Case Study prompt:
Vee is a 26-year-old African-American woman who presents with a history of non-suicidal self-injury, specifically cutting her arms and legs, since she was a teenager. She has made two suicide attempts by overdosing on prescribed medications, one as a teenager and one six months ago; she also reports chronic suicidal ideation, explaining that it gives her relief to think about suicide as a “way out.”
When she is stressed, Vee says that she often “zones out,” even in the middle of conversations or while at work. She states, “I don’t know who Vee really is,” and describes a longstanding pattern of changing her hobbies, style of clothing, and sometimes even her job based on who is in her social group. At times, she thinks that her partner is “the best thing that’s ever happened to me” and will impulsively buy him lavish gifts, send caring text messages, and the like; however, at other times she admits to thinking “I can’t stand him,” and will ignore or lash out at him, including yelling or throwing things. Immediately after doing so, she reports feeling regret and panic at the thought of him leaving her. Vee reports that, before she began dating her current partner, she sometimes engaged in sexual activity with multiple people per week, often with partners whom she did not know.
Remember to answer these questions from your textbooks and NP guidelines. At all times, explain your answers.
1. Describe the presenting problems.
2. Generate a primary and differential diagnosis using the DSM5 and ICD 10 codes.
3. Discuss which cluster the primary diagnosis belongs to.
4. Formulate and prioritize a treatment plan.
SOLUTION TO THE CASE STUDY
Describe the presenting problems.
Vee is a 26-year-old African-American woman presenting with various symptoms of a psychiatric disorder. She has a history of non-suicidal self-injury that include cutting her arms and legs. Her actions indicate she has anger issues and impulsivity observed through buying lavish gifts for her partner. Vee reports issues with concentration whereby she zones out in the middle of conversations and while at work. She has emotional dysregulation characterized by feelings of doing harm and regretting immediately. Other issues observed in the patient include risky behaviors like multiple sexual partners and suicidal thoughts.
Generate a primary and differential diagnosis using the DSM5 and ICD 10 codes.
According to the presenting symptoms, Vee has a borderline personality disorder. The DSM-5 describes borderline personality disorder (DSM-5 301.83 (F60.3) as a pattern of instability in interpersonal relationships, self-image, and affect (American Psychiatric Association, 2013). Patients with this disorder present with an intense fear of abandonment even when the patient is expecting separation. Affected individuals often exhibit changes in relationships and they will either strongly love or hate partners. Another common feature is a strong sense of emptiness that translate to self-harm behaviors like cutting, picking, burning, or suicidal ideations. Impulsivity is a feature of borderline personality disorder that sees patients do self-damaging acts like reckless driving, unsafe sex, unwise spending, or substance abuse (American Psychiatric Association, 2013). Vee presents with anger issues, impulsivity, disturbed self-image, intense fear of abandonment, self-harm, and suicidal ideations that are consistent with those with a borderline personality disorder.
Differential diagnosis is important for distinguishing borderline personality disorder from other mental illnesses like bipolar spectrum disorders. The first differential diagnosis is bipolar disorder because it is characterized by changes in mood leading to outcomes like frustration, separation, and anger. However, mood changes in borderline personality are short-lived and the oscillation is frequent (Perrotta, 2020). Post-traumatic stress disorder is another differential whereby the signs of anxiety, fear, and anger are prominent. This diagnosis is different from borderline because events leading to the signs are evident and often recent (Perrotta, 2020). Other differentials may include schizophrenia, somatoform disorder, and narcissistic personality disorder.
- Discuss which cluster the primary diagnosis belongs to.
Borderline personality disorder belongs to Cluster B of the ten personality disorders. It is often referred to as the dramatic, emotional, and erratic cluster (American Psychiatric Association, 2013). Cluster B also comprises disorders like antisocial personality disorder, narcissistic personality disorder, and histrionic personality disorder. The key features of diseases from this cluster are problems with impulse control and emotional deregulation.
Formulate and prioritize a treatment plan.
Although personality disorders are considered to be the most difficult to manage, the use of psychotropic drugs and psychotherapy can best serve to improve the patient’s condition. The primary goal of treatment is to reduce intense emotional reactions, improve impulse control and minimize or control self-injurious behaviors. Regarding pharmacological treatment, I will prescribe olanzapine 5mg orally once daily and consider increasing the dosage to 10mg after two weeks. Olanzapine is a second-generation antipsychotic drug whose efficacy for managing traits like impulsivity, aggression, anxiety, and psychotic symptoms are well-known (Gartlehner et al., 2021). The second step will involve referral to a psychotherapist for dialectical behavior therapy (DBT). This approach is supported by literature to be the most effective in managing emotional dysregulation and reduced impulse control (Reddy & Vijay, 2017). DBT uses a series of strategies and involves patients in a training aimed at increasing self-awareness and change.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Gartlehner, G., Crotty, K., Kennedy, S., Edlund, M. J., Ali, R., Siddiqui, M., … & Viswanathan, M. (2021). Pharmacological treatments for borderline personality disorder: A systematic review and meta-analysis. CNS Drugs, 35(10), 1053-1067. https://doi.org/10.1007/s40263-021-00855-4
Perrotta, G. (2020). Borderline personality disorder: Definition, differential diagnosis, clinical contexts, and therapeutic approaches. Annals of Psychiatry and Treatment, 4(1), 043-056. https://dx.doi.org/10.17352/apt.000020
Reddy, M. S., & Vijay, M. S. (2017). Empirical reality of dialectical behavioral therapy in borderline personality. Indian Journal of Psychological Medicine, 39(2), 105–108. https://doi.org/10.4103/IJPSYM.IJPSYM_132_17
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