Imagine that you are an intake clinician in a community mental health clinic and it is your job to assess individuals who come in who want mental health treatment, come up with a preliminary diagnosis, and recommend a treatment. One day you are assigned to assess a particular case:
The woman, Jocelyn, is a 24-year-old Hispanic woman who identifies as upper-middle class. Jocelyn reports not wanting to be here, but only came because her mother said she would get help or she would be kicked out of the house. While Jocelyn reports that she has not been feeling the best lately, she is ‘managing.’ However, her mother, who called the clinic to set up this appointment had already told you that Jocelyn has been incredibly aggressive lately, screaming at her and her other family members, destroying property such as flowerpots and pictures, and slamming doors. Her mother told you before you met that she has seen scars on her daughter’s wrists, and she suspects Jocelyn to be engaging in self-harm.
When you first speak with Jocelyn, she seems closed off and untrusting. However, as you get her to open up, she becomes much more talkative, and throughout the interview, becoming tearful at one moment, and laughing the next. When asked about her mother’s observations, she admits that she has been engaging in those behaviors, but only because ‘no one understands me.’ She admits to engaging in self-harm off and on, saying that she began when she was 18, but only engages in it as a way to ‘relieve my mental pain’ and only when she feels really down. She has often thought about suicide when she feels down and has fantasized about killing herself as a way to ‘get back at those who have been cruel to her but have never attempted it.
She reports periods throughout her life of being incredibly happy and elated, and other moments when she feels absolutely crushed and defeated. She says that she feels most happy when she is in a romantic relationship, but that because her relationships fluctuate so much she has difficulty keeping romantic partners and that they often end with disaster, leading to a downward spiral for her. She has reported having around 10 romantic partners since she was 16.
When asked why she has been struggling lately, she reports that her boyfriend of almost a year just broke up with her and that a week later, her older sister announced her engagement with her long-term boyfriend. Jocelyn said it was just ‘too much for her to bear, and she feel that she will be alone forever and no one will love her. She feels betrayed by her sister and that her family views her as a source of shame. She had been acting out because she thinks this is the only way to get them to notice the pain she is in.
What diagnosis do you think is most likely (specifically from the DSM-5)? What level of severity do you think it is? Why? What other information do you need to be more confident in this diagnosis? What other diagnoses would you want to rule out before settling on the most likely diagnosis? What kind of treatment would you recommend to treat this person? Why?
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