Presenting Problems

Vee is a 26-year-old African American female with a history of cutting her arms and legs as an
adolescent. She has a history of suicide attempt as a teenager and again six months ago by
overdosing on pills. Additionally, she has chronic suicidal ideation. Vee has been known to say
that she “doesn’t really know who Vee is” as evidenced by her history of changing styles,
hobbies and even jobs based on her current friend group. She is currently dating but admits to
turbulence in the relationship as well as feeling remorse when she lashes out at him. Prior to
this relationship she engaged in sexual activity with various partners both known and unknown
to her.

Diagnosis
According to the Diagnostic and Statistical Manual of Mental Disorders 5th Edition- Text Revised
(DSM-5-TR) Vee possesses nine out the nine behaviors for the diagnostic criteria for borderline
personality disorder (F60.3). Vee’s chameleon like tendencies in her appearance, hobbies and
job indicates her effort to avoid abandonment either real or imagined as well as a sign of
identity disturbance. The feeling of abandonment is evident in times of stress as she
disassociates from her conversations or at work by “[zoning] out” and depersonalizes herself by
stating “I don’t know who Vee really is.” Vee’s cutting behavior possibly intensifies during
periods of dissociation. Her history of cutting and suicide attempts are also signs of her
abandonment fears. The intensity of her relationship with her partner is reflected in the swings
from being caring to “I can’t stand him” which represents an internal conflict related to
abandonment. Her inability to manage her anger is seen in her ability to oscillate from caring to
volatile which is then followed by shame and guilt. Vee’s demonstrated recurrent self-
destructive acts of cutting, suicide attempts and ongoing suicidal thoughts are actually related
to her expectations or perceived threats of separation. In an attempt to reduce feelings of
emptiness or boredom, Vee engaged in sexual promiscuity prior to her current relationship. This
is also representative of her potentially self-destructive impulsivity as is her lavish gifting to her
boyfriend (American Psychiatric Association [APA], 2022; Barlow et al., 2022).

Differential diagnosis includes mood disorders like depression and bipolar disorders, histrionic
personality disorder and separation anxiety. Often borderline personality disorder coexists with
depression (F33.1-2) or bipolar disorders (F31.13) when criteria is met for both. For Vee this
may be the case as she presents with a longstanding history of dysfunction. Separation anxiety
(F93.0) is considered due to the multiple behaviors in regards to fear of abandonment however
Vee strongly represents the core characteristics of borderline personality disorder. To determine
a diagnosis of histrionic personality (F60.4), further interviewing would be necessary to assess
for interactions and behaviors of expression from style of speech to content of spontaneous
remarks and degree of being easily influenced (APA, 2022).

Cluster
Clustering of personality disorders is meant to group similar characteristics together. Not
surprisingly Cluster A patients are far less studied due to lack of patients seeking treatment
compared to those identified as Cluster B or Cluster C. Vee is a Cluster B personality disorder
which is characterized by dramatic, erratic and emotional displays of behavior. Cluster B
encompasses antisocial, borderline, histrionic, and narcissistic personality disorders. Research
indicates that different cluster types respond to different approaches to therapy. Explaining the
rationale for treatment approach with the patient enhances confidence through credibility and
knowledge (Barlow et al., 2022; Cersosimo & Hilsenroth, 2021).

Treatment Plan
The prognosis for borderline personality indicates a poor symptomatic course which does
decrease in intensity as the patient approaches their 30s and 40s. The immediate concern is
assessing for suicide and a making a contract with the patient for safety. Blood work, urine drug
screen and physical exam to rule out contributing causes such as endocrine dysfunction and
substance use are in order. Initially borderline personality impulsive behaviors diminish rapidly
with treatment while affective symptoms recede at a much slower rate. For this reason,
cognitive behavioral therapy, in particular dialectic behavior therapy, is useful in helping
patients cope with triggering stressors resulting in maladaptive behaviors. Dialectic therapy is
scheduled daily or weekly to support and continues to educate the patient on how to handle
stressors and their responses more effectively. Topics of these sessions include problem solving,
identifying and regulating emotions, and extinguishing reactivity. By the end of therapy, the
patient will have learned how to trust their own judgements and not react to the opinions of
those around them. Patients can expect the length of therapy to be one to three years.
Repeating the suicide assessment is important in the ongoing care as approximately 6% of
patients are projected to die by suicide (Barlow et al.,2022).

While borderline personality disorder is quite debilitating, there is no approved medication for
the disorder. This is interesting because almost 96% of patients diagnosed with the disorder are
prescribed at least one psychotropic medication. The reason may have to do with the
coexistence of other psychiatric disorders as previously stated. That being said, depending on
the features Vee presents with, consideration for a mood stabilizer such as lithium but perhaps
preferably Depakote may be in order due to her affect dysregulation of suicidal thoughts as well
as for her impulse control. Lithium has a narrower therapeutic index and does require frequent
blood work which may be problematic to accomplish with an impulsive patient (Epocrates,
2024; Gartlehner et al, 2021).

References
American Psychiatric Association. (2022). Personality disorders, depressive disorders and
anxiety disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
https://doi.org/10.1176/appi.books.9780890425787

Barlow, D. H., Durand, V. M., & Hofmann, S. G. (2022). Psychopathology: An integrative

approach to mental disorders (9th ed.). Cengage Learning.

Cersosimo, B., & Hilsenroth, M. (2021). Personality pathology severity, cluster type and specific
therapeutic interventions in outpatient psychotherapy. Counselling & Psychotherapy
Research, 21(1), 154–163. https://doi.org/10.1002/capr.12305

Epocrates. (2024). Depakote and lithium in Epocrates medical references (Version 24.1.0)
[Mobile app]. Apple store. https://www.epocrates.com

Gartlehner, G., Crotty, K., Kennedy, S., Edlund, M. J., Ali, R., Siddiqui, M., Fortman, R., Wines, R.,
Persad, E., & Viswanathan, M. (2021). Pharmacological treatments for borderline personality
disorder: A systematic review and meta-analysis. CNS drugs, 35(10), 1053–1067.
https://doi.org/10.1007/s40263-021-00855-4