MODEL ANSWERS

Behaviour and Appearance:

Patient was a slim, young woman who was dressed casually in a white sweater. Her hair was dishevelled. She had good eye contact. Rapport was initially difficult as she was hostile and sat with her arms folded across her chest. As the interview progressed, rapport with the doctor improved. There was no psychomotor retardation or agitation. There was no evidence of abnormal physical or neurological findings.

Orientation and Cognition:

Orientation and cognition were not formally tested. However, she was fully conscious with no evidence of fluctuation in sensorium. She also appeared oriented.

Affect and Mood:

Affect was appropriate to the content of the interview. Range was restricted to irritability and sadness. Mood was subjectively reported as “fine”, “alright”. Objectively, she was irritable, depressed and tearful a few times. Neurovegetative functions of sleep energy, concentration and appetite were normal.

Thought Form:

Thought form was logical and coherent.

Speech:

Rate, rhythm and volume were normal.

Thought Content:

Thought content focused on certain theme. She described constant feelings of abandonment by people around her. She felt that no one understands her. The patient showed a pattern of idealizing and devaluing significant people around her (boyfriends and counsellor). She reported dissociative like symptoms of “floating” in the midst of her distress which then resolves with cutting. There was no evidence of delusions, obsessions, compulsions or phobias.

Perceptual Disturbances:

No evidence for hallucinations.

Insight and Judgment:

She showed poor insight into her role in relationships. She blamed everyone else for her predicament. Judgment was poor as shown by repeated poor impulse control in conjunction with excessive alcohol use.

Safety Concerns:

She just took an overdose of paracetamol after feeling rejected by her boyfriend. She had multiple deliberate self-harm attempts in conjunction with alcohol use. These were triggered by perceived rejection by others. She denied any active thoughts of wanting to harm or kill herself at the moment. She was not sure about future chances of deliberate self-harm. Harm to others was not asked.

MODEL ANSWERS

Preferred Diagnosis in Axis 1 is Alcohol Abuse. In Axis II, her presentation is consistent with Borderline Personality Disorder.

Differential Diagnosis:

Tolerance to alcohol and or withdrawal needs to be asked to verify an Alcohol Dependence diagnosis

A chronic dysthyia or major depressive disorder are considerations because of the depressed mood presentation. However, neurovegetative symptoms were normal. Also, her mood presentation can be clearly explained by the personality disorder.

MODEL ANSWERS

Safety issues:

Jane presents with a chronic low risk for suicide. There is no need for acute hospitalization at this moment. Her last deliberate self-harm attempt had low lethality and high chance of rescue. Currently she is not suicidal. Her treatment should be at a community level.

Gathering more information and establishing the diagnosis:

1. It will be essential to get her previous medical records.

2. Getting information from her counsellor will help confirm the diagnosis.

3. Details of her alcohol use, tolerance, withdrawal symptoms need to be obtained.

4. A cognitive assessment should be performed post overdose.

5. Thoughts of harm to others should be asked.

6. Basic physical examination and laboratory parameters should be done prior to medical discharge.

Biopsychosocial management:

1. Medications at this point are not indicated. However, some borderline patients need medications (i.e. antidepressants, antipsychotics) depending on their symptom presentation.

2. Mainstay treatment for this patient would be psychological in nature. It is important to educate the patient regarding the possible diagnosis. Motivational Interviewing to try and get her to address her problematic alcohol use is needed. Dialectical Behavioural Therapy is the recommended treatment for Borderline Personality Disorder. This will address her chronic feelings of emptiness, emotional turmoil and recurrent self-harm.

3. Involving the patient’s supports or family should always be considered.