Dynamic Consultations with Psychiatrists. Jason Maratos

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СКАЧАТЬ her family. Yet, Ms. B denied a pervasive depressive mood. She still enjoyed part‐time work as basketball match referee assistant. Her self‐care and hygiene were satisfactory.

      On the day of admission, Ms. B reported that she and her boyfriend had been arguing from morning to night. She had discovered in WhatsApp a message in which her boyfriend had asked his friends' opinion whether he should send a bunch of flowers to his former girlfriend. She calmed down a little after an afternoon nap. The couple later went out and met their shared friends. Ms. B consumed two bottles of apple cider and became emotional again. She scolded their friends as she felt that they were colluding with her boyfriend for his unfaithfulness. She cried loudly and threw an empty glass bottle on the floor. She impulsively banged her head on a lamppost and hit the gate of a street shop. She also attempted to rush into the traffic but was stopped by her boyfriend. Later, her father and maternal aunt were called for help. She hid in a restaurant's toilet and expressed negative ideas to relatives: “You will regret this…. you can never find me; this will be the last time that you saw me.” Ms. B was subdued by father and was eventually sent to casualty.

      There was satisfactory self‐care and hygiene, and she was cooperative and respectful to the staff. Her mood was stable; she was not overly depressed and presented with congruent affect. Her speech was coherent and relevant, and she freely shared her feelings. She was not psychotic, suicidal, or aggressive. She had mixed feelings toward her boyfriend with grievance and guilt. She showed no psychomotor retardation.

      Ms. B was physically fit. There were many old slash marks over the volar aspect of both wrists. There was a tattoo (with the boyfriend's name) on her right thumb.

      Family History

      Her mother and maternal grandmother had been diagnosed with depression. Her mother committed suicide by jumping from height at the age of 32. Her father is 55 years old and, together with her stepmother, owned a logistic company. He suffered from hypertension, dyslipidemia, and ischemic heart disease. Her stepmother, 32 years old, had moved to the city from the country. Ms. B has a distant relationship with her stepmother. Her stepmother was thought to be greedy and irresponsible because she kept buying luxury goods even when the logistic company had financial deficit. Father and stepmother are currently living separately. Ms. B has three younger half‐siblings ages 15, 12, and 4. Ms. B has a close relationship with her second younger sister.

      Personal History

      Ms. B was born in the city; she felt that she was deprived of love from her parents. Her mother died when she was 2 years old, and she has no recollection of her. She felt that there was lack of emotional caring and love from her father who otherwise provided the patient with enough money and other material goods. Ms. B was brought up by her maternal grandmother. Ms. B felt that she was spoiled by her maternal grandmother and felt loved by maternal grandparents, uncle, aunt, and cousin. Ms. B described her primary school life as happy and had a good relationship with her teachers. Ms. B's academic results were below average.

When she was in higher forms in primary school, she was betrayed by one of her best friends in the class who had hacked into her internet account and spread a rumor about her relationship with some classmates. Ms. B was promoted to a local band three secondary school (not for high achievers). Ms. B felt isolated and picked on by classmates; she played truant. Her school attendance was around 80%. Ms. B maintained good relationship with her teachers.

      Ms. B achieved a pass grade on four subjects in the city diploma of secondary education examination. Ms. B then stayed in abroad for 1 year with her boyfriend who studied while there. She came back to the city and worked in her father's logistic company as a clerk for 1 year. She also worked in sales in a computer company for few months. Ms. B is currently employed as part‐time basketball match referee assistant. She is financially supported by her father.

      Ms. B has had many short‐lived courtships since Form 2. She started a relationship with the current boyfriend while in Form 3. They broke up and reconciled many times. Ms. B agreed that she was manipulative in the relationship and not loyal to her boyfriend; she initiated breakups on a few occasions. She had threatened her boyfriend with self‐harm behaviors and made suicidal threats during conflicts and when she was worried that she would be abandoned.

      Ms. B has no forensic record. She had made regular use of “ice” (an amphetamine) under peer influence at the age of 17. She stopped taking ice for 1 year when she lived abroad. She restarted taking ice at the age of 20 for 1 year after she came back to the city. Ms. B denies having used ice in the last year but believed that “amphetamines” gave her increased energy, euphoria, and weight loss. Ms. B experienced transient auditory hallucinations after taking ice. Ms. B made less frequent but regular use of cannabis at the age of 17; the last use of cannabis was a few days before admission. Ms. B also took slimming pills prescribed by her general practitioner from January to June 2017.

      Ms. B had a personality of being “hot tempered,” impulsive, outgoing, and willful. Her hobbies were outdoor activities, basketball, hiking, swimming, and badminton. Ms. B is not religious and enjoyed good past health. She is a smoker of about seven cigarettes per day and a social drinker.

      Past Psychiatric History

      Ms. B has been known to a private psychiatrist since 2011 when she experienced depressive symptoms after a relationship breakup (in her first relationship in Form 2). She consulted a private psychiatrist on an “as necessary” basis. In the last 2 months, Ms. B consulted a psychiatrist on three occasions. She presented with unstable emotions attributed to relationship problems Ms. B commented that “she had too much to ruminate about negative thoughts.” She felt that the doctor did not understand her needs and concerns. Ms. B was not known to the public mental health service.

      There is a history of a drug overdose of 20 tablets of Panadol/clonazepam (medications from maternal grandmother), which she took with alcohol in April 2018. She had then been admitted to the casualty and discharged. There is a history of overdoses with 80 tablets of hypnotics and an incident of climbing over the railing of a high slope in May 2018. Ms. B would eventually vomit the medications.

       Present Treatment and Management of Case

      Ms. B was given the diagnosis of Borderline Personality Disorder, adjustment disorder, and cannabis misuse with the possibility that she may have been suffering from a depressive episode. She was treated with antidepressant medication and counseling, which was focused on her relationship difficulties and her maladaptive coping techniques as well as anger management. She was offered a short stay (1 week) at the psychiatric hospital.

Ms. B settled well and was cooperative throughout the admission. She had no overt or pervasive depressive symptoms. She had no craving for substances or alcohol. She could sleep well without hypnotics. She was quite attentive and constructive when talking about relationship problems. She had no intention of giving up her boyfriend even though he appeared to be suspicious and unfaithful. She kept daily phone contact with her boyfriend. When her boyfriend visited her in the hospital (once), she mentioned that he cried in front of her. Ms. B said she missed the ward “a bit” at the time of discharge. She considered the hospital a safe and secure place. Ms. B also respected the staff and her doctor and asked to be followed‐up in the public sector.

      It was felt that the following factors were playing a part in her condition: a strong family history of depression; mother committed suicide; insecure attachment to parents; lack of care, love, and emotional expression from father and stepmother; lack of discipline from maternal grandmother who often satisfied her demands, irrespective of whether they were thought to be reasonable. There was a history of being betrayed by peers in primary school, which may have further intensified her feeling СКАЧАТЬ