CASE 01

CLIENT
AGE : 14 YEARS
GENDER : FEMALE

INFORMANT : MOTHER
AGE : 37 YEARS
CHIEF COMPLAINTS VERBATIM

 Anxiety and  "Anxiety hai, depression hai, anger issues hai"

depressive mood  "Hobbies mein interest nahi hai"
 Anger Issues
 Trust issues  "Trust issues bohot hai"

 Family Issues
(Conflicts between  "Don't like eating home cooked meals"
parents-prolonged) "Bina father ke family kaise chalegi?
 "Bachpan mein mumma ne bohot mara hai"
 Disturbed
interpersonal  "Friendships toot chuki hai"
relationships  "My friends bully me, severely"
 "Relationship mein breakup hua hai"
 Course : Progressive​

Duration : 1-1 ½ years​(Chronic)

Triggers – Family issues, Phone, Breakup, Bullying​

Perpetuating factors – Uncertainty about future, Bullying​

Protective factors - Phone

 HISTORY OF PRESENT ILLNESS

• Dad cheated on mother – multiple times

• Grandparents (Mother's in-laws) dislike her mother- Poison her against

the mother

• Doesn't trust anyone - progressive

• No interest in studies and hobbies – progressive
• Sleep issues – Cries a lot at night – Overthinking

• Intense worrying for younger sibling's future – Younger sister(Born in

pandemic)

• Mother had substance abuse problems – alcohol

 INFORMANT – MOTHER (37 YEARS)​
​
• Substance abuse while pregnant with younger sibling​

• Psychological stress and mood disturbances because husband has cheated

multiple times and progressive conflicts.​

• Wants to shift abroad in order to avoid further conflicts with her husband.

• Forces her decisions on her children.

• Currently unemployed

• Suicidal Ideation and attempt

Client (Past 1 week) Behaviour Checklist
Appetite : Unhealthy Disobedience
Sleep Pattern : Disturbed Tantrums
Time management : Poor
Medical history Self esteem : Low
Pre-diabetic
High TSH levels Conception : Unplanned (As
Vomiting- unusual amount of reported by informant-mother)
times Exposure to teratogens : None 
Illness at birth : Jaundice
Performance in school : Poor 
Attendance : Poor Physiological/Psychological illness
 Depression + Anxiety
 GENERAL APPEARANCE & BEHAVIOUR​
•  Appearance : Healthy (Normal)​
•  Facial Expression : Bored​
•  Posture : Relaxed​
•  Eye Contact : Maintained​
•  Rapport : Easily established​
•  Attitude towards examiner : Cooperative but not interested​
• Speech
Relevant, Low pitch, Monotonous tone, 
• Orientation
Time, Place and Person            :  Present 
Attention and Concentration  : Present 
Abstract thinking                  : Good 
Judgement                                 : Normal 
Emotional Insight                     : Present 
Parenting style : Authoritarian
Attachment : Insecure
Mother : Too controlling and unable to understand other's perspectives
Father : Neglecting
Client :A counselling session in Faridabad(Once) & School counsellor(Thrice)

Client Reported 
She has been a well-spoken and confident individual in the initial years of her
school life. She is also the part of NCC team at school.
But now, she's facing identity issues and self doubt, her relations with other people
are unstable due to mood swings and anger issues. Blames her family issues for her
mood and behaviour. Feels empty, helpless and alone most of the times. 
Her mother is planning to shift abroad for work purposes, also wants her and her
younger sister to come along.
Although she is bullied, she still prefers to stay at the same school.
Says, she requires external stimulants to stay level headed and escape from the
hard reality and stressors around her. 
 Probable Diagnosis : Borderline Personality Disorder 
(DSM-5 TR) Diagnostic Criteria
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked
impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or
more) of the following: 
1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating
behavior) 
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between
extremes of idealization and devaluation. 
3. Identity disturbance: markedly and persistently unstable selfimage or sense of self. 
4. Impulsivity in at least two areas that are potentially selfdamaging (e.g., spending, sex, substance abuse,
reckless driving, binge eating). (Note: Do not include suicidal or selfmutilating behavior)
5. Recurrent suicidal behavior, gestures, or threats, or selfmutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability,
or anxiety usually lasting a few hours and only rarely more than a few days). 
7. Chronic feelings of emptiness. 
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper,
constant anger, recurrent physical fights). 
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
 Borderline personality disorder has typically been thought of as an adult onset
disorder. 

 However, it has been found in treatment settings that symptoms in adolescents as

young as age 12 or 13 years can meet full criteria for the disorder. 
 It is not yet known what percentage of adults first entering treatment actually have
such an early onset of borderline personality disorder.
 They experience intense abandonment fears and inappropriate anger even when faced
with a realistic time-limited separation or when there are unavoidable changes in plans.
(Plans: Client's mother wants to shift abroad-change of school).
 Although they usually have a self-image that is based on the feeling of being bad or
evil, individuals with this disorder may at times have feelings that they do not exist at
all. This can be both painful and frightening to those with this disorder. Such
experiences usually occur in situations in which the individual feels a lack of a
meaningful relationship, nurturing, and support.
 These individuals may show worse performance in unstructured work or school
situations.
 Individuals with borderline personality disorder display impulsivity in at least
two areas that are potentially self-damaging (Criterion 4). Client : Unhealthy
eating.

 Physical and sexual abuse, neglect, hostile conflict, and early parental
loss/neglect are more common in the childhood histories of those with borderline
personality disorder.
Client : Conflict between parents, witnessed for 10 years now, she's 14 years at
present. Father is not a part of the family anymore, mother was never the
comforting figure and grandparents(Mother's in-laws) poison her against her
mother. 

3Cs of Borderline Personality Disorder

C- I didn't CAUSE it : Client: Blames her parents for all the issues she is facing.
C- I can't CURE it : Client: She feels helpless, can’t trust anyone anymore.
C- I can't CONTROL it : Client: Situations seem to not be in her favour. She seeks
external stimulants to avoid the stressful thoughts and events.
Risk and Prognosis

Both Environmental and Genetic factors are involved in the client's case.
Environmental : The atmosphere at home most of the times. Since the day she started
understanding words, she has seen her parents fight and the rage is very disturbing for the
client. Clearly a child who has witnessed conflict for almost 10 years now, will be
mentally disturbed and in need of severe help.
A Mother is a very influential being who is required to be present as the primary caregiver
in a child's early life. Client's was not appropriately present for the client. The conception
was sudden and unplanned. The mother didn't know how to take care of the client as an
infant, but she tried her best. But soon frustration took over and the mother became
addicted to alcohol. Conflicts became prominent in between the father and the mother. 

Genetic: The client's mother used substance and judging by her mother's current situation
and acquired history, we can conclude that she had been a troubled individual in her early
adulthood, who may have had issues with anger and impulsive decision making(Unplanned
conception and alcohol addiction during second pregnancy).
DIFFERENTIAL DIAGNOSIS
1. Identity problems
Borderline personality disorder should be distinguished from an identity problem, which is
reserved for identity concerns related to a developmental phase (e.g., adolescence) and does
not qualify as a mental disorder. Adolescents and young adults with identity problems
(especially when accompanied by substance use) may transiently display behaviors that
misleadingly give the impression of borderline personality disorder. Such situations are
characterized by emotional instability, existential dilemmas, uncertainty, anxiety-provoking
choices, conflicts about sexual orientation, and competing social pressures to decide on
careers.
2. Substance use disorders
Borderline personality disorder must also be distinguished from symptoms that may develop
in association with persistent substance use.