to be late adolescents, and 70% of females suffer from this disorder. Literature suggested that the symptom resolve over time, as 75% patient have been followed up for 15 years and no BPD have been found (Biskin, & Paris, 2012). A substantial ten years of empirical data concluded that the remission of the BPD had been investigated two years, but only 50% of participants get psychological functioning (Zanarini et al., 2010). The current article intends to investigate the diagnosis of BPD according to the Diagnostic and statistical manual (DSM, V) and how it differentiates the BPD from other disorder. Furthermore, the article highlights that which assessment modalities can be used for the identification of the disorder.
Reason
for Referral
The client was referred for the assessment
of the current psychological functioning such as suicidal idealisation,
aggression, quarrelling with others, sleeplessness, irrelevant talk and
devising a comprehensive management plan to improve psychological functioning.
Assessment
The assessment of the client's problems was
carried out through following modalities concerning the diagnostic criteria of
the borderline personality disorder. As the client was found to indulge in
suicidal idealisation, aggression, and quarrelling with others, therefore it
was hypothesised that the client was suffering from borderline or mood
disorder. Further assessment modalities would help in determining the
diagnosis. The diagnostic criteria require that at least five of the criteria
must be met for at least one year with significant stress or impairment in
social, personal and occupational functioning.
The following
tools were used to identify the clinical diagnosis of the client.
• Behavioural Observation
• Clinical Interview
• Thematic Apperception Test
• ABC model for Anger
• Borderline Personality Test
Behavioural Observation. Behavioural
Observation was carried out to assess the client interest, abilities and
appearance, his verbal and non- verbal cues.
Behavioural Observation is a systematic way
of recording the observable responses of behaviour (Pellering, 2014).
Behavioural Observation measures the
frequency, duration, topology, etc. of clients actions, usually in a natural
setting with non-interactive methods, For example, to assess the formal or
informal observations in the clinical setting or outside the setting.
The rational of Behavioral Observation was
to assess the client’s nonverbal behaviour, her posture, gesture, hygienic
condition and how he communicates with others without verbal communication.
The client was a middle-aged woman, sitting
in the rehabilitation ward and making embroidery on clothes. She was a healthy
woman with good hygienic condition. The client was wearing neat and ironed
dress. When the client was asked to come for the session, the client thought
for a while then came outside the room with his embroidery accessories. After
greetings, the client started showing
her work with energetic way, she was very happy about her work and it was
proudly told by the client that she earn herself for meeting the necessities of
her life. The client was shaking her
legs during conversation and sitting with the crossing arm posture. The speech
of the client was very clear, but she used trivial things without a break. Her
eye contact was adequately established, and she continually maintained her eye
contact during conversation, she did not blink her eyes during the speech. The
client mood remains happy for no reason; when she was telling about her divorce
and mother’s death, there was a smile on clients face. The client was
cooperative and taking an active part in session activities.
Clinical
Interview. The clinical interview was carried out to
assess the client own insight about her illness, his verbatim and views about
self and others.
A clinical Interview is a primary tool of
gathering information from client, parents, and other informants (Raynold
2014).
Clinical Interview was done to assess the
client own insight about his illness and problems which was very helpful to
understand his problems.
The client was being asked several
questions about her previous problem and the current situation. The client told
everything in details; somehow, she was using irrelevant material. It was
observed that the client had insight about her reason of referral as she told
all the weakness due to which she was admitted here.
Furthermore, the DIB-R semi-structured
interview was carried out to investigate the clinical dimension of borderline
personality disorder.
The DIB-R
comprised of 22 statements which have been divided into four categories, i.e.
cognition, affect, impulsiveness, interpersonal relationship. The
semi-structured interview had high reliability from .71 to.80.
Another tool
(CI-BPD), the childhood interview for the clinical disorder, was used to assess
the traits of BDP in childhood to adolescents.
The results of
the clinical interview and documentation of the client suggested the following
information.
Developmental
History of the Problem. The
client has attempt suicide twice with the big needle, she cut her arm on minor
issues with her mother. Furthermore, she also attacked her mother with the same weapon. The client always used to quarrel with sister, colleagues, mother
and sisters; she was very aggressive towards other people and used to coarse them. The client had insomnia as she sleeps only 2 to 3
hours at night; it was reported by the client that she always meets her mother in
dreams and loved her.
The client problem started due to excessive
work with no reinforcement; rather her mother used to abuse her for minor
mistakes. The siblings of the clients were not supportive towards client in
household chores. Her mother and father have not supported the client, which
left a negative impact on the client mind. The client was married to a drug
addicted man. Her husband used to abuse her and did not support the client
financially. According to client, her husband used to ask the client to earn
money or forced her for begging money from his in-laws. The parents of the
client belong to lower socioeconomic status, they refused to provide any
monetary assistance. Then the conflict started between the client and his
husband; at last, his husband divorced the client. The husband of the client
left the child to her maternal home, but the parents were not ready to accept
the child. The client forced her parents; consequently, they got agree to keep
the child with them. Then the incessant disputes at home made the client
mentally disturbed, and she started abusing, quarrelling or hitting other
family members as well as herself. It was also told by the client the owner of
her factory was not supportive towards her and wanted to keep physical relation
with the client, when the client refused then he dismissed the client from
work.
It was told by the client that her parent
married the client with an infertile man, unfortunately, the client was second
time divorced by his second husband as he accused that the client was barren. According
to the client, actually her husband was infertile. After a divorce, the client
became so aggressive, she attempted suicide twice and she attacked her mother
when she was abusing her for not taking any interest in domestic work. The
family of the client did not realized the client grief; rather they were
expecting household duties from client.
The current situation of the client found
to be quite better, but still, she reported minor symptoms of unstable
relationship, aggression, hitting and quarreling. The client was taking
vocational training and contented to earn money. The client was admitted in the hospital before
3, to 4 years and has been stayed Jinnah psychiatric hospital for several
years.
Personal
History. The client was social
and extrovert; she speaks without a break often says a trivial thing and detailed
explanation of each thing. The client
has learnt the art of embroidery, stitching, card making and cooking. It was
told by the client she is independent and earns money to spend her life in a more
comfortable way . She has desire to support her child after complete recovery.
The client has a great interest in holy verses and her voice was very alluring.
Premorbid
Personality. The client
was very social, and her functioning was very appropriate as she learnt all the
household and vocation task in her early life.
Family History. The client belongs to
the nuclear family system. There were eight family members in the client’s
family, mother, father, three sisters and three brothers of the client.
The client belongs to low socioeconomic
status; therefore, the home environment was very harsh and conflict-ridden. All
three sister and one brother were working on low wages which were not enough to
run the home circle. There were two rooms in client’s home and all sister,
brother and mother had to stay in a single room, which was frustrating for the
client. The client revealed her wish to
have a separate room after her recovery where she will stay with her son and
will led a peaceful life.
The father of the client was blind and
stayed at home all the time. The father was kind toward her daughter, and the
client expressed love for him. The mother of the client was suffering from
lungs cancer and diabetes. She loves the client but indulges her in excessive
domestic work from her childhood. She could not sympathies the client on her failure,
such as client’s divorce and low socio-economic condition. The client reported that
he recite some verses of the Holy Quran for the peace of her mother soul.
The client had two sisters, both
were studying and running a tuition centre to meet their educational expenses.
It was told by the client that both sisters have good relation and come to meet
the client in hospital and also taking care of the client’s child. The brother of the client was working in
private factories and come to meet her. It was felt that she loves her brother
and had a healthy relations with her brothers.
Educational
History. The qualification of the
client was metric. It was told by the client that she was average in her
studies. According to the client, her class fellows were not cooperative
towards her, did not support her in studies, and used to quarrel with the
client. The client had a positive attitude towards her teachers and remembered
the name of her best teachers.
Occupational
History. The client started working at the age of 15
years. She had work in a different factory and had been a school teacher for a
short period. It was also told by the client the owner of her factory was not
good with her and wants to keep relation with the client when the client
refused then he takes away the client from work.
Currently, the client earning money by
making bangles, embroidery, stitching and jewellery making and she was delighted
with her earning.
Medical
History. The client has been
using psychotropic and antidepressant medication.
History of psychiatry/Medical Illness. The father of the client was blind, and the mother
was suffering from hemorrhoids, lungs cancer and diabetes.
One of the client cousins also suffering
from a mental disorder and admitted in PIMH hospital.
Thematic
Apperception Test. TAT was used
to assess the hidden conflict about family unstable relation and causes of
aggressive behaviour.
TAT is a projective test design to let
a person respond to ambiguous stimuli, reveal the hidden and internal emotions
(Harvard, 1943).
Card 1. The client was shown a card in
which the child was sitting on a chair and reading a book which was lying on
the table. And the client was asked to make a story about the picture.
According to the client the child did not
want to study, but he will become a great businessman to support her family.
The client has visualised her wishes
towards her son as it was told by the client when his child would complete his
education then he will keep the client with him in his new house.
12 M. The client was shown a card of a
female and a kid.
According to the client the mother
loved her child who was afraid of her father. It was also told by the client
that the kid was afraid of darkness and mother consoling him.
This card was shown to the client to
know about her family environment, her attitude toward the child and the type
of conflict which the child had faced.
According to the story, it might be possible that the client had been a
victim of father’s aggression during drug addiction state and mother saved him
from his father. As the kid of the client was blind of one eye, so the darkness
may be associated with her blindness, and the client used to save him.
7 BM. To assess the father-child
relationship, the card of a man and kid was shown to the client.
According to the client they are
father, son and father were making his son frightening so that he could not
take her mother’s side.
It was revealing the strict environment
of client home and the role of her husband toward her kid and wife (Appendixes,
B1)
ABC model of Anger. ABC model was used to assess the activating event,
beliefs and reaction of anger and its frequency, intensity and duration, and
put the three components together to understand why behavior happens.
The ABC model is the three-term contingency
model, the Antecedent-Behavior-Consequence. An antecedent is something that
comes before a behaviour and may trigger that behaviour. A behaviour is
anything an individual does. A consequence is something that follows the
behaviour. (Miltenberger 2008; Reid & Parsons, 2007).
The client was asked to write down the
activating event which makes her aggressive towards others or her self. It was
reported by the client that when her mother doesn’t appreciate her after a
heavy load of work, rather she used abusive language for the client that thing
made him aggressive and she started to indulge in self-destructive behaviour.
About her marital life, the client reported that her husband used to beat her
for earning money or during drug addiction, and then she used to quarrel with
her husband and later on divorced by her husband. After her divorce, her mother
did not console the client appropriately and used to abuse her for work therefore,
the client attacked her mother with the needle. Figure 1
Symptom
Checklist for Borderline Symptoms. The checklist was used to assess the client’s a borderline feature in a
structured way, according to DSM V criteria of borderline disorder.
Borderline personality disorder (BPD) is a
mental health disorder that generates significant emotional instability. The
emotional instability leads to a variety of other stressful mental and
behavioural problems. This test is designed to help you understand the
Borderline Personality features. (Grohol, 2014)
The checklist consisted of twelve items;
each was indicated specific behaviour of borderline. The client has to respond
to each item with the given key of strongly disagrees, disagree, neutral,
strongly agree and agree. The client filled the form mostly agree and strongly
agreed, but on a few items, she showed her neutral response.
The results of the checklist indicate that
the client had borderline personality features.
Diagnosis. 301.83 (F60.3) Borderline personality disorder.
V61.03 (Z63.5) Disruption of a family by separation or divorce, V15.42 Personal
history of neglect in childhood.
Prognosis
As the client personal hygienic condition
and self-help skill was appropriate, she had learnt the vocational skill and
independently meeting her needs, hence it could be hypothesised that the prognosis
of the client was good.