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Severe mood disorders along with delusions are diagnosed as a form of borderline personality disorder (BPD). The symptoms are extremely hard to detect as people often display emotional stressors that creates mental insecurities, on how they relate to others and on how they behave. These conditions if not treated can lead to illnesses that will develop into serious health and mental conditions. Many BPD clients experience images within their minds where they feel worthless and flawed that their self-image and sense of self often rapidly changes. One symptom others will notice is angry dispositions as being impulsivity with frequent mood swings, which hinder relationships by pushing others away. However, BPD with proper treatment clients can live happier and peaceful lives. This hypothetical case study and treatment plan is pertaining to the client’s mood swings and anxiety experiences. It will define and described from the DSM-IV-TR psychologist diagnosis book the types of circumstances defining their psychological conditions.
This paper presents a hypothetical case of a male adult that is suffering from mood swings, obsessive anger as Borderline Personality Disorder (BPD) that 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).
Narrative Case Description
The client is a divorced male who is currently unemployed with a history of mood instability. The John Doe client has a career history of working in the field of liquidations with a successful managerial career of supervising others. However, displays high turnover in staffing due to his outrageous behavior. He received a new district manager who re-evaluated his high turnover of people reporting to him. Management after long thought and consideration decided that his services were not in the best interest of the company objectives. He was dismissed with a six month pay to support his needs until he was able to find work. However, this client also suppressed but suffers with episodes of severe idealization and devaluation, which has led to unstable and chaotic interpersonal relationships where he seems to be disturbed about his sense of self. He is fearful of being alone, shows impulsive and risky behaviors. The client has high levels of drastic and rapid shifts from one emotion to another.
Therefore, this patient clinician is finding it challenging with 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).
As the assigned therapist it is possible that this client would eventually self-harm himself where 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. Although the client has episodes of hostility, impulsive behaviors which has hindered relationships, the client is seeking treatment with this therapist on his own free will.
In reviewing the DSM-IV-TR for a diagnosis on patient the proposed treatment plan for this client 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 therapy part of the treatment will also include schema therapy, which is an integrative psychotherapy. Schema therapy is based on a cognitive schema model that is aimed at identification and adjustment of dysfunctional modes and schemas through cognitive, experiential and behavioral pathways the schema therapy has been specifically developed for patients with personality disorders (Linehan & Marsh, 1993). Although the effectiveness of this treatment has been demonstrated in controlled random trials, it has not been extensively evaluated in regular mental healthcare settings.
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 united 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 (Koehler, 2005). The identifying information of the patient, his name is John Doe, who is 56 years of age, Caucasian male, has a college degree in mathematics. The initial start date for this treatment plan will start immediately March 28, 2011up to four months. Then based on successful treatment responses other treatment plans will be determined at that time. The name of the assigned clinician providing treatment is Cynthia A Johnson.
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 (Brand, 2001). 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, et al., 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). The client John Doe is self-referred.
The client is seeking treatment, as a result of the symptoms of mental illness he faces. The client has been suffering from irrational mood swings and obsessive anger, which has led to instability in his personal relationship with other individuals, and has affected his self-image. The clients sought treatment as he was in a state of desperation, and had tried some other treatment plans, but had not received any treatment so far that greatly improved his own self-image.
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 patients (Austrian, 2000).
Axis I: 296.90 Mood Disorder NOS (Not otherwise specified)
Axis II: 301.83 BPD
Axis III: None
Axis IV: Client living alone and divorce-Social Problem
Axis V: GAF=30 (Current)
Long term Goals
The client John Doe’s long term treatment plan involves psychotherapy as well as medication. Drug prescription consists of atypical antipsychotics and in mood stabilizers. The Psychological aspect of the treatment combines cognitive behavioral therapy with group therapy.
This treatment plan will be beneficial to the client in several ways including the alleviation of mental illness symptoms, improvement of interpersonal relationships, and improvement of the client’s self image.
1. Alleviation of mental illness symptoms
The treatment plan will help in reducing symptoms thereby resulting in improvement in the client’s behavior and feelings.
2. Improvement of interpersonal relationships
This treatment plan will enable continued improvement in the client’s interpersonal functioning, even after the period of treatment.
3. Improvement of the client’s self image.
This plan is designed to help the client find help with emotional and relationship problems, thereby improving self image
Methods or Interventions
Typically, patients receiving treatment for mental illnesses are given anti-depressant medication and patients also receive counseling and psychotherapy in many cases, but the effectiveness of anti-depressant medicines in mild or moderate cases is questionable. By drawing the client’s attention to the important issues involved during treatment, the treatment plan will help the client to understand himself and the situation better and thus be able to change the way that the client responds to situations. This will also enable the meeting of long-term goals for this treatment plan.
Estimated Length of Treatment
The estimated length of treatment is 36 weeks. Appointments shall be scheduled once every week for the duration of the treatment.
The measures that will be used in assessing the progress of the patient include semi-structured interviews and self-report measures on the disorder, the quality of life, psychopathology, therapeutic alliance and costs during interval periods of 6 months, 12 months, 18 months and 36 months. The criteria for measuring recovery include the achievement and maintenance of good BPDSI-IV scores until the final assessment, as well as reliable change that reflects individual clinically significantly improvement (Aviram, Brodsky, & Stanley, 2006).
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.
Although the effectiveness of the schema therapy has been demonstrated in controlled random trials, it has not been extensively evaluated in regular mental healthcare settings. Another issue is the fact that clinical interventions with verified efficacy are not necessarily implemented in normal practice, and whenever these interventions are implemented, treatment results are not always equally as good as the results of the clinical trial. Patients being treated for borderline personality disorder need extra support from their therapist in between their scheduled sessions especially during a crisis. Studies have recently been carried out which suggest that support from the therapist in the form of patients accessibility to the therapists phone outside of office hours was a major issue (Nelson et.al., 2009). Thus, accessibility outside regular office hours has been perceived to be a critical obstacle to successful implementation of treatment.
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