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Case Vignette Analysis

0 May 25 2016, 11:47 in Psychology Essays

Case Vignette Analysis

Overview of the patient

Thirty eight years old Sara was referred by her employer for mandatory counseling. She is underweight and wears baggy clothing. Sara has tested positive for amphetamine at work and is currently suspended. She is taking antipsychotic medications and mood stabilizers. Symptoms of Sara includes self-injury and self-mutilation. She claims to cut herself whenever she hears voices telling to kill herself. She says that it is "nothing serious,just a scratch here and there.” She also needs to drink so that the voices stop and beast to calm. Sara loves excitement and risk-taking. Sara was born in Japan from a Native-American father and Japanese mother. Her family moved to the United States when she was 8. For her, this was the most difficult and darkest time of her life. She claims to see the spirit of her deceased grandmother at age 15. Extreme sadness has resulted in self-abuse,substance use,strict dieting. The "devil” tells her that the death of her grandmother was her fault. In terms of relationship,Sara has dated several times,but did not enter into long-term relationships due to extreme guilt and self-loathing.

Based on the above history,the patient is suffering from borderline personality disorder. This is a type of disorder developed from behavioral,mood and relationship instability. It is also associated with poor impulse control from which several functional impairments in all clinical settings (Paris,2010). This type of personality disorder is often associated with mood disorders,substance use disorders,anxiety disorders and other personality-related disorders. It is termed as "borderline” because it somehow falls in the middle of neurotic and psychotic symptoms. Patients experiencing BPD have micropsychotic and quasipsychotic presentations such as the presence of "voices” telling them to kill themselves (Oldham et al.,2011). In our case above,this is similar to the "devil” that tells Sara to kill herself. BPD patients also present paranoid feelings,such as the voice telling Sara that the death of her grandmother was actually her fault,resulting in extreme self-loathing and guilt. The feeling of depersonalization associated with BPD is also present in Sara’s condition, which is why she was not able to establish a long-term relationship with the opposite sex. She depersonalizes by claiming that the guys dating her are all "too good” for her that she does not even know why they still "hang around” with her.

Other important core symptoms of BPD,according to the DSM 5 criteria include mood instability along with a wide range of impulsive behavior including overdoses, self-injury and engagement in risky behaviors (Stone,2011). In order for a patient to be diagnosed with BPD, they need to meet the criteria required by the DSM 5,which include the following:

Self-functioning impairments – this means that the identity of the person with BPD is poorly developed,markedly impoverished and unstable. In Sara’s case, she is wearing baggy clothing and underweight,which means that she has poor body image associated with self-functioning impairments (Henry et al.,2010). This may be associated with her receiving constant criticisms and/or feelings of emptiness and stress. Patients with BPD also exhibited instability in creating life goals,career plans and values. In comparison,Sara has recently been suspended from work because of testing positive for substance use,which means that she is having problems creating long-term goals in life.

Impairments in interpersonal functioning – patients with BPD are often conflicted and unstable in forming close relationships similar with Sara,because people like her think of mistrust, deception and anxiety whenever they try to enter into relationships (Oldham et al.,2011).

Pathological traits characterized by negative emotional liability, anxiousness and depression – people with BPD are emotionally unstable who experience frequent mood changes that can be aroused by simple circumstances (Stone,2011). Anxiousness and depression are also characteristics of BPD as people often feel nervousness,uneasiness and panic in reaction to internal and external stressors. The "voices” being heard by Sara is an example of internal stressor that creates mood swings and anxiousness,which is why she feels threatened and guilty at the same time. This also results in depression from which she is unable to fully recover from the things that happened in her past life. Depression is the feeling of frequently being down along with hopelessness and miserable (Oldham et al., 2011). With this,thoughts of suicide come into her mind,but this is in the form of the "devil” which she hears telling to kill herself for the death of her grandmother.

Disinhibition characterized by risk taking behaviors – this is another hallmark characteristic of a BPD patient. They love to engage in risky and potentially dangerous and self-damaging activities in order to revert the negative thoughts in their minds (Oldham et al.,2011). The risk-taking behaviors performed by Sara are numerous – from substance use and drinking to self-injury and self-harm, these are all risky behaviors that make her feel more comfortable and satisfied than constantly feeling down and empty (Henry et al.,2010).

According to Paris (2010),the symptoms of borderline personality disorder begin in childhood and continue to present in adolescence. The symptoms may actually worsen by early adulthood and can subside by middle adulthood with proper treatment and psychotherapy. We can say that the onset of symptoms of Sara starting during her childhood when her grandmother died. Sara was close to her grandmother after leaving Japan for the US and after her father left her Japanese mother. The death of her grandmother is very depressing for Sara that she claims she sees her thereafter. The presence of the devil is a kind of guilt feeling that allows Sara to divert things that became painful for her. Because she does not have full parental support,Sara was able to carry these symptoms throughout her adulthood,which basically worsened over time because her coping mechanisms are not effective (Henry et al.,2010).

Comorbid disorders present

BPD patients often meet the criteria for various Axis I disorders of DSM 5. Since the disorder is associated with a multitude of symptoms, the presence of comorbid disorders is not surprising (Paris, 2010). The changes in the diagnosis of patients with BPD to any of the comorbid disorders focus on the aspect of symptoms,so it is necessary to take into account the four important clinical phenomena associated with BPD – that is,interpersonal,affective,impulsive and cognitive aspects.

It is easy to say that the diagnosis of major depressions is present in BPD,but the similarity of symptoms is derived from different causes. BPD causes of depression are deeply rooted in the past resulting in unstable or low mood,while symptoms of major depression may occur from current events,such as pain related to injury or anxiety from some serious form of clinical illness (Oldham et al.,2011).

When the DSM IV TR was made prior to DSM 5,it is strongly recommended that for BPD to be diagnoses the presence of three out of four criteria should be met. But in the new DSM 5 diagnosis,BPD should be ruled out if all of the criteria are met and these are associated with the clinical phenomena of affective, impulsive,interpersonal and cognitive aspects (Oldham et al., 2011). Patients should be merited with all these features to be able to accurately fall under the BPD diagnosis.

Differential diagnosis of BPD

BPD has a differential diagnosis of psychosis mainly because it is a "borderline” disorder between psychosis and neurosis. This is the reason why in the past BPD is termed as pseudoneurotic schizophrenia (Henry et al., 2010). The concept states that patients with a multitude of symptoms could be psychotic in a latent phase. But psychotic phase does not involve the presence of impulsivity and mood that primarily affect the cognitive aspects of a patient with BPD. But since there is no biological and familiar markers that link BPD and schizotypal disorders,the diagnosis of patients with cognitive symptoms and psychotic symptoms often fall under BPD and not schizophrenia secondary to psychosis. All cognitive symptoms of BPD are stress related either from past or present events,and the insights of patients are still retained unlike in psychosis where patients usually fall out of their insights when psychosis starts to exhibit (Oldham et al.,2011).

BPD is also differentially diagnosed as major depression mainly because it has the symptom of depression with it. In the past, BPD is thought to be an atypical form of depression,but it was soon discovered that symptoms of BPD depression are associated more with lowered mood and dysthymia with an onset during early childhood to adolescence (Henry et al.,2010). However,again,the presence of other impulsive symptoms such as substance use and mood swings is what differentiates BPD from major depressive disorders.

The family history of major depression also defines depression than the onset of symptoms in BPD which has an early onset. In a classical depression disorder, the mood of patients can be stable for weeks before entering a high and relatively unresponsive phase (Henry et al.,2010). This is very much different from BPD whose onset of depression are acute and can change in a single day,depending on the presence of other symptoms like impulsivity and cognitive affects. More importantly,depression in BPD patients does not respond effectively to anti-depressant drugs,because the presence of psychosis and neurosis intervenes with the effects of anti-depressants.

Since BPD condition is presented as a "borderline” between neurosis and psychosis,another differential diagnosis is bipolar spectrum, according to Paris (2010). Bipolar disorders can be further categorized into substance-induced bipolar disorder and/or ultra-rapid cycling bipolar. This is because the mood swings that are typically seen in patients with BPD are often present in patients with bipolar disorder. However, the difference lies in the fact that the mood swings in BPD patients constantly shifts and does not stick with one mood for days. In contrast, bipolar patients can have mood swings that last for days and is consistent throughout these time period (Henry et al.,2010). The emotion dysregulation is also a concept in mood swings of bipolar disorder,while BPD patients may switch back to impulsivity after a brief mood swing or depression. The impulsivity of patients with bipolar can also involve risky behaviors without feelings of remorse of guilt. This is very much different from the impulsivity experienced by BPD patients which is accompanied by a sudden guilt or loathsome feeling.

The final differential diagnosis to be discussed in this paper is about post-traumatic stress disorder. This is very much related with BPD since a "complex” form of stress disorder can be rooted in the patient’s past history,such as neglect,child abuse and/or traumatic experience (Henry et al., 2010). The problem,however,lies in the assumption that trauma causes BPD, rather than other important factors. What has been failed to be recognized is the fact that trauma is just one of the many reasons why BPD has developed in a patient. The psychological,social and biological factors are also taken into consideration when diagnosing BPD; and for these reasons we cannot rule out that Sara is a PTSD patient,because of the presence of other important criteria in the diagnosis of BPD.

Therapeutic models to treat presenting issues and diagnosis

Currently,there are several psychotherapeutic approaches to the treatment and management of BPD. The main therapeutic approaches are focused on the cognitive-behavioral,supportive and psychodynamic domains.

Psychodynamic approaches typically involve methods that are based on the assumption that conflicts and unconscious forces are buffeting the BPD patient and these are the main factors responsible for polarized attitudes and sharply oscillating behaviors. For example,BPD patients may change from contempt to adoration toward key figures in life or the presence of other coping mechanisms. However,most of the coping mechanisms are negative and are more considered as a source devaluation and idealization (such as drugs and alcohol use). The purpose of psychodynamic approach is to promote the integration of psychic forces through proper identification of polarized behaviors and their sources (Henry et al.,2010).

Psychodynamic approach can be divided into two categories – psychoanalytic and dialectical behavior therapy. Both of these treatments are effective methods,but they vary in duration. The common features of patients with BPD help guide therapists create an effective therapeutic approach regardless if they use dialectic or psychoanalytic. The establishment of strong therapeutic alliance between the patient and the therapist is the key towards creating a long-term effective approach. The positive working relationship can be enhanced by careful attention to details both on the part of the patient and the therapist,according to Henry et al. (2010). Moreover, clinicians may find it very useful to identify the source of patient’s symptoms and that there are instances when they would likely violate,test,redefine or cross boundaries depending on the situation (Ghaemi et al.,2012). Thus,the therapist must be active and responsive to the patient’s needs particularly the patient’s suicidal and self-harming behaviors.

The figure above shows the different treatment priorities between the dialectical behavior approach and the psychodynamic approach. The specific behaviors that the clinicians may encounter from their patients are outlined in the tables above (Henry et al.,2010). It is a form of "ladder” with the highest priority above followed by the lesser treatment priorities below. This means that the symptoms should be understood first prior to choosing what approach can be effective for the patient (Ghaemi et al.,2012). Again,greatest priority focuses on the suicidal behavior and self-injuring behaviors followed by other symptoms.

The focus of the psychodynamic approach is to reinforce positive self-attitude while allowing the patients to realize that they are responsible for their actions. Therefore,clinicians must validate first the sufferings of the patient,which is linked with their traumatic past. Many patients will try to blame themselves for any trauma they endured,similar to the case of Sara who tries to blame herself for the death of her grandmother when she was a teenager. The effectiveness of psychodynamic therapy will let the patients realize that they are not the ones responsible for such past incident and the real solution to the problem can be treated with proper therapies (Ghaemi et al.,2012). They should realize that it was a traumatic childhood incident that made them limit their life choices and resulted in poor coping skills such as substance abuse and drinking. The interpretations of the "here and now” should be properly reinforced as well,because this is the basis of the therapeutic approach rather than the "past.” However,the event in the past is useful for interpreting the basis of the problem so that the patient can formulate their own problem solving and decision-making skills (Henry et al.,2010).

More importantly,the clinicians should understand that BPD patients possess a wide range of weaknesses and strengths that allow them to function or become impaired and limited. This understanding is critical to the psychodynamic approach because the unconscious patterns of behavior might indicate the actual insight of the patient (Henry et al.,2010). It is then that supportive strategies could be developed so that overall therapy is conducive,empathetic,and strengthening.

Because the patient might exhibit impulsiveness throughout the therapy,clinicians must be firm in setting limitations to avoid escalation of self-harming behavior and to impose a positive self-image. At the same time,the therapists should convey the limitations of their therapy and the capacities at which they are only allowed to operate. This will give the patients an idea about the treatment process, and that the therapy can be discontinued at any point in time (Ghaemi et al., 2012). Based on clinical experience,BPD patients should usually be involved in self-reflection and promotion of conscious actions to prevent impulsiveness and mood swings. It is the role of the clinicians to actively engage patients in their own self-observation and awareness to make understand how behaviors generate and develop and what they can do to avoid negative thoughts and cognitions to succumb to them (Henry et al.,2010). These are some of the most important concepts of the psychodynamic approach that can be used for the patient in our case.

Conclusion

In this paper,we have discussed the diagnosis of Sara as our patient for this case vignette. Based on the presenting symptoms,she is suffering from borderline personality disorder. We have discussed how her symptoms are linked with BPD and why it is necessary to accurately diagnose her. The next sections of the paper discussed the comorbidities and differential diagnosis for BPD. We have argued and set the differences between BPD and the other conditions to be able to effectively rule out that Sara is indeed a BPD patient. The final discussions talked about the therapeutic approaches for BPD and what the clinicians should do to create an effective therapeutic plan. These include psychodynamic therapy and dialectic behavior therapy. The therapeutic approaches are necessary to improve the condition of the patient both in short- and long-term.

References

Ghaemi,T. et al. (2012). "Cade’s disease” and beyond: Misdiagnosis,antidepressant use,and a proposed definition for bipolar spectrum disorder.” Can J Psychiatry. 47: 125 – 134.

Henry,C. et al. (2010). "Affective instability and impulsivity in borderline personality and bipolar II disorders: Similarities and differences.” J Psychiatr Res. 35: 307 – 312.

Oldham,K. et al. (2011). "Treatment of Patients With Borderline Personality Disorder.”APA. 6: 1 – 40.

Paris,S. (2010). "Why Psychiatrists are Reluctant to Diagnose Borderline Personality Disorder.” Psych. 4: 35 – 39.

Stone,M. (2011). "Management of borderline personality disorder: a review of psychotherapeutic approaches.” World Psychiatry. 5(1): 15 – 20.

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