Cases That Test Your Skills

The manipulative self-harmer

Current Psychiatry. 2010 June;9(6):44-48

References

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OUTCOME: Some improvement

Ms. L has no dramatic suicidal gestures for 3 years. Although she continues to engage in self-injurious behaviors, the intensity and frequency are reduced and she does not inflict any serious injury for 18 months. Her mood and behavior continue to oscillate; she is relatively calm and satisfied 1 week, angry and assaultive the next. This stormy course is expected given her BPD diagnosis.

Initially, Ms. L resided in a locked residential unit and was minimally compliant with treatment recommendations and unit policies. As treatment progressed she moved to a different locked unit and eventually to an apartment. Recently, she was placed in a more restrictive setting because her hostile and self-destructive behavior escalated.

The authors’ observations

Clinical Point

It is not clear if the gains Ms. L made within a very structured treatment setting would have been possible if she was living on her own

Ms. L is no different from most Axis II Cluster B disordered patients. During treatment she shows improvement by refraining from self-destructive behaviors for up to 18 months, but she then briefly reverts back to maladaptive behaviors. Ms. L resides in a very structured treatment setting. It is not clear if the gains she made in treatment would have been possible if she was living on her own in the community.

One year after finishing the court-mandated “911 program,” Ms. L lives in the community, draws and paints quite well, attends weekly individual and group therapy, and refrains from self-mutilation. She still experiences volatile moods, but can handle them without inflicting self injury.

Related resources

Oldham JM. Guideline watch: practice guideline for the treatment of patients with borderline personality disorder. Arlington, VA: American Psychiatric Association; 2005. www.psychiatryonline.com/content.aspx?aID=148722.
Koenigsberg HW, Kernberg OF, Stone MH, et al. Borderline patients: extending the limits of treatability. New York, NY: Basic Books; 2000.

Drug brand names

Aripiprazole • Abilify
Buspirone • Buspar
Carbamazepine • Tegretol
Clonidine • Catapres
Divalproex • Depakote
Fluoxetine • Prozac
Fluoxetine-olanzapine • Symbyax
Lamotrigine • Lamictal
Lithium • Eskalith, Lithobid
Lorazepam • Ativan
Olanzapine • Zyprexa
Quetiapine • Seroquel
Pregabalin • Lyrica
Risperidone • Risperdal
Topiramate • Topamax
Valproic acid • Depakene
Venlafaxine XR • Effexor XR
Ziprasidone • Geodon

Disclosures

Dr. Hashmi is on the speakers bureau for AstraZeneca, Eli Lilly and Company, and Janssen.

Dr. Vowell reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.