Case Presentation

Mrs. N is a 63-year-old divorced white woman who presents to her psychologist at a local mental health center for weekly psychotherapy. Mrs. N appears clearly distressed and tells the psychologist that she saw her third ex-husband in a restaurant a few days ago having lunch with a young, attractive woman. Mrs. N reports that since then she has felt ugly, unattractive, and has resumed previous self-destructive behavior of sticking pins into her thighs. Mrs. N has a prior history of cutting herself with a small knife but had stopped this after she married her third husband. She has been married and divorced three times and has two children from her first marriage. Her two sons were raised by her ex-husband, and Mrs. N has not seen them in more than 10 years.

Mrs. N has a pattern of intense but short-lived relationships and often tells her psychologist that her 6-year course of therapy is the longest period of time that she has lasted with anyone. She has been attending weekly group therapy for patients with borderline personality disorder but frequently complains that “there is no one in the group who understands me.” Mrs. N frequently threatens to quit attending the group, but made an agreement that group therapy would be part of the conditions of her receiving treatment at the mental health center. Mrs. N goes out to movies and museums but has few friends aside from other patients from the mental health center. Mrs. N receives financial support from a trust fund left to her by her father. The trust is controlled by a bank officer whom Mrs. N frequently argues with when asking for additional money.

Mrs. N has hypertension and chronic obstructive pulmonary disease. She frequently changes her primary care physician, as she easily becomes angry if she has to wait prior to her appointment or feels that the doctor does not devote enough time and attention to her complaints. Mrs. N has been asked to leave the waiting room of several local physicians’ offices after she became loud and disruptive while having to wait to see her doctor. She admits that her compliance with medical treatment is poor, as she does not believe that her physicians are giving her adequate time to prescribe appropriate medications for her conditions. Mrs. N continues to smoke cigarettes and becomes angry when her physicians try to counsel her regarding smoking cessation.

The psychologist is concerned about Mrs. N’s distress, signs of negative affect, depressed mood, and increase in impulsivity and self-harm. The psychologist is also concerned about her poor compliance with medical treatment. Mrs. N denies wanting to kill herself and has always been able to contact her psychologist during times of distress. She does not take any psychiatric medications but has in the past been prescribed medications for periods of depression, impulsivity, and paranoia. Mrs. N is ambivalent about seeing a psychiatrist again, stating “they just take your money and prescribe pills.” She has threatened to sue several psychiatrists in the past after she developed side effects to medications; however, she has never acted on these threats and cannot describe the severity of the side effects other than to complain that the medications made her feel “crazy.” After encouragement, she agrees to see a psychiatrist affiliated with the mental health clinic.

Discussion

Borderline personality disorder is one of ten personality disorders described in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision.1 Personality disorders are all characterized by chronic and persistent maladaptive patterns of coping with the experiences, stressors, and relationships associated with daily living. Personality disorders are typically diagnosed in young adulthood but are enduring and persistent problems that continue into late life.1,2

Borderline personality disorder is characterized by a pattern of unstable or intense relationships, fears of abandonment, unstable mood with periods of uncontrollable anger, impulsive behavior with self-injurious behaviors, chronic feelings of emptiness, and disturbances in basic identity.1 Borderline personality disorder is found in 2% of the general population, but among patients who receive psychiatric services, the prevalence is higher. Among psychiatric outpatients, the prevalence of borderline personality disorder is 10%, while at least 20% of those admitted to inpatient psychiatric units are found to have this disorder.1,3 Of significance is that 75% of patients who meet criteria for borderline personality disorder are women. The self-destructive and self-injurious behaviors are common, as 90% of those who have the disorder will make at least one suicide attempt, and approximately 10% of patients with borderline personality disorder will die as a result of suicide.1-3

Borderline personality disorder has been found in different cultures throughout the world.4 Children of patients with borderline personality disorder are five times more likely than those in the general population to develop the disorder.1 The risk of developing substance use disorders and mood disorders is also increased among the first-degree relatives of those who have borderline personality disorder.3,4

The symptomatic course of the disorder is variable over the lifespan. Young adulthood, when the disorder is typically diagnosed, is often characterized by the greatest degree of poor impulse control, anger, mood instability, poor ability to form relationships, self-injurious behaviors, and suicidal threats. Use of mental health services, inpatient admissions, and poor ability to maintain interpersonal or occupational functioning are common.1,6 As patients age, impulse control and anger often improve, with fewer episodes of self-destructive behavior and less paranoid ideation during times of stress.7 Interpersonal relationships and occupational functioning remain highly variable as patients age. Only approximately 50% of patients who require inpatient admissions are able to achieve any degree of long-term relationships or successful employment.6,7 For those patients who are subject to chronic stressors, such as social or economic hardship, positive outcomes are greatly reduced.3,4

Aging presents many stressors for the patient with borderline personality disorder.2 The need for medical treatment for aging-related illness often triggers a crisis of identity and mood instability.3 Changes in occupational roles or the need to adjust to younger colleagues are often viewed as a threat to patients. Acting out or impulsive behavior that was stable for years may recur during these periods of new stress.6,7 Older adults with borderline personality disorder lack the coping skills and interpersonal and social supports needed to deal with the losses and stressors of aging.2 The clinician needs to remain aware that these deficits in coping and maladaptive behaviors persist into later life and must be considered a chronic illness that requires additional care.

The clinician is challenged in many ways when caring for a patient with borderline personality disorder (Table1,3,7-10). The poor coping skills and tendency to form intense, unstable relationships associated with these patients often identifies them early on as difficult and problematic.1 Treatment compliance is poor, and their behavior is often demanding, although they reject help.3 They may often idealize the physician as the only person who offers help and understanding, yet return for a follow-up visit expressing anger and hatred. The behavior of “splitting,” or viewing one member of the healthcare team as all good while another is all bad, is common in these patients.1,8 It is important that all members of a medical staff or unit team have a consistent approach to avoid the manipulative behavior that splitting may cause.

Medical treatment of the patient with borderline personality disorder requires that the clinician present a clear explanation of the roles and expectations of the treatment plan at each visit.3 It is important that the clinician serve as a role model of the boundaries, respect, and emotional control that is expected of the patient. Offering care that is empathic and centered on health promotion will often help with the fears of aging and physical decline that accompany the disorder.2,6 Encouraging mental health follow-up is often helpful as these patients tend to switch mental health providers often. Maintaining contact with the patient’s mental health clinician is also valuable to help with continuity of care.2,8

Treatments for borderline personality disorder focus on specific psychotherapies to reduce self-injurious behaviors and maintain mood stability.8,9 Psychotropic medications are used during periods of acute depression, impulsivity, or paranoia.7,10 Borderline personality disorder is by definition a chronic illness, and the goals of therapy are to reduce distress, minimize self-harm, and maximize the patient’s ability to function.1 Two forms of psychotherapy—dialectical behavioral therapy (DBT) and transference-focused psychotherapy (TFP)—have shown promise for patients with borderline personality disorder.8,9 DBT utilizes individual, group, and telephone counseling to teach skills designed to reduce self-harm, regulate emotions, improve relationships, and reduce overall distress.9 TFP uses an individual approach to help the patient understand the emotional conflicts and relationships in therapy and apply them to other people and situations.8 Other forms of psychotherapy, including individual and group-supportive interventions, have also been utilized.8-10

Medication management of borderline personality disorder includes a thorough evaluation of any comorbid psychiatric disorders such as depression, anxiety, or substance abuse. Any current distressing symptoms that are causing the patient significant distress or are leading to self-injurious behavior such as paranoia, anxiety, or impulsivity should be identified and a course of medication should be considered.10 Mood symptoms and anxiety are typically treated with antidepressant medications, such as serotonin reuptake inhibitors. Paranoia may be treated successfully with antipsychotic medication such as second-generation antipsychotic agents. It is important to re-evaluate the medication dose, side effects, and clinical effects on a regular basis, as patients may improve, engage in ongoing psychotherapy, and no longer require pharmacotherapy.4 As each patient with borderline personality disorder presents with a unique set of symptoms and challenges, the clinician must be prepared to monitor progress and adjust the medication as needed. Referral for substance abuse treatment if this is found to be an issue is vital, as chemical dependency is a common problem among these patients. Acute inpatient psychiatric hospitalization should be considered during periods of prolonged depression with self-injurious behavior, severe impulsivity, or any suicidal risk that cannot be managed with outpatient care.1-3

Information on personality disorders for professionals, patients, and families is available at the Substance Abuse and Mental Health Services Administration (SAMHSA) National Mental Health Information Center website: http://mentalhealth.samhsa.gov. Patients and families may find educational and research information at the Treatment and Research Advancements National Association for Personality Disorder (TARA) website: www.tara4bpd.org.

Outcome of the Case Patient

Mrs. N arrived 15 minutes late for her appointment with the psychiatrist, and started the session by stating that she expected to be seen for a full 50 minutes. The psychiatrist asked Mrs. N to describe the recent events in her life. Mrs. N reported seeing her ex-husband with a very attractive woman and developed referential ideas that the woman was sending her messages telling her that she is old, ugly, and on the verge of dying. Mrs. N reported that she had started sticking pins into her legs to make sure that she was alive. Mrs. N was very neatly dressed and groomed, had no signs of depression, and was not acting out of any suicidal wishes. She was very fearful of growing old and viewed this younger woman as a sign of her own mortality. Mrs. N remained oppositional toward her primary care physician but allowed the psychiatrist to speak with him in order to obtain her recent laboratory test results and electrocardiogram. The psychiatrist ended the session with a brief discussion of antipsychotic medication and asked Mrs. N to return for another appointment. Mrs. N became angry and hostile, screaming that she was supposed to have more time, and left the clinic. She called back several times later that day, demanding to be seen. She was given another appointment 3 days later and arrived on time.

Mrs. N appeared more suspicious and paranoid during her next appointment, stating that she wanted to know what her primary care physician said about her. She was also convinced that the woman she saw with her ex-husband was also seeing her primary care physician. Mrs. N was willing to take medication and was started on olanzapine 10 mg at bedtime. Her psychologist was made aware of the addition to her treatment plan, and Mrs. N was encouraged to share this information in her group therapy. Mrs. N left multiple messages for the psychiatrist, frequently stating that she was refusing and later taking the medication. Over the next 4 weeks, her suspiciousness and delusions improved. She was no longer focused as much on her ex-husband or the woman with him. She still stuck herself with pins but was able to limit the behavior to once weekly, on the day of the week that she initially had seen her ex-husband.

Due to her history of chronic self-injurious behavior and her lack of interpersonal relationships, Mrs. N was referred to a weekly DBT group in addition to her current therapies. With much encouragement, she agreed. She completed an initial 3-month course of DBT and entered a telephone counseling phase. Mrs. N stopped sticking herself with pins and was able to join a local book club.

At a 6-month follow-up visit with the psychiatrist, Mrs. N was no longer suspicious or paranoid, and the olanzapine was tapered to 5 mg at bedtime. One month later, Mrs. N remained free of delusions, and the olanzapine was discontinued. She continues to see her psychologist and attend a weekly supportive therapy group. She continues to smoke cigarettes but sees her primary care physician on a more regular basis.

The author reports no relevant financial relationships.

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Dr. Lantz is Chief of Geriatric Psychiatry, Beth Israel Medical Center, First Ave @ 16th Street #6K40, New York, NY 10003; (212) 420-2457; fax: (212) 844-7659; e-mail: mlantz@chpnet.org.