History Of Borderline Personality Disorder Research Articles

A man with intentional ingestion in a suicide attempt.

A 31-year-old man with a history of borderline personality disorder and multiple foreign bodies ingestion presented to the emergency department with generalized abdominal pain and suicidal thoughts. Vital signs showed a temperature of 38.3°C (101°F) with a pulse rate of 112 beats/min and blood pressure of 138/72 mm Hg. Physical examination revealed general abdominal pain with no guarding. Laboratory examination indicated a white blood cell (WBC) count of 16,760/μL and a C-reactive protein level of 201.76 mg/dL. The radiography for the chest and abdomen showed multiple cylindrical batteries, 15 batteries in the epigastric and left hypochondriac region (Figures 1 and 2), 4 batteries in the right lumbar region, and 1 battery in the hypogastrium (Figures 3 and 4). Deliberate foreign body ingestion is commonly observed in patients with borderline personality disorder and other mental disorders. The high number of batteries detected by radiography in different places of the gastrointestinal system is a risk for bowel obstruction, corrosive injuries,1, 2 peritonitis, perforation, and death. Guidelines indicate that cylindrical batteries that remain in the stomach for over 48 hours after ingestion should be removed,3 but in the case of suspected clinical complications, an emergency surgery should be planned. Because of the suspected corrosive injuries of the batteries, an exploratory laparotomy was performed. A total of 20 cylindrical AA batteries were removed with no visual bowel injuries.

1812 Upper Esophageal Stenosis Secondary to Multiple Foreign Body Ingestions

INTRODUCTION: Multiple episodes of foreign bodies ingestion and subsequent esophagogastroduodenoscopies (EGDs) can lead to an uncommon and disabling complication- esophageal stenosis. We present an interesting case of recurrent foreign body ingestions complicated by upper esophageal stenosis making further foreign body retrieval difficult. CASE DESCRIPTION/METHODS: A 33-year-old female with a past medical history of borderline personality disorder, impulse control disorder and recurrent non-suicidal foreign body ingestions requiring multiple EGDs and surgeries presents to the emergency department after ingesting a battery. On arrival, she complained of trouble swallowing, chest pain and abdominal pain. Physical examination was remarkable for abdominal tenderness and guarding. Laboratory results showed hemoglobin of 8.4 gm/dl and hematocrit of 27.8%. Plain radiography of the chest and abdomen revealed a radiopaque tubular device overlying the stomach (Figure 1a) and a cylindrical radiopaque foreign body overlying the left upper quadrant over the stomach (Figure 1b), respectively. Patient was intubated and scheduled for an EGD. During the procedure, the patient was noted to have scarring and granulation polyp in the mid esophagus. (Figure 2) A battery was found in the gastric body and removed via a snare. During retrieval, the cricopharyngeus muscles were found to be tight and did not enable the passage of the battery. That required the use of Miller blade to open up the pharynx to enable safe passage. Battery was intact on removal. (Figure 3) The patient tolerated the procedure well and was discharged home after a period of observation. DISCUSSION: Foreign body ingestion and subsequent endoscopic procedures are associated with a variety of complications, including perforation, bleeding and infection. Those complications may result from the sedation as well as the diagnostic and therapeutic maneuvers performed. Our patient had a history of multiple foreign body ingestions, including knives and razor blades, requiring multiple EGDs for their removal. These together led to scarring of her esophagus with subsequent healing and contraction, resulting in esophageal stenosis. This warranted additional intervention and multidisciplinary approach for safe removal of the foreign body. Given the risk of esophageal stenosis in patient with recurrent foreign body ingestions, endoscopists should keep this complication in mind and be prepared with the needed equipment.

Analysis of taxine B/isotaxine B in a plasma specimen by LC–MS/MS in a case of fatal poisoning: concealed suicide by ingestion of yew (Taxus L.) leaves of a patient with a long-term history of borderline personality disorder

This case report deals with a 25-year-old woman who suffered from a long-term borderline personality disorder and from acute suicidal tendencies, including the intentional consumption of poisonous plants. When questioned during her self-referral to the psychiatric emergency department, she denied any suicide attempt or consumption of poisonous agents. Due to her medical history, her admission was followed by an intensive medical observation. During this observation period, the patient suffered an episode of acute respiratory insufficiency, which was followed by cardiac arrest. All resuscitation attempts were futile. Due to the unexplained nature of her death, the case was referred to the criminal investigation department. All findings of the routine systematic toxicological analysis of the patient’s blood sample, including immunochemical examinations and a high-performance liquid chromatography general unknown screening for drugs, were in accordance with the patient’s medication regimen and did not indicate a lethal overdose of any drug. During the analytical examinations, the deceased’s mother informed the psychiatric outpatient service of having found yew leaves in her daughter’s clothes and at her flat. The liquid chromatography--tandem mass spectrometry target analysis for yew pseudo-alkaloids (taxine B/isotaxine B) yielded a combined concentration of 110 µg/L. No autopsy was performed, because no criminality was suspected. In conclusion, it seems most plausible to conclude that the patient died of yew intoxication.

Suicide kit purchased on the Internet: A case report of self-poisoning with pentobarbital

Popularization of assisted-suicide and increase of online drug sellers could lead to resurgence of self-poisoning by a forgotten drug: pentobarbital. We report a case of self-poisoning with pentobarbital purchased on a Chinese website. A 43-year old woman with a background history of borderline personality disorder ingested at home a “suicide kit” (pentobarbital sodium) purchased beforehand on the Internet, a few minutes before calling the French national emergency telephone number. Upon admission, she was comatose, Glasgow Coma Score (GCS) 3/15, symmetrical slight myosis, generalized hypotonia and hyporeflexia. Blood pressure was 96/66 mmHg, heart rate was 93/min, and body temperature was 33.3 °C. Blood gas analysis showed a metabolic acidosis and severe hypoxemia, related to an aspiration pneumonia (arterial pH 7.30, pCO 2 40.7 mmHg, pO 2 63.3 mmHg with F i O 2 = 1). Hemodynamic instability rapidly appeared and norepinephrine infusion was started (up to 0.32 μg/kg/min). At day 2, clinical examination revealed signs consistent with brain death, i.e. bilateral mydriasis with absence of pupillary and oculo-cardiac reflexes. Electroencephalographic study found a severe diffuse slowing compatible with a sedative state. Plasma pentobarbital concentration was 19.9 μg/mL. At day 3, brain-stem reflexes reappeared, although pentobarbital concentration was still beyond lethal range, at 18.1 μg/mL. Neurological evolution was then progressively favourable. GCS was 5/15 at day 5, corresponding to a concentration of 9.4 μg/mL, and 15/15 at day 6 allowing extubation of the patient. She was finally discharged to the psychiatry department at day 10. Pentobarbital is a short-acting barbiturate, now rarely used in suicide attempt because it is no longer prescribed for medical purposes in most countries. Only a few cases have been published in the last decade, mostly among veterinarians because this drug is used as euthanasia agent. Pentobarbital is indeed the drug of choice for assisted-suicide. Pentobarbital is a weak acid with high lipid-solubility. After oral absorption, it is readily absorbed with an onset of action of 10 to 60 minutes. The degree of protein binding is about 45 to 70% and the volume of distribution is 0.5 to 1L/Kg. The plasma half-life for pentobarbital is 15 to 50 hours and appears to be dose-dependent. Renal excretion is negligible (< 1%). Pentobarbital is metabolized by the liver and excreted in the urine as inactive metabolites. Consciousness impairment, respiratory and circulatory depression are the main effects of acute poisoning. At worst, severe poisoning can mimic clinical and EEG features of brain death. Therapeutic blood levels are 1–3 μg/mL; levels are considered toxic at 5 μg/mL or more and reported lethal blood concentrations range from 10 to 169 μg/mL. Management of pentobarbital poisoning is mainly based on supportive care. Invasive mechanical ventilation, fluid loading and vasopressors are required in most severe cases. Several procedures to enhance elimination have been reported. Forced diuresis with urinary alkalinisation is not effective for short-acting barbiturates. Hemodialysis, hemoperfusion or continuous venovenous hemodiafiltration have been proposed as therapeutic options but improvement in supportive therapies make these techniques obsolete. Pentobarbital is readily available without prescription on the Internet. Although there is little public awareness about this drug, current mediatisation of assisted-suicide could lead to an increased interest from suicide attempters. Supportive care is the cornerstone of medical management.

Antibiomania: Clarithromycin-Induced Mania?

The authors present a case of antibiomania in a 55-year-old woman with a previous history of borderline personality disorder, anorexia nervosa, and longlasting anxious and depressive symptomatology associated with her husband´s serious illness. The switch to mania occured after two 500mg doses of clarithromycin – the third antibiotic she had been administered in four months. Manic symptoms were so severe that involuntary hospitalization was required. Signs of mania disappeared within a week in the psychiatric ward. The authors submit the hypothesis that the pathogenetic pathway of this sudden reversal into mania may have been triggered by clarithromycin-induced dysmicrobia of the intestinal flora, which crossed into the CNS through either a leaky gut or by direct stimulation of the nervus vagus.

A Case of Factitious Subfascial Emphysema

A 44-year-old woman with a history of borderline personality disorder, Hepatitis C, and multiple hospital admissions for cellulitis and cutaneous abscesses presented with pain of several days duration in her left upper extremity following getting her left arm "stuck" in a subway turnstile. The pain and swelling had progressively worsened following the injury. At the time of presentation the patient's temperature was 98.6 degrees F, heart rate was 82 beats/minute, blood pressure of 116/60, and an oxygen saturation of 98% on room air. The left upper extremity was diffusely swollen but minimally tender throughout. Crepitus was noted along the left arm, elbow and forearm areas. No open wounds were visualized during the examination. Radiographs and computed tomography revealed diffuse subcutaneous emphysema extending from the left axillary region to the wrist, as well as gas beneath the fascia extending between multiple muscles in both the upper and lower areas of her left upper extremity. The possibility of necrotizing fasciitis or gas gangrene prompted immediate operative exploration. No evidence of infection was found during the exploration. Stat gram stains sent during the procedure revealed no organisms. Aerobic, anaerobic, fungal, and acid-fast bacteria cultures taken during the operation revealed no final growth. The patient was stable throughout the hospitalization, remaining afebrile with a normal white blood cell count. The gas in the subcutaneous and subfascial layers was not caused by infection but presumably was due to factitious self-injection of air.

Depression and chorea

3. Wilson’s disease. Depression and choreaJournal of Clinical NeuroscienceVol. 14Issue 9PreviewA 43 year old woman with a history of borderline personality disorder and depression presented with a debilitating movement disorder and leg weakness, progressive over a number of years. She described involuntary limb movements, decreased mobility with frequent falls as well as dysarthria and dysphagia. On examination she was alert and orientated, although emotionally labile. Her speech was slurred. Cranial nerve examination was unremarkable. Choreiform movements of her upper limbs were identified. Full-Text PDF

A Jacksonian and biopsychosocial hypothesis concerning borderline and related phenomena.

The aim of this paper is to develop an aetiological model for borderline personality disorder. The postulates of Hughlings Jackson are used to provide a preliminary explanatory framework for borderline phenomena. As a necessary background to this discussion, the findings concerning abuse in the early history of borderline personality disorder (BPD) and other conditions, notably somatisation disorder and dissociative states, are briefly reviewed. Other data, including family studies, which might have significance in the aetiology of BPD are also reviewed. The hypothesis is put forward that the symptoms of BPD are due to the failure of 'experience-dependent' maturation of a cascade of neural networks, with prefrontal connections, which become active relatively late in development and which coordinate disparate elements of central nervous system function. These networks subserve higher psychological functions, including attentional focus and affect regulation. They also underpin the reflective function necessary to the emergence of self as the stream of consciousness, which appears at about the age of 4 years. Adverse developmental circumstances may produce an interrelated set of symptom clusters, with associated neural network disturbances that are amenable to investigation with psychometric and brain imaging techniques. Since these disturbances are seen as 'experience-dependent', they are considered reversible, at least in part.

Effectiveness of psychotherapy for personality disorders.

The authors examined the evidence for the effectiveness of psychotherapy for personality disorders in psychotherapy outcome studies. Fifteen studies were located that reported data on pretreatment-to-posttreatment effects and/or recovery at follow-up, including three randomized, controlled treatment trials, three randomized comparisons of active treatments, and nine uncontrolled observational studies. They included psychodynamic/interpersonal, cognitive behavior, mixed, and supportive therapies. All studies reported improvement in personality disorders with psychotherapy. The mean pre-post effect sizes within treatments were large: 1.11 for self-report measures and 1.29 for observational measures. Among the three randomized, controlled treatment trials, active psychotherapy was more effective than no treatment according to self-report measures. In four studies, a mean of 52% of patients remaining in therapy recovered--defined as no longer meeting the full criteria for personality disorder--after a mean of 1.3 years of treatment. A heuristic model based on these findings estimated that 25.8% of personality disorder patients recovered per year of therapy, a rate sevenfold larger than that in a published model of the natural history of borderline personality disorder (3.7% recovered per year, with recovery of 50% of patients requiring 10.5 years of naturalistic follow-up). Psychotherapy is an effective treatment for personality disorders and may be associated with up to a sevenfold faster rate of recovery in comparison with the natural history of disorders. Future studies should examine specific therapies for specific personality disorders, using more uniform assessment of core pathology and outcome.

Intentional overdose by intravaginal insertion of lithium carbonate

To the Editor. —A 48-year-old woman with bipolar disorder and a history of borderline personality disorder and previous suicide attempts presented to an outlying emergency department, having recently vomited. She admitted to the ingestion, 60 minutes earlier, of 97 lithium carbonate tablets (immediate release, 300 mg each). Her vital signs were stable. Initial physical examination was normal except for mild lethargy and decreased patellar reflexes. An electrocardiogram showed mild T-wave flattening. Complete blood cell count and urinalysis were normal; a serum toxicology screen was negative except for lithium. Serum potassium was decreased at 3.3 mmol/L and serum lithium was 4.3 mmol/L. Gastric lavage revealed pill fragments. After stabilization, the patient was transported to our medical center's intensive care unit. On arrival the serum lithium level was 3.1 mmol/L. Potassium supplementation was provided along with intravenous fluids. Lithium levels rose to 3.5 mmol/L, and hemodialysis was instituted, resulting in a decrease