Kay is a 27-year-old female who is admitted to the mental health unit for feelings of depression and suicidal ideations. She has a history of cutting her legs and arms since she was a teenager. She started psychiatric treatment at age 16 and has been admitted to the psychiatric hospital three times due to overdoses. She admits to a history of promiscuous behavior and occasional marijuana use. She is unmarried but reports having several relationships with male partners. However, she shares that the relationships “never worked out” because the partners didn’t pay enough attention to her or text her as frequently as she expected, which made her angry. She describes feelings she experienced in relationships where one day she felt as if her partner was the “best thing ever,” but the next day she “can’t stand him.” She admits to abusive behaviors toward her partners when she was angry, but states that afterwards she experiences anxiety fearing the loss of the relationship. She acknowledges having trouble getting along with others. She has very few close friends and refers to previous friends as “losers.” She is unemployed with a history of several jobs from which she was terminated because of problems with anger control. There is evidence of scarring and recent cuts on bilateral lower arms. She related these injuries to self-cutting, which she reports “makes me feel better.” She reports attending dialectical behavior therapy (DBT) in the past but hasn’t attended therapy for over a year. She feels therapy helped her to learn how to feel more “in control of her extreme feelings.”

Critical Thinking Questions:

1. List the symptoms Kay is experiencing that supports the diagnosis of borderline personality disorder (BPD).

Symptoms of BPD include anger, anxiety, impulsiveness, difficulty controlling emotions, self-injury, suicidal, intense/stormy relationships, and risky behaviors. 

2. Identify possible risk factors contributing to BPD.

Possible risk factors include environmental factors that may contribute to BPD, including neglect, abuse, and genetics.

3. Discuss two types of psychotherapy that may be prescribed for clients diagnosed with BPD.

Cognitive behavioral therapy, dialectical behavioral therapy, interpersonal therapy, mentalization-based therapy, and psychodynamic therapy are types of psychotherapy that may be prescribed for clients.

4. List at least three nursing interventions that should be included in this client’s care plan.

• Explain policies, expectations, rules, and consequences upon admission.
• Search the client’s belongings and remove anything that could be used to inflict harm to self or others.
• Implement suicide precautions based on a suicide risk screening tool.
• Set and document clear boundaries and limits and share them with team members.
• Encourage consistent implementation of limits by all team members; do not allow bargaining.
• Call out manipulative behavior when it occurs. 
• If an episode of cutting occurs during hospitalization, remain neutral and dress the client’s self-inflicted wounds in a matter-of-fact manner. Ask the client to write down the sequence of events leading up to the injuries before discussing the event. Encourage the client to think independently about her triggers and behaviors and facilitate discussion about alternative actions.