Week (enter week #): Complex Case Study Presentation

Presentation Objectives

By the end of this presentation, viewers will be able to:

Describe the hallmark symptoms of borderline personality disorder and its impact on emotional regulation and interpersonal relationships.
Differentiate between borderline and paranoid personality disorder using DSM-5-TR diagnostic criteria.
Develop an individualized treatment plan for personality disorder utilizing evidence-based psychopharmacology and psychotherapy.
Evaluate the influence of occupational stress as a social determinant of health in patients with personality disorders: Week (enter week #): Complex Case Study Presentation

Subjective

CC (chief complaint): “I am doing okay, but my sleep has been off because of job stress. I also accused my wife of cheating again, but I am trying to manage it.”

HPI: The patient, B.M., is a 41-year-old Caucasian male who presents for psychiatric follow-up and reports medication complaints. He indicates no global change in mood stability and emotion regulation before lamotrigine administration. Nevertheless, he reports recent changes in sleep with disturbances associated with occupation-related stress and occasional paranoid thinking with false accusations of infidelity toward his wife.

The patient is aware of such behaviors and ascribes them to his borderline personality disorder diagnosis. He also reports great improvement in emotion regulation of anger and impulsivity, and he is willing to adopt the same coping techniques to control triggers related to trust.

Substance Current Use: Past history of alcohol dependence; ceased more than 3 years ago. Does not intend to take any alcohol, tobacco, or illicit substances now. No recent relapse patterns.

Medical History: Controlled hypertension, no surgeries, does not report chronic diseases or hospitalizations that are not connected to psychiatric disorders.

Current Medications:
- Lamotrigine 150 mg PO daily
- Propranolol 10 mg PO TID
- Melatonin 5 mg PO QHS PRN
Allergies: No known drug, food, or environmental allergies.

Reproductive Hx: Not applicable (married, no fertility concerns or contraceptive discussions initiated).

ROS:

GENERAL: There is no present weight loss or fatigue..
HEENT: No visual changes, hearing loss, or nasal congestion.
SKIN: No rashes or itching reported.
CARDIOVASCULAR: Denies chest pain or palpitations.
RESPIRATORY: No cough or shortness of breath.
GASTROINTESTINAL: No nausea, vomiting, or abdominal pain.
GENITOURINARY: No urinary complaints.
NEUROLOGICAL: No dizziness, headaches, or paresthesia.
MUSCULOSKELETAL: Denies joint or muscle pain.
HEMATOLOGIC: No bruising or bleeding.
LYMPHATICS: No lymphadenopathy.
ENDOCRINOLOGIC: No symptoms of thyroid dysfunction.

Objective

Diagnostic Results

No new diagnostic tests were conducted during this visit. Recent labs within normal range; no metabolic concerns. PHQ-9 score = 7 (mild), GAD-7 score = 10 (moderate).

Assessment

Mental Status Examination

The patient is a well-groomed, middle-aged Caucasian male who appears stated age. He is cooperative and maintains appropriate eye contact. Mood is “stressed but okay,” with congruent affect. Thought processes are logical but reveal intermittent paranoid content without fixed delusions.

No hallucinations noted. Insight is partial, especially into interpersonal conflict. Speech is normal in rate, rhythm, and tone.

No suicidal or homicidal ideation. Memory and cognition intact; alert and oriented ×4. Judgment is improving, but is impacted by stress. Insight is fair.

Diagnostic Impression

Primary Diagnosis: Borderline Personality Disorder (F60.3)

The patient’s primary diagnosis is borderline personality disorder, supported by DSM-5-TR criteria including affective instability, inappropriate anger, transient paranoia under stress, and intense, unstable relationships (Chapman et al., 2021). The patient reports accusing his wife of infidelity during emotionally charged periods, illustrating stress-induced paranoid ideation. He acknowledges longstanding difficulties managing anger, fluctuating interpersonal attachments, and emotional sensitivity.

These symptoms began in early adulthood and remain consistent across contexts. His insight has improved, and he is actively engaged in therapy. This diagnostic conclusion is reinforced by his emotional reactivity, impulsivity, and relational challenges, all consistent with BPD’s core features. Dialectical Behavior Therapy (DBT) is considered a first-line intervention, and the patient is responsive to current psychopharmacological support.

Generalized Anxiety Disorder (GAD) (F41.1)

GAD is appropriate as a comorbid consideration. The patient reports persistent worry, especially regarding occupational stress, accompanied by sleep disturbance and muscle tension. His GAD-7 score of 10 suggests moderate anxiety.

However, his worry appears context-driven rather than excessive across most domains of life. His anxiety symptoms are real but are better explained as secondary to his core personality disorder (Munir & Takov, 2022).

Alcohol Dependence, In Remission (F10.21)

The patient has a history of alcohol dependence but reports over three years of sustained remission. He denies cravings, recent use, or triggers. Although this diagnosis is not active, it remains relevant due to the historical impact on emotional regulation and stress coping.

Continued abstinence supports stability, but it is not the cause of current symptoms. No recent evidence suggests relapse or misuse (Palzes et al., 2020).

Overall, borderline personality disorder most accurately captures the patient’s enduring emotional dysregulation and interpersonal dysfunction, with comorbid anxiety contributing to current stress-related exacerbations.

Reflections

If I could conduct the session again, I would utilize a formal screening tool for paranoid ideation to objectively assess the severity and frequency of the patient’s suspicious thoughts. I would also explore his work environment and relational dynamics in more depth to better understand contextual stressors influencing his symptoms. I was able to follow up with the patient during a subsequent visit. He noted that he slept better and experienced fewer paranoid ideas when he used distress tolerance skills developed within DBT regularly and stuck to the prescribed treatment.

He was introduced to the Employee Assistance Program (EAP) over work-related stress, and he found it useful. These results indicate that the interventions worked in stabilizing his mood and increasing insight. Continuing DBT and guided therapeutic intervention will form crucial elements of his healthy emotional regulating and interpersonal functioning.

Discussion Questions for Classmates

What therapeutic approach would you prioritize in this case, DBT alone, or a blended model with CBT?
How do you validate and address intermittent paranoid thoughts while preserving therapeutic rapport?
What strategies have you used successfully to help patients with personality disorders manage symptoms triggered by job-related stress?

Case Formulation and Treatment Plan

The psychological treatment plan includes further ongoing Dialectical Behavior Therapy, which is proven to be the evidence-based treatment for borderline personality disorder. DBT will be dedicated to strengthening emotional control, distress tolerance, and interpersonal effectiveness, which are the skills necessary to work with the paranoid ideation of the patient and his emotional volatility (Vijayapriya & Tamarana, 2023). As a health promotion intervention, the patient was advised to start a strict routine of sleep hygiene with regular bedtime, no screens before bedtime, as well as relaxation methods, such as guided meditation.

Education of the patient involved psychoeducation about how occupational stress and sleep disruption may exacerbate symptoms of borderline personality disorder due to magnification of mood instability. The patient was advised to learn to predict the early signs of emotional dysregulation and apply acquired skills of coping in therapy.

The pharmacologic intervention consists of maintaining lamotrigine 150 mg daily as mood stabilization, propranolol 10 mg TID to counter somatic anxiety, and melatonin 5 mg nocte to enhance sleep onset. Among the nonpharmacologic options are prolonged therapy, recording of triggers, and the application of mindfulness-based smartphone applications (Chapman et al., 2021).

A key social determinant of health is occupational stress, which significantly contributes to his symptoms. I recommended referral to the employer’s Employee Assistance Program for counseling and work-life balance support. Literature supports EAP utilization as effective in reducing burnout, improving emotional resilience, and promoting long-term mental well-being (Couser et al., 2023).

A follow-up appointment is scheduled in four weeks to evaluate mood stability, paranoid ideation, and sleep quality. Adjustments to therapy or medication will be made based on progress.

References

Chapman, J., Jamil, R. T., & Fleisher, C. (2021). Borderline personality disorder. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/28613633/

Couser, G. P., Nation, J. L., Apker, D. P., Connaughty, S. M., & Hyde, M. A. (2023). The evolution of employee assistance programs to best support healthcare organizations. Journal of Healthcare Management, 68(6), 404–419. https://doi.org/10.1097/jhm-d-23-00085

Munir, S., & Takov, V. (2022, October 17). Generalized anxiety disorder. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/28722900/

Palzes, V. A., Kline-Simon, A. H., Satre, D. D., Sterling, S., Weisner, C., & Chi, F. W. (2020). Remission from unhealthy drinking among patients with an alcohol use disorder: A longitudinal study using systematic, primary care–based alcohol screening data. Journal of Studies on Alcohol and Drugs, 81(4), 436–445. https://doi.org/10.15288/jsad.2020.81.436

Vijayapriya, C. V., & Tamarana, R. (2023). Effectiveness of dialectical behavior therapy as a transdiagnostic treatment for improving cognitive functions: A systematic review. Research in Psychotherapy: Psychopathology, Process and Outcome, 26(2). https://doi.org/10.4081/ripppo.2023.662

PRECEPTOR VERFICIATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

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Question

Complex Case Study Presentation

This week you participate in the second of three clinical discussions called grand rounds. In one of these 3 weeks, you will be a presenter as well as help facilitate the online discussion; in the others you will be an active discussion participant. When it is your week to present, you will create a focused SOAP note and a short didactic (teaching) video presenting a real (but de-identified) complex patient case from your practicum experience.

You should have received an assignment from your Instructor letting you know which week of the course you are assigned to present.

To prepare:

Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
Select a child/adolescent patient from your clinical experience that presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources. All SOAP notes must be signed by your Preceptor. When you submit your SOAP note, you should include the complete SOAP note as a Word document and PDF/images of completed assignment signed by your Preceptor. You must submit your SOAP note using Turnitin.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
Then, based on your SOAP note of this patient, develop a video case study presentation. Set aside time to practice what you will say beforehand and ensure that you have the appropriate lighting and equipment to record the presentation.
Your presentation should include objectives for your audience, at least three possible discussion questions/prompts for your classmates to respond to, and at least five scholarly resources to support your diagnostic reasoning and treatment plan.

Video assignment for this week’s presenters:
Record yourself presenting the complex case study for your clinical patient. In your presentation:

Dress professionally and present yourself in a professional manner.
Display your photo ID at the start of the video when you introduce yourself.
Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.
Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.
Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide.
- Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
- Objective: What observations did you make during the psychiatric assessment?
- Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.
- Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Discuss an identified social determinate of health impacting this patient’s mental health status and provide your recommendation for a referral to assist this patient in meeting this identified need (students will need to conduct research on this topic both in the literature and for community resources).
- Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.
  Week (enter week #): Complex Case Study Presentation

A note on grading:

Presenters: Review the Grand Rounds Presenter Rubric attached to this discussion to ensure you meet the scoring criteria.
Participants: Review the Grand Rounds Participant Rubric located on the following Week 7 Assignment 1 page to ensure you meet the scoring criteria. Note the Week 7 Assignment 1 page is for viewing the participant rubric only. Your response should be posted in the forum of this page.

Week 7 Presenters:
By Day 3

Post your video and your focused SOAP note to the Grand Rounds Discussion forum. You must submit two files for the SOAP note, including a Word document and scanned PDF/images of completed assignment signed by your Preceptor. Then, actively respond to and guide the conversation as your colleagues post responses to your video.

Week 7 Participants:
By multiple days between Days 4 and 7

Respond at least 2 times each to all colleagues who presented this week (should be 2-3 presenters each week). The goal is for the discussion forum to function as robust clinical conferences on the patients. Provide a response to 1 of the 3 discussion prompts that your colleagues provided in their video presentations. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient.

Client’s Notes:

Hello. Please this is a detailed assignment, but this time I am the presenter. Please note the topic that was assigned to me is personality disorders.
I will also send a sketch reading of a patient that you will use for this complex case presentation.
- Patient sketch for complex case presentation.
  - BM a 41 year old male The patient reports overall well-being with effective medication management but notes recent sleep disturbances due to work stress. He has experienced transient stress-related paranoid ideations, accusing his wife of cheating twice, which he attributes to his borderline personality disorder. The patient acknowledges progress in managing anger and is open to applying similar strategies to address these thoughts. A follow-up appointment is scheduled in 4 weeks.
    - Undefined
    - (F41.1) Generalized anxiety disorder
    - (F60.3) Borderline personality disorder
    - (F10.21) Alcohol dependence, in remission
    - Lamotrigine (lamoTRIgine) 150 MG Oral Tablet
    - Melatonin-Pyridoxine (Melatonin) 3-10 MG Oral Tablet
    - Propranolol HCl 10 MG Oral Tablet
Please also remember to state the three key questions and main objectives
Please follow all rubrics and let me know any information you need. When time comes, i will message you to log into my portal for discussion replies to the students who shall comment.

Week (enter week #): Complex Case Study Presentation

Week (enter week #): Complex Case Study Presentation

References

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