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Dr. Andrew Rynne

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Treatment for bipolar I disorder, borderline personality disorder and obsessive compulsive personality disorder?

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Dr. Jonas Sundarakumar

Psychiatrist

Practicing since :2003

Answered : 2190 Questions

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Posted on Mon, 17 Dec 2012 in Mental Health
Question: Part 1
XXXXXXX is a 17-year-old female brought in for an evaluation by her mother, XXXXXXX Even before you XXXXXXX them, you hear the commotion in the waiting room, which concludes with XXXXXXX calling XXXXXXX a "XXXXXXX" and kicking a chair across the room.
Once in your office, the contrast between them is striking. The family lives in one of the pricier suburbs, and XXXXXXX works as an advertising executive. She is successful and well regarded, as is her husband, XXXXXXX father, who works in international banking. XXXXXXX says that he regrets not being present, but there was a sudden meeting in Barcelona that required his attention. XXXXXXX is well-dressed, poised, and soft-spoken.
XXXXXXX on the other hand, is quite gaunt, surly, noticeably unwashed, and dressed in full anarchist punk regalia. You count 11 piercings, some quite large, involving her tongue, lower lip, both nostrils, one eyebrow, and both ears; there may be more hidden by her dramatically dyed and styled hair.
XXXXXXX gives the following account as XXXXXXX shreds a Styrofoam cup, dropping the small pieces on the carpet, sighing loudly, scowling, and mumbling, "Bullshit XXXXXXX
XXXXXXX notes that she and her husband have "bent over backwards" to accept XXXXXXX "lifestyle choices" and her friends. XXXXXXX has not been appreciative, but they understand that adolescence is a difficult time. In the past few months, however, XXXXXXX has lost 25 pounds and has become verbally abusive. She also displays dramatic mood swings and is physically violent, and she is completely disengaged from school, family, and her old friends. She has also taken to hoarding strange objects, and XXXXXXX has noticed strange burns on XXXXXXX arms.
XXXXXXX has concluded that XXXXXXX has developed an eating disorder and is perhaps engaging in self-mutilation. XXXXXXX fears for XXXXXXX health and for the loss of educational opportunity that will occur if XXXXXXX continues nonparticipation in the expensive private school she attends. When you ask XXXXXXX her view on her mother's concerns, she says, "Whatever XXXXXXX
You take some initial background information. XXXXXXX has one sister, four years older, who attends an Ivy League school on the East coast. Her sister had "eating disorder issues" in her freshman year in college, but worked through them in therapy and is now doing well. XXXXXXX reports that XXXXXXX was without problems until last year, when she began hanging around "a rougher element XXXXXXX XXXXXXX and her friends often spent weekends in a cabin in an isolated rural area, and XXXXXXX initially discounted the dangers of these rougher companions, thinking, "How bad can they be if they are into nature?"
When questioned, XXXXXXX says that XXXXXXX has been hoarding all sorts of odd flasks and containers, "just junk XXXXXXX but XXXXXXX has not otherwise examined them because they smell bad. "They must be filthy; I wonder if she got them out of a dumpster XXXXXXX She also reports that XXXXXXX has broken furniture, driven one of the family sports cars through the XXXXXXX garden in a rage, and very recently physically threatened the housekeeper when she attempted to clean XXXXXXX room, to the extent that the housekeeper quit.
XXXXXXX has spoken to her other daughter's therapist, who suggested that as the eating disorder worsens, XXXXXXX self-esteem is plummeting, and as a result she associates more with "degrading people and objects XXXXXXX The therapist speculated that XXXXXXX might be giving herself cigarette burns. XXXXXXX also notes that XXXXXXX has taken up cigarette smoking in this period, and "smokes like a chimney XXXXXXX

Here is my diagnosis or I'm I off again???

Axis I:     296.6x     Bipolar I Disorder Most Recent Episode Mixed
Axis II:     301.83     Borderline Personality Disorder
     301.4     Obsessive Compulsive Personality Disorder
AXIS III:      None
AXIS IV:      None
AXIS V:     20

1. What further diagnostic evaluation do you believe is warranted?
2. What other psychological measures or evaluations/medical data that you would recommend to assist in your diagnosis?
doctor
Answered by Dr. Jonas Sundarakumar 20 hours later
Hi XXXXXXX

Considering the...
- pervasive nature of XXXXXXX problems
- pattern of behaviour which deviates form socio-cultural expectations (sharp contrast between her parents' behaviour, lifestyle, etc.)
- gradual onset
- typical age group of presentationConsidering the dramatic mood swings, impulsivity, emotional lability, self-harming behaviour, etc., a borderline personality disorder is likely. However we need more information to confirm this or see if she may be having features suggestive of other types of personality disorders also.

In the history, there are hints in two places that there has been a marked change in XXXXXXX behaviour since the last few months to a year, with specific problems such as:
- losing a significant amount of weight
- "eating disorder" - according to her mother (requires more exploration)
- "self-mutilation" (requires more exploration)
- hoarding junk articles
- significant decline in academic performance and not attending school

These features suggest that there could be a probable Axis I diagnosis also which could be accounting for these recent changes. The differentials I would like to consider are:
- Eating disorder (considering the significant loss of weight, the mother's account that she has eating problems and the family history)
- Schizophrenia (probably a simple schizophrenia considering the progressive personal and social decline with many odd behaviours)
- There is a minor possibility of an obsessive compulsive disorder, but other than the hoarding behaviour, there's nothing else to substantiate this.
- Regarding the possibility of a mood disorder, rather than a distinct / syndromal change in mood, she seems to be having predominantly erratic behaviours and mood instabilities / lability, and so, I my priority for a mood disorder would be relatively low.

Further diagnostic evaluation would include a more detailed and targetted history (exploring the possibilities considered in the differential diagnosis) and a mental status examination of the patient.

Other psychological measures would include administering a few clinical scales like:
- Personality inventory
- Y-BOCS symptom checklist (for OCD)
- Eating disorder checklist

Medical data which would aid in diagnosis would be information such as weight and height - for a BMI calculation, presence of amenorrhoea, history to rule out organicity and information about any other co-morbidities. Substance abuse also has to be explored.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Jonas Sundarakumar 5 hours later
Okay, based on the prior diagnosis….The axis would be….I wasn’t clear…

Axis I:     307.50     Eating disorder not otherwise specified
     295.90 Undifferentiated type
Axis II:     301.83     Borderline Personality Disorder
AXIS III:      None
AXIS IV:      None
AXIS V:      20

I’m I correct on this?

What if we found this new information during a second interview with the patient….

Part 2

• XXXXXXX asks to speak to you privately. She reports that a local pharmacist called her recently to inform her that last week XXXXXXX attempted to purchase a large supply of cold tablets.
• XXXXXXX looked through the trunk of XXXXXXX car and found a good-sized canister of anhydrous ammonia. She has also found a cache of batteries.
• XXXXXXX has learned from neighbors in the community that XXXXXXX has been seen around town with large sums of cash. She notes that she has been very careful to not disrupt XXXXXXX fragile self-esteem by depriving her of her allowance, which has always been generous. But the amounts reported were thousands of dollars. Despite the best efforts of XXXXXXX and her husband, XXXXXXX has never learned money management. It is very unlike her to have accumulated this much cash.
• XXXXXXX tells you that she thinks XXXXXXX is planning suicide, whether by overdose of over-the-counter medication, chemicals, or electrocution. She believes that XXXXXXX is spending all her money as a final fling before killing herself. XXXXXXX has been reading up on eating disorders and has learned that there is an increased risk of suicide in this group. XXXXXXX wants XXXXXXX hospitalized immediately.
• You interview XXXXXXX alone. She is again unresponsive to questions, but her physical appearance is somewhat different. She is very much on edge, seems to have difficulty concentrating, and is quite nervous and twitchy.

1.     What would the new diagnostic AXIS hypotheses would be just for this scenario?

Axis I:     296 Major Depressive Disorder
Axis II:     301.83     Borderline Personality Disorder
AXIS III:      None
AXIS IV:      Environmental
AXIS V:      5

I just not understanding…I guess if I’m not on the right track



2. What further diagnostic evaluation do you believe is warranted?
3. What other psychological measures or evaluations/medical data that you would recommend to assist in your diagnosis?
doctor
Answered by Dr. Jonas Sundarakumar 12 hours later
Hi XXXXXXX

Well in my previous answer, I had given a few differentials for the Axis 1 diagnosis, since the limited information given is insufficient to make a definitive diagnosis. In such cases, where the primary diagnosis is not clear, it is justifiable if we give two to three differential diagnoses (i.e. a list of possibilities). Actually, this is not a straightforward case case and it is indeed difficult to arrive at a clear Axis I diagnosis with the available information. So, don't worry too much if you find the Axis I diagnosis part confusing. In such scenarios what may be expected out of you is just a logical diagnostic approach, where you are able to piece together the information and consider two to three possible diagnoses; and have an idea as to what areas should be explored more in detail accordingly.

The second piece of information just gives us more clues of erratic behaviour and emotional instability and probably, a multiple substance abuse pattern. Again, frankly, I think it's still difficult to arrive at a definitive Axis I diagnosis at this stage.

So, my Axis hypothesis would be:
Axis I: Differential diagnoses: ? Multiple substance abuse
? Eating disorder
Axis II: Borderline personality disorder

Axis III: None
Axis IV: Family problems, social problems, problems at school
Axis V: 30

Further evaluations would include:
- Detailed history regarding substance abuse
- Further exploration into her probable eating problems
- Checking for any obsessive compulsive symptoms
- Ruling out a mood syndrome
- Ruling out psychosis
- Doing a detailed personality assessment / inventory
- Risk assessment for suicide / self-harm

Regards,
Dr. Jonas Sundarakumar
Consultant Psychiatrist
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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