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Ann is a 28-year-old single woman currently working as a barista in a coffee shop while attending college part time. She has been pursuing her college education for 8 years, as she has changed majors several times. She intermittently lives with her widowed mother and several short-term significant others. She describes herself as polyandrous, with her longest relationship lasting 2.5 years, which she attributes to others “not getting” her. Although she has several friends, she admits that her relationships are highly “dramatic,” with few enduring friendships. Ann has many pastimes, including roller derby, downhill skiing, bungee jumping, rock climbing, and kayaking.

Ann is the middle child with an older brother, who is a successful business man, and a younger sister, who is in dental school. Ann describes herself as the “underachiever.” Growing up was somewhat chaotic, as both parents were active duty military and the family moved every 18 months on average. Although neither parent had combat assignments, Ann believes her mother had a traumatic career due to possible military sexual assault. She describes her mother as tense and overprotective, as well as distant and aloof. Ann denies witnessing any violence in her family or experiencing abuse or neglect; however, she describes invalidation from her family regarding anything she did or tried. Ann believes her parents favor her siblings because she is the “overly sensitive one” in the family.

Beginning in her sophomore year of high school, Ann secretively cut her abdomen and thighs when she felt anxious and lonely because “it helped relieve the emotional pain.” She denied wanting to kill herself; however, in her senior year of high school she took an overdose of Advil® after a girlfriend ended their romantic relationship. Ann was hospitalized for 3 days on a psychiatric unit and began weekly therapy for approximately 3 months after discharge. She said the therapy helped some, but she continued to feel displaced and without a purpose. She experimented with relationships with men and women, always anticipating being rejected. She would go to great extents to please others but also acknowledged intense moodiness, irritability, and temper tantrums if she did not get what she wanted.

This year, Ann’s college advisor referred her to the student counseling center because he thought she was depressed and not doing well in her course work.

The psychiatric-mental health nurse practitioner (PMHNP) at the counseling center diagnosed Ann with BPD after several assessment sessions. After he explained BPD, Ann agreed with the diagnosis. They discussed the most distressing behaviors/symptoms that Ann wanted to focus on: moodiness with intense swings of anger and happiness even within a few hours; impulsiveness that sometimes included cutting and recklessness; unstable relationships with a prolonged sense of loneliness; and general depression with episodic intense anxiety that interfered with her studying. Ann denied suicidal ideation or substance use except for occasional marijuana use (legal in her state) and excessive alcohol consumption at parties.

 

The PMHNP met with Ann weekly for individual therapy sessions that focused on building a commitment to change targeted behaviors and learning coping skills. Ann agreed to call her therapist when she had the urge to cut and receive coaching to use alternative coping. After 6 weeks, she agreed to also participate in weekly skills group to learn mindfulness, emotional regulation, interpersonal effectiveness, and stress management. Even with this plan, Ann expressed intense sadness, despair, shame, and impulsive self-destructive urges. Finally, the PMHNP suggested they discuss medication to augment her psychotherapy and support her while she became more effective in her skills. He explained neurobiological reasons for her impulsivity and impaired judgment and ability to problem solve in stress situations (i.e., her frontal lobe [dorsolateral prefrontal cortex] that mediated problem solving and judgment had a broken connection with her limbic area [amygdala] that mediated her intense emotions). Because dopamine was a major neural circuit that connected these two regions and the neural firing of these nerves seemed to be irregular, two different types of medications might help her feel more in control of her emotions and behaviors. He discussed the medications for her to consider as possible choices and the side effects of each, as well as the process of titrating the dose over time to achieve relief of some symptoms. He emphasized that it would take time because the brain does not tolerate rapid change and she would have to tolerate side effects until the beneficial effects became evident. He validated that this would be difficult for her because he understood how much she wanted immediate relief. However, he emphasized that the medication would provide some relief as she became more skillful with her behavioral and environmental strategies.

Case extracted from Limandri, B.J. (2018). Psychopharmacology for borderline personality disorder. Journal of Psychosocial Nursing and Mental Health Services, 56(4), 8-11. doi:10.3928/02793695- 20180319-01

Tasks

Answer the following questions relevant to Ann’s case study.
What medication classes do you think the provider would recommended, and why?
What specific mechanism of actions of these medications would target Ann’s symptom clusters to provide the widest spectrum of outcomes?
What agreements does the medical provider need to secure before initiating the medication regimen?
Ann requests additional medication from the provider (she asked for lorazepam for a few days). How would you respond to Ann’s request?
Describe which treatment modalities would be beneficial as well as the role of medication.
Discuss communication strategies specific to Ann. Describe which behaviors would be most challenging and why. If Ann was diagnosed with a cluster A or B personality disorder, how would you tailor your communication strategies?
Along with answering the questions above, develop a care plan specific to Ann’s borderline personality disorder.

 

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