CASE STUDY TWO – 26-year-old BIPOC Female

Posted: January 20th, 2023

Medication Treatment Plan for a 26-Year-Old BIPOC Female with Borderline Personality Disorder and Bipolar Disorder

The patient is a 26-year-old BIPOC female diagnosed with borderline personality disorder (BPD) and bipolar disorder who presents with depression, anxiety, panic attacks, anorexia, a history of self-harm, and four prior psychiatric hospitalizations. She is currently prescribed lamotrigine 200 mg daily and clonazepam 0.5 mg twice daily. Based on her clinical presentation and history, the following medication treatment plan is recommended.

Medication Choice and Rationale
It is recommended to continue the patient’s current medications of lamotrigine and clonazepam at their prescribed doses. Lamotrigine is an anticonvulsant mood stabilizer indicated for maintenance treatment of bipolar I disorder to delay mood episodes (Stahl, 2021). Its mechanism of action involves inhibiting voltage-gated sodium channels and the release of glutamate, an excitatory neurotransmitter (Stahl, 2021). Lamotrigine has demonstrated efficacy in preventing depressive episodes in bipolar disorder, which aligns with this patient’s symptom profile (Yatham et al., 2018).

Clonazepam is a benzodiazepine anxiolytic that enhances GABAergic neurotransmission (Stahl, 2021). It is an appropriate choice for this patient given her comorbid anxiety and panic symptoms. The American Psychiatric Association practice guidelines for the treatment of BPD recommend using clonazepam or lorazepam for acute agitation or anxiety (Keepers et al., 2020).

Other medication options were considered but deemed less suitable for this patient. For example, second-generation antipsychotics like quetiapine are sometimes used off-label for BPD, but carry higher risks of adverse effects like metabolic syndrome (Ripoll, 2018). SSRI antidepressants have limited evidence in BPD and carry risks of inducing manic switch in bipolar disorder (Ripoll, 2018; Stahl, 2021). Lamotrigine’s more favorable side effect profile and specific benefits for bipolar depression make it the preferred mood stabilizer for this patient.

Patient Education
Key patient education points include:
1. Take lamotrigine and clonazepam exactly as prescribed. Do not adjust doses on your own.
2. Common side effects of lamotrigine include dizziness, drowsiness, blurred vision, and headache. Serious rashes can rarely occur. Seek immediate medical attention for any rashes, as they can progress to life-threatening conditions like Stevens-Johnson syndrome.
3. Clonazepam can cause sedation, dizziness, and impaired coordination. Avoid driving or operating machinery until you know how it affects you. Do not stop taking it abruptly, as this can cause seizures or rebound anxiety.
4. Immediately report any worsening of mood symptoms, unusual changes in behavior or thinking, or thoughts of self-harm to your healthcare provider.
5. Regularly attend therapy and all follow-up appointments to monitor your progress and adjust the treatment plan as needed.

Monitoring and Adverse Effect Management
The patient should be seen for a follow-up appointment in 4 weeks to evaluate the tolerability and efficacy of the medication regimen. Assess for common side effects of lamotrigine (dizziness, drowsiness, rash) and clonazepam (sedation, impaired coordination). Order a lamotrigine level if the patient exhibits signs of toxicity (ataxia, nystagmus, diplopia). Monitor for any emergence of manic or psychotic symptoms or increased suicidality. If serious adverse effects or clinical worsening occur, promptly adjust the medication regimen.

No major drug interactions are expected based on the patient’s medication list. However, advise the patient to inform all prescribers of her full medication regimen and report any new over-the-counter or herbal preparations to avoid potential interactions.

Treatment efficacy will be determined by the patient’s symptom improvement and functioning over the next 2-3 months. The goal is to see a clinically significant reduction in mood episodes, self-harm incidents, anxiety, and panic attacks, accompanied by improved eating patterns and psychosocial functioning. If the current regimen proves ineffective after an adequate trial or intolerable due to adverse effects, alternative treatment options include:
– Switching to or augmenting with other mood stabilizers like valproate or lithium
– Cautiously trying an atypical antipsychotic like quetiapine or a second-generation antipsychotic
– Combining with an SSRI antidepressant if depressive symptoms are severe and closely monitoring for manic switch
– Intensive dialectical behavior therapy

Considerations in Pregnancy
Both lamotrigine and clonazepam carry risks when used during pregnancy. Lamotrigine is a Pregnancy Category C drug, with some evidence of increased risk of cleft lip/palate and neurodevelopmental delays (Clark et al., 2019). Clonazepam is a Pregnancy Category D drug; neonatal exposure can cause “floppy baby syndrome” and neonatal benzodiazepine withdrawal (Stahl, 2021).

If this patient becomes pregnant, carefully weigh the risks and benefits of continuing lamotrigine and clonazepam versus switching to lower-risk mood stabilizers like lithium. Ideally, avoid benzodiazepines if possible. Engage the patient in informed decision-making, with close monitoring and coordination with an obstetrician. Consider tapering lamotrigine in the last month of pregnancy to minimize neonatal risks (Clark et al., 2019).

In conclusion, this BIPOC female patient with BPD and bipolar disorder may benefit from continuing lamotrigine and clonazepam based on their efficacy for her depressive and anxiety symptoms and favorable side effect profiles compared to alternative treatments. Close monitoring, patient education, and preparedness to adjust medications are crucial to optimizing outcomes. Special precautions are warranted if pregnancy occurs to minimize fetal and neonatal risks. With a collaborative, evidence-based, and patient-centered treatment approach, symptom remission, improved functioning, and recovery are achievable goals.

References:
Clark, C. T., Wisner, K. L., & Gollan, J. K. (2019). Treatment of peripartum bipolar disorder. Obstetrics and Gynecology Clinics of North America, 46(3), 441-451.

Keepers, G. A., Fochtmann, L. J., Anzia, J. M., Benjamin, S., Lyness, J. M., Mojtabai, R., … & Hong, S. H. (2020). The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. American Journal of Psychiatry, 177(9), 868-872.

Ripoll, L. H. (2018). Psychopharmacologic treatment for borderline personality disorder. Psychiatric Times, 35(11), 28-28.

Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications. Cambridge University Press.

Yatham, L. N., Kennedy, S. H., Parikh, S. V., Schaffer, A., Bond, D. J., Frey, B. N., … & Berk, M. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2), 97-170.
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CASE STUDY TWO – 26-year-old BIPOC Female
The patient is a 26-year-old BIPOC female who has been diagnosed with borderline personality disorder and bipolar disorder, and also experiences depression, anxiety, panic, and anorexia. She has a history of self-harm and four psychiatric hospitalizations, and is currently prescribed lamotrigine and clonazepam. She has a history of emotional abuse by her parents, a parental divorce as a teenager, and a history of anorexia and cutting. She reports difficulty sleeping and nightmares, and has a history of childhood sleep disruption. She is currently in a stable relationship and has a job as a sales representative. She reports fair appetite and weight within low to normal limits, and denies any significant medical or substance use history. She is seeking a new psychiatric provider to prescribe her medications.
CASE STUDY TWO – 26-yr-old female

The patient is a 26-year-old, single, BIPOC female who lives with her boyfriend. She has moved recently and needs a new psychiatric provider to prescribe her medications. She is scheduled to see a new dialectical behavioral therapist in a few days.

Chief Complaint: “Need a new psychiatrist.”

History of Presenting Problem/History of Present Illness:
The patient says that she has been diagnosed with borderline personality disorder and bipolar disorder. Has depression and anxiety, panic and anorexia. While out with her boyfriend in a restaurant, she became upset at comment he made that she now thinks was not inflammatory but at the time she thought it was meant to be hostile toward her. She went to the restroom and used a fork to scratch herself until she broke her skin. Then when she went home, she went to the bathroom again and started cutting her arm with a knife. Shortly after, she told her boyfriend. The wounds have since closed and healed. Now, she thinks there was really no reason for her to react the way she did, but at the time she interpreted his comments as a statement against her.

She is currently prescribed lamotrigine 200 mg daily and clonazepam 0.5 mg Q 12 hours.

Past Psychiatric History: The patient has had four psychiatric hospitalizations. The first hospitalization was when she was 13 years old after taking an overdose. The most recent hospitalization was three years ago. Denies any manic or psychotic symptoms. History of anorexia and cutting.
Medication history includes sertraline, fluoxetine, trazadone, quetiapine, lorazepam, gabapentin, and citalopram.

Substance Use: Only drank occasionally and has not drunk at all for several years. Uses nicotine vape. Denies caffeine.

Trauma/Abuse History: Patient made vague comments about emotional abuse by her parents but was unable to describe any specific traumatic incident. Parental divorce as a teenager.

Medical history: No acute or chronic medical conditions.

Birth/Developmental: Denies in-utero exposure, no complications at birth, met developmental milestones. Childhood sleep disruption-delayed onset, frequent nightmares.

Family History: Biological father-“had a problem with drinking”

Personal/Social History:
The patient was raised by both her parents until they divorced when she was a teen and then lived with her mother and stepfather. Angry at her mother but adores her stepfather. Will talk to him on the phone but not her mother. Her father had a problem with drinking when she was younger and has a good relationship with him now. CASE STUDY TWO – 26-year-old BIPOC Female
Childhood: Normal developmental achievements. Had nightmares on and off as a child. Always had difficulty falling asleep. Overdose at age 13 when parents separated.
Adolescence: Graduated high school.
Adulthood: Went to college off and on and finally graduated in the past year. Has a job as a sales
representative that she enjoys. Currently lives with boyfriend and thinks they have good relationship.

Review of Systems (ROS):

Constitutional:
-Sleep: Reports nightmares and night sweats. Problems with going to sleep and staying asleep. Takes over the counter Diphenhydramine as needed.
-Appetite: fair. Weight is within low to normal limits.”
NEURO: Denies HA’s, seizures, dizziness or syncopal episodes.
CARDIOPULMONARY: Denies CP, palpitations, SOB, cough, wheeze, edema.
GU/Reproductive: Reports regular menses. Uses OCP for birth control. Denies dysuria, frequency, or urgency.
INT: Scarring- superficial self-inflicted cut marks.
Psychiatric: See HPP/HPI above.
All other systems non-contributory.

MENTAL STATUS EXAMINATION

Appearance: Petite, thin, dressed in an attractive outfit. Appeared slightly anxious during the interview but did smile and laugh appropriately.

Behavior and Psychomotor activity: Good eye contact. No unusual movement.

Consciousness: Alert

Orientation: Oriented to person, place, time

Memory: Intact

Concentration and Attention: Within normal limits.

Intellectual Functioning: Average or above.

Speech and Language: Normal rate and volume.

Perception: No abnormalities evident.

Thought Process: Circumstantial but logical and coherent. Says her “mind runs 24/7”.

Thought Content: Within normal limits

Suicidality and Homicidality: Denied. Does report reactivity to stress that triggers self-injurious behavior like cutting

Mood: Feels “steady”

Affect: Appears mildly anxious.

Impulse Control: Good during interview but reports rapid impulse to cut when stressed.

Judgement/Insight/Reliability: Good

Diagnosis:

You agree with the historical diagnosis of borderline personality disorder.

Instructions:
For the patient you chose earlier, write a paper of 2-3 pages (using APA Paper Writing Service by Expert Writers Pro Paper Help: Online Research Essay Helpting and citations) discussing the following seven points based on the diagnosis given:
What medication do you choose? Provide the name, dose, and prescription instructions.
If your patient is NOT currently taking a medication:

What class of medication are you choosing and why?
Why you chose this med and not others. Include the pharmacodynamic action of the medication you are choosing versus the other options.
Include either a research article or evidenced based guideline that supports your decision making and selection process. Give rationale and reference your information.
If your patient is already prescribed a medication:

Do you choose to continue the medication as currently prescribed? Do you make changes to the current dose and/or instructions? Do choose to change the medication?
State your decision and answer the following questions:
(If you choose to change medications, state what medication you choose. Provide the name, dose, and prescription instructions. CASE STUDY TWO – 26-year-old BIPOC Female)

What class of medication are you choosing (whether changing or staying with current med) and why?
Why you chose this medication and not others. Include the pharmacodynamic action of the med you are choosing versus the other options.
Include either a research article or evidenced based guideline that supports your decision making and selection process. Give rationale and reference your information.
List 3-5 instructional points you would include in educating the patient/family.
Need first-class papers? Get Fast Essay Writers US & urgent essay writing service Ca – Note: There are probably many things you could include in your instruction but do not exceed 5 points. Select the most important points relative to this medication and this case. Don’t just copy and paste into this section. Make it meaningful to this patient.
What are the potential side effects and/or adverse drug reactions and how should they be managed? What would you expect (common or nuisance) that your patient might experience, and what are your worst-case scenarios? If these occur, what would you want your patient to do? Are there any monitoring considerations or tests you want to order? (Medication levels, blood tests, EKG, other screenings?)
What are potential drug interactions for THIS patient and what would your education and management be? (Need first-class papers? Get Fast Essay Writers US & urgent essay writing service Ca – Note: This answer may be none.) Don’t just copy and paste drug interactions into this area. What is applicable for this patient? If the answer is none, can you think of potential concerns or what instructions would you provide to them?
How would you monitor the efficacy of this medication? Specifically, when would you expect this medication to work? When would you want to see this patient again? How will you know it is working? Are there lab tests or other information that you would need to gather to see if this medication is efficacious?
What are alternative treatment plans should this option fail? Specifically address what medication, how and when you would use it.
How would this treatment change if the patient was pregnant? Specifically, what risk category risk in pregnancy is this medication? How would you approach this medication with a pregnant patient?
Click on “Add Submission” and upload your paper below. “SAVE”, and then “Submit for grading”
Your Instructor will be using the attached grading rubric. Need first-class papers? Get Fast Essay Writers US & urgent essay writing service Ca – Note the different criteria in rubric before you submit.
NOTE: You will post your paper in the last week Discussion Forum and will be expected to choose one other paper from your same case study topic area to review and comment on. This will be a great time to reach out to see what other possibilities there are for treatment and for you and others to discuss those treatments in a constructive way. Did you or others miss something, which approach might be better, etc. Is there a way you can help others in your cohort about different methods of treatment?
Refer to the Syllabus for point value of this assignment. Your Activity Completion checkbox will be marked when you submit to