Case Presentation and Treatment Plan for an adult client
This paper presents a case of an adult suffering from Borderline Personality Disorder (BPD), and proposes a treatment plan for this mental disorder. Borderline personality disorder is a mental ailment that involves prolonged disturbance of an individual's personality function, and is usually found in persons over eighteen years of age, although it can also occur in adolescence. Borderline personality disorder is characterized by deep and varying moods, and' involves unusual levels of instability in mood; black and white thinking, or splitting; the disorder often manifests itself in idealization and devaluation episodes, as well as chaotic and unstable interpersonal relationships, self-image, identity, and behavior; as well as a disturbance in the individual's sense of self.' (American Psychiatric Association, 2000).
Studies indicate that people with Borderline personality disorder tend to experience frequent, strong and long-lasting states of aversive tension, often triggered by perceived rejection, being alone or perceived failure. 'In extreme cases, this disturbance in the sense of self can lead to periods of dissociation. Patients may also experience temperamental sensitivity to emotive stimuli.' (American Psychiatric Association, 2000)
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The client is a 56 year old man with a history of mood instability. The client also suffers episodes of idealization and devaluation, which has led to unstable and chaotic interpersonal relationships and he seems to be disturbed about his sense of self. Some patients and clinicians the world over have been challenging the use of the word 'borderline' in describing this illness. Although there have been numerous articles written about the diagnosis of borderline personality disorder, and there is still little known about the nature of the illness, based on empirical research, there have been some studies carried out which suggest that people with borderline personality disorder frequently experience strong, sustained periods of aversive tension, which are usually set off when the patient perceives that he or she is being rejected, or due to perceived failure. 'Individuals with borderline personality disorder may fluctuate between anger and anxiety or between depression and anxiety and temperamental sensitivity to emotive stimuli.' (Koenigsberg et al., 2002)
Self-harming or suicidal behavior is a major diagnostic criterion in DSM-IV-TR, and after diagnosis, managing an illness of this nature and recovery can be a very challenging experience. Diagnosis of borderline personality is based on a clinical assessment of the case by qualified mental health professionals and assessing such a case will incorporate the self-reported experiences of the patient, and the observations of the mental health professional.
The proposed treatment plan will be based on psychotherapy, with medications playing a lesser role in the treatment. The individual case presentation here will form the foundation of the treatment plan. Although a number of techniques including interpersonal, psychodynamic and cognitive behavioral therapy have been studied for the treatment of borderline personality disorder, evidence suggests that medications like mood stabilizers, omega-3, fatty acids, anti-depressants and anti-psychotics will however, be utilized for treating depression and other co-morbid symptoms of this mental illness.
This proposed treatment plan consists of medication to contain the more stubborn affective symptoms, combined with some form of long-term psychotherapeutic intervention. Psychological treatment will be based on theories of personality, learning and interpersonal communication.
One possible course of therapy is Dialectical Behavioral Therapy (DBT). Dialectical Behavioral Therapy is a modern variant of cognitive therapy that was developed for treatment of mental ailments like Borderline personality disorder. This treatment plan appears to be as helpful in treatment as any other standard cognitive behavioral therapy.
The most widely used criteria for the diagnosis of borderline personality disorder, as well as for classifying mental disorders involves the International Classification of Diseases produced by the World Health Organization (WHO), and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) which is produced by the American Psychiatric Association (APA). Both list categories of disorder and provide standardized criteria for diagnosis. They have deliberately converged their codes in recent revisions so that the manuals are often broadly comparable, although significant differences remain. Other classification schemes may be used in non-western cultures (see, for example, the Chinese Classification of Mental Disorders), and other manuals may be used by those of alternative theoretical persuasions, for example the Psychodynamic Diagnostic Manual. In general, mental disorders are classified separately to neurological disorders, learning disabilities or mental retardation.
The negative emotional states specific to Borderline Personality Disorder may be grouped into four categories: destructive or self-destructive feelings; extreme feelings in general; feelings of fragmentation or lack of identity; and feelings of victimization. Individuals with Borderline Personality Disorder can be very sensitive to the way others treat them, reacting strongly to perceived criticism or hurtfulness. Their feelings about others often shift from positive to negative, generally after a disappointment or perceived threat of losing someone. 'Self-image can also change rapidly from extremely positive to extremely negative. Impulsive behaviors are common, including alcohol or drug abuse, unsafe sex, gambling and recklessness in general.' (Zanarini MC, Frankenburg FR, DeLuca CJ, Hennen J, Khera GS, Gunderson JG 1998). Research indicates that individuals with Borderline Personality Disorder are usually very novelty or intimacy seeking, but can be hyper-alert to any signs of rejection. Thus, they tend to be quite insecure, ambivalent, and display fearfully preoccupied patterns in their relationships with other people. 'They tend to view the world generally as dangerous and malevolent, and tend to view themselves as powerless, vulnerable, unacceptable and unsure in self-identity.' (American Psychiatric Association, 2001)
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DSM-IV-TR Multiaxial Diagnosis
There is some evidence that BPD diagnosed in adolescence is predictive of the disease continuing into adulthood. It is possible that the diagnosis, if applicable, would be helpful in creating a more effective treatment plan for the child or teen.
One large-scale study found that depression in bipolar disorder responds no better to an antidepressant with mood stabilizer than it does to a mood stabilizer alone. Omega 3 fatty acids, in addition to normal pharmacological treatment, may have beneficial effects on depressive symptoms, although studies have been scarce and of variable quality. Topiramate is an anticonvulsant sometimes prescribed as a mood stabilizer. However its efficay is unproven.
Long term Goals
Treatment involves medication and psychotherapy. Drug prescription usually consists in mood stabilizers and atypical antipsychotics. Among the formers lithium is the only compound approved by the FDA for children. Psychological treatment combines normally education on the disease, group therapy and cognitive behavioral therapy. Chronic medication is often needed.
In order to accomplish the longer term goals of this treatment plan,
Methods or Interventions
Estimated Length of Treatment
The measures that will be used in assessing the progress of the patient include
There are certain ethical issues concerning such a case.
The efficacy of mood stabilizers, fatty acids, anti-depressants and anti-psychotics that will be utilized for treating depression and other co-morbid symptoms of this mental illness is unproven. Although omega 3 fatty acids, may have beneficial effects on depressive symptoms in addition to normal pharmacological treatment, research about this has been scarce and of variable quality.
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