Assessment Process and Likely Co-morbid Conditions

Module 07 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?
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Therapeutic Communication and Principles of Cognitive Behavioral Therapy (CBT):

1. Validation: Begin by acknowledging S.’s feelings and experiences without judgment. Validate her emotions and struggles, showing empathy and understanding. For instance, you might say, “It sounds like you’ve been through a lot, and it’s completely understandable that you’re feeling upset and frustrated.”
2. Collaborative Goal-Setting: Involve S. in setting realistic and achievable goals for therapy. Help her identify areas where she wants to see improvement and work together to develop a plan to address those areas. This can help increase her sense of agency and motivation for treatment.
3. Psychoeducation: Provide S. with information about Borderline Personality Disorder (BPD) and how it may be impacting her thoughts, feelings, and behaviors. Help her understand the connection between her experiences and symptoms of BPD, such as fear of abandonment, unstable relationships, and impulsivity.
4. Cognitive Restructuring: Use CBT techniques to help S. identify and challenge maladaptive thoughts and beliefs that contribute to her distress. Help her recognize patterns of thinking that may be unhelpful or distorted, and work together to develop more balanced and adaptive ways of thinking.
5. Skill-Building: Reinforce the importance of continuing therapy, including DBT, and medication management. Work with S. to develop and practice coping skills for managing distressing emotions, such as mindfulness, distress tolerance, and emotion regulation techniques.

Assessment Process and Likely Co-morbid Conditions:

During the assessment process, it’s important to conduct a thorough evaluation of S.’s mental health history, current symptoms, and functional impairment. Likely co-morbid conditions may include:

1. Depression: S.’s reported history of stopping antidepressant medication and experiencing suicidal ideation suggests the presence of depressive symptoms.
2. Post-Traumatic Stress Disorder (PTSD): Given S.’s history of abuse by her ex-husband and past relationships characterized by abuse, she may also meet criteria for PTSD.
3. Substance Use Disorder: S. may engage in substance use as a way to cope with distressing emotions and interpersonal difficulties, which is common among individuals with BPD.

Nursing Diagnosis and Intervention:

Nursing Diagnosis: Impaired Social Interaction related to interpersonal difficulties and fear of abandonment.

Intervention:

• Establish a therapeutic relationship built on trust and empathy.
• Encourage S. to participate in group therapy or support groups focused on interpersonal skills and relationships.
• Teach assertiveness skills and boundary-setting techniques to improve communication and conflict resolution.
• Collaborate with other members of the treatment team to reinforce consistent messaging and support for S.’s goals and progress.

Interdisciplinary Referrals:

1. Psychiatrist/Psychopharmacologist: S. would benefit from a psychiatric evaluation to reassess her medication needs and explore alternative treatment options for managing her symptoms.
2. Individual Therapist/DBT Therapist: S. should be referred back to individual therapy, particularly DBT, to address her maladaptive behaviors and emotional dysregulation.
3. Domestic Violence Counselor: Given S.’s history of abuse, a referral to a counselor specializing in trauma and domestic violence may be appropriate to address unresolved trauma and develop safety planning strategies.

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