Alex is a 28-year-old male who presented to the emergency room in high distress. You have been consulted by psychiatry for a psychological assessment and diagnostic clarification.

Alex is currently employed as an administrative assistant and works part time. He has an extensive history of mental health diagnoses including major depressive disorder, generalized anxiety disorder, panic disorder, and bipolar II has been queried. He describes significant challenges with emotion regulation throughout his life. At times, he can feel intensely irritable, sad, or anxious with no apparent cause or trigger for these moods. He reported that he stays in these moods for a number of days before feeling relief.

In a chart review, Alex has presented to the emergency room over 20 times in the last five years in crisis. He has engaged in self-harm and been admitted four times for suicidal ideation. Alex has never made a formal attempt to end his life, but he has a detailed plan and reports no reason to live. He also has a significant history of substance abuse including cocaine, cannabis, and alcohol use that frequently co-occur. Alex has been reported to drive under the influence of substance and has subsequently lost his license.

When asked about his history, Alex shared that he grew up in foster care and has no biological family. He reported that throughout childhood and into his teen years he had very few close friendships. He shared that he struggles significantly with forming and maintaining close relationships. He often fears that others will leave him which in turn leads him to behave in ways that cause these relationships to end. Once he feels that he may be losing someone, he will do everything in his power to prevent them from ending their relationship. Alex reports he will text and call his friends and if they don't respond within a certain timeframe, he will show up at their house. When speaking to you about this, Alex shared that he is totally alone in this world and has nobody that is there for him.

Alex reported that he feels totally hopeless and has no reason to live. He described feeling that he has no purpose in life and has nothing to look forward to. He reported feeling sad and that he no longer enjoys any activities. He has a lot of difficulty falling and staying asleep and has difficulty concentrating at work.

Alex reported that his mother passed away from breast cancer when he was very young and there is a family history of alcohol addiction. He does not know his father. With no extended family, Alex was put into the foster care system following his mother's death. He currently takes no medications.

CASE SUMMARY

Provide information and empirical evidence to assist in making diagnostic, etiological, and treatment decisions

• What symptoms is the patient currently exhibiting and what diagnostic symptom clusters do these belong to?
• What is the most accurate DSM V diagnosis for these symptoms? What led you to rule out other possible diagnoses? Borderline personality disorder
• What information (if any) is still needed to strengthen the diagnosis? How will you obtain this information?
• What factors may have contributed to the onset/etiology of the disorder?
• What current factors might be maintaining the disorder?

TREATMENT PLAN

• What are your treatment recommendations and why? Dialectical behaviour therapy and meds
• Given the diagnosis, what is the scientific evidence supporting this treatment recommendation?
• If there have been previous unsuccessful treatments, how will your plan differ?
• Are there factors that might stand in the way of treatment success? If so, how will you get around them?
• Are there other individuals (e.g. family members, outside health care professionals) who will have to be incorporated into the treatment plan?
• How will you judge the success or failure of your treatment approach?

CASE CONCEPTUALIZATION

• Based on the case details, provide a plausible, theory-based hypothesis for the etiology and maintenance of the symptoms ("case conceptualization"). What scientific evidence supports this hypothesis?
• How does this case conceptualization lead to your treatment plan?
• What future evidence would support or disprove your case conceptualization?