Borderline Personality Disorder

HISTORY:

‍Mood swingsUnstable relationships for ‍ ‍hoursdays

Severity: ‍mildmoderateseveredebilitating, ‍causingwithout causing significant distress

Negative impact on: ‍daily activitiessocial lifeworkfamilypersonal relationships

Reaction to stressors is ‍more intenselonger-lasting than would normally be expected

Treatments tried: ‍none, ‍effectiveineffective

‍fear of abandonment

‍unstable personal relationships

‍unclear or shifting self-image

‍impulsive behaviors

‍self-destructive behaviors

‍self-harm

‍extreme emotional swings

‍chronic feelings of emptiness

‍explosive anger

‍feeling suspicious

‍feeling out of touch with reality



EXAM:

Mental Status:

Appearance: ‍well-dressed, ‍well-groomed, ‍goodpoor eye contact, appears ‍age-appropriate

Behavior: ‍cooperativenon-cooperative

Psychomotor activity: ‍normalretardedagitated

Speech: ‍clear, ‍slowrapid, ‍monotonoustalkative

Mood: ‍euthymicdysthymic, ‍anxious, ‍

Affect: ‍euthymic, ‍reactivenon-reactive, ‍full range, ‍appropriate to situation, ‍congruent with mood

Thought process: ‍organizeddisorganized, ‍coherentincoherent, ‍logicalillogical, ‍

Thought content: ‍normalpreoccupationshopelessness, ‍delusions, ‍suicidal ideations, ‍homicidal ideations

Perception: ‍normal, ‍hallucinations, ‍illusions

Cognition: ‍alert, oriented to ‍3 spheres, attention ‍intactdistractible, memory ‍intactimpaired

Judgment: ‍goodmoderatepoor

Insight: ‍goodmoderatepoor into condition

Reliability: ‍goodmoderatepoor



ASSESSMENT:

‍Borderline Personality Disorder ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍TSH

- Psychoeducation about borderline personality disorder

- Dialectical behavior therapy

- Cognitive behavioral therapy

- Mindfulness-based cognitive therapy

- Schema-focused therapy

- Advised that medication is not always helpful

- ‍Antidepressants

- ‍Mood stabilizers

- ‍Atypical antipsychotics

- Referral to psychologist

- Referral to social worker

- Referral to psychiatrist

- Follow-up in ‍ ‍weeksmonths

- Return if condition worsen or if new symptoms develop such as suicidal thoughts