Occupation:       Retail associate                             Family Constellation:    Lives with spouse and two children

Living Situation: Lives in a Stable home environment

History of present illness:

Characteristics of Personality Disorder

The characteristics of a personality disorder are impairments in self and interpersonal functioning, and the presence of pathological personality traits. To diagnose a personality disorder, the following criteria must be met:

•Substantial impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning

•One or more pathological personality trait domains or trait features

•These impairments in personality functioning and the individual’s personality traits are relatively stable across time and situation

•These impairments in personality functioning and personality trait expression are not considered as normal for the individual’s developmental stage or socio-cultural environment

•These impairments in personality function and trait expression are not due to the physiological effects of a medical condition or substance (APA, 2013).

Patterns of behavior (self-harm, alcohol, drug use, Addiction (shopping, gambling, pornography, video, gaming, etc.):

Shoplifting:

Legal issues:

Interpersonal functioning and relatedness:

Alterations in cognition:

Current and recent stressors:

Current coping skills:

Spirituality and/or religion:

Client and family’s perception of problem:

She had emotional dysregulation characterized by impulsivity and fear of abandonment and unstable relationships since adolescence. Previous therapy sessions had been unreliable; pharmacological treatments had been adhered to poorly. Psychotic symptoms were denied. The patient has had multiple job changes due to workplace conflicts, difficulty in sustaining friendships, and frequent arguments with family members. The patient has difficulty maintaining her responsibilities and frequently procrastinates tasks, which generate more stress for her.

The patient presents with Borderline Personality Disorder (BPD), a personality disorder under the Cluster B disorders. The condition affects their emotions, relationships, and sense of self. The patient constantly experiences frequent mood swings, has impulsive behaviors, and a sense of “being empty” (APA, 2022). All of these symptoms are ongoing and consequently cause drastic problems in her everyday life. The client easily overreacts to criticism either in the form of extreme rage or withdrawing. She  also has low self-esteem  and worthlessness, which contribute to her emotional instability.

·         Impairments in interpersonal and self-functioning: Unstable

·         Pathological personality features: Impulsive

·         Stability across time and situations: Persistent

·         Not usual for developmental stage or socio-cultural environment: Atypical

·         Not due to medical conditions or substance use: Psychological

·         Self-destructive (self-harm) behavior: self-cutting, and past attempts at suicide

·         Social use of alcohol: no substance use dependence

·         Compulsive spending, and bingeing on food.

·         No legal history

·         Excessive reassurance-seeking behaviors

·         Breaks down emotionally to minor mishaps

·         Intense unstable relationships.

·         Rapid shifts in mood and thoughts towards others

·         Fear of abandonment leading to excessive reassurance-seeking behaviors.

·         Reports feelings of being “empty” and having no stable sense of self.

·         Avoids social activity because of  fear of being criticized or rejected

·         Paranoid thinking and appears to dissociate when she is under stress.

·         Exhibits maladaptive thought patterns

·         Recurring fear of being abandoned by loved ones even without objective cause.

·         Has difficulty concentrating due to emotional distress

·         Interpersonal relationship conflict with spouse.

·         Work stress due to perceived rejection.

·         Recent argument with close friend that resulted in emotional pain.

·         Money problems due to irresponsible spending.

·         Ineffective coping (self-harm, avoidance).

·         Journaling and doing exercises occasionally.

·         Tried meditation but cannot continue.

·         Employs fleeting distractions like binge-watching TV shows

·         Reports being religious; using faith on occasion when distressed.

·         Reports feeling conflicted about religious beliefs when emotionally unstable.

·         Used spiritual counseling on occasion in the past for emotional guidance.

·         Client acknowledges emotional instability but attributes trouble to external factors.

·         Family reports frustration with erratic behavior.

·         Spouse worries about the impact of mood swings on home life.

·         Family perceives the client as overly sensitive and reactive

Family medical history:

Medications (side effects, adverse side effects, and treatment response) INCLUDE BELIEFS about medications

·         No significant medical illnesses in history.

·         Occasional gastrointestinal symptoms related to stress.

·         Father with hypertension and alcohol use disorder.

·         No known genetic predisposition to psychiatric conditions except for maternal depression.

·         Sibling diagnosed with an anxiety disorder.

·         Fluoxetine 20 mg daily (only partially adherent).

·         No severe side effects have been reported.

·         Patient has quit medications in the past due to fears of being dependent.

·         Patient has tried mood stabilizers but stopped them as they were very sedating.

·         She says that she takes melatonin for sleep but finds it inconsistent.

Legal, psychosocial, physical, interpersonal,    and occupational consequences.

Smoking history:

Alcohol use:

Marijuana use:

Illicit drugs:

·         No prescription medication misuse has ever been documented.

·         Caffeine is overused at times to counteract fatigue

·         No history of smoking

·         Drinks socially especially over the weekends

·         No history of marijuana use

·         Has no history of using illicit drugs

Complementary treatments:

·         Reports that she occasionally takes herbal supplements for stress relief.

·         Uses vitamin D

Psychotropic medications, side effects, adverse side effects, and treatment response:

·         No history of opioid misuse; dependence

·         Trialed on SSRIs and mood stabilizers with poor compliance.

·         History of benzodiazepine use for acute anxiety, but stopped due to dependency risk.

·         No antipsychotic medication use history

Family psychiatric history and/or substance use history:

Sociocultural history (family and social history, work history, current employment, volunteer work, legal history, active and past, current support system, marital status, and children):

Trauma history:

Trauma exposure (childhood abuse or neglect, rape or sexual assault, emotional abuse, domestic violence, military/combat service, and natural disasters, historical/political trauma):

History of head injury, loss of consciousness, seizures:

·         Individual therapy in the past, but stopped due to frustration at lack of perceived progress.

·         Group therapy in the past but felt uncomfortable discussing experiences

·         Mother diagnosed with depression.

·         No first-degree relative history of schizophrenia or bipolar disorder.

·         Reports family history of anxiety disorders.

·         Stable job but frequently has interpersonal conflicts with colleagues.

·         Developed in a home with significant parental conflict.

·         Reports poor social support network.

·         Unstable finances secondary to spending impulsively

·         Emotional abuse and neglect by parents during childhood.

·         Bullied during adolescence.

·         Difficulty trusting authority figures based on past negative experiences.

·         No significant history reported.

INCLUDE EVIDENCED- BASED THERAPEUTIC MODALITIES FOR THE IDENTIFIED PERSONALITY DISORDER

1)      Dialectical Behavior Therapy (DBT)

·         Weekly individual sessions to improve emotional regulation and distress tolerance.

·         Group therapy for skills training (Leichsenring et al., 2024).

·         Crisis intervention strategies (e.g., mindfulness, interpersonal effectiveness).

2)      Cognitive-Behavioral Therapy (CBT)

·         Identifying and modifying maladaptive thought patterns (Amano et al., 2023).

·         Behavioral activation for mood stabilization.

3)      Medication Management

·         Continue Fluoxetine and monitor adherence.

·         Consider low-dose atypical antipsychotics (e.g., Quetiapine) if severe mood instability persists.

·         Psychoeducation about the importance of medication compliance.

4.       Family Therapy

·         Education of the family members on the disorder BPD, and improvement of communication skills.

·         Reducing invalidation and increasing positive interactions in relationships (Leichsenring et al., 2024).

·         Encouragement of planned family sessions to improve the interaction of family members.

5.       Lifestyle Changes

·         Regulated schedule for stabilization of sleep and diet habits.

·         Systematic workout for enhanced emotional control.

·         Practicing self-caring activities like yoga and guided meditation (Girolamo et al., 2024).

6.       Crisis management plan

·         Suicidal prevention methods and crisis contacts.

·         Triggers understanding and controlling techniques.

·         Development of a personalized crisis response plan.