This week’s case scenario is of a 30-year-old Rhonda, a Hispanic female who presents to the psychiatric clinic with emotional fears of abandonment. She fears that her very few friends have abandoned her and she is left with no one. She reports being nice to people but this does not seem to help her situation currently including her nice boyfriend who she broke up with recently after he turned out to be a ‘monster.’ However, she does not regret the traumatic breakup with her ‘boyfriend’ citing her hatred for his guts.
Rhonda recalls a friend who falsely accused her of theft after the friend lent her the money but later backed out. The car that she just purchased using the money was repossessed as she had no other means of completing the payment. She blames her financial problems on her friends and associates since childhood. The friends and professional associates are ‘jealous’ of her and that is why she had lost her past two jobs. In her forensic history, there are reports of violence since tender age with friends and classmates. In her adulthood, she has been arrested and charged with illegal possession of firearms and illicit drugs. The mental state examination of Rhonda shows a labile affect with a subjectively ‘terrible’ mood. All other aspects are unremarkable and there are no psychotic symptoms.
Decision #1: Differential Diagnosis
Rhonda has a personality disorder associated with violence, mood problems, and fears of emotional abandonment. Her social life has been turbulent since childhood. The violence and antisocial behaviors suggest an antisocial personality disorder. One can also imply that Rhonda was simply trying to seek the attention of people by claiming fear of emotional abandonment. This would suggest the likelihood of histrionic personality disorder. However, these are not the most striking features in the psychiatric presentation of Rhonda. Borderline personality disorder more suits this patient than a histrionic and antisocial personality disorder.
The DSM-5 criteria for the diagnosis of Borderline Personality Disorder (BPD) define specific major requirements for delineation of BDP from other personality disorders. The presence of antisocial personality features and impulsivity and fears of emotional abandonment makes the patient’s diagnosis more likely to be BPD (Mulay et al., 2019). The basis of the diagnosis of BPD is dependent on two patient evaluation aspects: the instability of self-image, affect, & interpersonal relationships; and marked impulsivity (Lubit & Pataki, 2018). Rhonda had a labile affect with emotional instability regarding an imagined abandonment. Her impulsivity has been evident since childhood with a history of violence, criminal arrests, and forensic charges.
The decision to pick BPD over ASPD and HSP is informed by careful evaluation of the patient. However, the holistic assessment should include physical evaluation to rule out organic etiologies. Understanding why the patient presented to the clinic at that moment when she has had few friends and fears of emotional abonnement for a long time is still unclear from this psychiatric evaluation. The is no difference between the expected outcomes of the decision and the archived outcomes.
Decision #2: Treatment Plan for Psychotherapy
Psychotherapy is preferred over pharmacotherapy in the management of personality disorders. Various methods of psychotherapy apply in the management of personality disorders. However, tend to use cognitive-based therapy (CBT) more frequently compared to other methods. The best type of psychotherapy for Rhonda, according to Chapman et al. (2020), would be dialectical based therapy (DBT). DBT sessions would be important for Rhonda because her chief reason for this clinical visit emanates from emotional fears of imagined abandonment. DBT would, therefore, focus on the current emotion while enhancing her skills in dealing with emotional controls. She also showed signs of self-destructive behavior that would be managed well through dialectical behavior therapy. Rhonda would best benefit from individualized DBT therapy sessions with skills training. In cases of physical distance disadvantages, the therapist should weigh the benefits of DBT via phone call against the risks of poor outcomes.
Other types of psychotherap
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