Psychiatry · Year 3 · from Psychiatry
Case 1: Borderline Personality Disorder
Patient Demographics
- Age: 24 years old
- Sex: Female
- Occupation: Retail sales associate (frequently changing jobs)
Chief Complaint
"I cut myself again because my boyfriend didn't text me back."
History of Present Illness
The patient is a 24-year-old female presenting to the psychiatric emergency department after superficially cutting her forearms with a razor blade. She reports her boyfriend of 3 months did not respond to her text messages for 4 hours, leading her to conclude he was "definitely cheating" and "didn't care about her at all." She describes escalating emotional distress, texting him repeatedly (over 50 messages), and ultimately cutting herself "to feel something other than this emptiness." She denies suicidal intent, stating "I didn't want to die, I just needed the pain to stop." This is her 8th ED visit for self-harm in the past 2 years. She has a pattern of intense, unstable relationships that typically last 2-4 months before ending acrimoniously. She describes a chronic sense of emptiness and identity confusion ("I don't know who I am"). She reports impulsive behaviors including binge eating, reckless spending, and brief sexual encounters when feeling abandoned. Her emotional states shift rapidly, from idealization ("he's the most amazing person") to devaluation ("he's just like everyone else who abandons me") within hours. She has a history of childhood sexual abuse by a family member from ages 8-12.
Mental Status Examination
Appearance: Young woman with visible superficial lacerations on bilateral forearms (cleaned and bandaged), multiple healed scars visible, nose piercing, tattoos on arms
Behavior: Initially tearful and clinging to interviewer, alternating between expressions of distress and anger; at times dismissive and irritable when questions felt challenging
Speech: Variable rate - rapid when distressed, normal when calm; normal volume; occasionally pressured
Mood: "Empty and abandoned"
Affect: Labile, shifting from tearful to angry to calm within the interview; dramatic quality; intense
Thought Process: Linear but emotionally driven; tendency toward black-and-white thinking ("he either loves me completely or doesn't care at all")
Thought Content:
- Preoccupation with abandonment by boyfriend
- Chronic passive suicidal ideation ("Sometimes I wish I wouldn't wake up")
- Self-harm ideation present but no active suicidal plan
- Identity disturbance ("I don't know who I really am")
- No psychotic symptoms
Perceptions: No hallucinations; reports occasional brief dissociative episodes during emotional distress ("I feel like I'm watching myself from outside")
Cognition: Alert and oriented x4; attention and memory intact
Insight: Partial - recognizes pattern of unstable relationships but externalizes blame
Judgment: Impaired - self-harm as coping mechanism
Psychiatric Workup
Screening Tools:
- McLean Screening Instrument for BPD: 8/10 (positive screen)
- PHQ-9: 16 (moderately severe depression)
- Columbia Suicide Severity Rating Scale: Chronic passive ideation, no current plan or intent
- Dissociative Experiences Scale: 28 (elevated, consistent with trauma history)
Previous Treatment History:
- 5 prior psychiatric hospitalizations for suicidal ideation/self-harm
- Multiple medication trials (SSRIs, mood stabilizers, antipsychotics) with limited benefit
- Started DBT 6 months ago but attendance inconsistent
Diagnosis
Borderline Personality Disorder (F60.3)
DSM-5 Criteria Met (8 of 9):
- Frantic efforts to avoid real or imagined abandonment (texting 50+ times)
- Pattern of unstable, intense interpersonal relationships with alternating idealization/devaluation
- Identity disturbance: unstable self-image
- Impulsivity in at least 2 areas (spending, sex, binge eating)
- Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior
- Affective instability due to marked reactivity of mood
- Chronic feelings of emptiness
- Transient, stress-related paranoid ideation or dissociative symptoms
Comorbid Diagnoses:
- Major Depressive Disorder, recurrent (may be difficult to distinguish from BPD mood instability)
- Post-Traumatic Stress Disorder (related to childhood sexual abuse - requires further assessment)
Treatment Plan
Acute Management:
- Medical clearance for lacerations (superficial, no sutures needed)
- Safety assessment: Does not meet criteria for inpatient admission given lack of suicidal intent
- Discharge to outpatient care with safety plan
Primary Treatment - Dialectical Behavior Therapy (DBT):
- Refer to comprehensive DBT program including:
- Weekly individual therapy
- Weekly skills group (mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness)
- Phone coaching for crisis situations
- Therapist consultation team
- Emphasize importance of consistent attendance
Pharmacotherapy (Adjunctive):
- Continue current SSRI (sertraline 100 mg daily) for depressive symptoms
- No medication is FDA-approved for BPD; medications target specific symptoms
- Consider low-dose quetiapine PRN for acute emotional dysregulation episodes
Safety Planning:
- Detailed safety plan completed
- Identify warning signs (feeling abandoned, emptiness escalating)
- Coping strategies (DBT distress tolerance skills: ice cubes, intense exercise)
- Remove access to cutting implements
- Support persons identified
- Crisis resources: Crisis Text Line, 988
Follow-up:
- DBT individual therapist within 48 hours
- Crisis plan if unable to maintain safety before appointment