Ann is a 28-year-old single woman currently working as a barista in a coffee shop while attending college part time. She has been pursuing her college education for 8 years, as she has changed majors several times. She intermittently lives with her widowed mother and several short-term significant others. She describes herself as polyandrous, with her longest relationship lasting 2.5 years, which she attributes to others “not getting” her. Although she has several friends, she admits that her relationships are highly “dramatic,” with few enduring friendships. Ann has many pastimes, including roller derby, downhill skiing, bungee jumping, rock climbing, and kayaking.
Ann is the middle child with an older brother, who is a successful businessman, and a younger sister, who is in dental school. Ann describes herself as the “underachiever.” Growing up was somewhat chaotic, as both parents were active duty military and the family moved every 18 months on average. Although neither parent had combat assignments, Ann believes her mother had a traumatic career due to possible military sexual assault. She describes her mother as tense and overprotective, as well as distant and aloof. Ann denies witnessing any violence in her family or experiencing abuse or neglect; however, she describes invalidation from her family regarding anything she did or tried. Ann believes her parents favor her siblings because she is the “overly sensitive one” in the family.
Beginning in her sophomore year of high school, Ann secretively cut her abdomen and thighs when she felt anxious and lonely because “it helped relieve the emotional pain.” She denied wanting to kill herself; however, in her senior year of high school she took an overdose of Advil® after a girl-friend ended their romantic relationship. Ann was hospitalized for 3 days on a psychiatric unit and began weekly therapy for approximately 3 months after discharge. She said the therapy helped some, but she continued to feel displaced and without a purpose. She experimented with relationships with men and women, always anticipating being rejected. She would go to great extents to please others but also acknowledged intense moodiness, irritability, and temper tantrums if she did not get what she wanted.
This year, Ann's college advisor referred her to the student counseling center because he thought she was depressed and not doing well in her course work.
The psychiatric–mental health nurse practitioner (PMHNP) at the counseling center diagnosed Ann with BPD after several assessment sessions. After he explained BPD, Ann agreed with the diagnosis. They discussed the most distressing behaviors/symptoms that Ann wanted to focus on: moodiness with intense swings of anger and happiness even within a few hours; impulsiveness that sometimes included cutting and recklessness; unstable relationships with a prolonged sense of loneliness; and general depression with episodic intense anxiety that interfered with her studying. Ann denied suicidal ideation or substance use except for occasional marijuana use (legal in her state) and excessive alcohol consumption at parties.
The PMHNP met with Ann weekly for individual therapy sessions that focused on building a commitment to change targeted behaviors and learning coping skills. Ann agreed to call her therapist when she had the urge to cut and receive coaching to use alternative coping. After 6 weeks, she agreed to also participate in weekly skills group to learn mindfulness, emotional regulation, interpersonal effectiveness, and stress management. Even with this plan, Ann expressed intense sadness, despair, shame, and impulsive self-destructive urges. Finally, the PMHNP suggested they discuss medication to augment her psychotherapy and support her while she became more effective in her skills. He explained neurobiological reasons for her impulsivity and impaired judgment and ability to problem solve in stress situations (i.e., her frontal lobe [dorsolateral prefrontal cortex] that mediated problem solving and judgment had a broken connection with her limbic area [amygdala] that mediated her intense emotions). Because dopamine was a major neural circuit that connected these two regions and the neural firing of these nerves seemed to be irregular, two different types of medications might help her feel more in control of her emotions and behaviors. He discussed the medications for her to consider as possible choices and the side effects of each, as well as the process of titrating the dose over time to achieve relief of some symptoms. He emphasized that it would take time because the brain does not tolerate rapid change and she would have to tolerate side effects until the beneficial effects became evident. He validated that this would be difficult for her because he understood how much she wanted immediate relief. However, he emphasized that the medication would provide some relief as she became more skillful with her behavioral and environmental strategies.
Case Study Questions
What medication classes do you think the PMHNP recommended?
What specific mechanism of actions of these medications would target Ann's symptom clusters to provide the widest spectrum of outcomes?
What agreements does the PMHNP need to secure before initiating the medication regimen?
Continuation of Treatment
The PMHNP and Ann agreed that she would try aripiprazole 2.5 mg daily, even though she was fearful of gaining weight. She agreed to continue with the daily dosage for 4 weeks and call if she had the urge to suddenly stop taking the medication or change the dosage. At every follow-up appointment, the PMHNP assessed for extrapyramidal effects and akathisia, which Ann experienced mildly for the first 3 weeks. The dosage was increased to 5 mg after 4 weeks because Ann felt little improvement in her moodiness or impulsivity. After 2 months on the medication, Ann noticed she had gained 5 pounds without change in her diet or exercise and insisted that this was unacceptable. They agreed to taper the aripiprazole and try the other medication that the PMHNP recommended, lamotrigine. Ann was fearful of trying this medication because of the possible rash and the amount of time it would take to achieve a therapeutic dosage, but she was not willing to continue with the aripiprazole or try the alternative brexpiprazole.
Case Study Questions
What alternatives to aripiprazole could the PMHNP offer and why?
Given Ann's concerns, what are the risks and benefits to consider for such possibilities as quetiapine, olanzapine, or risperidone?
Why might the PMHNP suggest lamotrigine over valproate, lithium, or topiramate? What would you offer?
For 1 week, Ann took aripiprazole 2.5 mg with lamotrigine 25 mg daily. The next week she stopped aripiprazole but continued lamotrigine 25 mg daily. The next 2 weeks she increased the lamotrigine to 50 mg daily and noticed a slight improvement in her impulsivity but was concerned that she was getting a rash. The PMHNP asked her to send him a picture of the rash and compared it with images of Stevens–Johnson rash before her next visit. He asked if she had other symptoms (e.g., fever, itching, malaise, achy muscles, mouth sores), which she denied. He advised her that the rash appeared to be a contact dermatitis but if she was worried to go to Urgent Care. At the next appointment, he saw that the rash was flat and reddish without blistering, which Ann noted was itchy. The rash covered approximately 3 mm under her chin. He recommended monitoring it for 1 week, using an over-the-counter cortisone cream, and not changing her soap or laundry detergent or eating unusual foods for the time being. The rash subsided in 10 days and Ann continued the lamotrigine at an increase of 75 mg for the next 2 weeks. She expressed concern that she was still feeling somewhat impulsive, needing to use her emotional regulation skills several times per day, but was otherwise managing. She expressed frustration at how long it was taking to get results and that she would never get better. The PMHNP acknowledged how frustrating it was and added that he noticed improvement in her thinking about her urges, absence of any cutting for 4 weeks, and persistence in therapy and school. He reminded her of how long she had experienced these symptoms and that even small improvement was indication that she could get better. Although she expressed anger with his unwillingness to add more medication, she agreed to continue with the regimen.
Case Study Questions
In response to Ann's request for additional medication (she asked if he would prescribe lorazepam for a few days), how would you respond?
Why would the PMHNP not increase the lamotrigine titration to 100 mg daily in response to Ann's request instead of continuing with the 75 mg after the fifth week of gradual titration?
What is the target dosage of lamotrigine to level the daily dosing?
After 6 weeks of gradual titration of the lamotrigine, Ann was noting in her daily diary card that she had fewer episodes of angry outbursts, had no urges to cut in the past 1 week, and was using her skills 5 of 7 days per week with effective results. She still felt “barely in control” and depressed. She complained that “this is too hard” and asked if there were other medications to help her feel better. She told her skills group leader that the PMHNP was being cruel and did not realize how difficult it was for her. The skills group leader and PMHNP met with Ann together to discuss her plan of care and what additional resources she needed to feel successful. After a long meeting, they agreed Ann would continue the lamotrigine and weekly individual sessions and skills group. She would advance to the next level of group where she would practice her skills more than the didactic group. Ann also agreed to pair with another group member to coach each other through instant messaging. After 3 weeks of this plan, Ann noted she was feeling more confident and wanted to stop therapy altogether. The therapist and PMHNP met with Ann separately and assured her that this was a positive indication of her improvement and a “flight into health.” They negotiated with her to continue lamotrigine at 100 mg daily and check in monthly with the PMHNP. She would continue with peer coaching and advanced skills group and check in with her therapist monthly for the next 3 months. Both clinicians emphasized their availability for coaching calls or scheduled appointments as needed.