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Borderline Personality Disorder Case Study

S.is a 48-year-old divorced woman with one adult daughter and three grandchildren. She is
currently working as an LPN part-time in a nursing home and works at a convenience store one
or two days per week. She has had many jobs over the last 22 years, usually changing every one
or two years to a new job. S notes that she has been called less often to work in the
convenience store and worries that they don’t like her anymore. She reports being written up
several times for arguing with customers. She also reports that she liked her supervisor at; first;
she says, “Now I hate her; she’s trying to get me fired.” S. reports that she has tried to get fulltime jobs five times in the last four years was hired for three but only lasted one or two weeks
at each one.
S. reports that she is currently not talking to her daughter because “she is mean to me and she
needs to apologize, or I won’t talk to her again.” She is upset that she hasn’t seen her three
small grandchildren in about a year. She sends them presents and cards frequently that say “I
still love you! Grandma” but hasn’t called them since she stopped talking to her daughter. She is
considering reporting to the county that her daughter is keeping her grandchildren from her.
S. is very unhappy that she isn’t in a relationship. She was abused by her ex-husband and had a
pattern of meeting and dating men who eventually abused her. She states that her last
relationship was very good; the man was not abusive, and “I loved him very much.” The
relationship ended for reasons that S. doesn’t understand. However, she does report many
arguments that ended in “scenes,” such as her throwing chairs, stomping out of the house,
making crank phone calls to his family, and calling the police with false reports. But S. also
reports that she “couldn’t have loved him more, and I showed it.” She gives examples of going
to her boyfriend’s place of work with flowers, buying him expensive presents, surprising him
with tickets to Mexico at the last minute – she was very upset that he wasn’t willing to drop
everything and go with her. S. reports asking him why he didn’t love her and what she was
doing wrong regularly. When the boyfriend asked to break up, S. reported sitting outside his
house for weeks, crying; she called his mother, called his boss, and called and texted him until
he filed a restraining order. This occurred about four months ago.
S. admitted herself to the mental health unit when she felt suicidal. She reports that she had
stopped her psychotherapy three months ago and stopped going to DBT. She also stopped her
anti-depressant at that time, as she felt it wasn’t working, and missed her last two psychiatrist
appointments.

How would you use therapeutic communication and principles of cognitive behavioral
therapy with the client?

Describe your assessment process. What are some likely co-morbid conditions? List one
nursing diagnosis and an appropriate nursing intervention.

What interdisciplinary referrals might be appropriate?

Sample Answer

Therapeutic Communication and CBT with S.

Therapeutic Communication:

Empathy and validation: Acknowledge S.’s feelings and struggles without judgment. Use reflective listening to understand her perspective and build rapport.
Open-ended questions: Encourage S. to elaborate on her experiences and thoughts. Examples: “Tell me more about your concerns with the convenience store.” “What were some positive aspects of your previous relationship?”
I statements: Share your observations and concerns clearly, focusing on specific behaviors and avoiding blame. Example: “I noticed you mentioned feeling like you can’t control your anger during arguments. Can you tell me more about this?”
Setting boundaries: Establish clear limits in a respectful and supportive manner. Address harmful behaviors like threats or blaming others.

Full Answer Section

CBT Principles:

Identifying cognitive distortions: Help S. recognize negative thought patterns that contribute to her distress. Examples: all-or-nothing thinking, catastrophizing, emotional reasoning.
Challenging distorted thoughts: Guide S. to explore evidence for and against her negative thoughts. Encourage her to develop more realistic and helpful perspectives.
Behavioral activation: Encourage S. to engage in activities that bring her joy and satisfaction, even if she doesn’t feel motivated. This can improve mood and self-esteem.
Problem-solving skills: Work with S. to develop constructive strategies for dealing with challenging situations, like communication skills and conflict resolution techniques.

Assessment Process:

History taking: Explore S.’s social, medical, and mental health history. This includes details about her work, relationships, family dynamics, past diagnoses, and treatment experiences.
Mental status examination: Assess S.’s mood, affect, thought processes, cognition, and suicidality.
Behavioral observation: Observe S.’s communication style, body language, and overall presentation during the session.
Rating scales: Utilize standardized rating scales like the Beck Depression Inventory or Borderline Personality Inventory to assess her symptoms further.

Likely Co-morbid Conditions:

Borderline Personality Disorder (BPD): Features like unstable relationships, impulsivity, emotional dysregulation, and difficulty managing anger align with some of S.’s behaviors.
Major Depressive Disorder (MDD): Her mood changes, decreased motivation, and suicidal thoughts suggest potential depression.
Post-traumatic Stress Disorder (PTSD): Trauma history with abusive relationships could point towards PTSD symptoms.

Nursing Diagnosis:

Risk for Ineffective Coping related to emotional dysregulation, as evidenced by arguing with customers, unstable relationships, and self-harming behaviors.

Nursing Intervention:

Individual psychotherapy: Encourage S. to resume individual therapy with a therapist trained in dialectical behavior therapy (DBT), specifically designed for borderline personality disorder traits.
Medication management: Collaborate with the psychiatrist to assess the need for medication adjustments or resuming antidepressants.
Support groups: Connect S. with support groups for individuals with BPD or trauma survivors for peer support and skills development.
Family therapy: Consider family therapy if a supportive and healthy relationship with her daughter is desired.

Interdisciplinary Referrals:

Psychiatrist: For medication management and diagnosis clarification.
Dialectical Behavior Therapy (DBT) therapist: To equip S. with skills for emotional regulation and managing her relationships.
Vocational rehabilitation counselor: To assist with job searching and maintaining employment.
Domestic violence support group: If relevant, to address past trauma and develop healthy relationship patterns.

Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment recommendations.

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