CLINICAL CASE

Berrio Quintanilla, Jonathan

Condori Arias, Yaime
Corrales Santos, Elizabeth
 ANAMNESIS
FILIATION
• Name : MRHJ
• Age : 18 years
• Sex : Female
• Civil status : Single woman
• Current occupation : University student
• Degree of : Upper incomplete
instruction : 31-07-2000
• Birthdate : Fist
• place of birth : Arequipa
• Origin : 10/12//2018 26th day of
• Date of admission hospitalization
: The patient, sister, mother
• Informant
 CURRENT ILLNESS
• Illness time: 7 years

• Main symptoms: emotional

instability, impulsivity, self-harm,
hopelessness

• Onset: insidious Course:

progressive
History of the disease:
Family member reports that his illness began 7 years ago (11
years old), ingesting 1 sachet of rat poison , as a reaction to
his parents not giving him permission to attend a classmate's
party, his mother realizing the In fact, he gave her “burnt
bread,” then she had whitish vomiting, and she did not
receive medical attention.
The same year, she cut her left forearm with a cutter
because her parents scolded her.
At the age of 12 , he ingested 1 sachet of rat poison , and an
hour later, he told his sister “I have taken poison and I feel
bad”, the sister only gives him milk, which causes him to
vomit, he did not receive any attention . medical
At the age of 14 , she ingested 1 sachet of rat
poison , because her parents did not give her
History of the disease:
permission to attend a party. She was taken to
ESSALUD-Puno , where she underwent gastric
lavage, she was hospitalized for 3 days, and
discharged without being evaluated by Psychiatry.

Relatives indicate that from that moment on he took

a “blackmailing” attitude when his parents did not
pay attention to his requests, he repeatedly said “I'm
going to kill myself, you don't love me.”
At the age of 16 , he began drinking beer and wine ,
frequently twice a month, until today.
In addition, he began smoking marijuana in a pipe, 1
History of the disease:
pipe every 15 days, he did it with friends from the
neighborhood and school, for 6 months.
Marijuana consumption increased to 5 times/week,
in January and February of this year, with friends
from the university. He reports feeling joy, forgetting
about problems, and greater sexual pleasure.
He stopped using marijuana until 3 months ago.
3 months ago, while intoxicated, he verbally and
physically attacked his sister , causing a mild ECT, because
his sister did not want to open the door at home, so his
parents decided that he should live in a separate
apartment.
History of the disease:
A month ago , she ended her relationship with her lover
because she felt jealousy and infidelity on his part . She
checked her cell phone to see the messages she received,
called him insistently, and when he didn't answer her calls,
she cut herself on her left forearm with a knife. cutter,
indicating “I don't feel like doing anything”, “I miss my
partner”, “I shouldn't be so jealous”, you feel sadness,
you cry, you don't find meaning in life.
2 days before her admission , when she woke up, she decided
not to attend the university. She reported that she felt tired,
without the desire to do things, “it's not worth living.” He left
his apartment to buy rat poison , and at home he dissolved the
packet of poison in a glass of yogurt , ingesting it at noon, after
15 minutes , he had intense cramping abdominal pain, nausea,
History of the disease:
and vomiting. Then she called her ex-lover to tell him that she
had ingested poison. She was taken to the ESSALUD-Yanahuara
hospital with blurred vision, and only response to stimuli when
her voice was raised. Gastric lavage was performed, and she
was referred to our hospital, where her hospitalization was
decided.
Biological functions :

• Appetite: Preserved
• Thirst: Conserved
• Urinations: Preserved in frequency and volume, with normal
characteristics
• Depositions: Preserved
History of the disease:
• Dream: Preserved
QUESTIONS?
 BACKGROUND
• PERINATAL AND NATAL:
– Gestational age: Refers to “full term”
– Care and type of delivery: Eutocic, care in ESSALUD-Puno
hospital
– Crying at birth : Yes
• Breastfeeding: Up to 18 months of age
• Immunizations: Refer complete

*Mother reports receiving constant physical and verbal

aggression from her partner throughout pregnancy.
• Psychomotor development:
Apparently normal. Walks at 1.5 years old. Sphincter
 control at 2 years old. First words at 7 months and
appropriately at 5 years.

• Child psychopathology and adolescence:

• Childhood : She was very calm, loving,
responsible, was not aggressive, not very
communicative, had few friends, shy, very
demanding with cleanliness
• Adolescence : She became rebellious, disobedient,
arguing frequently with her sister because she
wore her clothes, and with her mother because
she constantly scolded her.
ACADEMIC-SCHOOL HISTORY
• Nido: State school, average performance, they made fun of
 her because she didn't pronounce words well
• Kindergarten : State, regular performance, good relationship
with classmates. Proper language pronunciation.
• Primary : 1st and 2nd year at state school, regular
performance, good relationship with classmates, she was
“quiet.” The 3rd year, she was transferred to a private school,
where her performance improved. Reports inappropriate
touching by the teacher.
• Secondary : Private school, regular performance until the 2nd
year (13 years old), then it decreases because his behavior
becomes rebellious, and he begins to consume alcoholic
beverages and marijuana, induced by a previous lover.
• Higher education : Private university, study
mechatronic engineering, regular performance, here he
meets his last partner, with whom he consumed alcohol and
marijuana.
WORK HISTORY:
• At 17 years old, waitress in a tourist restaurant for a month.
PSYCHOSEXUALITY:
- Menarche: 13 years
- Catamenial regime: Every 30 days/6 days
- FUR: 09/22/2018
- Obstetric formula: G:0 P: P T :0 P PT :0 A:0 H V :0
- IRS: 15 years
- MAC: None
- Mastubation: Denies
- Sexual partners: 6 (5 in love)
- Sexual abuse: Reports inappropriate touching at the age of 8, by a
teacher
- Sexual identity: Identifies as female, orientation
Heterosexual.
PATHOLOGICAL PERSONAL HISTORY

• Previous hospital admissions:

 – 2013, ESSALUD-Puno, for attempted suicide
• Previous surgical interventions: None
• Previous illnesses:
– Diabetes, HTN, dyslipidemia, thyroid diseases: Denies
– Tuberculosis : Denies STI: Denies others: Denies
• Previous accidents : None
• Blood transfusions : None
• Allergies : None
• usual medication : None
HARMFUL HABITS:

*Alcohol: Starts drinking at age 16, drinks beer or wine with school friends and in
love. It does not reach drunkenness.
• Frequency: Since it started 2 times a month
• FUC: September 10, 2018

* Drugs: Marijuana, started using it at 16 years of age, using a pipe (01), at the
same frequency as consuming alcohol. In January and February the consumption
of 01 pipe daily.
 – FUC: 3 months ago (younger sister finds a packet of marijuana after she
arrives from a party)

o Tobacco: denies
o Coffee: denies
o Others: denies
• AUTOLYTIC ATTEMPTS
At 11, 12, 14 years old, only at the last opportunity did
they take her to ESSALUD-Puno, where they
performed gastric lavage, and she was hospitalized for
3 days, without being evaluated by psychiatry.

• SELF-INJURY
Cuts were made to the left forearm at ages 11, 17 and
18, and one last self-harm was performed a month
before admission.
 • COMPLAINTS: Does not refer

FAMILY BACKGROUND
• FATHER: 48 years old, APS, occupation: police, drinks alcoholic beverages
sporadically, becoming drunk and in an intoxicated state attacks the patient's
mother
• MOTHER: 42 years old, APS, nurse, does not drink alcoholic beverages
• SISTERS: (02) 20 and 10 years old, APS, Older sister, medical technology
student. And younger sister, a primary school student in Puno.

• FAMILY DYNAMICS
• He comes from a family where the parents are married by civil marriage,
currently divorced due to the father's infidelity.
• Relationship with the “distant” father. Little communication. Father lives in Ica
for work. He only visited her 2 times this year.
• Relationship with mother, “bad relationship.” He reports suffering verbal
aggression from his mother when he disobeys her. Mother lives in Puno.
• Relationship with the sisters: with the eldest, “bad relationship”, he verbally
and physically attacked her while intoxicated. Sister younger than 10 years
 old, “good relationship,” gives him affection and shows him affection.
• SOCIOECONOMIC BACKGROUND
He lives in a rented apartment made of noble
materials, since he began his university studies, he
collects garbage twice a week, and he depends
financially on his parents.

• PREMORBID PERSONALITY
Quiet, obedient, not very communicative with her
friends, not very talkative, reserved, she collaborated
with her friends and family, very affectionate with her
pets, from the age of 16 to the present she had five
lovers.
QUESTIONS?
Physical exam
Vital functions :
• HR: 76x
• FR: 20 x
• BP: 100/70 mmHg
• SatO2: 94%
• Weight: 61.7 Kg
• Size: 1.60 m
• BMI: 24.68
Patient in fair general condition, good state of hydration, fair
state of nutrition , collaborates with the examination and
questioning.
• Regular subcutaneous cellular tissue, fill capillary for 2
 seconds, nails in good condition and hygiene.
• Presence of multiple tattoos: at the level of the ankle of
the right foot on the inner side, which according to the
patient means the year of her birth in binary numbers, on
the right upper limb (3), on the right arm , on the ventral
side, an image of the moon, a vehicle, patient reports that
they mean "dream, feel and live." On the right forearm (2)
tattoos, one in the upper third, with three united triangles
that have no meaning for the patient and another tattoo of
a heart and the infinity symbol intertwined. On the left
forearm (2), in its proximal third, there is an image of a
"rune", which means his pet with the date when he was
born and another tattoo at the distal third, with the image
of a marijuana leaf.
• There is also the presence of old superficial scars in the
distal third of the left forearm and also recent scars
(approximately 15).
• Head: Without alterations.
• Eyes: Without alterations.
• Nasal pyramid: Without alteration
• Auricular pavilions: Without alteration
• Mouth: Teeth in a fair state of hygiene.
• Oropharynx: Tongue with the presence of
piercing in the central region of the distal
third.
• Neck: No alterations
• Thorax: Without alterations
• Heart: Without alterations.
• Abdomen: Without alterations.
• Abdomen: Without alterations.
• Genitourinary: No alterations.
• Spine: No alterations
• Neurological: Without alterations.
 mental exam
• Appearance and attitude: Female patient, who
appears to be of a given age, partially dressed,
presence of a tongue piercing in the central region of
the distal third, with 8 tattoos on the upper limbs and
right ankle, old and recent scars are seen on the left
forearm, distal third, maintains eye contact at times ,
emotionally unstable , poor impulse control, poor
tolerance for frustration , with a feeling of emptiness ,
low self-esteem , feeling of guilt , manipulative ,
pretends to be the center of attraction , seductive ,
impresses minimizing information.
mental exam
• Psychomotor skills : Eubasic gait, no tremor in the
upper limbs, no tics.
• Mood : Sad, anxious at times and consistent affection
• Language : Coherent, fluent in regular tone.
• Thought : Abstract , at the moment unstructured
suicidal ideation, with ideas of guilt and
worthlessness, jealousy.
• Perception : No sensory-perceptive alterations at the
time of the examination.
• Sensory : Wake up, euprosexic, oriented
space, time and person, recent and immediate remote
memory preserved, basic calculation preserved.
• Judgment : Preserved
• Introspection : Without awareness of illness
What type of disorder does the
patient?
Which cluster does it belong
to?
Type A personality disorder
Paranoid of the schizoid Schizotypal of the
personality personality personality

Patient
with a
Prolonged and pattern
suspicion assign Social
and to isolation.
distrust of others introversi
the rest They on.
They are They are
reject the usually seen as
responsib hostile, eccentric,
ility of irritable isolated
his and and
feelings angry lonely.
Type A personality disorder
They are extrava ce,
usually gant or illusions
hostile, rare and
irritable Thought derealizati
and angry. magical on are
People , ideas part of
markedly referen life
daily.
 Type A personality disorder
get angry if
Histrionic they are not purposes
the center of selfish
attention.
Narcissite Limit
They are
No fit excitable and
rules that emotional, they Great sense of w
They govern behave in a self-importance Extraordinary
society. picturesque, and great emotional,
dramatic senses of behavioral,
They are
manner singularity. relationship
tricksters.
They consider and self-image
Extremely themselves instability.
manipulative to and
extrovert special and Exaggerated
achieve material expect to reaction to
gratification. Exaggerate stressful
receive a deal
special. They states.
their
feign sympathy There may be
thoughts and
for self-mutilation.
feelings. They
their Manipulates
Type A personality disorder
to get
affection.
 DIAGNOSTIC IMPRESSION
• Borderline personality disorder.
Theoretical review
Borderline Disorder
personality
Introduction
Patients with this disorder are located on the border
between psychosis and neurosis.
They are characterized by extraordinary emotional
instability, behavioral, of object relations and
self-image.
It has also been called ambulatory schizophrenia,
pseudoneurotic personality, psychotic disorder of the
character, personality as if, disorder of
personality due to instability.
Epidemiology
♦ There are no definitive studies on its
prevalence.
♦ But it is believed to affect 1 to 2% of
the population.
♦ It is 2 times more common in women
than in men.
♦ In the first-degree relatives of these
patients, a higher prevalence of major
depressive disorder, alcohol or other
substance abuse disorder has been observed.
 Clinical manifestations
♦ They almost always seem to be in a
state of crisis.
♦ Mood changes are frequent.
♦ Sometimes they suffer short-term
psychotic episodes.
♦ Their behavior is very unpredictable
and their achievements rarely match
their abilities.
♦ They can cut their veins
either
self-mutilate for call the
attention of others.
♦ They feel dependent and hostile
people, they maintain conflictive
relationships with others.
 Clinical manifestations
♦ They express enormous anger to their closest
friends when they feel they have
let them down.
♦ They do not tolerate loneliness.
♦ They present search
frenetic company, however
unsatisfactory.
♦ They complain of chronic feelings
of emptiness.
 Clinical manifestations
♦ They show normal reasoning
ability.
♦ They distort their relationships
with the the rest
considering them absolutely
good or bad.
♦ Some specialists use the
concepts of panphobia,
pananxiety, panambivalence,
and
chaotic sexuality.
 DSM 5 Criteria
• Dominant pattern of instability of interpersonal
relationships, self-image and emotions,
intense impulsivity, which begins in the early
stages of adulthood and is present in various
contexts, and which is manifested by 5 (or
more) of the following 9 criteria
1. Desperate efforts to avoid real or imagined helplessness
2. Pattern of unstable and intense interpersonal relationships
that is characterized by an alternation between extremes of
idealization and devaluation.
3. Identity disturbance: Intense and persistent instability of
self-image and sense of self.
4. Impulsivity in two or more areas that are potentially self-
harming.
5. Recurrent suicidal behavior or threats.
6. Affective instability due to a notable reactivity of the
mood.
7. Chronic feeling of emptiness.
8. Inappropriate and intense anger, or difficulty controlling
anger.
9. Transient paranoid ideas related to stress or severe
dissociative symptoms.
ICD-10:
❖ In this classification it is included under the name Personality Disorder
due to Emotional Instability.
❖ PD due to emotional instability is characterized by a marked
predisposition to act impulsively without taking into account the
consequences, along with an unstable and capricious mood. The
planning capacity is minimal and intense outbursts of anger frequently
 lead to violent attitudes or explosive demonstrations; These are easily
provoked by receiving criticism or being frustrated in their impulsive
actions.
❖ In the borderline type, several characteristics of emotional instability are
present. In addition, self-image, objects, and internal preferences
(including sexual ones) are often confused or altered. The ease of being
involved in intense and unstable relationships can cause repeated
emotional crises and be accompanied by a succession of suicidal threats
or self-harming acts (although these can also occur without clear
precipitating factors).
❖ Includes: borderline personality and borderline personality disorder.