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The patient is a 26-year-old, single white female who lives with her girlfriend. She moved recently and needs a new psychiatric provider to prescribe medications.  She is scheduled to see a new DBT therapist in a few days.  She has been diagnosed with borderline personality disorder and has depression and anxiety, panic and anorexia.  While out with her girlfriend in a restaurant she became upset with a comment her girlfriend made and went to the bathroom and scratched her arm.  Back at home she again started cutting her arm. 

PSYCHIATRIC HISTORY:

She has had four psychiatric hospitalizations.  The first at 13 after taking an overdose.  The most recent 3 years ago.  She denies any manic or psychotic symptoms.  She has a history of anorexia and cutting.  Medication history includes sertraline, fluoxetine, trazodone, quetiapine, lorazepam, gabapentin, and citalopram.  She is currently prescribed lamotrigine 200mg daily and clonazepam 0.5 mg Q 12 hours. 

MEDICAL HISTORY:

No acute or chronic medical conditions.  Reports problems with going to sleep and staying asleep.  Takes over the counter diphenhydramine as needed for sleep.  Appetite fair, weight within normal limits.  Reports regular menses. 

 

1  Which diagnosis (or diagnoses) should be considered? Include rationale for each.

 

2 What else would you want to know about this patient?

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