The client is a 35-year-old Black, married, female, with 2 children ages 3 & 10 who live with her. She states she has been feeling down because she hates her job and she has had at least 4 new jobs in the past year.  She hates how she looks, she believes people do not like her and are often jealous of her. She reports difficulty getting along with others and most of her relationships with family and friends are strained. She reports she has had at least 2 plastic surgeries to fix the things she sees wrong with her body and plans to get a 3rd surgery to get breast implants next year. She reports feeling irritated easily with others and will isolate at least 1/2 the day. She states she has “some good days but they never last long.” The client grew up witnessing her father physically abuse her mother daily and she reports a family friend inappropriately touched her multiple times from ages 9-11. The client attempted Suicide 6 months ago and was admitted into a psychiatric hospital for a 1 week stay. The client stated her symptoms began when she was 20 and have gotten worse in the past 2 years.

1. What is her diagnosis and why?

2. What medication would you prescribe and why?

1. Dx:
2. Differential diagnosis

ANSWER

Understanding and Diagnosing the Client’s Mental Health Concerns

Introduction

In this case, we encounter a 35-year-old Black female who presents with a range of psychological and emotional difficulties. To develop an accurate diagnosis, we must consider the client’s symptoms, life experiences, and clinical observations. We will explore potential diagnoses and differential diagnoses, along with considerations for medication, if necessary.

Diagnosis and Rationale

The client’s presentation suggests that she may meet the diagnostic criteria for several mental health conditions, but the primary diagnosis that best fits her symptoms is Borderline Personality Disorder (BPD).

Borderline Personality Disorder (BPD)

Reasoning: The client exhibits several hallmark symptoms of BPD, including unstable self-image, impulsivity (evidenced by frequent job changes and plastic surgeries), strained interpersonal relationships, irritability, and emotional instability. Her history of suicidal ideation and attempts, along with childhood trauma, align with BPD’s diagnostic criteria. The chronicity of her symptoms and the recent worsening suggest a long-standing pattern.

Differential Diagnosis

It’s important to consider other potential diagnoses due to the complexity of the client’s symptoms:

Major Depressive Disorder (MDD)

Reasoning: The client reports persistent low mood, feelings of worthlessness, and a recent suicide attempt, which may indicate MDD. However, the impulsivity, unstable self-image, and strained relationships are better explained by BPD.

Narcissistic Personality Disorder (NPD)

Reasoning: Some of the client’s symptoms, such as dissatisfaction with her appearance, perceptions of jealousy in others, and the pursuit of multiple plastic surgeries, may suggest NPD. However, her self-esteem appears to be unstable, and NPD does not encompass the chronic emotional instability and self-harm tendencies seen in BPD.

Post-Traumatic Stress Disorder (PTSD):

Reasoning: The client’s history of childhood trauma and the inappropriate touching by a family friend could lead to PTSD symptoms, including flashbacks and hypervigilance. However, her pervasive emotional instability and difficulty in maintaining relationships extend beyond the typical symptoms of PTSD.

Histrionic Personality Disorder

Reasoning: Some features of the client’s presentation, such as attention-seeking behavior, may resemble Histrionic Personality Disorder. However, her impulsivity, self-image instability, and self-harm tendencies align more closely with BPD.

Medication Considerations

Medication should be considered as part of a comprehensive treatment plan. For individuals with BPD, medications are typically used to manage specific symptoms, such as depression, anxiety, or impulsivity. Medication options may include:

Antidepressants: Selective Serotonin Reuptake Inhibitors (SSRIs) or other antidepressants may be prescribed to address depressive symptoms and mood stabilization.

Mood Stabilizers: Medications like mood stabilizers or antipsychotics can help manage emotional dysregulation and impulsivity.

Anti-Anxiety Medications: In cases of severe anxiety or panic symptoms, anti-anxiety medications may be considered.

It is crucial to approach medication cautiously and only as part of a broader treatment plan. Psychotherapy, particularly Dialectical Behavior Therapy (DBT), is considered the primary treatment for BPD. The combination of therapy and, if necessary, medication can provide the most comprehensive support for the client’s recovery.

Conclusion

In diagnosing this complex case, Borderline Personality Disorder (BPD) appears to be the most suitable diagnosis due to the client’s chronic emotional instability, impulsivity, strained relationships, and history of self-harm and suicide attempts. However, considering differential diagnoses is crucial to ensure a comprehensive assessment. Medication may be considered as part of the treatment plan, but it should be approached judiciously and in conjunction with psychotherapy to provide the client with the most effective support and intervention.