Description
You are a PMHNP in a private outpatient clinic. Kelly is a 28 year old female who presents for an initial intake. She was previously treated by a local psychiatrist but stated that she was “kicked out of his practice” and does not know why. She states that her history is as follows “Major depression, bipolar disorder, ADHD, PTSD, panic attacks, and insomnia.” She states that she has been told in the past that she may have borderline personality disorder, but “that doctor didn’t know what he was talking about.” She reports a history of multiple past suicide attempts, primarily by overdose. She also has a history of self injury, mostly by cutting on her wrists and thighs. She reports that she cuts about 1-2x/week, “whenever I get pissed off.” She reports a history of >15 inpatient hospitalizations. Her current medications include Prozac 60mg, Seroquel 25mg qAM and 600mg qHS, Wellbutrin XL 450mg qAM, Adderall 20mg TID, clonidine 0.2mg qHS, Ambien 10mg qHS PRN (takes nightly), and Klonopin 1mg TID PRN (generally takes 2-3x every day). She states that every time she is admitted inpatient, a new medication is typically added. She also reports that “nothing works” and that “therapy is stupid.” She reports today that her mood is irritable, sleep is poor, and states “if I don’t get any better, I’ll probably just overdose again.” However, she also states that she is unwilling to change her medication until she knows that she can trust you. Based upon Kelly’s history, answer the following questions, 1. Her medication regimen is far from ideal. In reducing polypharmacy & focusing on managing her symptoms, what would be your first approach in altering her medication regimen? 2. Given the frequency of self injurious behavior, as well as her history of suicide attempts & veiled threats of suicide at today’s appointment, at what point would you consider inpatient hospitalization? How might that affect your therapeutic rapport with her? 3. What alarms you the most about her self-reported list of diagnoses? How might you approach discussing a diagnosis of borderline personality disorder with her?