Case Study 1: Borderline Personality Disorder: Toni Abbott Part 1Toni Abbott is an 18 year old woman who lives at home with her mother and step-father. Toni recently surprised everyone by completing her Year 12 schooling - just. She is now enrolled in her first semester at the Canberra Institute of Technology (CIT), where she is studying a Certificate III in Childcare.Toni’s parents split up when she was 3yrs old, and she hasn't seen her father since. Hermother remarried, and she has two younger step sisters aged 13yrs and 11yrs. Toni has been healthy all her life, with no long term medical problems. She broke her arm during a scrag fight when she was in Yr 10, but that has been her only trip to hospital. She is tall and thin, with a body mass index of about 20. Her mother and sisters have no health problems, but her step-father has a dodgy back after a motorbike accident six years ago.Casey is Toni's partner, and is also aged 18 yrs. The pair met in Year 9 at Lake Serenity High School. They have had an on-again off again relationship ever since. Other than Casey, Toni doesn't really have any friends. Casey lives close by, and spends much time at Toni's place.Finances are quite tight in the Abbott household. Toni's mother is the manager of the nearby Diamonds Jewellery Store, and her step-father is a casual afternoon truck driver with ‘Post it Australia’. They have a mortgage on their home, but despite the tight finances they manage to pay for private health insurance. Toni is not eligible to receive a government benefit as her parents earn over the maximum income for her to receive a NewStart Allowance. This is irritating to Toni, who subsequently expects her family to financially support her until she gets a job. Toni earns $75 per week from her mother, in lieu of caring for her sisters each school afternoon.For some years now, Toni has been self harming by cutting her wrists with a razor. She cannot quite recall when this started, but probably it was some time after she refused to go to Toowoomba for the school holidays when she was in Yr 8. Toni had spent many school holidays in Queensland with her maternal grandparents, and it was something that she had previously enjoyed. However, her younger sisters still go there for school holidays.The cutting was fairly minor and well hidden, until about twelve months or so ago, when Toni became the victim of cyber-bullying. Like most teenagers, Toni has a facebook account that she accesses on a daily basis via her iPhone Facebook app. A very small number of previous school peers were always writing horrid things about Toni, and sometimes Casey as well. Toni describes this information as “nasty and bitchy”, and she also admits that she finds negative facebook comments incredibly difficult to manage. To overcome this, Toni has started connecting with a few of her CIT peers on social media.边缘性人格障碍 (Borderline personality disorder，简称BPD)。

Unfortunately, after some lively discussion in the CIT classroom about the pros and cons of smacking children, Toni wrote on her Facebook page about her classmates – who were all morons in her opinion. This posting resulted in some of her classmates retaliating and making derogatory comments about her. Toni was livid when she read the postings, and impulsively, she deeply cut her wrist with a razor.The attending RN sutured and steri-stripped Toni’s wrist and referred her back to her GP forfollow-up. Toni promised that she would attend her GP within the week, but that wasmonths ago and she still hasn’t bothered to make an appointment. Tonight, Casey has driven Toni to the hospital after they had a row about whether to watch the Socceroo’s o r the State of Origin match, and Toni slashed her thighs with a razor when she didn’t get her own way. Toni did not want to go to hospital, but Casey insisted, because Toni had never cut her thighs before.You are on duty in ED when Toni and Casey arrive.Questions:1. How would you summarise the issues for Toni?2. What mental health symptoms does Toni present with?3. What personality issues does Toni present with?4. What provisional diagnosis could apply in this situation?5. What are your recommendations for a supportive plan for Toni?6. What are the benefits of having private health insurance in this scenario?Part 2On occasion, when she knows she won't be caught, Toni steals money from her mother's wallet. She is very cautious about doing this, because the one time her step-father caught her in the act, he punished her by hitting her with his belt. When money goes missing now, Toni is aware her parents argue about which child it might be. If asked, Toni always blames her youngest sister. The two younger girls don’t spend much time with Toni. Even when she is looking after them in the afternoons, they do n’t engage much. Toni calls then horrible names and is always hurting them – playfully of course, but for some reason they always end up hurt.Toni's parents argue incessantly about money, and Toni copes with their squabbling by drinking large amounts of alcohol. While Toni is intoxicated, she verbally abuses her younger sisters, who inevitably end up in tears, stating they hate Toni and they wish she would go away. In fact, her accommodation at home is under threat due to her poor behaviour toward her family members. Toni’s mother is at a loss how to manage this situation, and her step-father just wants Toni to move out. There is much conflict in the Abbott household.Toni has not spoken to Casey for six days following the hospital episode. Toni did not want to go to hospital, but Casey took her anyway. The morning after they’d been to the hospital, Toni sent Casey a text saying “you’re dumped”, and Casey has not made contact since. In their last two break-ups, Casey has begged Toni to get back together, but that has not happened this time. Instead, Casey is nowhere to be seen. Toni sends Casey a text saying “I am going to really hurt myself if you don’t get here quickly. I need you”. Casey does not reply, and feeling abandoned, Toni starts drinking alcohol earlier than usual.Unexpectedly, Toni’s step-father arrives home early. Due to a restructure within ‘Post it Australia’, he has lost his job. He loses his temper when he finds Toni drinking when she is supposed to be looking after her sisters. He screams at her that she is to pack her bags, get out and never come back. Toni screams back that he is an asshole of a father, she hates his guts, and she wishes he was dead. She picks up her glass and throws it at her step-father, narrowly missing him and one of her sisters. Then she hurls the rum bottle at the wall as well.When the police arrive, Toni is sitting against the lounge-room wall with a large piece of glass in her hand, threatening self harm. The police officers call the Mental Health Crisis & Assessment Treatment Team (CATT), who attend the house and speak with Toni. Toni is hysterical and crying, saying that she would be better off dead, and that her partner left her and her parents don’t love her. She is in no position to guarantee her personal safety, and so the two CATT clinicians negotiate with Toni to attend the hospital for a mental health assessment.Questions:1. How would you summarise the issues for Toni?2. What information would you request from the family in this situation?3. What are the immediate risk issues that need addressing?4. What are perpetuating issues in this situation that require addressing?5. What is the best method to conduct an alcohol consumption assessment?6. What are your recommendations for a supportive plan for Toni?Part 3After an initial assessment in ED, Toni spends the night in the acute mental health facility. The following morning, she meets some wonderful people in the unit, including a nice man called Quentin, with whom she spends lots of time. Toni also feels welcomed and supported by the other consumers, and decides she is really enjoying her admission to hospital. The Psychiatric Registrar comes to assess Toni and says that she can go home, gives her the crisis team phone number and refers her to the local community mental health team. Toni does not want to go home just yet, and she asks one of the nurses if she can stay for several days. The nurse explains that this is not possible, and when Toni’s mother arrives to pick her up, Toni unhappily leaves the facility.On the way home, Toni sends Casey a text saying that she wants to get back together and that her life isn’t worth living without Casey being in it. Again, Casey does not reply. Things at home are settled for several days, Toni occasionally attends CIT, but mostly she thinks about Casey.The next week, Toni attends the community mental health centre and meets the intake officer. When asked about the main concerns in her life, Toni relays that since she broke up with Casey, she is a bit lonely, and she doesn't have any other friends. She doesn't mind not having any friends, because most people her age are idiots anyway. But she does often feel like hurting herself, and when she does cut her wrists, she sees blood and feels pain and this makes her know she is alive. She always feels much better after a self-harm episode.She has been finding her CIT course very hard, and her attendance has declined. She thinks she did "ok" in the test she just had, but overall, s he hasn’t been able to concentrate on the work, and doesn’t like most of her classmates. Toni describes her classmates as “too nice and too plastic”– just like a stupid Barbie doll.Toni tells the intake officer that home life is totally crap: she feels she gets blamed for everything and anything that goes wrong, and even gets blamed when her sisters are in trouble. She talked a little about her grandfather, and how he blamed her for the things that happened between them, and why she doesn't want anything to do with him.Ideally she would like to move out and live independently, but her mother and step-father won’t support her financially to do this. She is not sure what sort of job she might eventually do. The intake officer tells Toni that within the next few days she will be contacted by a case manager, who will help sort these issues out with her.Toni catches a bus home. She wishes she had a car. Casey has a car, but Toni doesn’t. She lies awake that night ruminating about Casey’s car. She gets out of bed, gets dressed and starts walking toward Casey’s house, only three streets away. Casey’s car is parked out on the street, and it is easy for Toni to let down all four tires, without anyone noticing. She walks back home feeling quite smug with herself, and falls into a deep sleep.The next morning, Toni gets her first exam result via text. She has failed. This news instantly pushes her over the edge and she feels suicidal. She sends Casey a text message saying that she is going to kill herself unless they get back together. Casey does not reply within two minutes, and so Toni swallows eight Panadol tablets. She then rings the crisis line phone number, and you answer the phone...Questions:1. What is your immediate reaction to this situation?2. What are the legal / ethical issues that need addressing in this scenario?3. How would you summarise this situation to handover to your peers?4. What education does Toni require?5. What other interventions do you consider is necessary at this stage?Part 4Toni is assessed and medically treated in ED, and then transferred to the acute mental health facility. As she is entering the unit, she recognises some consumers and greets them like long lost friends. She is soon the centre of attention in the dining room: charming and entertaining to all those present.Toni gets a message from the nursing staff that her new case manager is already on the way in to see her. Toni is pleased to have such a quick response to her troubles. She is rather unimpressed however, when she meets her case manager for the first time. She hates him on sight. He is too tall and far too old to be involved with her care. She causes a scene, making loud and rude comments that she cannot possibly have someone twice her age as her case manager, and she demands to be seen by a female worker. The male case manager stands to leave, and informs Toni that he will go back to the office and see if a female health professional is available to replace him.Toni wanders into the dining room where people have gathered, waiting for lunch to arrive. She hasn't a clue what the meal will be, but she feels like savoury pancakes. When the meal trolley arrives and the spare lamb casserole is given to her for lunch, she goes ballistic. Toni is a vegetarian and prides herself on maintaining her 60kg weight. She refuses the hospital meal, telling the staff that s he “isn't eating that crap” because if she does, she'll end up looking fat and ugly like them!. She demands that they bring her something more suitable.The RN in charge of the shift attempts to speak to Toni about the meal issue. Toni dismisses her and says she is going home. She tells them to ring her a taxi. The taxi arrives to collect Toni and the driver notices that she doesn't have a bag or wallet. He asks her if she has any money to pay for the fare. Toni tells him that she doesn't, but her mum will pay when they get to her place. The driver refuses to take her anywhere unless she has money. Toni is so annoyed that she starts to kick in the passenger door, all the while screaming racial abuse at the driver.The staff approach Toni after hearing a kerfuffle. The driver says he is calling the police. Toni is yelling and screaming saying she can't possibly stay here, and she needs to go home. The staff physically return Toni to the ward, and discuss what to do next.Questions:1. How would you summarise the issues for Toni?2. What mental health symptoms does Toni present with?3. What personality traits does Toni present with?4. What provisional diagnosis could apply in this situation?5. What are your treatment recommendations for your provisional diagnosis?6. What are your thoughts on whether consumers can dictate the gender of the health care professional allocated to their care? Is it reasonable for a nurse to be restricted from providing care on the basis that a consumer doesn't like them- even when they provide safe nursing care which is free from discrimination? What rights does the health care worker have to be treated in a fair and reasonable way- free from discrimination? Discuss the legal, ethical and professional considerations of this issue- for both the consumer and the health care professional.。