A 44-year-old woman with borderline personality disorder.

Abstract

DR BURNS: Ms J is a 44-year-old woman with a history of borderline personality disorder. She lives alone and currently works full-time as a residential counselor in the mental health field. She purchases Medicaid-type insurance through Common Health in Massachusetts. She initially came to see Dr M in July 2000 because she was unhappy with her previous primary care physician. Ms J has an extensive psychiatric and comorbid medical history. She first had contact with a mental health care professional at the age of 22 after moving away from home and starting her first job. The transition precipitated extreme anxiety, and Ms J lost her sense of self-direction. She became extremely dependent on others and feared abandonment. When other changes and personal losses occurred, Ms J reacted with intense emotional instability, marked by depression and intermittent anger. She has had numerous, prolonged hospitalizations for depression, suicidal ideation, and suicidal behavior with multiple drug overdoses and selfinjury. These factors led to the diagnosis of borderline personality disorder. Additionally, Ms J has many medical problems that have necessitated additional hospitalizations, surgery, and orthopedic interventions. Some physicians have questioned whether these medical problems had a psychological component to them. Ms J has been in outpatient treatment with various health care providers since about 1978. She has had multiple psychiatric and medical inpatient hospitalizations. Over the years she also has participated in day treatment programs, residential treatment, and a supportive housing program that helps individuals access housing and live independently. Ms J has participated in several dialectical behavior therapy (DBT) skills training groups. Her medical history is significant for arthritis following a motor vehicle collision, chronic back pain, seizure disorder, sleep apnea for which she receives continuous positive airway pressure, nocturnal myoclonus, migraine headaches, hyperlipidemia, and gastroesophageal reflux disease. Ms J has a history of asthma and psychogenic laryngospasm that required tracheostomy placement for 4 months in 1999. She had a hysterectomy in 1996. She cannot tolerate hormone replacement therapy due to worsening depression. Despite this history, Ms J has made tremendous strides in the past 4 years. Five years ago, she was hospitalized for 265 days in 1 year; however, during 2001 she was hospitalized for only 4 days. In the past, she has taken lamotrigine, nortriptyline, desipramine, imipramine, fluoxetine, sertraline, paroxetine, citalopram, nefazodone, venlafaxine, tranylcypromine, isocarboxazid, phenelzine, quetiapine, olanzapine, risperidone, and lithium. Her current psychiatric medications are sustained-release bupropion, 150 mg/d; topiramate, 100 mg twice daily; and amitriptyline, 10 mg at bedtime. She is no longer taking clonazepam after 20 years of use. Her medical regimen includes albuterol, fexofenadine, fluticasone, omeprazole, montelukast, carbamazepine, tramadol, zolmitriptan, verapamil, and rofecoxib. Both she and the nurse specialist who provides her medications are now comfortable with her having a 1-month supply of medications, along with refills. Ms J attributes her improvement to a good working relationship with her current therapist, a clinical social worker, and a DBT program. She has a close relationship with her parents and all but one of her sisters. She also has established close and supportive friendships. There is no family history of mental illness in firstdegree relatives. Her parents are in their 70s. She does not smoke or drink alcohol. She reports being allergic to penicillin, erythromycin, phenytoin, acetaminophen/ oxycodone hydrochloride, sertraline, tetracycline, intravenous pyelogram dye, novocaine, haloperidol, sulfacontaining medications, and diazepam. Ms J wonders what her future will bring, whether she can maintain her progress, and what could help her be successful in the long run.