Biopsychosocial Assessment
Initials: YU Age: 26 Weight: 5.5 Ethnicity: Afro-American Race:
Black Allergies: NKA Occupation:
Maintenance
Living Situation:
Family Constellation:
Presenting complaint:
History of present
illness:
Characteristics of
Personality Disorder
The characteristics of a
personality disorder are
impairments in self and
“I have dizziness and weakness”
A 26-year-old women presents to the office referral for her PCP
because she is concerned about feelings of dizziness and weakness. By
her PCP the patient medical history is unremarkable.
During the interview, the women's despondent facial expression and
inquiries about other issues. She admits that she has not slept in 2 days
because of tension in her relationship with her husband, who is visiting
his family in another part of the country. Her husband had seemed
somewhat distant on the phone with her, and she is concerned that he
is spending time with his former ex-wife, who resides in the same
town as his family. She asks for medication to help her sleep and, after
a few minutes, opens up about the mood swings that she has recently
been experiencing. She admits that once before, when she liked a man
and discovered that he was not interested in her, she became hopeless
and despondent. She acknowledged thinking that she did not want to
live anymore and that he would never be able to find anyone, but she
did not have thoughts of ending her own life at that time. Instead, she
took comfort from donating blood, as the sight of her own blood was
extremely soothing to her, and she felt safe in the controlled
environment of the blood donation center. However, she states that
this time the intensity of her suffering is worse, and that she feels
"alone in the world" and that even her friends are "out to get her."
Borderline Personality Disorder Symptoms
Pervasive distrust of others.
Inappropriate intense anger.
Feelings of emptiness.
interpersonal
functioning, and the
presence of pathological
personality traits. To
diagnose a personality
disorder, the following
criteria must be met:
•Substantial
impairments in self
(identity or self-
direction) and
interpersonal (empathy
or intimacy) functioning
•One or more
pathological personality
trait domains or trait
features
•These impairments in
personality functioning
and the individual’s
personality traits are
relatively stable across
time and situation
•These impairments in
personality functioning
and personality trait
expression are not
considered as normal for
the individual’s
developmental stage or
socio-cultural
environment
•These impairments in
personality function and
trait expression are not
Extreme fear of abandonment.
Unstable relationships
Impulsive ad self-destructive behaviors.
Self-harm and suicidal thoughts.
Extreme emotional swings
Shifting self-image
Explosive anger
Out of touch with reality.
due to the physiological
effects of a medical
condition or substance
(APA, 2013).
Patterns of behavior
(self-harm, alcohol, drug
use, Addiction
(shopping, gambling,
pornography, video,
gaming, etc.)
Shoplifting:
Legal issues:
Interpersonal
functioning and
relatedness:
Alterations in cognition:
Current and recent
stressors:
Individuals with borderline personality disorder may engage in
impulsive and risky behaviors. These includes behaviors such a:
Gambling
Impulsive spending
Reckless driving
Drug and substance abuse
Broken relationships
Individuals with borderline personality disorder may also be entangled
in various legal issues such as shoplifting, violence, truancy, child
abuse and neglect, alcohol and illicit substance abuse (Wirth-Cauchon,
2001).
Impulsive behavior and other patterns of behavior associated
with borderline personality disorder may adversely affect
interpersonal functioning and relationships with others.
Current coping skills:
Spirituality and/or
religion:
Client and family’s
perception of problem:
There are several coping skills that can help the patient control and
effectively manage her BPD symptoms. These skills include:
Playing music
Engaging in other activities for behavioral activation.
Finding support from family, relatives, friends and other social
groups.
Being mindful
Physical exercise
T
The patient’s family history does not reveal any possibility of
hereditary. The patient does not have any close relatives who have or
are undergoing treatment for BPD.
Past medical history
(medical history,
treatment and outcomes,
recent and past
hospitalizations,
surgeries):
Family medical history:
Medications (side
effects, adverse side
effects, and treatment
response) INCLUDE
BELIEFS about
medications
The patient was recently being treated for Pneumocystis carinii
pneumonia (PCP).
The patient has referral for her PCP after she is concerned
about feelings of dizziness and weakness.
By her PCP, the patient medical history is unremarkable.
The patient’s nuclear family members does not have significant
relationships. (She suspects her husband of an affair with his
former wife).
Non-prescription
drugs/OTC:
Substance use history The patient does not have any substance use history.
(for each substance,
identify the type and
details to include:
duration, frequency, last
use; blackouts;
withdrawal seizures;
drug-related psychosis).
Legal, psychosocial,
physical, interpersonal,
and occupational
consequences.
Smoking history:
Alcohol use:
Marijuana use:
Illicit drugs:
The patient does have any smoking history for alcohol,
marijuana use, and illicit drugs.
Herbals:
Complementary
treatments:
Include exposure to
prescription opioids
(reasons for use, pain,
duration, frequency etc.)
Psychotropic
medications, side effects,
adverse side effects, and
treatment response:
The patient has not been exposed to any prescription opioids.
However, she has taken sleeping pills to help overcome her
insomnia.
Sleeping oils have several side effects such as:
Dizziness
Headache
Prolonged drowsiness
Parasomnia
Withdrawals
Allergic reactions
Memory problems
Past psychiatric history
(psychiatric
history/treatment and
outcomes, recent and
The patient history reveals she has exhibited BPD symptoms
before.
She reveals that she once liked a man and discovered that he
was not interested in her, she became hopeless and despondent.
past psychiatric or
substance abuse
hospitalizations,
residential or outpatient
treatments):
Family psychiatric
history and/or substance
use history:
Sociocultural history
(family and social
history, work history,
current employment,
volunteer work, legal
history, active and past,
current support system,
marital status, and
children):
Trauma history:
Trauma exposure
(childhood abuse or
neglect, rape or sexual
assault, emotional abuse,
domestic violence,
military/combat service,
and natural disasters,
historical/political
trauma):
History of head injury,
loss of consciousness,
seizures:
She acknowledged thinking that she did not want to live
anymore and that he would never be able to find anyone.
The patient suspects her husband of cheating on her with his
ex-wife.
Her loneliness makes her “alone in the world.”
The patient history does not reveal nay history of trauma or
dead injury nor loss of consciousness.
COMPREHENSIVE Medication
TREATMENT PLAN:
INCLUDE
EVIDENCED- BASED
THERAPEUTIC
MODALITIES FOR
THE IDENTIFIED
PERSONALITY
DISORDER
Topiramate (Topamax)-Belongs to a class of medications
known as mood stabilizers
Mood stabilizers are commonly used in treating individuals
suffering from partial complex seizure disorder.
Topiramate is used in combination of other medications in the
prevention and control of seizures.
It works on certain chemicals, channels, receptors, and
enzymes in the human brain to help control seizures and
prevent migraines.
Dosage- Patient should start with 25 to 50 mg taken orally once a
day. Also, the dosage may be increased by 25 to 50 mg orally daily
every week (WebMD, 2019).
Side effects:-nausea, diarrhea, loss of appetite, weight loss and
nosebleeds.
Psychotherapy
The goals of psychotherapy include: focusing on the patients current
ability to function, teaching ways to manage emotions and feel more
comfortable, reduction of impulsiveness, improvement if relationships.
Some of the type of psychotherapy that should be considered for this
patient include:
i. Dialectical behavior therapy (DBT)
This includes various group and individual therapy that
employ skills-based approach to teach the patient how to
manage her symptoms (Help Guide, 2020).
Schema-focused therapy
This type of psychotherapy seeks to identify the patient thoughts and
feelings while also creating an alternative perspective to their problem
or situation.
Mentalization-based therapy (MBT)
It seeks to help the patient identify thoughts and feelings and to create
a new way of viewing and understanding situations.
Systems training for emotional predictability and
problem-solving (STEPPS) (Aguirre & Galen
2015).
According to Mayo Clinic (2019) “STEPPS is a 20-week treatment
that involves working in groups that incorporate your family members,
caregivers, friends or significant others into treatment. STEPPS is used
in addition to other types of psychotherapy.”
Other types of psychotherapy that may be considered include:
Transference-focused psychotherapy (TFP), Good psychiatric
management, and Good psychiatric management.
References
Aguirre, B., & Galen, G. (2015).BCoping with BPD: DBT and CBT Skills to Soothe the Symptoms
of Borderline Personality Disorder. New Harbinger Publications.
Help Guide (2020). Borderline Personality Disorder (BPD). Retrieved from
https://www.helpguide.org/articles/mental-disorders/borderline-personality-disorder.htm
Mayo Clinic (2019). Borderline personality disorder. Retrieved from
https://www.mayoclinic.org/diseases-conditions/borderline-personality-disorder/
symptoms-causes/syc-20370237
WebMD (2019). Topamax. Retrieved from
https://www.webmd.com/drugs/2/drug-14494-6019/topamax-oral/topiramate-oral/details
Wirth-Cauchon, J. (2001).BWomen and borderline personality disorder: Symptoms and stories.
New Brunswick, NJ: Rutgers University Press.
