Borderline Personality Disorder Case Conceptualization

Borderline Personality Disorder Case Conceptualization
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Case Conceptualization
Background
Stella is a 28-year old Caucasian female who checked in at the outpatient clinic after a string of failed relationships and chronic depression symptoms. Stella was raised in Albuquerque, New Mexico, but moved to New York after securing a placement at the City University of New York. She has been living by herself ever since and rarely visits her kin back home. The patient has had five long-term relationships since her college years, but they have always ended tragically, with most boyfriends terming her as “controlling,” “manipulative,” “psychotic,” and “violent.” Stella admits to having a closer relationship with her younger brother and cousins than with either of her parents. Her parents divorced when she was 13 years old, and she has not seen either of them in four years. However, Stella admits to having a few close friends and that they support each other.
Stella reported having bipolar disorder symptoms and that her irritability started while she was still in middle school. The patient stated that she has difficulty adjusting to new people or situations and that her parents assumed that she would eventually grow out of her “childish behavior.” However, her tendency to quickly get upset and have tantrums intensified in her teenage years. She was very dependent on her father, who was often away from home (working in California), and that she suffered separation anxiety every time he left for work. As her inability to control her mood swings increased, so did her tendency to engage in impulsive behaviors such as running away from home or yelling at her teachers in school. Stella had very few friends in high school, but her friendships would always end in conflict, something her mother scolded her for. She talked about feeling isolated, bored, and incapable of sustaining any meaningful relationship for longer than three months. Before leaving for college, her life had started spiraling out of control, and her emotional instability became more uncontrollable.
She would fight with her mother incessantly over little things and experience intense depression with suicidal thoughts. However, she found a way to distance herself from college and preferred short-term relationships to long-term ones. Along the way, she managed to have several serious love interests who would put up with her behavior for several months before ending the relationship. Although she is a hard worker, the patient stated that her manipulative, impulsive, and antisocial tendencies had cost her several jobs owing to explosive disagreements with coworkers and supervisors. Stella has attempted suicide several times, but all have been unsuccessful until recently when her roommate found her in the act of slashing her wrists with her hair clippers. Her friend then decided that it was time to find help and advised her to see a psychiatrist in the area.
Session Overview
The clinician first evaluated the patient to determine if an inpatient or outpatient treatment approach would help counter Stella’s suicidal ideation. After a safety evaluation, it was decided that the patient needed to receive care in a partial hospitalization given her dangerous impulsive behavior, complex comorbidity, and severe symptoms, which interfered with daily functioning. After the initial assessment, a more comprehensive evaluation was conducted. The focus was on determining the severity and type of functional impairment, presence of comorbid disorders, intrapsychic defenses and conflicts, psychosocial stressors, and maladaptive coping mechanisms. Treatment planning was founded on addressing comorbid disorders from axis I and axis II. After that, the clinician discussed with the patient the etiology of borderline personality disorder and accompanying comorbidities, therapy goals, treatment interventions, frequency of sessions, reporting of social conflicts, and a plan for crises management.
Vulnerabilities
Stella demonstrated pervasive affective instability, unstable personal relationships, suicidal thoughts, self-image issues, and impulsivity. She confessed that her behavior varied from irritating to manipulative tendencies to assertiveness and “roller-coaster” emotional attachments. Some of her previous boyfriends and coworkers had termed her as “impossible” and that these vulnerabilities were the source of constant friction with those she interacted with. Stella reported feeling helpless and bitter about her swirl of shifting emotions and unrelenting compulsions that roiled her daily life. The patient reported experiencing changing emotions rapidly and that she was highly reactive to surrounding people and events. This short fuse of anger, impulsive behavior, and anger resulted in antisocial behaviors and the breakdown of her friendships and relationships. Her extreme emotional reactions to minor daily disappointments made coping with her impossible. For instance, she reported shouting at her coworker in one of her “emotional storms” to delay picking a ringing office phone.
This incident disrupted her close relationship with the staff member, who was taken aback by her aggression over a simple matter. She would take longer to calm down after these “emotional storms” and often after the damage was done and irreversible. All her boyfriends had ended the relationship after these intense emotional reactions, where she would sometimes get physically abusive. Stella also admitted that her reckless gambling and promiscuous relationships with her subordinates always followed the loss of a close friend or love interest. The temporary relief of indulging herself with abandon after her breakups always resulted in long-term problems. For instance, one of her former bosses suspended her for three weeks after discovering that she was stealing the company’s petty cash to feed her gambling addiction. Stella admitted that these extreme, impulsive, and reckless behaviors had become a severe form of vulnerability and impediment to cultivating meaningful relationships and that she wanted to change.
Triggers
Stella admitted that her emotional outbursts, irritability, attention-seeking, manipulative tendencies, aggressiveness, and accompanying impulsive actions heightened after tragic interpersonal relationship events. The biggest trigger was the actual or perceived rejection or separation from her close friends and love interests. Any disagreement that appeared to teeter on the edge of a breakup would increase her feelings of abandonment and isolation, which resulted in intense feelings of suicidal thoughts, anger, self-harm, fear, and rash decisions like gambling and engaging in promiscuous entanglements. Stella described her relationships as passionate and dependent, and any event that signaled rejection by the other party would increase her symptoms. Other events included losing a job, failure to be invited to a social event, or even when a love interest delayed in calling back or returning her texts. For instance, she admitted that when her boyfriends would delay calling back, she would think that “he doesn’t love me” or “I will never find someone who is faithful to me.”
She also narrated that after losing her previous job for shouting back at her boss, she went on a spiral for six months before a close friend helped her secure her current placement, where she regained some form of stability. In addition to these relationship triggers, Stella stated that cognitive triggers such as the bitter memory of her father failing to come to her school’s prize-giving day would trigger intense emotions and impulsive behaviors. Other times, happy memories of her previous relationships would lead her to think that things were not as good as they were then, and they made her despair.
Core Bel...