Borderline Patient Research Articles

Evaluation of thyroid dysfunction in childhood-onset systemic lupus erythematosus: Risk factors for Hashimoto's thyroiditis.

Increased frequency of autoimmune thyroid disease, particularly Hashimoto's thyroiditis (HT) was reported several studies in the literature, in individuals with childhood-onset systemic lupus erythematosus (cSLE). Our study aimed to investigate the prevalence and contributing factors of thyroid dysfunction and HT among cSLE patients. Thyroid function tests were obtained cross-sectionally from cSLE patients. Demographic, clinical, and laboratory characteristics and activity scores were collected from medical records. Patients diagnosed with cSLE were compared to the healthy control group for the frequency of thyroid dysfunction. The Mann-Whitney U, independent samples t test, and the Chi-square or Fisher's exact test were used to compare study groups. A p-value below 0.05 was considered statistically significant. Out of 73 cSLE patients, 14 (19.1%) had subclinical hypothyroidism, 9 (12.3%) had clinical hypothyroidism, 12 (16.4%) were diagnosed with HT, and 12 (16.4%) had a family history of HT. Thyroid USG was performed in 5 euthyroid patients and 1 borderline subclinical hypothyroid patient with positive thyroid autoantibody and reported as diffuse heterogeneous echogenicity enlargement in the thyroid gland. There were no significant differences in clinical and laboratory data or medication used between the groups with and without HT; however, patients with HT had a higher frequency of clinical hypothyroidism and family history of HT. Cumulative prednisolone dose was significantly lower in patients diagnosed with HT. The frequency of HT was considerably higher in patients with cSLE compared to the healthy control group. The results demonstrate an increased incidence of HT in cSLE patients, even if they are euthyroid, and recommend that cSLE patients be screened more frequently.

Dream themes and rejection sensitivity of individuals with and without borderline personality disorder: a comparative study

Objectives: This study aims to determine how the dream themes of borderline personality disorder patients differ from those of without borderline personality disorder diagnosis and the mediating role of rejection sensitivity in this differentiation process. Methods: The convenience sampling method was used in the study, and the participants were 79 female borderline patients diagnosed with semi-structured interviews with criteria of DSM-5 and 79 female individuals who had not received a psychological diagnosis before and at the study interviews. Sociodemographic Information Form, Dream Themes Scale, Borderline Personality Questionnaire, and Rejection Sensitivity Scale were used in the study. Linear Regression Analysis, Hierarchical Regression Analysis, and Independent Groups T-Test were used during the investigations. Results: Borderline personality disorder patients scored higher in all sub-dimensions of the dream themes scale and rejection sensitivity scale than the control group. Borderline personality traits predicted rejection sensitivity. Borderline personality traits and rejection sensitivity together predicted dream themes. Borderline personality predicts anxiety dreams, fear dreams, and experience dreams, and rejection sensitivity mediates these predictive relationships. Conclusions: The dreams of borderline personality disorder patients have negative content covered by the impact of experiences sub-dimension on dream themes, as they contain reflections of negative content in beliefs, thoughts and emotions related to their daily lives. Rejection sensitivity plays a mediator role in borderline patient’s dreams. The study results show that it would be beneficial not to ignore the content of dreams in patients with borderline personality disorder, considering the relationship of negative dreams with daily functioning, dissociative symptoms, self-harming behaviors, and suicide attempts. Results also indicate that it might be beneficial to target rejection sensitivity to reduce aggravating dream contents.

Strongyloidiasis infection in a borderline lepromatous leprosy patient with adrenocorticoid insufficiency undergoing corticosteroid treatment: a case report

Strongyloidiasis is a soil-transmitted helminthiasis mainly caused by Strongyloides stercoralis. It is endemic to the tropics and subtropics. Sri Lanka has a 0-1.6% prevalence rate. S. stercoralis infection was identified in a 33-year-old Sri Lankan male patient treated with corticosteroids for borderline lepromatous leprosy with adrenocortical dysfunction. In March 2020, a 33-year-old Sri Lankan (Sinhalese) male patient presented with watery diarrhea, lower abdominal pain, and post-prandial abdominal fullness. Previously, he was diagnosed with borderline lepromatous leprosy and was treated with rifampicin, clofazimine, and prednisolone 60mg daily since July 2019. After developing gastrointestinal symptoms, he had defaulted leprosy treatment including the prednisolone for 3months. Duodenal biopsy revealed numerous intraepithelial nematodes within the lumina of glands in the duodenum whose appearance favored Strongyloides. Fecal wet smear revealed numerous Strongyloidisstercoralis L1 rhabditiform larvae. Larval tracks were seen in the agar plate culture. L3 filariform larvae of Strongyloidis stercoralis were seen in the Harada-Mori culture. In addition, the short synacthen test revealed adrenocortical insufficiency, and oral hydrocortisone and fludrocortisone were started with albendazole treatment against strongyloidiasis. Fecal wet smear and culture repeated after treatment with albendazole were negative for Strongyloidisstercoralis. The patient was discharged in July 2020 on oral hydrocortisone. Onemonth later his condition was reviewed and the repeated fecal wet smear and agar plate culture was normal. He is being followed up every 3months. This is the first case of strongyloidiasis diagnosed in a patient with borderline lepromatous leprosy from Sri Lanka. The patient manifested symptoms of strongyloidiasis while on high-dose steroid therapy for his lepromatous reaction. Subsequently, the patient not only discontinued his steroid therapy, but also developed adrenocortical insufficiency as a complication of leprosy. Therefore, although diagnosis of strongyloidiasis was delayed, his subsequent low steroid levels probably protected him from disseminated disease. This is an interesting case where symptomatic strongyloidiasis was diagnosed in a patient who was initially treated with high-dose steroids but subsequently developed adrenocortical insufficiency. We emphasize the need to screen all patients prior to the commencement of immunosuppressive therapy.

The hidden borderline patient: patients with borderline personality disorder who do not engage in recurrent suicidal or self-injurious behavior.

Despite the significant psychosocial morbidity associated with borderline personality disorder (BPD), its underrecognition is a significant clinical problem. BPD is likely underdiagnosed, in part, because patients with BPD usually present with chief complaints associated with mood, anxiety, and substance use disorders. When patients with BPD do not exhibit self-harm behavior, we suspect that BPD is less likely to recognized. An important question is whether the absence of this criterion, which might attenuate the likelihood of recognizing and diagnosing the disorder, identifies a subgroup of patients with BPD who are 'less borderline' than patients with BPD who do not manifest this criterion. Psychiatric outpatients were evaluated with a semi-structured diagnostic interview for DSM-IV BPD, 390 of whom were diagnosed with BPD. We compared the demographic and clinical characteristics of patients with BPD who do and do not engage in repeated suicidal and self-harm behavior. Approximately half of the patients with BPD did not meet the suicidality/self-injury diagnostic criterion for the disorder. There were no differences between the patients who did and did not meet this criterion in occupational impairment, likelihood of receiving disability payments, impairment in social functioning, level of educational achievement, comorbid psychiatric disorders, history of childhood trauma, or severity of depression, anxiety, or anger upon presentation for treatment. Repeated self-injurious and suicidal behavior is not synonymous with BPD. It is critical for clinicians to be aware that the absence of repeated self-injury and suicide threats/gestures or attempts does not rule out the diagnosis of BPD.

Overview of practice of Consultation-Liaison Psychiatry.

Overview of practice of Consultation-Liaison Psychiatry.

What does preoperative three-dimensional image contribute to complex pancreatic surgery?

The possibility of modelling diagnostic images in three dimensions (3D) in pancreatic surgery is a novelty that provides us multiple advantages. A better visualization of the structures allows us a more accurate planning of the surgical technique and makes it easier the surgery in complex cases.We present the case study of a borderline pancreatic head adenocarcinoma patient to illustrate the advantages of 3D modelling in complex pancreatic surgery.The help of 3D technology allowed us to optimally plan the intervention and facilitate surgical resection. The use of this tool could translate into: shorter operative time, fewer intraoperative complications or an increase in R0 resections. The usability of the program used in our case, agile and intuitive, was an added advantage.

A prospective, randomized, double-blind trial of intravenous chlorpromazine versus intravenous prochlorperazine for the treatment of acute migraine in adults presenting to the emergency department.

To compare the efficacy of intravenous chlorpromazine versus intravenous prochlorperazine for the treatment of acute migraine in adults presenting to the emergency department (ED). Migraine is a common, incapacitating neurological condition. Although chlorpromazine and prochlorperazine are known to be safe, efficacious treatments for migraine, they have never been directly compared. We performed a prospective, randomized, double-blind clinical trial at a tertiary hospital in Melbourne, Australia. Adults aged 18-65years, who presented with migraine, were eligible for recruitment. Sixty-six patients were randomized to either chlorpromazine 12.5mg or prochlorperazine 12.5mg, both infused in 500ml of sodium chloride 0.9% over 30min. Headache severity score, nausea severity score, and the presence of photophobia and phonophobia were assessed at 0, 30, 60, and 120min. Adverse effects and the need for rescue therapy were recorded. The primary outcome was a reduction in headache severity score from baseline at 60min post-commencement of the study medicine infusion. Sixty-five patients were included in the analysis. There was a median reduction in headache severity score at 60min of 3.0 (interquartile range 1.0-4.0) in the chlorpromazine arm versus 2.0 (1.0-4.0) in the prochlorperazine arm (median difference -0.5 (95% confidence interval, -1.9 to 0.9)). We saw no evidence of a difference in secondary outcomes at 30, 60, or 120min. Side effects were reported in 16/32 (50%) patients in the chlorpromazine group versus 7/33 (21%) in the prochlorperazine group (p=0.020). Rescue therapy was required in 7/32 (22%) patients in the chlorpromazine group versus 12/33 (36%) in the prochlorperazine group (p=0.277). Both chlorpromazine and prochlorperazine are efficacious treatments for acute migraine in adult patients presenting to the ED. This trial found no evidence of superiority of either agent over the other. Caution should be used when prescribing these medicines in the borderline hypotensive patient; in that circumstance, prochlorperazine should be preferentially used.

¿Qué aporta la imagen tridimensional preoperatoria en la cirugía pancreática compleja?

The possibility of modelling diagnostic images in three dimensions (3D) in pancreatic surgery is a novelty that provides us multiple advantages. A better visualization of the structures allows us a more accurate planning of the surgical technique and makes it easier the surgery in complex cases.We present the case study of a borderline pancreatic head adenocarcinoma patient to illustrate the advantages of 3D modelling in complex pancreatic surgery.The help of 3D technology allowed us to optimally plan the intervention and facilitate surgical resection. The use of this tool could translate into: shorter operative time, fewer intraoperative complications or an increase in R0 resections. The usability of the program used in our case, agile and intuitive, was an added advantage.

Working With Severe Borderline Patients: A Clinical Study of Destructiveness and Its Communicative Potential.

Destructive behavior is one of the most challenging aspects when treating severe borderline patients because both the therapist and the psychotherapeutic method are called into question. Drawing on three in-depth psychoanalytic sessions of a severe borderline patient, the authors present and discuss the communicative potential of destructive behavior in the transference relationship during treatment. A step-by-step analysis and the working through process of the therapist's countertransference led the authors to recognize several complex dynamics of the patient's pathological organization and to the containment and first representation of unsymbolized early anxieties generated during the original encounter with the object.

Periacetabular Osteotomy for Mild or Borderline Acetabular Dysplasia

Evaluating the adolescent and young adult hip can be challenging given the rapid evolutions in the field over the last 10-20 years. One of the more difficult groups of patients to evaluate are those that fall into the mild or borderline acetabular dysplasia . We must determine whether the patient's pain and chondrolabral disease is due to their acetabular morphoplogy or their associated femoral morphology and therefore is more of an unstable or an impingement hip. A thorough history, physical examination, and imaging evaluation are needed to determine the best treatment option in these patients. When this evaluation determines that the patient is suffering from a primary instability problem, these patients are best treated with a surgery that improves the stability of the hip. Here we describe the patient evaluation and periacetabular osteotomy technique in the mild or borderline dysplastic patient.

The complexities of the borderline patient: how much more complex when considering physical health?

Borderline Personality Disorder is associated with a substantially reduced life expectancy, mostly due to physical health conditions that are life-shortening. This clinical review highlights pertinent risk issues for such conditions in Borderline Personality Disorder and suggests ways in which clinicians might address these. Selective literature review. People with Borderline Personality Disorder have a reduced life expectancy of some 20 years, attributable largely to physical health maladies, notably cardiovascular. Risk factors include obesity, sedentary lifestyle, poor diet and smoking. Added to these are other physical health problems, including poor sexual health, self-harm, substance use and blood-borne viruses. Chronic pain and opioid and benzodiazepine use are also common in people with Borderline Personality Disorder. Some psychiatric medications commonly used in people with Borderline Personality Disorder - notably certain antipsychotic agents - can add to the metabolic burden. Barriers to care include self-stigma and erratic adherence to medical care, as well as stigma on the part of clinicians, who often do not screen or provide adequate care for the physical health problems suffered by people with Borderline Personality Disorder. Clinicians need to be aware of the physical health problems in people with Borderline Personality Disorder and ensure appropriate screening and interventions, both preventative and therapeutic, are offered routinely.

A rare case of type 1 leprosy reactions following tetanus infection in a borderline tuberculoid leprosy patient and a literature review

BackgroundType 1 leprosy reaction, also known as “reversal reaction”, is related to cellular immune responses to Mycobacterium leprae antigens. The risk factors that trigger type 1 leprosy reactions are poorly understood. Leprosy with concurrent tetanus is rare, and there are no publicly available reports of a leprosy patient infected with tetanus that induced type 1 leprosy reactions.Case presentationA 56-year-old Chinese Han female presented to our hospital with symptoms of erythematous plaques and pain over her left upper limb for 2 days and foreign object sensation in her throat for 3 days. The patient had a 6-year history of leprosy. Type 1 leprosy reactions were initially considered, followed by treatment with methylprednisolone. Two days later, the patient’s symptoms were aggravated, with neck muscle tension and difficulty in opening her mouth, and the erythematous plaques had spread over most of her left upper limb. After further careful examinations, we confirmed the diagnosis of tetanus with concurrent type 1 leprosy reactions. The patient was given anti-tetanus treatment for 12 days and anti-leprosy reaction treatment for 4 months; the diseases were eventually controlled.ConclusionsThis report suggests that tetanus infection may be a trigger for type 1 leprosy reactions.

Integração entre pesquisa empírica e prática clínica psicanalítica: um estudo ilustrativo

Entre as alternativas para superar a dissociacao entre a investigacao cientifica e a pratica clinica psicanalitica, destaca-se a utilizacao de procedimentos empiricos que avaliam questoes clinicamente importantes, como a inclusao da perspectiva do psicoterapeuta no estudo e a publicacao de resultados de pesquisa em linguagem acessivel ao psicoterapeuta. O presente trabalho mostra, por meio de um estudo sistematico de caso unico de uma psicoterapia com uma paciente borderline, como dados clinicos e empiricos podem ser conjugados para ampliar a compreensao da paciente e das mudancas no seu funcionamento ao longo do 1o ano do tratamento. A sistematizacao do caso foi baseada nas anotacoes clinicas da psicoterapeuta e na aplicacao de dois instrumentos: o SWAP-200, que avalia personalidade, e o SCL-90-R, que examina a sintomatologia. Esses dados foram integrados para formular uma hipotese compreensiva clinico-empirica sobre o processo psicoterapico e as mudancas no funcionamento da paciente no 1o ano de tratamento. A conclusao indica que, embora nao seja uma tarefa simples, a integracao entre a pesquisa empirica e a pratica clinica psicanalitica e possivel e potencialmente util para ambos os campos. A superacao dessa historica separacao depende do esforco conjunto de psicoterapeutas e pesquisadores.Palavras-chave: pesquisa em psicoterapia psicanalitica, estudo de caso sistematico, processo psicoterapico.

Profile of Serum Interferon Gamma Induced Protein 10 in Borderline Leprosy Patients with and without Type 1 Leprosy Reaction

Background: Leprosy reaction is an acute episode in leprosy characterized by acute inflammation sometimes accompanied with systemic symptoms. Leprosy type 1 reaction often occurs in borderline leprosy patients. Leprosy type 1 reaction can cause peripheral nerve damage through neuritis that can lead to disability. Interferon-γ induced protein 10 (IP10) is a chemokine with chemotaxis function to various immune cells such as macrophage, dendritic cells, Natural Killer cells, and activated T lymphocites. Several studies have found an increase of IP10 serum level when type 1 reaction occurred. Purpose: To evaluate the profile of IP10 serum levels in borderline patients with and without type 1 leprosy reaction. Methods: This is a descriptive cross-sectional study, with 34 borderline leprosy patients of which 17 had leprosy type 1 reaction and 17 without reaction that qualify inclusion and exclusion criteria. Results: Mean serum IP10 levels in leprosy type 1 reaction groups are 594,123 ± 327,628 pg/mL and 331,648 ± 101,819 pg/mL in groups without reaction. Conclusions: Serum IP10 levels in borderline leprosy patient with type 1 reaction is higher than patients without reaction, although confounding factors in borderline leprosy patients with type 1 reaction that can influence serum IP10 levels cannot be eliminated. Further studies are needed to reveal the role of IP`10 in type 1 leprosy reaction.

Influence of clinicians' experience and gender on extraction decision in orthodontics.

To determine whether, in Class I borderline cases, experienced orthodontists choose nonextraction treatment more frequently than do orthodontists with less experience. A secondary aim was to evaluate whether clinicians' gender and place of education play a role in extraction decision making. An online survey was developed using three Class I borderline patient cases. The survey included questions about clinicians' demographics as well as questions about the selected cases. The survey was distributed to approximately 2000 clinicians through the American Association of Orthodontics. Of the 253 responses collected, a trend was observed wherein clinicians with more than 15 years of experience preferred an extraction treatment option more frequently than did clinicians with less than 5 years of experience. There was no association between gender and place of education and the decision to extract in the selected borderline cases. Crowding, patient's profile, and mandibular incisor inclination were among the top three reasons chosen by clinicians for both the extraction and nonextraction treatment decisions. A trend was observed in which clinicians with more experience chose an extraction treatment option more frequently in borderline cases than did those with less experience. Clinicians' gender did not play a role in extraction decision making.

The Powerless Therapist and the Helpless Borderline: Acceptance, Aloneness, and Dyadic Joining

ABSTRACTThe encounter between therapist and borderline patient brings with it a humbling experience of powerlessness. The therapist or helping agent must confront her or his own feelings of inability to change anything in the patient's mental or material life. With this comes a corresponding reality that the locus of therapeutic action remains very circumscribed indeed. Many therapists, particularly new ones to the field, may feel overwhelmed by anxiety, grief, guilt, and fear, tempting them to jump precipitously into interpretations or thinly veiled advice-giving—or, alternatively, to deflect emotion with hollow “empathic” mirroring. By actively getting in touch with and using his or her experience of powerlessness, however, the therapist can find a way forward that relies on dyadic joining and a more useful conception of the therapist/patient system (whose dynamics, as we will see, are also increasingly clarified thanks to emergent neuroscience findings). Central aspects of this approach have been present since borderline first appeared in the literature, continuing through more recent contributions, notably those of Marsha Linehan and the Dialectical Behavior Therapy (DBT) school.

Ulysses contracts regarding compulsory care for patients with borderline personality syndrome

Introduction Compulsory care is controversial, since respect for the patient’s autonomy is a standard requirement in health care. Many psychiatrists have experienced that patients with borderline personality syndrome sometimes demand compulsory care for themselves in order not to exert self-harm—like Ulysses contracts. The aim of this study was to examine the possible existence and extent of borderline personality syndrome-patient demands for Ulysses contracts regarding compulsory care in acute psychiatry, and how external influences and demands could affect the caregivers’ decisions about compulsory care. Method An anonymous questionnaire, with three questions with fixed answers, was distributed to 42 licensed medical doctors on call at the psychiatric emergency unit in the city of Stockholm. Thirty-three questionnaires were answered, giving a response rate of 79%. Results Ninety-four percent of the respondents recognized the phenomenon of borderline personality syndrome patients requesting compulsory care, 21% stated that this request had affected their clinical decision, and 55% had used compulsory care for other reasons than the patient’s best interest. Discussion The results indicate that compulsory care is sometimes given in the form of Ulysses contracts for borderline personality syndrome patients. Also, compulsory care is sometimes used for other reasons than the borderline personality syndrome patient’s best interest. Psychological mechanisms affect the decisions of both patients and caregivers. More research should be done concerning to whom, why, and with what consequences compulsory care is prescribed.

Recurrent Foreign Body Ingestions Following Rapid Methadone Taper: Neurological Aspects of Self-Injury and Opioid Therapy

Recurrent Foreign Body Ingestions Following Rapid Methadone Taper: Neurological Aspects of Self-Injury and Opioid Therapy

A Lacanian Perspective on the Case of Colette

A Lacanian perspective privileges speech as the motor of cure in the treatment of this borderline patient. In assuming such an ethical position, the clinician fostered a symbolic transference marked by an outburst of rage that signified a rupture of her entanglement with her mother. In this way, the clinician’s promotion of “full speech” breached the patient’s defensive need for “invisibility” and led her to produce a socially useful project.

Mentalization within Intensive Analysis with a Borderline Patient

The author discusses whether the concepts of mentalization are helpful within intensive, individual analytic work with a personality disordered patient. Child and adult technique within the widening scope of psychopathology can be thought of as building on developmental help, studied at the Anna Freud Centre from the sixties to reach ‘atypical’ children who could not use classical analysis. The first two years of work with Jenny, a young borderline woman, were anchored by developmental research on attachment and early parent–infant relating. Later, when her capacity to symbolize, tolerate and communicate affect had greatly improved, she could accept and use interpretations, and working in the transference was gradually able to be accepted as thinking and not only as action. The infantile modes of experiencing psychic reality hypothesized in mentalization theory are illustrated from the material, and the status of attachment within psychoanalytic theory is reconsidered. In the last section, how each psychotherapist specifically shapes the process of change will be discussed, building on the concept of ‘marked mirroring’.