worth, she should also realize that it is good in the world. Another long-term goal is to complete college and secure employment where she feels she does not have to mask herself. This will allow her financial stability that will lead her to independence and having her bedroom door back.
- Which therapeutic strategy seems the most appropriate in this case? Why?
- Psychotherapy via Dialectical Behavior Therapy (DBT) seems to be the most promising in treating Becky. DBT aims to help individuals better regulate emotional responses by accepting the issue they are facing (Johnson, Gentile, & Correll, 2010). It is believed that self-harm is a way to reduce discomfort from affect (Johnson, Gentile, & Correll, 2010). CBT begins by reducing the treatment-disruptive behavior, in Becky’s case, cutting, to effectively teach coping for emotional regulation and interpersonal relatedness skills (Johnson, et al., 2010). Additionally, talk therapy should be utilized to resolve the issues between Becky and her family. Although the root cause is known at this time, talk therapy can help Becky effectively process her childhood experiences and grow from them. According to the treatment section of the interactive, it is vital that therapists should “maintain open communication” to develop trust between themselves and the Becky. Becky stated that she is fond of her therapist because he is open and honest and has shared personal experiences with her that relate to an experience she had. However, a behavioral contract should be included to protect the therapist and Becky safety throughout the course of treatment. It seems at this point; the self-mutilation has increased even with treatment implying Becky is in need of intensive therapeutic services. The interactive also claimed it is beneficial for therapists to practice splitting during treatment. This would allow Becky two therapists who swap out in the event Becky became angry with one. Splitting would allow Becky to remain comfortable in sessions and also a collaborative approach to reconditioning negative thoughts and behavior.
- Which therapeutic modality seems the most appropriate in this case? Why?
- Pharmacotherapy such as serotonin reuptake inhibitors helps deter and regulate dangerous and impulsive behavior. Becky exhibits increasing self-harm techniques and has admitted to impulsive behavior and major mood swings. Additionally, she suffers panic and anxiety attacks in situations that bring focus to her. The attacks are triggers for self-mutilation which in turn brings feelings of relief, but also emptiness and worthlessness. Becky relates her mental state to others that result in death such as AIDs, which implies that she could be worse off by dying. Becky’s ideations and professed feelings lead one to believe she would benefit from anxiety and depression medications as well. Additionally, through DBT, Becky will learn healthy patterns of thinking about herself and the world, positive self-image, non-destructive coping skills and adaptive interpersonal skills. Reversing the pessimism brings about a positive change necessary for Becky to establish a successful and independent life.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Dick, Ph. D., D. M., & Agrawal, Ph. D., A. (2008). The genetics of alcohol and other drug dependence. Alcohol Research and Health, 3(2), 111- 118. Retrieved from http://pubs.niaaa.nih.gov/publications/arh312/111-118.pdf
Johnson, A. B., Gentile, J. P., & Correll, T. L. (2010). Accurately diagnosing and treating borderline personality disorder: a psychotherapeutic case. Psychiatry (Edgmont), 7(4), 21–30.
McGraw Hill Higher Education. (2007). Faces of abnormal psychology interactive [Multimedia]. Retrieved from McGraw Hill Higher Education, Maladaptive Behavior & Psychopathology | FP6005 A01 website.
NAMI. (2016). Retrieved from https://www.nami.org/Learn-More/Mental-Health-Conditions/Borderline-Personality-Disorder
NIH. (2012). Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment/evidence-based-approaches-to-drug-addiction-treatment/behavioral-therapiesNIH. Retrieved from http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml
Nolen-Hoeksema, Susan. (12/2013). Abnormal psychology, 6th edition. [VitalSource Bookshelf Online]. Retrieved fromhttps://digitalbookshelf.argosy.edu/#/books/1259316335/
Zickler, P. (2002, April). Childhood sex abuse increases risk for drug dependence in adult women. NIDA, 17(1),. Retrieved from http://archives.drugabuse.gov/NIDA_Notes/NNVol17N1/Childhood.html