Borderline personality disorder: a case study

Presenting Symptoms

Robin Henderson was being treated by a clinical psychologist primarily regarding her suicidal and self-mutilating gestures, and intense, erratic behaviour in her familial and interpersonal relationships. These behaviours had been occurring over the course of at least three years. Treatment had been attempted, with Robin’s psychologist treating her with anti-depressant medication.

Background Information & Personal History

At the time of her suicide, Robin was a 30-year old Caucasian woman, who had recently been divorced from her husband. Robin grew up as an only child in an abusive household in which both her mother and father suffered from alcoholism and depression. Throughout her childhood, Robin was subjected to physical abuse from her mother, and at around five years old, non-violent sexual abuse from her father. However, the sexual abuse eventually escalated and became physically violent at the age of 12 and continued through Robin’s early high school years. Robin has a history of both alcohol abuse and restrictive bulimia nervosa, both of which began at age 14, and continued throughout high school and intermittently in college. During her college years, Robin sought treatment for her alcohol abuse, attending Alcoholics Anonymous meetings. After successfully completing her college degree, Robin completed two years of medical school, however in her second year, a classmate she hardly knew killed themselves. This prompted Robin to drop out of school, becoming actively suicidal, with virtually no idea as to why she was experiencing these feelings. Before being referred to the clinical psychologist, Robin was seeing a psychiatrist.

Assigned Diagnosis

Based on Robin’s symptoms and history, a borderline personality diagnosis seems appropriate. To appropriately assign a diagnosis of borderline personality disorder, the DSM-V requires that a minimum of five of the nine listed criteria are met. Robin clearly meets six of the nine necessary criteria needed to be eligible for this diagnosis.

Rationale for Diagnosis

Robin meets the majority of criteria for a borderline personality disorder diagnosis. Robin’s unstable sense of personal identity was especially prevalent when she attempted to kill herself after a similar incident with a classmate she barely knew, also supporting the requirement of suicidal ideation. Robin has demonstrated instances of suicidal and self-harmful gestures since this incident, including 10 occasions of hospitalization in the 18-month period in which the psychiatrist had been treating her, as well as multiple instances of cutting and burning herself, with a case so severe Robin required reconstructive surgery. Despite her extreme symptoms and behaviours, Robin insisted on continuing outpatient treatment as opposed to inpatient treatment, in an effort to prevent abandonment from those close to her. The DSM-V indicates that patients with borderline personality disorder engage in behaviours which are self-damaging but are not considered suicidal. Robin has displayed multiple behaviours which reflect this, including consistent alcohol abuse throughout high school and college, and restrictive bulimia nervosa through college and adulthood. Robin’s alcohol and illegal drug use which preceded her suicide also support this criterion. In addition to the DSM criteria, Robin meets several circumstantial criteria for a borderline personality disorder diagnosis. Both Robin’s mother and father had a history of depression, which is relevant as multiple studies have found that borderline personality disorder is frequently seen in patients who come from families with mood disorders (Barlow, Durand, Hofmann, & Lalumière, 2018). Additionally, research has shown that approximately 76 percent of women with borderline personality disorder reported experiencing sexual abuse as a child (Barlow, Durand, Hofmann, & Lalumière, 2018), as Robin did with her father.

Potential Differential Diagnoses

Another potential diagnosis for Robin’s behaviour would be major depressive disorder, with a single episode. Robin’s behaviour after her classmate committed suicide supports this, as she reported becoming deeply depressed and suicidal. In addition to this, Robin’s significant appetite fluctuation, and suicidal and self-mutilating gestures further support this diagnosis. Robin also suffers from restrictive bulimia nervosa, as she has described periods of binge eating, which are followed by periods of fasting, with no reported purging.

Treatment Recommendations

The primary treatment recommended for Robin’s borderline personality disorder is dialectical behaviour therapy, as well as continuing the anti-depressants prescribed by her psychologist. Dialectical behaviour therapy is specifically recommended to aide in decreasing Robin’s suicidal and self-harmful behaviours- as these are the primary presenting symptoms- and to improve Robin’s social interactions with others. At its core, dialectical behaviour therapy is a form of cognitive behavioural therapy, in which the patient learns to recognize specific reactions and behaviours to a situation or action and working on new behaviours to combat negative thoughts (Neacsiu, Rizvi, & Linehan, 2010). There are typically four modules involved in dialectical behaviour therapy, mindfulness, interpersonal effectiveness, distress tolerance, and emotion regulation, all of which would be beneficial given Robin’s state. Anti-depressants have been found to moderately help patients with borderline personality disorder, specifically in decreasing anger (Mercer, Douglass, & Links, 2009). Couples therapy would not be recommended as primary treatment for Robin and her husband, as Robin falls under the impulsive subtype put forward by Links & Stockwell, in which the patient is prone to self-harmful behaviour (Links & Stockwell, 2001). If Robin and her husband were to pursue couples therapy, it would need to be after Robin has successfully completed her dialectical behaviour therapy in order to guarantee any kind of positive outcome.

Prognosis

Due to the delayed treatment Robin received, her symptoms did not improve and this ultimately led her to take her own life. Had Robin been treated with both anti-depressants and dialectical behaviour therapy Robin’s symptoms would improve, as long as Robin attended all sessions, as dialectical behaviour therapy is an ongoing process. Overall, with the recommended treatment, Robin would be very likely to show improvement.

References

• Barlow, D. H., Durand, V. M., & Hoffmann, S. G., & Lalumière, M. L. (2018). Abnormal psychology: an integrative approach. Boston, MA: Cengage Learning.
• Links, P. S., & Stockwell, M. (2001). Is Couple Therapy Indicated for Borderline Personality Disorder? American Journal of Psychotherapy, 55(4), 491-506. doi: 10. 1176/appi. psychotherapy. 2001. 55. 491
• Mercer D., Douglass, A. B., & Links, P. S. (2009). Meta-analyses of mood stabilizers, antidepressants and antipsychotics in the treatment of borderline personality disorder: Effectiveness for depression and anger symptoms. Journal of Personality Disorders, 23(2), 156-174. doi: 10. 1521/pedi. 2009. 23. 2. 156
• Neacsiu, A. D., Rizvi, S. L., & Linehan, M. M. (2010). Dialectical behaviour therapy skills use as a mediator and outcome of treatment for borderline personality disorder. Behaviour Research and Therapy, 48(9), 832-839. doi: 10. 1016/j. brat. 2010. 05. 017