Should I approve FMLA for a patient with MDD, GAD, and ADHD, who is tapering off Venlafaxine and exhibiting potential Borderline Personality Disorder symptoms?

FMLA Approval for Patient with MDD, GAD, ADHD, and Potential Borderline Personality Disorder

FMLA approval is not recommended for this patient due to inconsistent symptom reporting, potential borderline personality disorder traits, and lack of objective evidence supporting work disability. 1, 2

Assessment of Current Presentation

The patient presents with several concerning features that suggest potential borderline personality disorder (BPD) traits rather than simply worsening of her diagnosed conditions:

• Inconsistent symptom reporting (reporting agitation and irritability now, but denied these symptoms at previous follow-up)
• Emotional lability
• Frequent messaging to provider
• Hanging up when requests aren't met
• Social withdrawal and avoidance behaviors

These behaviors align with diagnostic criteria for BPD, which include:

• Unstable interpersonal relationships
• Affective instability
• Impulsivity
• Emotional dysregulation 2

Diagnostic Considerations

Borderline Personality Disorder vs. Medication Effects

While the patient attributes her symptoms to venlafaxine tapering, her previous report contradicts this claim. The Delphi consensus guidelines for psychiatric disorders note that "individuals with a diagnosis of personality disorder (especially borderline personality disorder) frequently meet criteria for MDD, but antidepressants are unlikely to be effective and hence may mimic a non-response" 1.

The FDA label for venlafaxine notes potential withdrawal symptoms during tapering, but the patient's inconsistent reporting makes it difficult to attribute her current symptoms solely to medication effects 3.

Diagnostic Challenges

A common pitfall in psychiatric assessment is confusing acute stress reactions with personality disorders 2. However, this patient's pattern of behavior over time (frequent messaging, emotional lability, hanging up when frustrated) suggests more persistent traits consistent with BPD rather than simply an acute reaction to work stress.

FMLA Considerations

FMLA approval requires:

1. A serious health condition that makes the employee unable to perform essential job functions
2. Objective evidence of functional impairment
3. Consistent documentation of symptoms affecting work performance

In this case:

• The patient's inconsistent symptom reporting undermines the reliability of her claims
• Her behavior pattern suggests potential manipulation to obtain FMLA approval
• There is insufficient objective evidence that her condition currently prevents her from working

Management Recommendations

1. Complete the BPD diagnostic assessment before making determinations about work disability

   • Use structured assessment tools like the Structured Clinical Interview for DSM-5 Alternative Model for Personality Disorders 4
   • Gather collateral information from previous providers

2. Stabilize medication management

   • Continue venlafaxine tapering with close monitoring
   • Document symptoms objectively at each visit

3. Implement appropriate communication boundaries

   • Schedule regular visits rather than responding to frequent messages
   • Set clear limits on communication
   • Maintain professional boundaries 4

4. Consider referral for specialized therapy

   • Dialectical Behavior Therapy (DBT) or Mentalization-Based Therapy if BPD is confirmed 4, 5

Alternative Approaches

If the patient's condition deteriorates significantly with objective evidence of functional impairment, reconsider FMLA approval with:

• Clear documentation of symptoms
• Specific work limitations
• Time-limited approval with reassessment
• Treatment compliance requirements

Conclusion

The current presentation suggests potential BPD traits that require further assessment before FMLA approval. Approving FMLA without addressing these underlying issues may reinforce maladaptive patterns and hinder appropriate treatment. Focus on proper diagnosis and targeted treatment rather than accommodating potentially manipulative behaviors.