An Interesting Case of Personality Disorder

I’m on my psychiatry placement at the moment and the patients are really interesting. I do find psychiatry quite puzzling at times though and feel that making a diagnosis isn’t very clear-cut as there are some features (i.e. psychosis or impulsivity) that could be present in a range of disorders.

Today I observed a consultation in an outpatient clinic where the patient had a previous diagnosis of generalized anxiety disorder. He was feeling very low, was drinking a lot to make himself feel better and felt suicidal at times. He bought his ex partner to the consultation as well who he said (in front of her) that she just couldn’t cope anymore because he was very detached and had mood swings. 

He appeared to be very calm and euthymic (of a normal mood) but at one point he started crying when the psychiatrist said that it’s not normal to want to kill yourself. This was after he very casually disclosed that he took lots of his prescribed venlefaxine and pregabalin in one go, because he just didn’t want to live. He had also self-harmed in the past and there was some sexual abuse by an ‘older lad’ when he was young, which he sometimes thought about.

The psychiatrist told the patient at the end of the consultation that he did not agree with the diagnosis and was going to change it to an emotionally unstable personality disorder. When I asked why that was the case, he said it was very clear from the way he acted that he could not regulate his emotions well. He was very impulsive – one minute crying and the next moment laughing and being completely fine.

To me, the diagnosis did not seem clear at all, as much as it may have been to the psychiatrist. In my mind, I thought could he be depressed but was trying hard to mask it? He didn’t look depressed at all. He looked very healthy and he had a good job. He had had many short-lived relationships that didn’t work out. But surely these things are normal right?

There were many abnormal things he mentioned as well – such as the excessive drinking, the self-harming, the overdosing, the mood-swings and the sexual abuse. And whilst the patient was saying all of this, he didn’t display any emotion on his face. He even said at one point that he didnt feel himself and sometimes feels separate to himself which is known as depersonalization.

Personality disorders baffle me. When I look at the different types of personalities, it makes me think, surely it is normal for people to have dysfunctional aspects of their personality right? No-one is perfect. I am sensitive to criticism, I can be quite self-conscious and doubt myself. I can be quite distrustful of others too. Would that mean that I have a personality disorder?

I would like to think that I have some good relationships in my life though and I do Alhamdulillah. There are some friends that I have who I have known for years. Yes, we might not talk all the time and we all have our very own separate lives and sometimes we go ages without meeting up or talking, but I know that I value them and I know that I am valued by them.

The patients I have been seeing recently – I try to identify with them and feel as if I am in their shoes but sometimes I think I identify with them too much and it makes me feel sad that that patient could easily be me, due to my own troubles and past experiences.

However, I need to keep aware of the bigger picture and remind myself that I am not a self-harmer, nor have I ever taken drugs/alcohol (or want to), nor do I take out my anger on the people around me and most importantly, I wasn’t physically or sexually abused when I was younger. 

So there is more evidence to cancel out me having a personality disorder than there is Alhamdulillah.

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