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J Am Board Fam Pract: first published as 10.3122/jabfm.6.4.385 on 1 July 1993. Downloaded from As A Manifestation Of Borderline Personality Disorder In Primary Care

Thomas M. johnson, PhD

IltIcllground: Patients with borderline personality disorder often are found and treated in psychia1ric settings following episodes of self-mutilation, such as wrist-slashing. Family physicians care for many patients with borderline personality disorder, but in primary care settings wist-slashing or other physical muti1ation is a less common presenting problem. Frequently these patients complain of such symptoms as and vomiting that do not so obviously suggest psychopathology. Methods: Three primary care patients with borderline personality disorder in whom episodic vomiting was the chief complaint are presented. Hypotheses from the literature about the neurobiology of vomiting and self-mutilation are discussed. Results: Vomiting is a primary care analogue of self-muti1ation in some patients with borderline personality disorder. Conclusions: Family physicians should include careful history 1aking to corroborate other features of borderline personality disorder in evaluating patients with persistent, episodic vomiting. Obtaining a history of early sexual abuse or chronic interpersonal problems as an adult should not only mitigate the compulsion for extensive, costly, and invasive gastrointestinal system evaluations in such patients, but also suggest more effective treatment strategies. (J Am Board Fam Pract 1993; 6:385-94.)

Personality disorders (axis IT disorders in the sive gastrointestinal system evaluations in certain DSM-ill-Rl) are relatively inflexible, maladap­ primary care patients with episodic vomiting. tive ways of perceiving and relating to both one­ self and others, leading to personal distress and Borderline Personality Disorder impairment of social and occupational function­ Borderline personality disorder is estimated to ing. They also are the least likely common psychi­ affect 5 to 10 percent of the general population http://www.jabfm.org/ atric problems to be diagnosed by primary care and perhaps 15 percent of hospitalized patients.3-5 physicians.2 Borderline personality disorder is a A recent review summarized borderline personal­ particularly pernicious condition that frequently ity disorder and its treatment in primary care.6 is diagnosed in emergency department settings Although there could be a biological predisposi­ when patients are treated for self-mutilation, tion to the disorder,4 the genesis of borderline typically by wrist-slashing. personality disorder is usually attributed to perva­

This report of three patients shows that pa­ sive inconsistencies in early relationships with on 25 September 2021 by guest. Protected copyright. tients with borderline personality disorder can others, such as abandonment by parents or by come to a family physician with a different com­ sexual, emotional, or physical abuse/-to The be­ plaint - episodic vomiting - which can be viewed havioral manifestations of borderline personality as a primary care analogue of self-mutilation. By disorder are outlined in the DSM-ill-R (fable 1). taking a careful history, family physicians can in­ The lives of persons with borderline personal­ crease their awareness of borderline personality ity disorder are marked by episodic affective and disorder while simultaneously mitigating the behavioral instability, although periods of pro­ compulsion to conduct extensive, costly, and inva- found upheaval are typically interspersed with periods of apparent competence. Persons with Submitted, revised, 9 March 1993. borderline personality disorder have chaotic From the School of Primary Medical Care, University of Ala­ interpersonal relationships, which result from bama in Huntsville. Address reprint requests to Thomas M.John­ lack of a capacity for basic trust so profound that son, PhD, School of Primary Medical Care, University of Ala­ bama in Huntsville, 201 Governors Drive, Sw, Huntsville, AL they vacillate between overidealization and de­ 35801. valuation of both themselves and others as they

Vomiting and Borderline Personality Disorder 385 J Am Board Fam Pract: first published as 10.3122/jabfm.6.4.385 on 1 July 1993. Downloaded from

Table 1. DSM-II1-R Criteria for Borderline Personality Explanations for self-mutilation in individuals Disorder. with borderline personality disorder include 1. A pattern of unstable and intense interpersonal relation­ (1) expressions of rage turned inward, (2) at­ ships characterized by alternating between extremes of tempts to communicate, and (3) strategies for overidealization and devaluation relieving dysphoria. The first is an expression of 2. Impulsiveness in at least two areas that are potentially self­ rage resulting from some perceived wrong or the damaging failure of others to be supportive and caring. In 3. Affective instability: marked shifts from baseline mood to the second, self-mutilation is a manipulative way , irritability, or , usually lasting a few hours and rarely more than a few days of expressing hurt, anger, frustration, and needi­ 4. Inappropriate, intense anger or lack of control of anger ness. The third explanation is based on the recog­ (e.g., frequent displays of temper, constant anger) nition that self-mutilation usually occurs when 5. Recurrent suicidal threats, gestures, or behavior, or self­ patients feel extreme dysphoria. mutilating behavior Phenomenologically, borderline personality 6. Marked and persistent identity disturbance manifested by disorder patients describe tension and feelings of uncertainty about at least two of the following: self-image, "coming part inside," "shrinking into nothing­ sexual orientation, long-term career goals or career choice, type of friends desired, preferred values ness," "," or "lack of feeling." Although there can be amnesia to the actual physical act and 7. Chronic feelings of emptiness or boredom the resultant pain, patients who slash their wrists 8. Frantic efforts to avoid real or imagined abandonment typically report feeling relief from dysphoria at the moment of the act, followed by a trancelike desperately search for evidence that individuals state of calm. Afterward, there often are feelings are either all good or all bad (tenned splitting). of self-reproach or self-hatred and a recognition Borderline patients also are highly sensitive to that what they had done was dangerous. Sub­ rejection and susceptible to abandonment depres­ sequendy, patients again faced with the dysphoria sion. Having a poor self-image, such patients have might try to postpone self-mutilation but finally strong needs to be in relationships in which they succumb when anxiety becomes intolerable. are dependent (tenned object hunger). Never­ Self-mutilating patients with borderline per­ theless, they expect to be abandoned and often sonality disorder seem to experience a special react in hostile and accusatory ways to seemingly type of anticipatory anhedonia. Although they benign behavior on the part of others. cannot anticipate pleasure, once they become http://www.jabfm.org/ Family physicians often experience patients with involved in an activity, they have some capacity borderline personality disorder as emotionally drain­ for enjoying it. 5 It is important to distinguish ing because such patients experience few sustained between anticipatory anhedonia and the more periods of physical or emotional well-being. global anhedonia experienced by suicidal patients Borderline personality disorder patients often with classic major depressions. Some individ­ create disagreement and tunnoil among office uals with borderline personality disorder who on 25 September 2021 by guest. Protected copyright. staff3,6 and also can be frustrating for family phy­ self-mutilate also suffer from superimposed, clas­ sicians because they typically present with difficult­ sic endogenous depressions and are at much to-treat problems, such as dysthymia, major de­ greater risk for planned, lethal suicide attempts. pression, substance abuse, or somatofonn disorders. The borderline patient with only anticipatory anhedonia is more prone to low-risk, impulsive Self-Mutilation ,,, Patients UJltb Ikmlerll"e self-mutilation. Perstmililty DIsorder One symptom thought to be pathognomonic of Case Reports borderline personality disorder in psychiatric set­ Each of the following family practice patients had tings is repetitive self-destructive acts. These acts episodic vomiting as a primary complaint. Careful can take more subde forms, such as drug and history and psychodiagnostic interviewing re­ abuse, or they can involve more overt vealed that all three patients met criteria for self-mutilation, including wrist-slashing, ciga­ borderline personality disorder and that the rette bums, or scratching the skin, always without vomiting had dysphoria-reducing or attention­ the intention of producing death. seeking qualities.

386 JABFP July-August 1993 Vol. 6 No.4 J J Am Board Fam Pract: first published as 10.3122/jabfm.6.4.385 on 1 July 1993. Downloaded from lAse 1 was soft with infrequent bowel sounds A 26-year-old woman was hospitalized after being and no rebound or guarding. Guaiac testing of seen twice in 3 days in a family medicine out­ stool for occult was negative. A urine preg­ patient clinic. On her initial clinic visit she com­ nancy test was negative. Laboratory data were plained of persistent nausea, vomiting, and mild essentially unchanged. Diagnostic work-up in­ abdominal cramping for 4 days. She denied any cluded a gallbladder sonogram, an upper gastro­ fever, chills, , or . She also intestinal barium radiograph with a small-bowel complained of constant, dull, left-Iower-quadrant follow-through, and computed tomographic (CI) , as well as a creamy vaginal dis­ scans of the abdomen and pelvis. Upright and charge and dysuria. During the physical examina­ plane films of the abdomen, as well as a barium tion the patient was in no apparent distress; her enema, were obtained. All findings were within abdomen was soft and without guarding, rebound normal limits, although slight was tenderness, or palpable masses. A foul-smelling noted on abdominal CT scan. Gynecologic con­ vaginal discharge showed clue cells on micro­ sultants did not believe that there was an organic scopic examination. A gonorrhea culture was disorder to explain the patient's symptoms. negative. There were no other unusual physical Although the patient was witnessed vomiting findings. The patient's condition was diagnosed as small amounts in the hospital, she was never mild pelvic inflammatory disease and nonspecific awakened by nausea and vomiting at night. Sev­ vaginitis, and she was sent home with prescrip­ eral days into her hospitalization, nursing staff tions for doxycycline 100 mg twice a day for 10 observed the patient to be chewing her , days and promethazine suppositories 25 mg every mixing it with fluid, and spitting it back into the 4 to 6 hours. emesis trays, pretending to be . In addi­ The patient returned to the outpatient clinic tion to no abnormalities indicative of 2 days later complaining of continued nausea and protracted vomiting, promethazine administered vomiting, despite using promethazine supposi­ orally, rectally, intramuscularly, and intravenously tories. She appeared to have no acute distress, and did not alleviate the symptoms, which became good skin turgor and moist mucous membranes worse each time discharge plans were discussed. were noted. Her abdominal examination was re­ Psychological consultation was obtained on the markable for continued mild pain, now in the left patient's 12th hospital day. Diagnostic interviews upper quadrant, as well as bilateral pelvic tender­ were conducted, and a Minnesota Multiphasic http://www.jabfm.org/ ness. Her weight was 152.5 pounds, blood pres­ Personality Inventory (MMPl)ll was obtained sure 110170 mmHg, and temperature 99.0°F. and scored. Pertinent details of the patient's his­ Laboratory data were sodium 142 mEqlL, potas­ tory were that she was sexually abused by a grand­ sium 4.7 mEqIL, chloride 109 mEqlL, blood father from the ages of 2 to 20 years, and she had nitrogen (BUN) 22 mg/dL, creatinine 1.5 mg/dL, been in therapy at a local women's center for the glucose 81 mgldL. Because borderline elevations year before this admission. She had 3 children, of BUN and creatinine could be attributed to each with a different father. Two of the children on 25 September 2021 by guest. Protected copyright. mild , she was given fluids intra­ lived with the patient at the time of hospitaliza­ venously. She also received intramuscular tion, although she had no contact with either ceftriaxon and promethazine in the clinic and was father. WIth her third pregnancy, the result of a referred for an abdominal sonogram, which was. rape, the baby was carried to term and given up unremarkable. for adoption. The patient was engaged but had no The patient was admitted to the hospital the immediate plans to marry, and she had a turbulent next day complaining of continued intractable relationship with her fiance, as well as with her vomiting, fever, chills, and no bowel movements mother. for 7 days. On admission her temperature was Importantly, the patient's therapist at the 99.2°F, blood pressure 120/90 mmHg, and pulse women's center terminated therapy approxi­ 76 beats per minute. Physical examination was mately 1 week before her admission to the hospi­ unremarkable except for moderate bilateral tal, reportedly because she believed the patient suprapubic tenderness, mild cervical motion ten­ was "not going anywhere in therapy." The thera­ derness, and bilateral adenexal tenderness. The pist reported she could not do enough to help the

Vomiting and Borderline Personality Disorder 387 J Am Board Fam Pract: first published as 10.3122/jabfm.6.4.385 on 1 July 1993. Downloaded from patient, who regarded her therapy "more as nursing staff during the latter part of her hospitali­ friendship." The therapist described the patient zation, worsened in the hours before discharge. as a "very dependent person who suffered bouts of On her first evening out of the hospital, she took nausea and vomiting on many previous occa­ an. overdose of amitriptyline and was readmitted sions." The patient admitted that she had a his­ to a psychiatric inpatient facility. She was dis­ tory of similar episodes of nausea and vomiting charged after 2 days, with follow-up care to be every 6 to 12 months for several years and had provided by her original outpatient therapist. been hospitalized for similar conditions in 1985. She described vomiting as a response to feeling Csse2 "empty," "worthless," and "frantic." Although she A 33-year-old woman was seen in 1989 by a new thought that she could not express such thoughts family medicine resident in the outpatient clinic to anyone directly, her dysphoria would be re­ for complaints of chronic depression and weight lieved temporarily by vomiting. Also, when she gain. Her weight at the time of that visit was 170 was sick, her mother and boyfriend would help lb (height 5 ft 5 in), up 6lb from 6 months before, with chores around the house; at other times she but up 30 lb from the previous year. Her blood was unsure about their support. Regarding her pressure was 138175 mmHg, pulse 59 beats per therapy, the patient said that she was "really get­ minute, and temperature 98.5°F. Because she had ting something out of therapy" and felt puzzled a positive family history of bipolar affective disor­ and abandoned when it stopped. der and had "been on several antidepressants that The patient's MMPI profile (Welsh code didn't work before," she had been prescribed car­ 1*2"867304'9-5 F"L'K: ) was suggestive of some­ bamazepine. Because the carbamazepine "made one admitting to severe psychological problems her feel drugged and gain weight," she was pre­ while naively trying to appear psychologically scribed fluoxetine and referred for counseling at sound, suggesting a lack of self-insight and psycho­ the local mental health center. logical sophistication. The patient appeared to be She returned to the clinic 1 month later com­ either "faking bad," malingering, or "crying for plaining of nausea and vomiting for 3 days and help" in her approach to the MMPI. right-upper-quadrant pain, and she was provided Persons with such profiles have profound de­ prochlorperazine suppositories. A sonogram and pression and attacks of anxiety and typically de­ function tests were ordered, which revealed

velop immobilizing physical symptoms. The pro­ a "fatty liver," elevated liver function tests (aspar­ http://www.jabfm.org/ file is characteristic of those who are overwhelmed tate aminotransferase [AST] 51 VIL, total biliru­ by feelings of guilt, inadequacy, self-doubt, or bin 0.5 mg/dL, direct bilirubin 0.1 mg/dL, alka­ worthlessness. Such persons typically are described line phosphatase 118 V IL, lactic dehydrogenase as shy, submissive, inhibited, and ruminative. They [LOH] 202 VII), normal gall bladder, and normal tend to have recurrent marital or work problems. In pancreas. On physical examination, the patient's medical settings they tend to be cynical or critical of abdomen was mildly tender, with no distension, on 25 September 2021 by guest. Protected copyright. caregivers who are perceived as not giving enough rebound tenderness, or guarding. Bowel sounds attention to their physical problems. were active. The profile is consistent with psychogenic Findings of a review of her records from earlier vomiting. Although the condition was unrecog­ hospitalizations and physician visits were striking. nized by her family physicians, she had apparendy The patient's complaints of depression dated back reacted to stressful situations with similar symp­ for a decade and included a psychiatric hospitali­ toms in the past. The immediate stressor most zation 1 year before coming to our clinic. In addi­ likely responsible for the exacerbation leading to tion, her medical history included three obstetric hospitalization was perceived abandonment by hospitalizations, a dilatation and curettage, at least her therapist, as well as fears of being abandoned three inpatient admissions for nausea and vomit­ by her fiance. ing, a hysterectomy and left oophorectomy, hos­ The patient was discharged from the hospital pitalization for several episodes ofcolitis, and a right after 14 days, even though her vomiting, which oophorectomy for an ovarian cyst; early in 1989 had become much less frequent following a covert she underwent a cholecystectomy that did not behavior modification plan carried through by provide any relief from her nausea and vomiting.

388 JABFP July-August 1993 Vol. 6 No.4 J Am Board Fam Pract: first published as 10.3122/jabfm.6.4.385 on 1 July 1993. Downloaded from The patient had first received treatment for polar affective disorder, in addition to somatic depression 5 years previously, following a divorce diagnoses including sinusitis, possible connective from her first husband and the death of her tissue disorder, , possible mother. She was prescribed a combination of cholelithiasis, possible endometriosis, possible maprotiline (150 mg at bedtime) and weekly thyroid disorder. With the exception of chronic, psychotherapy. She did well for about 1 year but mild elevations in liver function tests (AST 51-88 began to complain about tension , mus­ UIL, alkaline phosphatase 118-122 UIL, LDH cle , abdominal pain, sweating, palpita­ 171-202 UIL), other laboratory data were consis­ tions, breast pain, leg pains, and . She tently within nonnal limits. Upper also complained about mood swings, exhaustion, had revealed erosive on two occasions; uncontrollable anger, and . Im­ she also had undergone radiologic upper and portantly, on an average of about twice each year, lower gastrointestinal studies and a liver biopsy she complained of episodes of nausea and vomit­ with negative results. ing, each time associated with subjective feelings Her weight continued to increase (Figure 2), of stress in her family life. Figure 1 shows that, as and her remained within nonnal her psychotherapy visits declined in frequency, limits despite episodes of vomiting. During the her visits for physical complaints increased, and 5-year period before 1989 for which medical rec­ vice versa. ords were available, the patient was prescribed The review of medical records also revealed a multiple , including maprotiline, plethora of psychiatric diagnostic impressions, chlordiazepoxide-clidinium bromide, alprazolam, including depression, hysteroid personality, amitriptyline, , , car­ disorder, anxiety, premenstrual syn­ bamazepine, fluoxetine, carbonate, and drome, stress-irritable bowel syndrome, and bi- hydroxyzine, in addition to perphenazine and

Visits 12

10 + + http://www.jabfm.org/ Psychological Visits 8

6 + Medical Visits on 25 September 2021 by guest. Protected copyright. 4

2

0 3 4 2 3 4 234 234 234 234 84 85 86 87 88 89 90 1 Dates (QuarterlYear)

Type of Service

D Medical + Psychological

Figure 1. Type and number of clinic visits in case 2. Note: points show actual number of visits; lines are the best-fit-of-data points and illustrate trends over time.

Vomiting and Borderline Personality Disorder 389 J Am Board Fam Pract: first published as 10.3122/jabfm.6.4.385 on 1 July 1993. Downloaded from

Pounds 200

150 L...... -J-----I._.....

100

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3 4 2 3 4 234 234 2 3 4 234 1 84 87 1 85 86 88 89 190 Dates (QuarterlYear)

a Weight

Figure 2. Weight of patient in case 2 during treatment. Note: points show actual weight in pounds; line is the best-fit-of-data points and illustrates trend over time. promethazine, in attempts to control nausea and showed surprisingly little affect. She reported vomiting. feeling "guilty," "disintegrating inside," and "un­ http://www.jabfm.org/ The patient reported having been raised as the able to cope" before each episode. Vomiting made 3rd of 5 children in a "close family" that "always her feel transiently better emotionally, but this did everything together." She denied emotional relief soon gave way to even stronger feelings of problems in the family but reported that her helplessness, hopelessness, guilt, and worthless­ mother was frequently ill and not emotionally ness. Although husbands or boyfriends initially

available to her and that her father had alcohol responded with concern or made fewer demands on 25 September 2021 by guest. Protected copyright. problems. on her, each quickly learned to ignore her distress. She first married at the age of 17 years to a man who was physically and emotionally abusive, had Case 3 a daughter, and divorced. She remarried 5 years A 35-year-old woman who worked part time and later and had 2 sons, one who was schizophrenic without great ambition as an attorney in a group and the other who had attention deficit hyperac­ practice came to the outpatient clinic with com­ tivity disorder. Both sons also suffered from enco­ plaints of episodic nausea and vomiting and presis and were institutionalized for periods of chronic depression. Her nausea and vomiting had time. After divorcing her second husband, the occurred numerous times during the past several patient had several boyfriends and finally remar­ years and was typically associated with periods of ried for a third time, although they had a stormy emotional turmoil. Most recently, she had experi­ relationship and regularly discussed divorce. enced two episodes of emesis, one each morning The patient had been out of work for 1 year, upon arising for the past 2 days. All laboratory primarily because of the nausea and vomiting. values were within normal limits, and a pregnancy When questioned about her vomiting, the patient test was negative. Her physical examination was

390 JABFP July-August 1993 Vol. 6 No.4 J Am Board Fam Pract: first published as 10.3122/jabfm.6.4.385 on 1 July 1993. Downloaded from unremarkable, and the patient was in no apparent that between 30 percent and 57 percent of pa­ physical distress, although she did become tearful tients with eating disorders have histories of self­ during the interview. injurious behavior or diagnoses of personality dis­ This patient related her rather chronic dyspho­ order13 and that among patients selected for ria to the impending divorce from her husband of self-mutilating behavior, there are comparable 7 years, an investment banker from whom she had rates of bulimia, especially bulimia complicated been separated for approximately 3 months. She by laxative abuse. 14 The rates of personality disor­ reported that their unsatisfactory relationship was der in patients with bulimia have been reported at more "like a friendship," and that she had sought between 56 percent and 63 percent.15,16 In one other sexual partners at various times during the study of 12 consecutive admissions for bulimia, marriage. Interestingly, she reported that even 9 patients also had borderline personality disor­ before her marriage she seemed to have either der diagnoses. 17 sexual relationships that were chaotic or good A second key is an examination of the phenom­ friendships that were platonic but could not de­ enological descriptions of self-mutilation by indi­ velop a relationship with someone that was both viduals with borderline personality disorder and sexual and interpersonally satisfying. bulimia, which reveals striking parallels. When For the 2 months before she came to the clinic, studying patients who chronically self-mutilate, she had been living with a woman coworker with five stages consistently define the self-injuring whom she had become sexually involved. This acts: (1) a precipitating event, such as real or lesbian experience was her first, and she described threatened loss of an important relationship, the relationship as "wonderful" and "just what I (2) escalation of dysphoria, (3) attempts to fore­ have always been looking for." In the day or two stall the self-injury, (4) self-mutilation, and (5) a leading up to her clinic visit, however, this friend clear aftermath with relief from tension.18 Pa­ had begun to ask for even greater commitment tients report that feelings of pain are absent or and to express doubts about the future of the that pain perception is experienced as relief, reas­ relationship if such assurances from the patient surance, distraction from dysphoria, or empower­ were not forthcoming. The patient noted that as ment in the face of helplessness. 14 Much as the they discussed these issues, she began to feel borderline personality disorder patients described "panicky and frantic" but "paralyzed and empty above, patients who are bulimic also report esca­ inside." This feeling became overwhelming and lating dysphoria that is relieved by vomiting. As http://www.jabfm.org/ was quickly followed by vomiting, which not only do many borderline personality disorder patients elicited attention from her partner but also re­ after self-mutilation, patients who are bulimic de­ sulted in a temporary feeling of "calmness." scribe a feeling of calm and dissociation after Further social history revealed that the patient vomiting and often plan purging to ensure that had been sexually abused between the ages of they will be able to sit quietly in a relaxed environ­ 5 and 9 years by a relative who lived nearby and ment afterward. Interestingly, the same descrip­ on 25 September 2021 by guest. Protected copyright. that she had not told anyone about this abuse up tions of escalating dysphoria followed by calm to the present time. after their "fixes" are typical of opiate abusers. The patient was prescribed fluoxetine and re­ The similarities in phenomenological descrip­ ceived intensive psychotherapy, and she had only tions by patients with borderline personality dis­ one additional episode of vomiting during the order, bulimia, and opiate addiction suggest a next 6 months. third basis for equating self-mutilation and vomit­ ing: the possibility that there is a common neuro­ Discussion biologic pathway to explain the similar psycho­ Psychobiology ofSelj-Mutlllltkm IIU Yomltlfl, logical effects of self-mutilation and vomiting. What is the basis for equating self-mutilation and One possible explanation rests with the recogni­ vomiting in patients with borderline personality tion that painful stimulation results in increased disorder? One key is an epidemiological associa­ endorphin release 19: in response to painful tion between self-mutilation and bulimia. Such an stimuli, endogenous opiates are produced, lead­ association was hypothesized as early as 1978.12 ing to feelings of well-being, greater tolerance for Subsequent studies have been cited indicating pain, and so on. Indeed, when retarded and other

Vomiting and Borderline Personality Disorder 391 J Am Board Fam Pract: first published as 10.3122/jabfm.6.4.385 on 1 July 1993. Downloaded from

self-mutilating patients have been given other hand, there are certain patients in primary or naltrexone (opiate antagonists) to block the care whose complaints ofvomiting deserve simul­ pleasurable effects of endorphins, there is reduc­ taneous evaluation from a psychiatric perspective. tion in such behavior, suggesting that pleasurable The cases presented suggest that patients who stimulation of endogenous opiates can result chronically complain about episodic vomiting with­ from, and operantly reinforce, self-mutilation.14 out or other obvious physical find­ Furthermore, measurements of plasma neuro­ ings, for example, should have their complaints peptides in self-injurious patients indicate that assessed by the following approach (Table 2). such patients have higher levels of metenkephalin, First, the patient's attitude toward vomiting which presumably mirror higher levels in the cen­ needs to be carefully characterized. Does the pa­ tral nervous system.20 tient have a type of indifference to his or her Self-injurious behavior can also be viewed as a symptoms (sometimes referred to as la belle indif­ form of aggression, which is associated with ference)? This air of complaining without concern serotonergic depletion in the central nervous sys­ often is thought of as part of a histrionic or con­ tem. Some studies have reported reduction in version disorder profile but could also be charac­ self-injurious behavior in patients with Lesch­ teristic of patients with borderline personality Nyhan syndrome when administered 5-hydroxy­ disorder. tryptophan (a precursor).14 More im­ Second, upon careful questioning, does the pa­ portantly, however, are similarities noted between tient describe feelings of escalating dysphoria self-injurious behavior and obsessive-compulsive leading up to vomiting, followed by temporary disorder, a condition that has been associated with relief from the dysphoria? Moreover, does the serotonin deficiency and treated with the new vomiting tend to occur following interactions selective serotonin reuptake inhibitors (SSRIs).21,22 with others in which there is a threat of abandon­ Studies of serotonergic activity in patients with ment? Typically, patients with borderline person­ various personality disorders have indicated that ality disorder will be very sensitive to rejection or patients with borderline personality disorder who lack of interest. In the cases presented above, self-mutilate show the greatest variance from vomiting always occurred when abandonment de­ controls.23 ,24 In short, neuroendocrinologic dys­ pression, the psychological manifestation of re­ regulation appears to underlie obsessive-compul­ jection sensitivity, was aroused. sive disorder, vomiting in bulimia, and the self­ Third, is the patient's social history compatible http://www.jabfm.org/ mutilation in borderline personality disorder, all with borderline personality disorder, such as of which also are characterized by irresistible urges multiple marriages, patterns of unstable employ- and gradually increasing tension as attempts are made to control the urges, followed by great relief Table 2. Screening Questions for Evaluating Episodic after expression of the urges in actual behavior. Vomiting in Patients.

Finally, there is some suggestion from the on 25 September 2021 by guest. Protected copyright. treatment literature that there might be a com­ 1. Does the patient exhibit indifference to his or her vomiting? mon neurobiologic pathway underlying the self­ 2. Does the patient describe feelings of escalating dysphoria before vomiting? mutilation of borderline personality disorder and 3. Does vomiting tend to occur following interactions in vomiting in bulimia. Tricotillomania, a mild form which there is a real or imagined threat of abandonment? of self-mutilation, has been treated successfully 4. Is the patient's social history characterized by instability, with the serotonin reuptake inhibitor fluoxe­ such as multiple marriages, inconsistent employment, or tine. 25 Borderline personality disorder patients chaotic interpersonal relationships? who self-mutilate have been successfully treated 5. Is there evidence from childhood history of indifferent or with both monoamine oxidase inhibitors and abusive parents or a history of sexual abuse? fluoxetine, as well as with carbamazepine.26 6. Is there a history of suicide attempts or self-mutilation? 7. Is there a history of emotional lability or difficulty Treatment Implications and Recommendations controlling emotions? "When a family practice patient complains of 8. Is there evidence of overidealization and devaluation in relationships? vomiting, it is clear that initial investigation of possible organic causes is appropriate. On the 9. Is vomiting followed by temporary relief from dysphoria?

392 JABFP July-August 1993 Vol. 6 No.4 J Am Board Fam Pract: first published as 10.3122/jabfm.6.4.385 on 1 July 1993. Downloaded from ment, or chaotic interpersonal relationships? Is acterological, and social resources to respond well there evidence from early developmental history to therapy. Others will regress and persist in of indifferent or abusive parents? Is there a history vomiting to- the point that hospitalization might of sexual abuse? Is there a history of self-mutila­ be necessary. In either case, astute clinicians will tion or suicide attempts? These types of histories realize that borderline personality disorder pa­ seem to be associated with borderline personality tients are very dependent underneath an inde­ disorder. pendent facade and will be hypervigilant to aban­ Fourth, is there a history of emotional lability donment by caregivers. When working with such with difficulty controlling emotions? Moreover, is patients, particular attention must be paid to the there evidence of overidealization and devalua­ implicit and explicit dynamics of the physician­ tion in relationships? Some forewarning of this patient relationship. In very regressed borderline tendency could come in the form of the patient personality disorder patients who are hospitalized saying something to the effect of "I've been to and whose vomiting has stopped, vomiting might several doctors about this and they were all recur as soon as discharge plans are discussed. worthless ... I'm glad I have found you because I can tell you really care and will help me!" This approach by patients might be flattering, but it References must be viewed as part of the splitting and over­ 1. Diagnostic and statistical manual of mental disor­ idealization that is so typical in borderline person­ ders. 3rd ed. Revised. Washington, DC: American ality disorder patients. Psychiatric Association, 1987. 2. Andersen SM, Harthom BH. The recognition, diag­ Clearly, much of the information needed to nosis, and treatment of mental disorders by primary raise clinical suspicion for borderline personality care physicians. Med Care 1989; 27:869-86. disorder in the of the vom­ 3. Magill MK, Garrett RW Borderline personality dis­ iting patient can be gleaned from careful ques­ order. Am Fam Physician 1987; 35:187-95. tioning and observation in the outpatient setting. 4. Gunderson JG. Borderline personality disorder. Interviewing an informant, which is important Washington, DC: American Psychiatric Press, 1984. 5. Gardner DL, Cowdry RW Suicidal and parasuicidal when trying to assess borderline personality dis­ behavior in borderline personality disorder. Psy­ order from a research standpoint,27 also might chiatr Clin NorthAm 1985; 8:389-403. prove helpful in clinical practice. Guidelines for 6. Searight HR. Borderline personality disorder: diag­ caring for borderline personality disorder pa­ nosis and management in primary care. J Fam Prac­ http://www.jabfm.org/ tients, in general, should be applied to the vomit­ tice 1992; 34:605-12. 6 7. Kemberg OF. Borderline conditions and pathologi­ ing patient with borderline personality disorder. cal . New York: Jason Aronson, 1975. Information gathered from the above approach 8. Zetzel ER. A developmental approach to the border­ that suggests borderline personality disorder line patient. AmJ Psychiatry 1971; 127:867-71. could mitigate the costly search for organic causes 9. MastersonJF. Psychotherapy of the borderline adult: a developmental approach. New York: Brunner/

of vomiting. Instead, cognitive and behavioral ap­ on 25 September 2021 by guest. Protected copyright. proaches, in which the patient is taught to recog­ Mazel, 1976. 10. Idem. The narcissistic and borderline disorders: nize that emotional upheaval and vomiting are an integrated developmental approach. New York: linked experientially and neuroendocrinologically Brunner/Mazel,1981. and in which the patient is encouraged to begin to 11. Hathaway SR, McKinley JC. Manual for adminis­ modulate emotions, can be effective. Simulta­ tration and scoring of the MMPI. Minneapolis: neous pharmacotherapy, using drugs that treat National Computer Systems, 1983. 12. Yaryura-Tobias JA, Neziroglu F. Compulsions, affective instability and rejection sensitivity in aggression and self-mutilation: a hypothalamic dis­ borderline personality disorder patients (such as order? J Orthomol Psychiatry 1978; 7:114-7. fluoxetine, the newer selective serotonin reuptake l3. Gartner AF, Marcus RN, Halmi K, Loranger AW inhibitors, or carbamazepine), can be beneficial. DSM-ill-R personality disorders in patients with Benwdiazepines should not be used, as they tend eating disorders. AmJ Psychiatry 1989; 146:1585-91. to increase disinhibition and affective expression. 14. Wmchel RM, Stanley M. Self-injurious behavior: a review of the behavior and biology of self-mutila­ There is a spectrum of severity in borderline tion. AmJ Psychiatry 1991; 148:306-17. personality disorder. Some patients are relatively 15. Levin AP, Hyler SE. DSM-ill personality diagnosis high functioning and have the intellectual, char- in bulimia. Compr Psychiatry 1986; 27:47-53.

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16. Gwirtsman HE, Roy-Byrne P, Yager], Gerner RN. 23. Coccaro EF, Siever L], Klar HM, Friedman RA, Neuroendocrine abnonnalities in bulimia. Am] Psy­ Moskowitz RN, Davis KL. 5-HT function in chiatry 1983; 140:559-63. borderline personality disorders. In: New research 17. Katz SE, Levendusky PG. Cognitive-behavioral ap­ program and abstracts, 140th annual meeting of the proaches to treating borderline and self-mutilating American Psychiatric Association. Washington, DC: patients. Bull Menninger Clin 1990; 54:398-408. American Psychiatric Association, 1987. 18. Leibenluft E, Gardner DL, Cowdry RW. The inner 24. Coccaro EF, Siever L], Klar HM, Maurer G, Coch­ experience of the borderline self-mutilator. ] Pers rane K, Cooper TB. Serotonergic studies in patients Disorders 1987; 1:317-24. with affective and personality disorders: correlates 19. WIller]C, Dehen H, CambierJ. Stress induced anal­ with suicidal and impulsive and aggressive behavior. gesia in humans: endogenous and naloxone­ Arch Gen Psychiatry 1989; 46:587-99. reversible depression of pain reflexes. Science 1981; 25. Swedo SE, Leonard HL, Rapoport]L, Lenane MC, 212:680-91. Goldberger EL, Cheslow DL. A double-blind com­ 20. Coid ], Allolio B, Rees LH. Raised plasma parison of clomipramine and desipramine in the metenkephalin in patients who habitually mutilate treatment of trichotillomania (hair-pulling). N Engl themselves. Lancet 1983; 2:545-6. ] Med 1989; 321:497-501. 21. Thoren P, Asberg M, Cronholm B, ]ornestedt L, 26. Gardner DL, Cowdry RW. Positive effects of car­ Traskman L. Clomipramine treatment of obsessive­ bamazepine on behavioral dyscontrol in borderline compulsive disorder, I. A controlled clinical trial. personality disorder. Am] Psychiatry 1986; 143:519-22. Arch Gen Psychiatry 1980; 37:1281-5. 27. Zimmerman M, Pfohl B, Stangl D, Corenthal C. As­ 22. Goodman WK, Price LH, Charney DS. Fluvoxa­ sessment of DSM-III personality disorders: the im­ mine in obsessive-compulsive disorder. Psychiatr portance of interviewing an infonnant. ] Clin Ann 1989; 19:92-6. Psychiatry 1986; 47:261-3. http://www.jabfm.org/ on 25 September 2021 by guest. Protected copyright.

394 JABFP July-August 1993 Vol. 6 No.4