# Clinical Cases: Personality Disorders ## 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):** 1. Frantic efforts to avoid real or imagined abandonment (texting 50+ times) 2. Pattern of unstable, intense interpersonal relationships with alternating idealization/devaluation 3. Identity disturbance: unstable self-image 4. Impulsivity in at least 2 areas (spending, sex, binge eating) 5. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior 6. Affective instability due to marked reactivity of mood 7. Chronic feelings of emptiness 8. 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 --- ## Case 2: Antisocial Personality Disorder with Comorbid Substance Use ### Patient Demographics - **Age:** 35 years old - **Sex:** Male - **Occupation:** Unemployed (history of various jobs, none lasting >6 months) ### Chief Complaint "The court said I had to come here or go to jail." ### History of Present Illness The patient is a 35-year-old male presenting for court-mandated psychiatric evaluation following his third arrest for assault in 5 years. The current charge involves a bar fight where he struck another patron with a bottle after a perceived insult. He shows no remorse for his actions, stating "He had it coming. He disrespected me." He has an extensive criminal history beginning at age 14, including theft, vandalism, fraud, drug possession, and multiple assaults. He reports a pattern of impulsive aggression when he feels challenged or "looked at wrong." He has never maintained stable employment due to conflicts with supervisors and coworkers. He describes multiple relationships characterized by manipulation and exploitation, including using partners financially. He reports methamphetamine and alcohol use, which he minimizes ("I can stop anytime"). He denies any psychiatric symptoms beyond stating he has "anger problems." He expresses that treatment is "pointless" and he is only present to satisfy court requirements. ### Mental Status Examination **Appearance:** Well-groomed male, muscular build, multiple tattoos including facial tattoos, relaxed posture, direct eye contact bordering on challenging **Behavior:** Superficially charming initially, becoming dismissive and irritable when confronted; minimizes behaviors; attempts to control interview **Speech:** Normal rate, normal volume, confident tone, occasionally condescending **Mood:** "Fine" **Affect:** Shallow, limited emotional range, dismissive when discussing victims of his behavior **Thought Process:** Linear, goal-directed, calculating **Thought Content:** - No suicidal or homicidal ideation expressed - Grandiose view of self ("I'm smarter than most people") - Externalizes blame consistently ("Everyone else causes my problems") - No delusions **Perceptions:** No hallucinations **Cognition:** Alert and oriented x4; intelligence appears above average; attention and memory intact **Insight:** Absent - does not recognize behavior as problematic, views self as victim of circumstances **Judgment:** Poor - repeated criminal behavior despite consequences ### Collateral Information **Criminal Record Review:** - Age 14: Juvenile detention for theft and vandalism - Age 18: Arrested for fraud (plea deal, probation) - Age 22: Assault (6 months incarceration) - Age 25: Drug possession, DUI - Age 30: Assault with weapon (18 months incarceration) - Age 35: Current charge - aggravated assault **Family History:** - Father: Incarcerated for most of patient's childhood (robbery, assault) - Mother: Substance use disorder - History of childhood neglect and physical abuse ### Psychiatric Workup **Screening Tools:** - PCL-R (Psychopathy Checklist-Revised): 32/40 (high psychopathy) - AUDIT: 18 (hazardous alcohol use) - DAST-10: 6 (moderate drug use severity) **Laboratory Studies:** - Urine drug screen: Positive for methamphetamine, THC - Blood alcohol level: 0 ### Diagnosis **Antisocial Personality Disorder (F60.2)** **DSM-5 Criteria Met:** A. Pervasive pattern of disregard for and violation of rights of others since age 15: 1. Failure to conform to social norms (repeated arrests) 2. Deceitfulness (lying, manipulation, fraud history) 3. Impulsivity (job instability, reactive aggression) 4. Irritability and aggressiveness (repeated assaults) 5. Reckless disregard for safety of self or others 6. Consistent irresponsibility (cannot maintain employment) 7. Lack of remorse (indifferent to having hurt others) B. Individual is at least 18 years old C. Evidence of conduct disorder onset before age 15 (documented juvenile record for theft, vandalism, school expulsion) D. Not occurring exclusively during schizophrenia or bipolar episode **Comorbid Diagnoses:** - Stimulant Use Disorder (Methamphetamine), Moderate - Alcohol Use Disorder, Moderate **Specifier:** - With psychopathic features (high PCL-R score, callous-unemotional traits) ### Treatment Plan **Prognostic Considerations:** - ASPD is notoriously difficult to treat - Limited motivation (external motivation only - court mandate) - High psychopathy score suggests poorer prognosis - Comorbid substance use complicates treatment **Recommended Interventions:** **1. Court-Mandated Treatment Program:** - Structured, confrontational group therapy program designed for criminal justice populations - Cognitive-behavioral interventions targeting criminal thinking patterns - Anger management skills training - Contingency management (clear consequences for behavior) **2. Substance Use Treatment:** - Mandatory drug testing as condition of probation - Outpatient substance use treatment - Consider contingency management for stimulant use disorder **3. Pharmacotherapy:** - Limited role for medications in ASPD specifically - Consider mood stabilizer (valproate) for impulsive aggression - Treat comorbid conditions if present **4. Risk Management:** - High risk for violence - document risk assessment - Coordinate with probation officer - Clear behavioral expectations with consequences - Recommend continued monitoring by criminal justice system **Limitations:** - Poor prognosis given lack of internal motivation - Treatment adherence likely to be minimal without external enforcement - Focus may need to be on harm reduction and community safety rather than personality change --- ## Image Attribution ![Borderline Personality Disorder Mood Patterns](case_01_image.jpg) *Image: Illustration depicting emotional dysregulation patterns characteristic of borderline personality disorder. Source: Wikimedia Commons. Used for educational purposes under Creative Commons license.*