Clinical Geriatrics

Case Presentation

Mrs. N is a 63-year-old divorced white woman who presents to her psychologist at a local mental health center for weekly psychotherapy. Mrs. N appears clearly distressed and tells the psychologist that she saw her third ex-husband in a restaurant a few days ago having lunch with a young, attractive woman. Mrs. N reports that since then she has felt ugly, unattractive, and has resumed previous self-destructive behavior of sticking pins into her thighs. Mrs. N has a prior history of cutting herself with a small knife but had stopped this after she married her third husband. She has been married and divorced three times and has two children from her first marriage. Her two sons were raised by her ex-husband, and Mrs. N has not seen them in more than 10 years.

Mrs. N has a pattern of intense but short-lived relationships and often tells her psychologist that her 6-year course of therapy is the longest period of time that she has lasted with anyone. She has been attending weekly group therapy for patients with borderline personality disorder but frequently complains that “there is no one in the group who understands me.” Mrs. N frequently threatens to quit attending the group, but made an agreement that group therapy would be part of the conditions of her receiving treatment at the mental health center. Mrs. N goes out to movies and museums but has few friends aside from other patients from the mental health center. Mrs. N receives financial support from a trust fund left to her by her father. The trust is controlled by a bank officer whom Mrs. N frequently argues with when asking for additional money.

Mrs. N has hypertension and chronic obstructive pulmonary disease. She frequently changes her primary care physician, as she easily becomes angry if she has to wait prior to her appointment or feels that the doctor does not devote enough time and attention to her complaints. Mrs. N has been asked to leave the waiting room of several local physicians’ offices after she became loud and disruptive while having to wait to see her doctor. She admits that her compliance with medical treatment is poor, as she does not believe that her physicians are giving her adequate time to prescribe appropriate medications for her conditions. Mrs. N continues to smoke cigarettes and becomes angry when her physicians try to counsel her regarding smoking cessation.

The psychologist is concerned about Mrs. N’s distress, signs of negative affect, depressed mood, and increase in impulsivity and self-harm. The psychologist is also concerned about her poor compliance with medical treatment. Mrs. N denies wanting to kill herself and has always been able to contact her psychologist during times of distress. She does not take any psychiatric medications but has in the past been prescribed medications for periods of depression, impulsivity, and paranoia. Mrs. N is ambivalent about seeing a psychiatrist again, stating “they just take your money and prescribe pills.” She has threatened to sue several psychiatrists in the past after she developed side effects to medications; however, she has never acted on these threats and cannot describe the severity of the side effects other than to complain that the medications made her feel “crazy.” After encouragement, she agrees to see a psychiatrist affiliated with the mental health clinic.

Discussion

Borderline personality disorder is one of ten personality disorders described in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision.1 Personality disorders are all characterized by chronic and persistent maladaptive patterns of coping with the experiences, stressors, and relationships associated with daily living.