Cases That Test Your Skills

The manipulative self-harmer Ali Hashmi, MD, and Dennis R. Vowell, Jr, PsyD

How would you Involuntarily admitted to a forensic unit, Ms. L often tests handle this case? the staff by hurting herself and making suicidal gestures. Visit CurrentPsychiatry.com to input your answers Which treatments would you try? and see how your colleagues responded

CASE Self-destructive behaviors injuring herself after perceived wrongdoings by After being acquitted of 4 counts of second- staff. For example, after her therapist resched- degree forgery for writing checks from her ules a meeting because of an emergency, Ms. L mother’s bank account, Ms. L, age 52, is sent to pours scalding water on her foot. the state hospital for a forensic examination to determine competency. Two years later she is How would you address Ms. L’s manipulative granted conditional release from the hospital, self-harm? transferred to our not-for-profit community a) confront her in therapy to process trans- mental health center, and enrolled in an in- ferential issues tensive inpatient treatment program to moni- b) help her develop less destructive coping tor forensic patients. She is legally required to skills comply with treatment recommendations. c) help her identify patterns of irrational At admission, Ms. L is diagnosed with major thoughts that contribute to self-harm depression, recurrent, and borderline personal- d) ignore the acts ity disorder (BPD). She has no history of antiso- cial behavior or criminal acts other than forging The authors’ observations checks and has never spent time in prison, Ms. L consistently displays 3 common con- which makes it unlikely she has co­morbid anti- structs of BPD: social personality disorder (Table 1).1 • primitive defense mechanisms Over the next 5 years Ms. L tests limits with • identity diffusion the treatment team and acts out by engaging • generally intact reality testing.2 in self-harming behaviors. In 1 instance, she Defense mechanisms are psychological cuts her forearm deeply, stuffs the wound with attempts to deal with intrapsychic stress. mayonnaise and paper towels, and wraps her Splitting—vacillating between extremes arm with a bandage. She wears a long-sleeved of idealization and devaluation—is a fun- shirt to hide her wound, which is not discov- damental primitive defense mechanism ered until a severe infection develops. that is the root of BPD.2 Identity diffusion Ms. L has difficulty with coping skills and causes confusion about life goals and val-

interpersonal relationships. She approaches Dr. Hashmi is medical director, Mid-South Health Systems, others with ambivalence and mistrust and con- Jonesboro, AR, and clinical instructor, department of psychiatry, sistently expects them to demean or take ad- University of Arkansas for Medical Science, College of Medicine, Current Psychiatry Little Rock, AR. Dr. Vowell is a clinical psychologist, Mid-South 44 June 2010 vantage of her. Ms. L is manipulative, at times Health Systems, Paragould, AR. Cases That Test Your Skills

Table 1 Cluster B personality disorders: Differential diagnosis Diagnosis Features Borderline personality Self-destructiveness, angry disruptions in close relationships, and disorder chronic feelings of deep emptiness and loneliness Histrionic personality disorder Attention seeking, manipulative behavior, and rapidly shifting emotions Antisocial personality disorder Manipulative to gain profit, power, or other material gratification Source: Reference 1

ues and feelings of boredom and empti- should have my head cut open and cut into ness. This internal world leads a patient to little pieces for thinking such mean thoughts.” Clinical Point have the same perception of the external Ms. L dropped out of school in the twelfth Impulsivity, substance world, which explains many symptoms of grade but obtained her general educational BPD, such as rapidly shifting moods, in- development certificate. abuse, and parental tense anger, lack of clear sense of self, fear Notes and letters Ms. L wrote while in treat- neglect—all of which of abandonment, and unstable and intense ment consistently refer to her negative self- are associated with interpersonal relationships.2 image. Ms. L writes that she feels she does not BPD—can increase deserve to “be a part of this world,” is “never Early in treatment, Ms. L had difficulty risk of criminality breaking a cycle of self-defeating behavior, good enough for anyone,” and “should be such as destroying personal items, trying thrown away with the garbage.” to hang herself, and gluing an ear plug in Ms. L vacillates between desiring a closer her ear. During an argument with a staff relationship with her parents, especially her member, Ms. L punched a wall and frac- mother, and wanting to “cut them out of my tured her left hand. BPD patients some- life for good.” She has minimal contact with times will “up the ante” when acting out. her older sister. Ms. L is divorced and has 2 For example, one of our patients claimed adult sons. She was involved sporadically in to have planted a bomb in an elementary her sons’ lives when they were children, but school and another swallowed inedible now has no contact with them. objects, including spoons, forks, and butter knives. In Ms. L’s case, we addressed her self-harm behavior by helping her: BPD and crime • develop less destructive coping skills Ms. L is enrolled in the “911 program,” such as drawing or painting which monitors individuals who have • identify irrational thoughts that con- been found not guilty by reason of men- tribute to self harm. tal defect. Individuals with BPD often are convicted of serious and violent crimes, which may be because of BPD features HISTORY Troubled past such as interpersonal hostility and self- Raised by her biologic parents, Ms. L met all harm. Impulsivity, substance abuse, and developmental milestones. She denies a his- parental neglect—all of which are associ- tory of childhood abuse but reports expe- ated with BPD—can increase risk of crimi- riencing “depression and memory loss” and nality.3 There is no evidence to suggest a relationship problems with her parents dur- direct link between BPD and criminality; ing adolescence. As a child she often missed however, over-representation of BPD in school because she “did not want anyone to prison populations suggest that in severe Current Psychiatry know what a disgusting person I was” and “I cases it may increase criminogenic risk.1,3 Vol. 9, No. 6 45 continued Cases That Test Your Skills

Table 2 Features of psychotherapeutic modalities for BPD Description Mode of treatment Skills taught Dialectical Manualized, time-limited, Individual therapy, group Core mindfulness skills, behavior cognitive-behavioral skills training, telephone interpersonal effectiveness therapy approach based on the contact, and therapist skills, emotion modulation biosocial theory of BPD consultation skills, and distress tolerance skills Systems Manual-based, group 20-week basic skills Awareness of illness, Training for treatment that includes group and a 1-year, emotion management Emotional a systems component twice-monthly advanced skills, and behavior Predictability to train family members, group program; utilizes management skills and Problem friends, and significant a classroom ‘seminar’ Solving others format Clinical Point BPD: borderline personality disorder Pharmacotherapy typically targets affective dysregulation, TREATMENT Worsened depression and impulse control but the consulting neu- impulsive-behavioral When Ms. L arrives at our facility, her medica- rologist prescribes carbamazepine, 400 mg/d, 5,6 dyscontrol, and tion regimen includes fluoxetine, 80 mg/d, and her pain improves. risperidone, 2 mg/d, and buspirone, 20 mg/d. cognitive-perceptual Risperidone and buspirone are discontinued How would you treat Ms. L? symptoms because of perceived lack of efficacy. Venlafax- a) restart the higher dose of venlafaxine ine XR is added and titrated to 300 mg/d, and b) add a mood stabilizer, such as valproic Ms. L receives lorazepam, 1 and 2 mg as need- acid or lithium ed. However, lorazepam carries risks because c) add a second-generation antipsychotic, impulsivity and impaired judgment—which such as ziprasidone or olanzapine are common in BPD—can lead to dependence d) increase the frequency and intensity of psy- and abuse. We feel that in a supervised setting chotherapy sessions with an emphasis on the risks can be managed. setting limits on her self-injurious behavior. Recently, staff witnessed Ms. L experienc- ing an episode that appeared to be a grand The authors’ observations mal seizure. After Ms. L is evaluated at the lo- BPD treatment primarily is psychothera- cal emergency room, her EEG is normal, but a peutic and emphasizes skill building neurologic consult recommends discontinu- (Table 2) with focused, symptom-targeted ing fluoxetine or venlafaxine XR because they pharmacotherapy as indicated.4 Pharma- may have contributed to the seizure. We taper cotherapy typically targets 3 domains: and discontinue venlafaxine XR but Ms. L com- • affective dysregulation plains bitterly that she is getting increasingly • impulsive-behavioral dyscontrol depressed. On several occasions she attempts symptoms to pit team members against each other. • cognitive-perceptual symptoms. Ms. L falls, injures her back, and begins to Patients with prominent anxiety may abuse opiates. After her prescription runs out, benefit from benzodiazepines, although she obtains more from an intellectually lim- research on these agents for BPD is lim- ited patient in her treatment program. Ms. L ited. Recent studies show efficacy with says she is getting more depressed, threatens fluoxetine, olanzapine, or a combination suicide, and is placed in a more restrictive in- of both,7 and divalproex.8 Preliminary data patient setting. We consider adding pregaba- supports the use of topiramate, quetiapine, Current Psychiatry 46 June 2010 lin to address her pain and help with anxiety risperidone, ziprasidone, lamotrigine, and Cases That Test Your Skills

Table 3 Pharmacotherapy for BPD: What the evidence says Study Design Results Hollander et 96 patients with Cluster B personality Divalproex was superior to placebo al, 20039 disorders randomized to divalproex or placebo in treating impulsive aggression, for 12 weeks irritability, and global severity Hilger et al, Case report of 2 women with BPD and Quetiapine resulted in a marked 200310 severe self-mutilation receiving quetiapine improvement of impulsive behavior monotherapy and overall level of function Rizvi, 200211 Case report of a 14-year-old female with Over 6 months of inpatient borderline personality traits admitted to an treatment, suicidal behavior and inpatient facility for suicide attempt, impulsive ideation diminished and impulse behavior, and mood lability. Lamotrigine was control and mood lability improved; started at 25 mg/d and titrated to 200 mg/d. continued improvement at 1-year At admission, she was receiving clonazepam, follow up Clinical Point valproic acid, quetiapine, and fluoxetine, which were tapered and discontinued A recent review Rocca et al, 15 BPD outpatients with aggressive behavior Risperidone produced a significant and meta-analysis 200212 given risperidone (mean dose 3.27 mg/d) in an reduction in aggression based on showed efficacy 8-week open-label study AQ scores, reduction in depressive symptoms, and an increase in with topiramate, energy and global functioning lamotrigine, valproate, Philipsen et 14 women with BPD given oral clonidine, Clonidine significantly decreased al, 200413 75 and 150 µg, while experiencing strong aversive inner tension, dissociative aripiprazole, and aversive inner tension and urge to commit symptoms, and urge to commit olanzapine self-injury self-injury as measured by self- rated scales Pascual et al, A 2-week open-label study of 10 females and 9 patients who completed 200414 2 males presenting to psychiatric emergency the study showed statistically service for self-injurious behavior, aggression/ significant improvements on hostility, loss of impulse control, and severe CGI-S, HAM-D-17, HAM-A, BPRS, anxiety/depressive symptoms received IM and BIS ziprasidone, 20 mg, followed by flexible oral dosing between 40 mg/d and 160 mg/d AQ: Aggression Questionnaire; BIS: Barratt Impulsiveness Scale; BPD: borderline personality disorder; BPRS: Brief Psychiatric Rating Scale; CGI-S: Clinical Global Impressions-Severity of Illness; HAM-A: Hamilton Anxiety Rating scale; HAM-D-17: 17-item Hamilton Depression Rating scale

clonidine (Table 3).9-14 A recent review and self-injurious behaviors, the intensity and fre- meta-analysis showed efficacy with topira- quency are reduced and she does not inflict mate, lamotrigine, valproate, aripiprazole, any serious injury for 18 months. Her mood and olanzapine.15 and behavior continue to oscillate; she is rel- For Ms. L, we restart venlafaxine at atively calm and satisfied 1 week, angry and a lower dose of 50 mg/d and titrate it to assaultive the next. This stormy course is ex- 150 mg/d, which is still lower than her pected given her BPD diagnosis. previous dose of 300 mg/d. She has no Initially, Ms. L resided in a locked residen- recurrence of seizures and her depression tial unit and was minimally compliant with improves. treatment recommendations and unit poli- cies. As treatment progressed she moved to a different locked unit and eventually to an OUTCOME Some improvement apartment. Recently, she was placed in a more Ms. L has no dramatic suicidal gestures for 3 restrictive setting because her hostile and self- Current Psychiatry years. Although she continues to engage in destructive behavior escalated. Vol. 9, No. 6 47 continued Cases That Test Your Skills

therapy, and refrains from self-mutilation. Related Resources She still experiences volatile moods, but can • Oldham JM. Guideline watch: practice guideline for the handle them without inflicting self injury. treatment of patients with borderline personality disorder. Arlington, VA: American Psychiatric Association; 2005. www. psychiatryonline.com/content.aspx?aID=148722. References 1. Diagnostic and statistical manual of mental disorders, 4th • Koenigsberg HW, Kernberg OF, Stone MH, et al. Borderline ed, text revision. Washington, DC: American Psychiatric patients: extending the limits of treatability. New York, NY: Basic Association; 2000. Books; 2000. 2. Koenigsberg HW, Kernberg OF, Stone MH, et al. Borderline patients: extending the limits of treatability. New York, NY: Drug Brand Names Basic Books; 2000. Aripiprazole • Abilify Lorazepam • Ativan 3. Nee C, Farman S. Female prisoners with borderline Buspirone • Buspar Olanzapine • Zyprexa personality disorder: some promising treatment Carbamazepine • Tegretol Quetiapine • Seroquel developments. Crim Behav Ment Health. 2005;15:2-16. Clonidine • Catapres Pregabalin • Lyrica 4. Oldham JM, Bender DS, Skodol AE, et al. Testing an Divalproex • Depakote Risperidone • Risperdal APA practice guideline: symptom-targeted medication utilization for patients with borderline personality Fluoxetine • Prozac Topiramate • Topamax disorder. J Psychiatr Pract. 2004;10:156-161. Fluoxetine-olanzapine • Valproic acid • Depakene Clinical Point 5. American Psychiatric Association Practice Guidelines. Symbyax Venlafaxine XR • Effexor XR Practice guideline for the treatment of patients with Lamotrigine • Lamictal Ziprasidone • Geodon borderline personality disorder. Am J Psychiatry. It is not clear if Lithium • Eskalith, Lithobid 2001;158(suppl 10):1-52. the gains Ms. L 6. Yatham LN. Newer anticonvulsants in the treatment of Disclosures bipolar disorder. J Clin Psychiatry. 2004;65(suppl 10):28-35. made within a very Dr. Hashmi is on the speakers bureau for AstraZeneca, Eli Lilly and 7. Rinne T, van den Brink W, Wouters L, et al. SSRI treatment Company, and Janssen. of borderline personality disorder: a randomized, placebo- structured treatment controlled clinical trial for female patients with borderline Dr. Vowell reports no financial relationship with any company personality disorder. Am J Psychiatry. 2002;159(12): setting would have whose products are mentioned in this article or with 2048-2054. manufacturers of competing products. 8. Zanarini MC, Frankenburg FR, Parachini EA. A been possible if she preliminary, randomized trial of fluoxetine, olanzapine, and the olanzapine-fluoxetine combination in women was living on her own with borderline personality disorder. J Clin Psychiatry. 2004;65(7):903-907. 9. Hollander E, Tracy KA, Swann AC, et al. Divalproex in The authors’ observations the treatment of impulsive aggression: efficacy in cluster B personality disorders. Neuropsychopharmacology. 2003; Ms. L is no different from most Axis II 28(6):1186-1197. Cluster B disordered patients. During 10. Hilger E, Barnas C, Kasper S. Quetiapine in the treatment of borderline personality disorder. World J Biol Psychiatry. treatment she shows improvement by re- 2003;4(1):42-44. fraining from self-destructive behaviors 11. Rizvi ST. Lamotrigine and borderline personality disorder. J Child Adolesc Psychopharmacol. 2002;12(4):365-366. for up to 18 months, but she then briefly re- 12. Rocca P, Marchiaro L, Cocuzza E, et al. Treatment of verts back to maladaptive behaviors. Ms. L borderline personality disorder with risperidone. J Clin Psychiatry. 2002;63(3):241-244. resides in a very structured treatment set- 13. Philipsen A, Richter H, Schmahl C, et al. Clonidine in ting. It is not clear if the gains she made in acute aversive inner tension and self-injurious behavior in female patients with borderline personality disorder. J Clin treatment would have been possible if she Psychiatry. 2004;65(10):1414-1419. was living on her own in the community. 14. Pascual JC, Oller S, Soler J, et al. Ziprasidone in the acute treatment of borderline personality disorder in One year after finishing the court- psychiatric emergency services. J Clin Psychiatry. 2004; 65(9):1281-1282. mandated “911 program,” Ms. L lives in 15. Lieb K, Völlm B, Rücker G, et al. Pharmacotherapy for the community, draws and paints quite borderline personality disorder: Cochrane systematic review of randomised trials. Br J Psychiatry. 2010;196(1): well, attends weekly individual and group 4-12.

Bottom Line Patients with severe borderline personality disorder (BPD) often exhibit hostility, impulse dyscontrol, and self-harm behaviors, which can lead treating clinicians to feel frustrated, helpless, and angry. BPD treatment is primarily psychotherapeutic, but pharmacotherapy Current Psychiatry 48 June 2010 may relieve specific symptoms.