BORDERLINE PERSONALITY CASE STUDY

Sarah Newman

Mental Health Case Study

03/11/2018

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Abstract

The purpose of writing this case study was to interview a patient and analyze the precipitating

factors that led to hospital admission. The following study defines the patient’s date of admission

and psychiatric diagnosis. A summarization of the psychiatric diagnosis and expected behaviors

is included. I will also be identifying stressors and behaviors that precipitated the patient’s

current hospitalization, as well as the patient and family history of mental illness. Nursing

diagnosis and care plans have been created for this patient. A Mini-Mental Status Examination

(MMSE) has also been conducted and results revealed.

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Objective data: Female patient was admitted to the unit on February 2, 2018. I was assigned this

patient on February 6, 2018. The psychiatric diagnosis that was given to this patient was “Mood

Disorder with suicidal ideations.” The patient also had several other medical conditions,

including: Depression, Headache, Anxiety, and Attention Deficit Hyperactivity Disorder

(ADHD). Patient feels that her parents do not understand how she feels. She states that she has

tried to talk to them, but the shrug it off. She states that she does not want to die, but wants to

feel something; therefore she cuts herself. Patient is friendly to staff and is willing to answer any

questions, however, at times it seemed as though she was unsure about how to elaborate on

topics. Often her topics would have loose associations with one another. She appeared sad and

depressed, but also was neat in her dress, and held a relaxed posture as we spoke. Safety is an

apparent problem after suicidal ideations and threatened attempts have been made. Current

psychiatric medications used include: dextroamphetamine (Adderall), aripiprazole (Abilify),

citalopram (Celexa), and lorazepam (Ativan). These medications are used to reverse the effects

of depression, anxiety, agitation, and for control of Attention Deficit Hyperactivity Disorder

(ADHD).

Axis 1: Mood Disorder with suicidal ideations

Axis 2: Borderline Personality Disorder

Axis 3: Attention Deficit Hyperactivity Disorder (ADHD)

Axis 4: Parents divorced

Axis 5: GAF scale of 51-60 [Moderate symptoms OR moderate difficulty in one of the

following: social, occupational, or school functioning.]

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Summarize: The National Institution of Mental Health (2017) defined Borderline Personality

Disorder as the following:

Borderline personality disorder is a mental illness marked by an ongoing pattern of

varying moods, self-image, and behavior. These symptoms often result in impulsive actions and

problems in relationships. People with borderline personality disorder may experience intense

episodes of anger, depression, and anxiety that can last from a few hours to days.

According to the NIMH (2017), common signs and symptoms of Borderline Personality

Disorder include mood swings, role uncertainty, extreme viewpoints of things (either good or

bad), distorted and unstable self-image, a pattern of intense and unstable relationships, efforts to

avoid real or imagined abandonment, self-harming behavior such as cutting, impulsive and often

dangerous behaviors (such as, shopping spree, substance abuse, reckless driving), inappropriate

and intense anger or problems controlling anger, chronic feelings of emptiness, intense and

highly changeable moods, recurring thoughts of suicidal behaviors or threats, difficulty trusting,

and feelings of dissociation.

There are five major risk factors for the development of Borderline Personality Disorder.

These factors include: family history, brain factors, environmental factors, social factors, and

cultural factors (NIMH, 2017). Family history: People who have a close family member, such as

a parent or sibling with the disorder may be at higher risk of developing borderline personality

disorder (NIMH, 2017). Brain factors: Studies show that people with borderline personality

disorder can have structural and functional changes in the brain especially in the areas that

control impulses and emotional regulation (NIMH, 2017). Environmental, cultural, and social

factors: Many people with borderline personality disorder report experiencing traumatic life

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events, such as abuse, abandonment, or adversity during childhood. Others may have been

exposed to unstable, invalidating relationships, and hostile conflicts (NIMH, 2017).

According to the National Institute of Mental Health (2017), “Psychotherapy is the first-

line treatment for people with borderline personality disorder.” A therapist can provide one-on-

one treatment between the therapist and patient, or treatment in a group setting (NIMH, 2017).

Therapist-led group sessions may help teach people with borderline personality disorder how to

interact with others and how to effectively express themselves (NIMH, 2017).

Identify: Patient has had worsening thoughts of suicidal ideations since Christmas Eve (2017).

In the past week (week of February 1, 2017) the patient has had increased thoughts of suicide

and has developed plans. The patient had devised completing the action by committing either of

the following two plans: overdosing on whatever medication she could find in the house, or

parking the car in the garage and allowing the carbon monoxide to build up in her lungs. Her

parents noticed that this was going on and brought her to her counselor, who then pink slipped

her and thus brought about her admission to St. Elizabeth in Youngstown, OH. She claims to

have always had these feelings, and what caused them to progress and spiral into her admission

was a falling out that she had with her close friends. She already feels that she cannot talk to her

parents, so when she was “abandoned” by her once close friends, she felt that she had nowhere

left to turn. She began to cut more and when that did not help she began devising suicidal plans.

Discuss: According to the patient and her medical record on file, no one else in the family has a

history of any sort of psychiatric disorder. For this reason, she feels that she cannot talk to her

family, since they would not understand. Patient states that she has always felt anxiety and

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depression in her history; never was a time where she felt truly happy. She was recently

diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and was prescribed Adderall.

According to her recent lab results, her amphetamine screening came back positive. This

indicates that she is successfully taking her medication. By the end of our conversation, the

patient was able to discuss some positive methods for coping with her depressed feelings,

besides cutting and suicide. One of these coping mechanisms included walking around the mall.

This was something she enjoyed doing with her friends prior to their “falling out.”

Describe: One of the psychiatric evidenced based nursing care that is provided includes

Psychotherapy. According to Paley & Shapiro (2001), Psychotherapy provides “understanding,

warmth, the instillation of hope and of feeling supported, as well as the ‘ritual’ associated with

the provision of therapy.” Research suggests that any form of counselling that: leads to the

development of a therapeutic relationship between nurse and client; offers some form of

structure to the counselling and attends to changes or problems in the therapeutic process

between nurse and client throughout the course of the counselling could justifiably be regarded

as evidence-based. However (Paley & Shapiro, 2001).

According to the authors at Current Nursing (2013), there are three goals to Milieu

Therapy: “1.) Manipulate the environment so that all aspects of client’s hospital experience are

considered therapeutic. 2.) Client is expected to learn adaptive coping, interaction and

relationship skills that can be generalized to other aspects of his or her life. 3.) Achieving client

autonomy.” The first Milieu Therapy Activity that was utilized was containment, which occurred

on admission. Containment is the process of providing safety and security and involves the

patient’s access to food and shelter (Current Nursing, 2013). In a well contained milieu, patient

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feels safe from their illnesses and protected against social stigma (Current Nursing, 2013). The

second Milieu Therapy Activity that was utilized was structured interaction. Structured

interaction includes purposeful interactions that allows patients to interact with others in a useful

way (Current Nursing, 2013). The daily community meeting provides structure to explain unit

rules and consequences of violations (Current Nursing, 2013). The third Milieu Therapy Activity

utilized was open communication. In open communication, staff and patient willingly share

information (Current Nursing, 2013). Staff members invite the patient’s self-disclosure within

the support of a nurse- patient relationship (Current Nursing, 2013). In addition, they provide a

model of effective communication when interacting with one another as well as with patients

(Current Nursing, 2013). Support, attention, praise and reassurance given to patients improve

self-esteem and increase confidence (Current Nursing, 2013).

Analyze: Patient did not specify any ethnic, spiritual, or cultural influences in her life. However,

she does enjoy her transition from high school to college. This is her first semester at college,

and she likes the change of setting. Likes the independence and the more “grown up” feel, that is

different from the childish games she felt were occurring in her high school classes. She enjoys

working at her retail job, however feels bullied by her coworkers. She states that her feeling

chronically mentally ill is interfering with her life.

Evaluate: There are several patient outcomes related to this specific patient’s care. Some of

these outcomes are listed as followed: The patient will identify behaviors leading to

hospitalization. This outcome allows the patient to reflect on the events leading to the mental

break, which allows her to create goals for the future. The patient will be free from self-inflicted

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injury. This outcome is in regard to her safety. She was admitted because of her plan of

committing self-harm. It is our goal to keep her free from harm. The patient will demonstrate two

new coping skills that work for the client for when tension mounts and impulse returns. The

patient currently using cutting as a coping mechanism. By the end of hospitalization, we would

like her to be able to identify new healthy coping strategies. Patient will identify three strengths

in work/school life. She has demonstrated a distortion in her own self-image. This will encourage

her to find some positives in her life, as well as things that she likes about herself.

Summarize: Plans for discharge include safety precautions in regard to her suicidal ideations.

Effective coping mechanisms plays a huge role in her discharge. Since the patient only uses

cutting as a way to escape the pain, our goal for discharge is to see her effectively start new ways

of coping. She previously mentioned that she likes going to the mall. A good discharge

instruction for her would to ensure that she makes a trip once a week. Another discharge goal for

her is to open up communication with her family. Inform them of the warning signs of when she

starts to go down the dark path, as well as what she would like her family to do in order to help

her during these times. She states that she does not want to make it back to this facility, so

implementing this open communication may give her an outlet to prevent readmission.

Prioritized: The following is a list of all actual diagnoses using individualized NANDA format.

1.) Risk for injury related to suicidal thoughts as evidenced by an attempt at self-harm.

Interventions: 1. Remove all possible hazards in the environment. 2. Place injury

prone client close to nurse’s station.

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2.) Ineffective coping related to inadequate social support as evidenced by cutting for

pain release.

Interventions: 1. Help client set realistic goals. 2. Use of active listening and

acceptance.

3.) Hopelessness related to emotional state as evidenced by a desire to cut herself.

Interventions: 1. Point out reasons for living. 2. Assist client with looking at

alternatives.

List: Below is a list of potential nursing diagnoses

1.) Risk for suicide r/t threats of killing oneself

2.) Risk for anxiety r/t unmet needs

3.) Risk for complicated grieving r/t lack of social support

4.) Powerless r/t lifestyle of helplessness

5.) Fear r/t crisis situation

6.) Risk for situational low self-esteem r/t situational crisis

7.) Risk for disturbed personal identity r/t dissociative identity disorder

Conclusion: This case study allowed me to develop my care plan skills on a deeper level. It

required me to take what little information I had and to create a nursing diagnosis, care plan, and

interventions to help out a patient. One of the major skills I learned was how to complete a Mini-

Mental State Examination (MMSE). The exam went as follows: Orientation she received a 5/5

on both subgroups, registration she received a 3/3, attention and calculation a 4/5, recall a 2/3,

naming a 2/2, repetition a 1/1, 3-stage command a 3/3, reading a 1/1, writing a 1/1, and copying

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a 0/1. Her total score was a 26/30 which defined her as having mild cognitive impairment.

Mental health patients have a high incidence of returning. It was educational for me to look at

potential nursing diagnoses for this patient. The goal of any hospital is to prevent readmission, so

by identifying potential diagnoses, we may be able to intervene and prevent readmission of this

patient.

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Citations:

Current Nursing. (2013, September 19). Nurse's Role in Milieu Therapy. Retrieved March 11,

2018, from http://currentnursing.com/pn/milieu_therapy.html

National Institute of Mental Health (NIMH). (2017, December). Borderline Personality Disorder.

Retrieved March 11, 2018, from https://www.nimh.nih.gov/health/topics/borderline-

personality-disorder/index.shtml

Paley, G., & Shapiro, D. (2001, January 18). Evidence-based psychological interventions in

mental health nursing. Retrieved March 11, 2018, from

https://www.nursingtimes.net/roles/mental-health-nurses/evidence-based-psychological-

interventions-in-mental-health-nursing/206109.article

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