BPD
Age: years old
Gender:
HISTORY:
Presents with a - history of
Severity is , significant distress
Negative impact on
Reaction to stressors is more intense or longer-lasting than would normally be expected
Alleviating factors: ,
Associated symptoms: *Try using right-click for negatives*
Contributing factors:
no history of: , , , , ,
no childhood history of , ,
no family history of:
EXAM:
Mental Status:
Appearance: , , eye contact, appears
Behavior:
Psychomotor activity:
Speech: , ,
Mood: , ,
Affect: , , , to situation, with mood
Thought process: , , ,
Thought content: , , ,
Perception: , ,
Cognition: , oriented to , disoriented to , attention , memory
Judgment:
Insight: into condition
Reliability:
ASSESSMENT:
DDx: borderline personality disorder, personality disorder, other personality disorders, bipolar disorder, major depressive disorder, post-traumatic stress disorder, anxiety disorders, adjustment disorder, substance use disorders, eating disorders, attention-deficit/hyperactivity disorder, dissociative disorders, neurocognitive disorders, premenstrual dysphoric disorder
PLAN:
Investigations:
- Blood work: ,
Treatments:
- 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
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Further care:
- Referral to psychologist
- Referral to social worker
- Referral to psychiatrist
- Follow-up in
- Return if condition worsen or if new symptoms develop such as suicidal thoughts
HISTORY: Associated symptoms: EXAM: Mental Status: ASSESSMENT: PLAN: