Introduction
Childhood sexual abuse is an increasing problem in modern society, and the victims of it often develop various mental and physical health issues later in life. Any childhood maltreatment was found to be a significant risk factor for the early onset of various psychiatric diseases and resistance to treatment (Thomas et al., 2019). Examples of long-term complications include anxiety, depression, sex work, sleep disturbance, schizophrenia, eating disorder, self-injurious behavior, suicidal attempts, somatoform disorders, and substance abuse (Almuneef, 2021; Hailes et al., 2019).
In the presented case, the teenage girl named Alice was continuously raped by her stepbrother, which later resulted in her becoming depressed and anxious as well as having behavioral and substance use issues. Since abuse affected her attachment model, the girl could not imagine spending time alone; thus, she started skipping classes, engaging in random sexual relationships, and using illicit drugs. Her promiscuous behavior and substance use not only affected her academic performance but also caused the appearance of other psychiatric problems. Although Alice was hospitalized several times, pharmacotherapy does not seem to help her; therefore, it may be helpful to implement mentalization-based therapy (MBT) and peer support.
Formulation
In the presented case, the patient’s diagnoses included brief psychotic disorder, atypical anxiety disorder, major depression, adjustment disorder, substance use disorder, and borderline personality disorder (BPD). The latter is characterized by suicidality, self-harming behavior, impulsivity, affective dysregulation, and functional impairment (Videler et al., 2019). The diagnosis is established if these symptoms were present in a person above age 18 for at least one year (Videler et al., 2019).
This patient’s psychotic symptoms, including the fact of feeling that her body is unreal, hallucinations, delusions, and erotomania, are not uncommon. In fact, according to Chanen et al. (2020), “psychotic symptoms in BPD are restricted to transient, stress-related paranoid ideation or severe dissociative symptoms” (p. 24). In terms of major depressive disorder, Alice does not seem to have fatigue, psychomotor agitation, or weight fluctuations, but she reported feelings of worthlessness, poor decision-making capacity, and suicidal ideation. Depression and anxiety, which often co-occur, are not unusual consequences of childhood sexual abuse or neglect (De Bellis et al., 2019; Kalin, 2020). The main problem appears to be that this patient’s mental health issues are resistant to pharmacologic intervention because her symptoms do not improve.
Alice developed a drug addiction in addition to her personality and mood disorder caused by sexual abuse. Since the adolescent brain only undergoes a maturation process, it is more susceptible to the development of addictive behavior. The latter, in the case of various mind-altering substances, impairs memory, attention, concentration, and cognitive flexibility (Kulak & Griswold, 2019). Research shows that those who have an insecure attachment style are more likely to develop substance use disorder (Ensink et al., 2019; Schindler, 2019). Alice, being sexually abused during childhood and early teenage years, appears to have this model of attachment and thus possibly engaged in street drug use. People under severe emotional stress view any addictive substances as a quick relief of their mental health issues, which is an apparently false perception (Schindler, 2019).
The problems and negative consequences of drug addiction are immeasurable because it leads to poor educational outcomes, unemployment, violence, and possibly other forms of criminal behavior (Ignaszewski, 2021). This patient was under substantial pressure at home; hence, she viewed drugs offered by her circle as the decision to resolve her problems or eradicate complex feelings she had.
Another problem this patient had was adjustment disorder (AD), which was clinically presented by self-injurious acts like cutting her wrists. AD is characterized as having depressive or anxious symptoms after being exposed to a stressful situation or event (Fegan & Doherty, 2019). Alice was repeatedly abused sexually by her stepbrother and did not develop trusting relationships with her stepfather or even her mother. Being raped as a child may often result in post-traumatic stress disorder, but occasionally individuals adjust through substance use and self-destructive thoughts or behavior (Ensink et al., 2019; Fegan & Doherty, 2019).
This diagnosis is only established at least six months after removing the stressing factor (Fegan & Doherty, 2019). It is not surprising that Alice has both AD and depression, considering the overlapping criteria that these disorders require for establishing the diagnosis. Regardless of the number of mental health issues this patient has, the best therapeutic approach will be to alter the girl’s mindset to change her behavior. It is crucial to do because some of her psychiatric symptoms were discovered to be resistant to pharmacologic treatment.
Clinical Inferences
The presented case is complex considering the number of mental health issues this patient has, but it was caused by one stressful but repeated event, which is sexual abuse. Since the girl did not share this problem with her mother or other people to receive timely intervention, she developed both mood disorder, conduct problems, and addiction. Furthermore, Alice had brief psychotic episodes, probably multiple times, since she often used illicit drugs, even during hospitalization. However, in this case, the primary diagnosis is a borderline personality disorder characterized by impulsivity, which in turn leads to substance abuse. Notably, substance use disorder was found to be strongly associated with impulsive behavior (Kozak et al., 2019). According to Kozak et al. (2019), four types of impulsivity are known: no perseverance, lack of medication, urgency, and seeking sensation. The latter seems to drive Alice’s decisions regarding her promiscuity and drug. On the one hand, she cannot resist the desire to have sexual interaction; on the other hand, the girl tries to forget her trauma. She successfully attains her goal but only briefly while the drug affects the neurocircuit.
The patient has sensations of derealization that make her continue her self-injurious behavior to ensure that her body is real. Still, in BPD, patients mainly have pseudo-hallucinations that were caused by a situational crisis and were likely exacerbated by substance use (D’Agostino et al., 2019). It should be differentiated from real hallucinations present in schizophrenia since, in this case, the problem is permanent and usually cannot be linked to one specific inciting event (D’Agostino et al., 2019). Additionally, delusional ideation is often associated with BPD, but again despite being paranoid, such thoughts are usually not disconnected from reality, unlike in psychotic disorders (D’Agostino et al., 2019). Indeed, Alice’s derealization feelings appeared due to sexual abuse, and her delusional thoughts were about being romantically attached to one of the patients she spent some time together.
Intervention Plan
Since pharmacologic therapy did not resolve the issues Alice has, it is better to implement MBT as well as peer support to at least help improve her conduct and assist in quitting her drug dependence. MBT and peer support may help resolve some other issues of this girl, including depression and anxiety. Indeed, the cohort study by Scardera et al. (2020) revealed that there is a statistically significant association between social support and a lower number of anxious, depressive, and suicidal behavior. Peer support was found to be effective in improving conduct and affect in BPD. Regarding the girl’s substance use, a more complex approach may be required. Specifically, drug abuse is usually treated using initially pharmacologic and then behavioral and neuropsychologic intervention (Kozak et al., 2018).
Depression and anxiety may require individual cognitive-behavioral therapy (CBT) as well as the involvement of family in the case of children and teenagers (Bear et al., 2020). Overall, the treatment plan for this patient is MBT, CBT, family therapy, and connection with peers or other individuals who successfully overcame similar mental health problems.
Justification of Chosen Intervention
MBT is known to be the most effective approach for BPD and may be effective for this girl’s drug addiction considering the neuropsychologic approach of this methodology. In fact, MBT is based on neurobiology, attachment theory, and psychodynamics (Beck et al., 2020). The mentalization component of MBT “is defined as a developmentally-acquired capacity to understand and interpret one’s own and others’ behavior as an expression of mental states” (Beck et al., 2020, p. 595). MBT is helpful for BPD because it can help one regain control of her responses and conduct in response to senses or events (Beck et al., 2020). Therefore, MBT may not only improve Alice’s behavior but can also treat her substance addiction. It may be effective to treat the latter since substance use, in this situation, is caused by impulsive thoughts and unstable affect both due to experienced childhood trauma and adolescent age (Videler et al., 2019). With this approach, the girl will be able to respond, analyze, interpret, and respond to impulsive thoughts that make her intake illicit drugs and injure herself.
Pharmacologic therapy may not be excluded entirely, but it should be minimized gradually since sudden withdrawal may lead to adverse outcomes. The likely reason why this case is resistant to treatment with antipsychotics and mood stabilizers is that many psychiatric conditions caused by childhood abuse are resistant to such interventions (Thomas et al., 2019). Antidepressants and mood stabilizers were ineffective if BPD and antipsychotics only mildly improved symptoms of unstable affect and dissociation (Stoffers-Winterling et al., 2020). Notably, using only medications alone not only had no significant positive impact on BPD patients but also increased suicide rates among these individuals (Stoffers-Winterling et al., 2020). According to Iqbal et al. (2019), when such mood disorders as anxiety and depression co-exist with substance abuse, they are more challenging to treat than when present alone. Therefore, MBT, CBT, and peer support are preferable to pharmacologic approaches because the latter may or may not produce temporary symptomatic relief.
Goals
Apart from symptomatic relief, the therapeutic goal for Alice is to make sure she improves her behavior, becomes more flexible for future education and employment, and eradicates her substance addiction. Another essential aim of the chosen treatment approach is to ensure that the patient’s anxiety and depression improve. Furthermore, it is critical to attain the point when she terminates her attempts to injure herself or talk about committing suicide. BPD should be treated in this girl because otherwise, she will not be able to complete her education, find a job, or build healthy relationships.
The whole recovery process may be challenging both for the patient and one’s family; thus, adequate peer support should be provided throughout the entire therapy. In fact, research shows that significant improvement in the outcomes can be attained with additional help (Barr et al., 2020). Moreover, CBT should be used in addition to Alice’s mood disorders because she will not be able to perform well in any area of her life. Considering the traumatic feature of this patient’s past experience that caused various mental health issues, individual MBT and CBT will be better than group therapy. Still, it is essential not to withdraw peer support, which should also be personalized to match Alice with one of the patients with a similar journey but already in remission.
Conclusion and Prognosis
The outcome of the selected treatment approach depends on different external and internal factors. The primary determinant of this therapy is adherence and commitment to every session with the mental health worker. Unfortunately, since Alice is still an adolescent and her brain is undergoing maturation, it will take some time for her to become more mindful and develop a stable mood, affect, and conduct. In this case, the main complicating and causative variable is that the girl was sexually abused since childhood by her stepbrother. The patient was diagnosed with brief psychosis, depression, anxiety, substance use disorder, and borderline personality disorder. Since her symptoms were found to be resistant to pharmacologic intervention, it is recommended to initiate mentalization-based therapy and peer support to treat BPD and drug abuse and a cognitive-behavioral approach for her mood disturbances.
References
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