Psychiatry · Year 2 · from Psychiatry
Case 1: Borderline Personality Disorder
Patient Presentation
Demographics: 24-year-old female
Chief Complaint: "I can't handle it anymore. I cut myself again."
History of Present Illness: A 24-year-old woman presents to the emergency department after her boyfriend discovered superficial lacerations on her forearms. She reports cutting herself with a razor 2 hours ago after an argument with her boyfriend about him spending time with friends. She describes feeling "abandoned and empty" when he left the apartment, followed by escalating emotional pain that felt "unbearable." Cutting brought immediate relief: "It's the only thing that stops the pain inside." She denies suicidal intent: "I don't want to die, I just needed the pain to stop." She reports this has happened approximately 20 times over the past 5 years. She has a pattern of intense, unstable relationships, describing her boyfriend as "perfect" one moment and "the worst person ever" when she perceives rejection. She has chronic feelings of emptiness, makes impulsive decisions (spent her rent money on online shopping during distress), and has rapidly shifting moods. She has been hospitalized twice for similar presentations. Between crises, she works as a barista but has had difficulty maintaining friendships. She has tried multiple medications (SSRIs, mood stabilizers) with minimal benefit.
Physical Examination:
- Vital signs: Stable
- Skin: Multiple superficial, parallel lacerations on bilateral forearms (some fresh, some healed scars); no wounds requiring sutures
- Exam otherwise unremarkable
Mental Status Examination:
- Appearance: Age-appropriate, tearful, multiple healed scars visible
- Behavior: Alternately tearful and calm; engaged with staff
- Mood: "Empty, miserable"
- Affect: Labile, rapidly shifting from tears to calm to angry when discussing boyfriend
- Thought content: No suicidal intent ("I want to feel better, not die"), distress about relationship; pattern of idealization/devaluation evident when discussing boyfriend
- Insight: Partial - recognizes cutting is problematic but struggles to find alternatives
- Judgment: Impaired during emotional crises
Workup:
- PHQ-9: Score 14 (moderate depressive symptoms)
- **No medical workup needed for superficial self-injury without suicidal intent
Diagnosis: Borderline Personality Disorder
Treatment:
- Safety assessment confirmed: Self-harm without suicidal intent
- Wound care provided
- Brief crisis intervention focused on validation and distress tolerance
- Discussed the self-harm cycle: emotional pain → cutting → temporary relief → shame/guilt → emotional pain
- Safety plan developed collaboratively: warning signs, coping strategies, contacts, reasons for living
- NOT admitted - hospitalization for non-suicidal self-injury can reinforce the behavior
- Referral to Dialectical Behavior Therapy (DBT) program - first-line treatment for BPD
- Individual therapy
- Skills group (distress tolerance, emotion regulation, interpersonal effectiveness, mindfulness)
- Phone coaching for between-session crises
- Current sertraline continued at 100 mg for depressive symptoms
- Follow-up in 1 week, then begin DBT
- At 6-month follow-up after DBT completion: Self-harm episodes reduced from monthly to one incident in 6 months; improved ability to tolerate distress
Clinical Pearl: Borderline personality disorder features a pervasive pattern of instability in relationships (idealization/devaluation), self-image, and affect, along with marked impulsivity. Non-suicidal self-injury is common and serves to regulate overwhelming emotions rather than end life - distinguishing this from suicidal behavior is critical for management. DBT is the first-line treatment with the strongest evidence, teaching skills to manage intense emotions. Hospitalization for non-suicidal self-injury should generally be avoided as it can reinforce the behavior; crisis intervention focuses on validation, safety planning, and connection to appropriate outpatient care.