Psychology Assessment

Running Head: PERSONALITY DISORDER PAPER 1

PERSONALITY DISORDER PAPER 5

Assessment

BSW student is meeting with client, Clementine, who has been diagnosed with Borderline Personality Disorder. Clementine is being seen as an outpatient, referred by her psychiatrist for counseling. This is Clementine’s initial meeting with this BSW student. The BSW student’s goal of this session is to gain a better understanding of what Clementine believes her current problems are and what symptoms she may be exhibiting through Clementine’s descriptions and observed behaviors.

Subjective (S)

Clementine presents to the session fifteen minutes late. She states that she is sorry for her lateness, blaming it on the traffic. When asked what brought her to meet with this BSW student today she explains she has been having difficulty in relationships and liking herself. BSW student asked her to explain further and she shares that she is ready to break up with her current partner because she is “bored” with him and is beginning to “feel trapped.” She describes having a pattern of relationships in this manner. She states she meets men and quickly begins a relationship with them, often being intimate within the first day or two. She states she has had many sexual partners. She describes meeting her current partner at a party and that she had him break into a home with her. She states she told him on the first day they met, “I’m gonna marry you, I know it.” Right now she states she feels like, “I’m fucking crawling out of my skin” in the relationship. She describes a recent argument they had in which she told him “I want to have a baby,” and he told her he did not think she was ready for the responsibility. She describes getting very angry at him in public and telling him, “You have no idea how lucky you are I’m interested in you, maybe I should end this right here.” She describes picking fights with him and getting irritable with him for minor actions and statements. She states she feels like he does not trust her. When prompted to ask why she feels this way she states she does all the talking and he does not talk to her. She states he told her she constantly talks and that is not the same as sharing. She appeared angry, stating, “I don’t constantly talk, people have to share things…that’s what intimacy is.” She states she warned him when she first met him that she was not nice and that she was “a vindictive little bitch, truth be told.” She also reports she told him she is “high maintenance.” She states she is “just a fucked up girl who’s looking for my own peace of mind” and explains she feels like men are always trying to idealize her. She describes getting easily angered with men she is in relationships with when she feels they are not open enough or giving enough. She describes a pattern of getting into arguments.

She shares that her current partner thinks she drinks too much. When asked if she thinks she does, she denies, but does report drinking multiple drinks, daily, sometimes having alcohol in her coffee in the morning. She states she got into an argument with her significant other about wrecking his car when she had driven while “a little tipsy.” She states she told him he was probably really upset because he thought she was out with someone else. Clementine then shared that he told her he assumed she had sex with someone because that is how she gets people to like her. She states this angered her and she left.

Clementine then changed topics stating, “I’m always anxious thinking I’m not living my life to the fullest…taking advantage of every possibility making sure I’m not wasting one second of the little time I have.” She points to her hair and states, “It changes a lot, the color. I apply my personality in a paste.” She explains, “I’m impulsive…I can’t tell from one moment to the next what I’m going to like.” She states she has been crying more and has been asking her partner if he finds her ugly and if she likes him. She states, “I’m a mess…I’m lost I’m scared I feel like I’m disappearing. My skins coming off I’m getting old. Nothing makes any sense.” The session ends with Clementine describing that she has felt this way since she was a kid— feeling afraid that she was ugly, not liked, and that people would leave her (Gondry, 2004).

Objective (O)

Clementine is a never married, Caucasian female in her thirties who has been diagnosed with Borderline Personality Disorder. Clementine seems to be in an elevated mood with congruent affect. Her grooming and hygiene are fair and her hair has been colored bright orange. Her eye contact is good. Her speech is somewhat rapid at times but overall within normal limits. Her thought process is somewhat tangential. She appears to consistently move her fingers through her hair.

Assessment (A)

Clementine appears to exhibit traits of borderline personality disorder. She describes having unstable relationships and self-image. She appears to continuously look for outside validation of her self-worth. She seems to have impulsive behaviors like breaking into a home and dying her hair various colors. She describes having a fear of abandonment and this may explain her quick intimate relationships. Clementine appears to abuse substances and has exhibited reckless driving with her driving under the influence of alcohol. She describes constant anxiety, feeling like she is missing something that seems in line with chronic feelings of emptiness. Clementine participates in bouts of displaying anger as evidenced by her self-confession of picking fights with her partner. It is unclear if she has exhibited self-injurious behaviors as this was not fully explored.

Plan (P)

This BSW student will meet with Clementine again in one week to further assess her symptoms and appropriateness for psychoeducational or dialectical behavioral therapy groups. BSW intern will also explore any history or current report of self-injurious behaviors.

Eric Culbreath, BSW Student

May 3rd 2019

Diagnosis

F-code and Axis I-V

F-code: F60.3

Axis I: N/A

Axis II: Borderline Personality Disorder

Axis III: N/A

Axis IV: Relationship problems

Axis V: 61-70

References

Gondry, M. (Director). (2004). Eternal sunshine of the spotless mind [Motion picture on DVD]. United States: Produced by Georges Bermann, Anthony Bregman, David L. Bushell, Steve Golin, Charlie Kaufman, Glenn Williamson.