From the Guidelines
The next step for this patient should be a comprehensive psychiatric evaluation and integrated care approach, focusing on Dialectical Behavior Therapy (DBT) for borderline personality disorder, trauma-focused psychotherapy for PTSD, and optimization of her current medication regimen for bipolar disorder. Given her complex psychiatric history, including bipolar disorder, PTSD, and suspected borderline personality disorder, it is crucial to address her mental health needs while also managing her frequent presentations with vague physical complaints 1. The patient's history of self-directed violence and suicidal ideation, common in borderline personality disorder, necessitates a careful and structured approach to her care.
Key components of her care should include:
- Referral to a psychiatrist specializing in complex cases involving mood disorders and trauma
- Reassessment of her current medication regimen for bipolar disorder, considering mood stabilizers and antipsychotics
- Trauma-focused psychotherapy for PTSD, such as Cognitive Processing Therapy or EMDR
- Dialectical Behavior Therapy (DBT) for borderline personality disorder, which has been shown to reduce nonsuicidal and suicidal self-directed violence 1
- Establishing a consistent schedule of appointments with her primary care provider to address medical concerns and reduce frequent unscheduled visits
This approach acknowledges her physical complaints while avoiding unnecessary testing and provides appropriate psychiatric care for her underlying conditions. The frequent presentations with vague physical complaints may represent somatization, common in patients with complex trauma histories and personality disorders, requiring a balanced approach that validates her distress while avoiding iatrogenic harm from excessive interventions 1.
From the Research
Patient Assessment and Diagnosis
The patient, a 23-year-old female, presents with bipolar disorder, post-traumatic stress disorder (PTSD), and suspected borderline personality disorder, along with somatic disorder. She frequently visits the primary care office with vague physical complaints, including a recent complaint of ear leaking, despite unremarkable exams.
Treatment Options
- Dialectical behavior therapy (DBT) has been shown to be effective in treating borderline personality disorder and PTSD, as well as bipolar disorder 2, 3, 4.
- Cognitive-behavioral therapy (CBT) has also been found to be effective in treating borderline personality disorder and reducing symptoms of PTSD and bipolar disorder 3, 5.
- A combination of DBT and social rhythm therapy (SRT) may be beneficial for patients with co-occurring bipolar disorder and borderline personality disorder 2.
Differentiation of Borderline Personality Disorder and Bipolar Disorder
- Emotional dysregulation is a common feature of both borderline personality disorder and bipolar disorder, but identity disturbance is more specific to borderline personality disorder 6.
- A comprehensive diagnostic assessment is necessary to differentiate between borderline personality disorder and bipolar disorder, and to develop an effective treatment plan.
Next Steps
- Consider referring the patient to a mental health specialist for a comprehensive diagnostic assessment and treatment plan.
- Explore the possibility of DBT or CBT as a treatment option, either individually or in combination with other therapies.
- Continue to monitor the patient's physical complaints and address any underlying medical issues, while also addressing the patient's mental health needs 4, 5.