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Psychiatric History of Borderline Personality Disorder

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Psychiatric History of Borderline Personality Disorder
PSYCHIATRIC HISTORY
Cognitive impairments: None reported
Psychotic Symptoms: None reported
Dissociative problems: Pt is observed with bruising on her wrists, in which pt claims she has no bones in her wrist
Irrational anxiety
Unusual fears: Pt reports fear of
Repetitive thoughts or actions
Paranoia
Avoidance
Increased arousal
Hyper vigilance
Flashbacks: Pt reports having flashbacks of her attempted suicide, although pt denies taking a bottle of aspirin with Vodka
Mood problems/changes: Pt reports highly reactive and intense moods
Sleeping problems: None reporte
Eating Problems: None reported
Problems with Impulse control
Physical complaints about illness or pain: Pt reports her overriding emotion is exhaustion
Adjustment problems—in the last 3 months have you been worried or upset about something that happened to you? Like a death, loss, separation from a job, friend, divorce, an accident, serious illness, or something like that?
Identify symptoms
Duration
Assess severity
Assess social interference
Assess associated symptoms
SEXUAL HISTORY
Sexual problems/complaints: Pt reports having sexual intercourse with her high school teacher who was married
Religious/spiritual issues: None Reported
Cultural/diversity issues: None Reported
SUBSTANCE ABUSE HISTORY (Past/Present)
Alcohol
Drugs: Alcohol
Tobacco: Cigarettes
Caffeine: Coffee, Soda
ABUSE HISTORY
Sexual: None reported
Physical: Pt reports physical abuse by mother
Emotional: Pt reports emotional abuse by mother and father
Rape Trauma: None reported
Domestic Violence: None reported
EATING DISORDERS
Anorexia Nervosa: Have you ever deliberately lost so much weight on a diet that people started to seriously worry about your health?
Bulimia nervosa: Did you ever have a problem with binge eating, when you would eat so much food so fast that it made you feel sick?
When you were doing this did you feel you’re eating binges were not really normal?
Was the urge to binge sometimes so
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