NURS 6670 Week 3 Case 1: A Woman with Personality Disorder
Personality Disorder CASE #1 Sample Paper
This week’s case scenario is of a 30-year-old Rhonda, a Hispanic female who presents to the psychiatric clinic with emotional fears of abandonment. She fears that her very few friends have abandoned her and she is left with no one. She reports being nice to people but this does not seem to help her situation currently including her nice boyfriend who she broke up with recently after he turned out to be a ‘monster.’ However, she does not regret the traumatic breakup with her ‘boyfriend’ citing her hatred for his guts.
Rhonda recalls a friend who falsely accused her of theft after the friend lent her the money but later backed out. The car that she just purchased using the money was repossessed as she had no other means of completing the payment. She blames her financial problems on her friends and associates since childhood. The friends and professional associates are ‘jealous’ of her and that is why she had lost her past two jobs. In her forensic history, there are reports of violence since tender age with friends and classmates. In her adulthood, she has been arrested and charged with illegal possession of firearms and illicit drugs. The mental state examination of Rhonda shows a labile affect with a subjectively ‘terrible’ mood. All other aspects are unremarkable and there are no psychotic symptoms.
Decision #1: Differential Diagnosis
Rhonda has a personality disorder associated with violence, mood problems, and fears of emotional abandonment. Her social life has been turbulent since childhood. The violence and antisocial behaviors suggest an antisocial personality disorder. One can also imply that Rhonda was simply trying to seek the attention of people by claiming fear of emotional abandonment. This would suggest the likelihood of histrionic personality disorder. However, these are not the most striking features in the psychiatric presentation of Rhonda. Borderline personality disorder more suits this patient than a histrionic and antisocial personality disorder.
The DSM-5 criteria for the diagnosis of Borderline Personality Disorder (BPD) define specific major requirements for delineation of BDP from other personality disorders. The presence of antisocial personality features and impulsivity and fears of emotional abandonment makes the patient’s diagnosis more likely to be BPD (Mulay et al., 2019). The basis of the diagnosis of BPD is dependent on two patient evaluation aspects: the instability of self-image, affect, & interpersonal relationships; and marked impulsivity (Lubit & Pataki, 2018). Rhonda had a labile affect with emotional instability regarding an imagined abandonment. Her impulsivity has been evident since childhood with a history of violence, criminal arrests, and forensic charges.
The decision to pick BPD over ASPD and HSP is informed by careful evaluation of the patient. However, the holistic assessment should include physical evaluation to rule out organic etiologies. Understanding why the patient presented to the clinic at that moment when she has had few friends and fears of emotional abonnement for a long time is still unclear from this psychiatric evaluation. The is no difference between the expected outcomes of the decision and the archived outcomes.
Decision #2: Treatment Plan for Psychotherapy
Psychotherapy is preferred over pharmacotherapy in the management of personality disorders. Various methods of psychotherapy apply in the management of personality disorders. However, tend to use cognitive-based therapy (CBT) more frequently compared to other methods. The best type of psychotherapy for Rhonda, according to Chapman et al. (2020), would be dialectical based therapy (DBT). DBT sessions would be important for Rhonda because her chief reason for this clinical visit emanates from emotional fears of imagined abandonment. DBT would, therefore, focus on the current emotion while enhancing her skills in dealing with emotional controls. She also showed signs of self-destructive behavior that would be managed well through dialectical behavior therapy. Rhonda would best benefit from individualized DBT therapy sessions with skills training. In cases of physical distance disadvantages, the therapist should weigh the benefits of DBT via phone call against the risks of poor outcomes.
Other types of psychotherapy interventions are available for non-drug management of Rhonda. These treatment methods include Mentalization-based therapy (MBT) and Transference-focused therapy (TFP) (National Education Alliance for Borderline Personality Disorder, n.d.). MBT would be used as an additional modality if DBT fails to meet the set goals (Storebø et al., 2018). Other non-drug therapies that are not included in psychotherapy require the patient’s input in their care. These include adequate sleep, nutrition, and exercise management. Adherence to psychotherapy would benefit Rhonda greatly.
The decision to adopt DBT for Rhonda was informed by the need to treat her condition using a single therapy modality. However, the DBT alone may not be fully beneficial in the management of her BPD. The outcome would require augmentation with other therapies. The difference in the outcomes and the expectations can be attributed to the complex presentation for the patient. Alongside self-destructive behaviors, Rhonda also has other mood disorders.
Decision #3: Treatment Plan for Psychopharmacology
The FDA is yet to approve medications for use in the management of BPD. Medication management for BPD are largely off-label treatments (Choi-Kain et al., 2017). The management of moods and psychiatric symptoms may require the use of medication in some cases. The patient had a labile affect and a ‘terrible mood.’ The presence of psychiatric symptoms cannot be completely ruled out in this patient. Medications would be added but with proper evaluation to avoid undesired effects and to improve treatment adherence. The best medication should stabilize the mood while preventing psychiatric symptoms as well. However, Rhonda would not need medications at the current stage of treatment. Monitoring of the outcomes of her psychotherapy would inform the need to include medication therapy.
The decision to avoid pharmacotherapy can be supported by the need to prevent ‘unnecessary’ adverse drug effects. Her impulsivity and self-destructive behaviors can be adequately managed by psychotherapy. The endpoints of this therapy are yet to be set because the direction of her therapy would be determined by adherence and response to psychotherapy.
Ethical Consideration in Management
Rhonda has a right to have a voice in her care. However, her input and the subjective decision would best be made by the family members. The care must enhance nonmaleficence and therefore, the drugs that would cause undesirable adverse effects should be avoided unless the benefits outweigh the risks. It would be ethically just to allow the family members to approve her enrollment in the psychotherapy sessions. They would be educated on the adverse effects of medication should there be need to medicate her at a later stage of treatment. Therefore, ethics play a crucial role in the advancement of the treatment of Rhonda.
Conclusion
A borderline personality disorder is characterized by impulsivity, emotional instability, and unstable self-image. Rhonda’s case is most likely due to BPD. Her management would mainly comprise psychotherapy with DBT as the mainstay of treatment. The additional pharmacotherapy would be indicated in case the self-destructive behaviors cannot be controlled by psychotherapy. The care should ensure autonomy by including family members and nonmaleficence by avoiding unnecessary drug therapies.
References
Chapman, J., Jamil, R. T., & Fleisher, C. (2020). Borderline Personality Disorder. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430883/
Choi-Kain, L. W., Finch, E. F., Masland, S. R., Jenkins, J. A., & Unruh, B. T. (2017). What works in the treatment of borderline personality disorder. Current Behavioral Neuroscience Reports, 4(1), 21–30. https://doi.org/10.1007/s40473-017-0103-z
Lubit, R. H., & Pataki, C. (2018). What are the DSM-5 diagnostic criteria for borderline personality disorder (BPD)? Medscape. https://www.medscape.com/answers/913575-165741/what-are-the-dsm-5-diagnostic-criteria-for-borderline-personality-disorder-bpd#:~:text=Markedly%20and%20persistently%20unstable%20self,behavior%20covered%20in%20criterion%205
Mulay, A. L., Waugh, M. H., Fillauer, J. P., Bender, D. S., Bram, A., Cain, N. M., Caligor, E., Forbes, M. K., Goodrich, L. B., Kamphuis, J. H., Keeley, J. W., Krueger, R. F., Kurtz, J. E., Jacobsson, P., Lewis, K. C., Rossi, G. M. P., Ridenour, J. M., Roche, M., Sellbom, M., … Skodol, A. E. (2019). Borderline personality disorder diagnosis in a new key. Borderline Personality Disorder and Emotion Dysregulation, 6(1), 18. https://doi.org/10.1186/s40479-019-0116-1
National Education Alliance for Borderline Personality Disorder. (n.d.). Treatments for Borderline Personality Disorder. Borderlinepersonalitydisorder.Org. Retrieved March 18, 2021, from https://www.borderlinepersonalitydisorder.org/what-is-bpd/treating-bpd/
Storebø, O. J., Stoffers-Winterling, J. M., Völlm, B. A., Kongerslev, M. T., Mattivi, J. T., Kielsholm, M. L., Nielsen, S. S., Jørgensen, M. P., Faltinsen, E. G., Lieb, K., & Simonsen, E. (2018). Psychological therapies for people with a borderline personality disorder. The Cochrane Library. https://doi.org/10.1002/14651858.cd012955
