# Clinical Cases: Personality Disorders ## 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. --- ## Case 2: Antisocial Personality Disorder ### Patient Presentation **Demographics:** 32-year-old male **Chief Complaint:** Psychiatric evaluation ordered by court following assault charge **History of Present Illness:** A 32-year-old man presents for court-ordered psychiatric evaluation after being arrested for assault. He punched a man at a bar after a disagreement over a pool game. He shows no remorse: "He disrespected me. He had it coming." Review of records reveals an extensive history: multiple arrests for assault, theft, and drug possession beginning at age 14, two periods of incarceration, and violation of probation multiple times. He was diagnosed with conduct disorder at age 12 after repeated truancy, fighting, and cruelty to animals. He has never held a job for more than 6 months due to conflicts with supervisors or absenteeism. He has two children from different relationships whom he rarely sees and for whom he pays no support. He has a history of polysubstance use including alcohol, cocaine, and opioids. He presents as charming initially but becomes irritable when questioned about his history. He denies any problems: "Everyone else causes problems, not me." **Mental Status Examination:** - Appearance: Well-groomed, confident demeanor, multiple tattoos - Behavior: Initially charming, becomes dismissive and irritable; no psychomotor abnormalities - Speech: Glib, superficial - Mood: "Fine. I don't have any problems." - Affect: Shallow, restricted range, no apparent distress - Thought content: Minimizes antisocial behavior, blames others, no insight into impact on victims - Cognition: Intact - Insight: Absent - does not perceive any problems with behavior - Judgment: Poor - repeated poor decisions with foreseeable consequences **Relevant History:** - Conduct disorder diagnosis at age 12 (required for ASPD diagnosis) - Juvenile detention at ages 14 and 16 - Adult incarcerations at 22 and 27 - History of domestic violence (prior partner) - Positive for ADHD symptoms in childhood (untreated) **Workup:** - **PCL-R (Psychopathy Checklist-Revised):** Score 32 (high - indicates psychopathic traits) - **Urine drug screen:** Positive for cocaine - Records confirm conduct disorder before age 15 **Diagnosis:** Antisocial Personality Disorder; Stimulant Use Disorder (cocaine), moderate **Treatment/Recommendations:** - Diagnosis confirmed for court documentation - Treatment recommendations: - Substance abuse treatment (primary focus - more treatable than ASPD itself) - Anger management program - Vocational rehabilitation - Clear contingencies and consequences for behavior - Prognosis discussion: Limited evidence for treatments directly targeting ASPD; focus on harm reduction and managing comorbid conditions - ASPD may improve somewhat with age, particularly impulsive features - Treatment setting must have clear boundaries and consistent consequences - Verification of information recommended (tendency toward manipulation and deceit) - Report provided to court with diagnosis and treatment recommendations **Clinical Pearl:** Antisocial personality disorder requires evidence of conduct disorder before age 15 and at least 3 criteria including failure to conform to social norms, deceitfulness, impulsivity, irritability/aggressiveness, reckless disregard for safety, irresponsibility, and lack of remorse. Treatment is challenging due to limited motivation and poor insight. Focus is typically on managing comorbid conditions (especially substance use) and harm reduction rather than expecting personality transformation. The Psychopathy Checklist-Revised (PCL-R) assesses psychopathic traits, which overlap with but are distinct from ASPD. Information should be verified from collateral sources given the tendency toward manipulation. --- ## Case 3: Narcissistic Personality Disorder ### Patient Presentation **Demographics:** 45-year-old male **Chief Complaint:** "My wife says I need therapy or she's leaving. She doesn't understand how special I am." **History of Present Illness:** A 45-year-old businessman presents at the ultimatum of his wife, who is threatening divorce. He initially states that therapy is "beneath" him and that his marriage problems are entirely his wife's fault because she "doesn't appreciate" him. He describes himself as "exceptional" and states he has accomplished more than anyone he knows. He expects special treatment in all settings and becomes enraged when he feels disrespected - recently berated a restaurant server to the point of making them cry because his steak was "slightly overcooked." He admits to feeling "devastated" when he was passed over for a promotion last year, describing it as "the worst injustice imaginable" and stating the person who was promoted "doesn't deserve to breathe the same air" as him. He has no close friends because "no one can keep up" with him. When his wife complains about his behavior, he feels deeply wounded and retaliates with criticism. He admits that he often feels empty inside despite outward success. He becomes tearful briefly when discussing his father, who was highly critical and "never thought I was good enough." **Mental Status Examination:** - Appearance: Impeccably dressed in expensive suit, well-groomed - Behavior: Initially dismissive, became more engaged when talking about himself; entitled manner with staff - Speech: Eloquent, self-aggrandizing - Mood: "Superior, mostly. But sometimes... empty." - Affect: Grandiose, but briefly vulnerable when discussing father - Thought content: Grandiosity, sense of entitlement, lack of empathy, preoccupation with success and admiration; briefly acknowledged emptiness and vulnerability - Insight: Minimal - attributes problems to others - Judgment: Impaired in interpersonal relationships **Workup:** - **No formal psychological testing performed at initial visit - Collateral from wife confirms pattern of entitlement, rage, and difficulty maintaining relationships **Diagnosis:** Narcissistic Personality Disorder **Treatment:** - Initial approach: Engage patient's desire for self-improvement rather than framing as "fixing" him - Acknowledged his accomplishments while exploring relationship difficulties - Gradually explored the shame and emptiness beneath the grandiose exterior - Individual psychotherapy recommended - long-term, insight-oriented - Focus on developing empathy - Understanding impact of behavior on others - Addressing vulnerability without defensive grandiosity - Couples therapy recommended if wife willing - Medications: Not indicated unless comorbid depression emerges - Challenges in treatment: - Tendency to devalue therapist when narcissistic injury occurs - Dropout risk when uncomfortable material addressed - Power struggles over therapy frame - At 6-month follow-up: Sporadic attendance initially, but engagement improved - Beginning to recognize impact of behavior on wife - Marriage in process of repair **Clinical Pearl:** Narcissistic personality disorder features grandiosity, need for admiration, and lack of empathy, but underneath often lies profound vulnerability to shame and emptiness. Understanding this dynamic is key to treatment engagement. The therapist must avoid power struggles while gradually addressing underlying vulnerability. Treatment is long-term and challenging, with high dropout rates. No medications treat NPD directly, but comorbid depression is common, especially when narcissistic supply is disrupted (job loss, divorce, aging). NPD is often more persistent and treatment-resistant than borderline personality disorder. --- ## Clinical Image ![DBT emotion regulation](case_01_image.jpg) **Image Description:** Diagram illustrating the four modules of Dialectical Behavior Therapy (DBT): Mindfulness (core skills for awareness and presence), Distress Tolerance (crisis survival skills), Emotion Regulation (understanding and managing emotions), and Interpersonal Effectiveness (communication and relationship skills). DBT is the gold-standard treatment for borderline personality disorder. **Attribution:** Educational diagram of DBT modules. DBT was developed by Marsha Linehan for the treatment of borderline personality disorder. **Image Source:** Educational resource - Create or source diagram of DBT components