Case Study of Shanae: Understanding Borderline Personality Disorder and Inpatient Interventions

This case study explores the experiences and traumas that have contributed to Shanae's borderline personality disorder. It also discusses inpatient interventions and care for her condition.

Running head: CASE STUDY OF SHANAE
CASE STUDY OF SHANAE
Name of the student:
Name of the university:
Author note:

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Introduction:
Borderline personality disorder can be explained as the mental disorder that can be
characterised by ongoing pattern of varying moods as well as self-image and behaviours.
Studies opine that symptoms of this disorder often result in different impulsive actions as
well as problems in relationships (Averbe et al., 2018). Individuals suffering from this
disorder are often found to experience intense episodes of depression, anger as well as
anxiety, which can last from few hours to even days. People suffering from this disorder also
experience mood swings and they exhibit uncertainty about ways they visualise themselves
and even their roles in the world. Therefore, often their roles and values are also seen to
change quickly (Kirkhanm & Seitz, 2018). This assignment speaks of a similar patient named
Shanae who is 22 years old and suffering from borderline personality disorder. She had been
admitted to the ward following overdose and suicidal ideations identified by her former
partner. The assignment would be mainly be focusing on the various factors that had
contributed to such situation and even the inpatient holistic care that needs to be given to her.
It will also talk about the different referrals that the mental health nurse would suggest to the
patient so that she can get support from such services to ensure development of her mental
health.
Past trauma and experiences that contribute to the situation:
Often biological differences as well as genetics play important contributors in the
development of BPD. Kessing et al. (2016) were of the opinion that individuals suffering
from BPD have been often identified to have various types of physical changes in the brain.
However, the significance of such alterations is still not clear among the researchers. Many of
the studies are supportive of the fact that neurotransmitter imbalances play an important role
in many mood disorders that include BPD. Others have found that hormonal imbalances

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trigger or cause BPD. BPD might be also common in people who have their first-degree
relatives like parents or siblings to be suffering from BPD (Pan et al., 2016). In case of
Shanae, it is not known whether her family members share the same disorder but alteration in
the brain with ineffective functioning of neurotransmitter or hormonal imbalances cannot be
rejected.
Apart from this biological health, concern for Shanae number of psychological health
issues rising from social concerns need to be discussed that might have affected Shanae
immensely. Studies are of the opinion that high levels of stress are directly associated with
BPD (Hollis et al., 2015). Individuals who suffer from this disorder are found to have
experienced traumatic events like childhood factors of sexual pr physical abuse, death of the
parent, neglects, and many other traumatic events. Even highly stressful situations resulting
from loss of job, locating in a new place as well as experiencing the death of family member,
separation from close ones can indeed trigger manic as well as depressive episodes (Michalak
et al., 2016)). Shanae had been particularly seen to have gone through a number of
experiences that have traumatised her and created high levels of stress in her. One of the most
important social concerns that had contributed to the experiences of trauma is the loss of
employment. She had been terminated from her organisation after she had been found to not
attend her job for days. The loss of job and financial troubles that she faced which was
evident from her not being able to pay the home rent can easily explain the stress that was
building in her for few days that contributed to symptoms of BPD. Another social concern
that had indeed turned out to be a traumatic event in her life is the break-up and separation
she faced with her present boyfriend. This mainly added to her suffering when her boyfriend
disclosed to her that he would not be able to continue the relationship because he was shifting
to the new city. This had immense impact on her creating high levels of stress in her. Voort et
al. (2016) is of the opinion that many people have a much higher sensitivity towards

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abandonment and that they can experience intense anger, fear, impulsivity, self-harm and
even suicidality in the different relationship events that ultimately make them feel rejected,
abandoned as well as criticised (Rogers & Taylor, 2017). There is high probability that
Shanae had gone through similar feelings when she had a break-up with her partner. These
two traumas can be considered to be contributing factors for her present health condition.
Another important aspect that can be also noted here was that she was not wanting to
remember experiences in her childhood as that would have causes her more suffering, pain
and distress. This implies that she might have gone through certain traumatic events that she
is dreadful of them to discuss. Studies have found that individuals who have felt afraid, upset,
unsupported as well invalidated remain at higher chances of developing BPD (Patel et al.,
2015). In childhood, family difficulties as well as instabilities like living with parents having
addiction also increases the vulnerability of the child to grow with BPD. Other childhood
experiences like sexual, physical as well as emotional abuse and neglect are other
contributing factors for the disorder (Hardoon et al., 2016). Losing a parent in childhood
causes the disorder. Therefore, Shanae might have gone through the traumatic events in the
childhood, which could have contributed, to development of BPD.
Another contributor to the development of BPD is the excessive substance abuse done
by many of the vulnerable individuals. Patel et al. (2015) are of the opinion that people who
abuse drugs and alcohol remain at greater risk for development of BPD. However, it is to be
noted that substance use do not cause the disorder but it can result in making the episodes
worse or might be also seen to be worsening or hastening of the symptoms (Syan et al.,
2017). Even certain medications can also cause onset of different types of manic as well as
depressive episodes. It had been found in case of Shanae, that is addicted to smoking or
tobacco when she tried to force her way through the healthcare professionals to return back
home for smoke. Even the loss of job was because she had abused drugs like that of

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methamphetamine and MDMA when she was out with friends. Therefore, her excessive
levels of addiction and substance abuse might have contributed in making her mental health
conditions of BPD much worse.
Inpatient interventions:
The nursing professionals handling Shanae need to follow an approach that would
make Shanae empowered in ways by which she can develop her life in ways, which are full
of aspirations with no rooms for suffering from the trauma. In order to develop her potential
to feel strong and overcome her present crisis level recovery based approach needs to be
taken. This form of approach acknowledges that every person is expert of his or her own lives
and that recovery includes nurses in working in partnership with the individuals as well as
their caregivers for providing support in ways that make them support to the vulnerable
people. Bauer et al., (2016) are of the opinion that recovery based approach would mainly
aim in enabling people with mental health disorders like BPD to look beyond survival as well
as existence. This is seen to encourage the vulnerable people in moving forward and setting
new goals. This actually helps in supporting the view that affected individuals should not
look back as to what affected them but should move forward to get on with their lives, do
things and thereby develop relationships with them that gives their lives meanings (Morton et
al., 2018). Therefore, nursing professionals need to ensure that they are following the
recovery-based approach to care for Shanae to make her feel empowered and develop
positive outlook towards life and develop meaning for her existence.
It has been seen that Shanae is suffering from multiple traumatic events and
experiences in her life that are contributing to development and occurrence of BPD. Hence,
the nursing professionals attending her should be following the trauma-informed care as well
as practices. Johanson and Bejerholm (2017) state that the trauma-informed practice is

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actually a strength-based framework that is grounded in the understanding of as well as
responsiveness to the impact of the trauma thereby emphasizing on physical, emotional as
well as psychological safety for everyone. This helps in creation of the opportunities for
surviving as well as rebuilding a sense of empowerment and control. Michalak et al. (2016)
are of the opinion that this model of care is informed by the new knowledge around
attachments, development as well as working with that of the body, memory and
understanding of their self (Bernanrdo et al., 2018). The nurse attending Shanae should be
trying to attend five important principles to ensure that she gradually overcome the fear and
stress caused by the events and become empowered to live better quality life. One of the most
important principles is safety. The nurse attending Shane, in order to maintain safety, should
be including developing spaces where Shanae would be feeling culturally, physically as well
as emotionally safe. This principle also guided nurses in helping the patients to develop
awareness about the unease to discomfort about herself or himself (Girlanda et al., 2017).
Another important principle is called the transparency and trustworthiness. The nurse would
be providing full and accurate information to the patient about what is happening and what
would also happen in the next (Granek et al., 2016). The nurse should then follow the
principle of choices for Shanae and this is seen to include the recognition for the need of the
approach that would honour the dignity of the individual. The fourth principle that the nurses
should adopt in her intervention is collaboration as well as mutuality. The nurse would try to
help Shanae recognise that healing happens in the relationships and partnerships with that of
shared shared decision-making. The fifth principle that the nurse should also be following is
the empowerment where they should be trying to help the patient in recognising if the
individual strengths and such strengths are built on and validated.
One of the most important nursing priorities would be to prevent Shanae from self-
injury. She also could not promise that she would be not undertaking any more suicidal

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actions. Studies state that in such situation, the nurses in the ward of the hospital attending the
patient should provide her with structured solitary activities with their assistance. The main
rationale is that structure provides security and focus. The nurse should also provide frequent
rest periods as this helps in preventing exhaustion. The nurse should also provide frequent
high-calorie fluids like fruit shake and milk and this would help in prevention of exhaustion.
The nurse should then try to maintain a low level of stimuli in the client environment like
reduce loud noises as well as bright light and low temperature ventilation. This would help in
minimising escalation as well as anxiety (Jin & McCrone, 2015). Redirection of the violent
behaviour is important as physical exercise can help in decreasing tension and providing
focus. The nurse should be careful in removing away any hazardous objects that can be used
by Shanae when she has suicidal ideations. This would reduce chances of self-harm as well as
attack on others. The nurse should continue to assess behaviour of Shanae for signs of any
types of increased agitation as well as hyperactivity. Studies opine that early detection as well
as intervention for escalation of mania can thereby prevent possibility of harm for self and
others, reducing chances of exclusions (McNamara et al., 2017). The nurse should be also
using a calm and firm approach thereby providing structure and control for Shanae who
might sometimes get out of control. In such situations, nurses should use short, simple and
brief explanations and statements. The rationale is that short attention span limits helps in
understanding by the clients about the small process of information. The nurse should try to
be neutral with patient and never argue. She should maintain a consistent approach thereby
employing consistent expectations and providing structured environment. It has been found
that indeed clear and consistent limits as well as expectations help in minimising potential for
manipulation of staffs by the clients. The nurse should try to redirect agitation as well as
violent behaviours of patients towards physical outlets in the area of low stimulation like
punching bags as this can help in relieving pen-up hostility as well as relieving muscle

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tensions (Medici et al., 2015). One important action that nurse would need to take is making
proper notes and records about what escalates agitation, what helps in calming agitation, the
rime when (PRN) medications were given and their effect and what were seen to be helpful
and many others. This would help nurses to identify recognising potential signals for
escalation of such behaviours and that they would have guidelines for what could prove best
for managing Shanae. She hallucinates about a person named Peter berating her that could
enhance her aggressive behaviours. Such interventions would help in managing her suicidal
ideations and aggression.
Patient named Shanae is seen to have inability in coping with stress and traumas and
that she is also seen to have poor social interaction for which she is not having social
supports. The nurse should observe Shanae every minute to check whether she is suicidal and
remove all dangerous and sharp objects. The nurse should follow the principles of recovery
based approach and trauma care approach. She should assist Shanae is evaluating the positive
as well as negative aspects of her life and thereby encourage the appropriate expressions of
her angry feelings (Hidalgo-Mazzei et al., 2016). The nurse should schedule regular periods
throughout the entire day for recreational as well as occupational therapy and empower the
client in grooming herself and then offer praise for completing grooming. The nurse should
encourage patients in taking mood-stabilising medications and should watch them to
swallow. The nurse should also encourage the patient in engaging in interpersonal therapies,
cognitive-behavioural therapy and others.
The nurse should be also be focussing on drug therapy for development of Shanae. (()
is of the opinion that Lithium carbonate is the common prescribed long term drug that helps
in treatment of chronic episodes of depression an well as mania or hypomania. They should
be having this medication for 6 months. Nurses treating patients like Shanae also consider of
anticonvulsants for the treatment of mania episodes. They should be also considering

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antipsychotics like Aripiprazole, olanzapine, risperidone if patients like Shanae show very
disturbed behaviours and severe symptoms (Hanford et al., 2016).
The nursing professionals if experienced can initiate or collaborate with
psychotherapists can initiate certain therapies that can be continued even after her discharge
from the hospital. One of the type of cognitive behavioural therapy is the dialectical
behavioural therapy. This therapy mainly is a skill-based approach for teaching patients about
ways for managing emotions, tolerating distress and well as improving relationships. They
are found to help in controlling and managing aggressive behaviours and suicidal ideations in
patients. The nurse can also initiate schema-focused therapy. This therapy mainly helps in
identifying the unmet needs of the patients that lead to negative life patterns, which at any
particular time may have been helpful in survival but as adults, they mat be hurtful in specific
areas of life (Bauer et al., 2016). This therapy would help Shanae in focusing on helping
patients meeting their needs in a healthy manner for promoting positive life patterns. Studies
have also talked about the importance of Metallisation-based therapy. This is a form of talk
therapy that help in identification of own thoughts and feelings of the patients at any given
time and help in developing an alternate perspective on the situation. As this therapy helps in
thinking before acting, this would prevent Shanae from taking any drastic steps when suicidal
ideations develop. Another important therapy that can also be adopted is the transference-
focused psychotherapy. This mainly aims in helping the patient in understanding emotions
and different types of interpersonal difficulties through the developing relationship between
the patient and healthcare professional (Syan et al., 2017). These therapies would help Shanae
to overcome symptoms of BPD gradually.

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Plan of referrals:
The nurse and physiotherapists at the hospital attending Shanae should plan a number
of referrals so that she can continue her treatment and care even when she is realised from
hospital. The nurse should refer her to a primary healthcare psychotherapist so that she can
continue her therapies of the hospital are difficult for reaching for the follow-ups. A clinical
social worker would be helpful. She would be providing liaison contact with the patient’s
family and help in convening family meetings. She would be helping in different practical
concerns like getting a license of driver, application to jobs, preparations for job interview
and making proper life transitions from previous life to a newly fulfilling and potentially
successful life. Occupational therapists would be mainly helping Shanae to cope with daily
activities of living. Bernardo et al. (2018) are of the opinion that occupational therapy helps
individuals in overcoming emotional, physical and social disabilities thereby promoting,
maintaining and restoring functional independence in daily living skills. They help patients in
developing, recovering, improving and maintaining skills required for daily activities.
Dieticians help in developing food charts for Shanae, as she is having no appetite for food for
long time for which she might be suffering from lack of nutrients. The dietician would be
helping her to develop a balanced chart of food so that she can develop her health physically.
Even art therapies are found among many literatures that help people with BPD to express
about the thoughts and feelings, which they are finding difficult to express. This therapy
helps in development of something that can act as the way of expressing feelings. Shanae can
attend art therapy, dance movement therapy, music therapy and drama therapy, which falls
into categories of arts therapies (Michalak et al., 2016). An important concept that can be
found to be helpful for Shanae is therapeutic communities preventing her from loneliness and
suicidal ideations. Therapeutic communities are structured environments where people come
together with range of complex psychological conditions and needs for interacting and taking

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part in therapy. They professionals there, help in teaching skills to patients required for
interacting socially with others, empowering them to improve their social skills and self-
confidence through meal preparation, household chores, games and sports and recreational
activities and others. Shanae would be benefitted here.
Conclusion:
Shanae is suffering from borderline personality disorder. Hence, nursing professionals
would first need to identify the trauma and experiences that result in developing the
symptoms. Following this, the nurse should apply interventions following the recovery
oriented approach and trauma-informed approach. Apart from the various nursing
interventions, nurses should administer proper drugs and conduct psychotherapy sessions.
Following this, they should arrange for referrals so that patient can continue getting support
and empower them helping them to develop quality lives.

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