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A Case Study about Severe Borderline Personality Disorder.

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DOI: 10.13140/RG.2.2.10057.77928

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A Case Study about how initially practiced Self-harming for relief eventually lead to a Severe

Borderline Personality Disorder

Disorder. [DSM-5 301.83 (F60.3)]

Ekata Deb-1738501

Department of Psychology: Christ University, Bangalore, Karnataka, India.

MSc Behavioral Science, (Choice Based Credit System)

CIA-11 Submission: Mental Health at Workplace

SAMPLE COPY
Severe Borderline Personality Disorder with bizarre fantasies accommodated by beastly attitudes. 2

Abstract

A 23 year old white man named Jacob having severe borderline personality disorder is briefly

discussed here. The case of this man is presented here with massive depressive symptoms, Self-

mutilation, multiple suicidal attempts, bizarre anti-social fantasies, self-lacerating, depersonalization,

irregular emotional stability and exposure, along with self-harming apathetic attitude with lots of

guilt feelings. He was also massive anxiety and stress, self-doubt, a huge internal conflicts and

pandemonium comprising abandonment, loneliness, failure and resentment. There was a very poor

adjustment with his widowed mother and also a deep longing as well as detachment from a fatherly

like figure. He had lost his father in a motor vehicle accident when he was 12 years old. Mental

status examination and a round of hospitalization of almost 5 times in seventeen months, along with

outpatient therapy, both through intervention of behavioral medications and psychotherapies

declared him suffering from a severe Borderline Personality Disorder, [DSM-5 Criteria Code: 301.83

(F60.3)]. The root cause of the same was found to be from a series of misfortune and bad experiences

from his childhood and adolescence period. Later on, it was also found that he was using self-

mutilating and self-laceration methods with razors to give him intense and immediate relief from his

anxiety and mental pain. The same kind of self-harming activities were not committed out from a

slashing moment of ravage or anger. They were also not so brief but contained a well defined

purpose, care and attention of the patient.

Keywords: Borderline Personality Disorder, Self-mutilation, Self-laceration, anxiety, de-

personalization, psychotherapy, pharmacotherapy, Stress, Identity-crisis, aggressive behavior,

Diagnostic and Statistical Manual of Mental Disorders-V.

Introduction

Borderline Personality disorder is cluster B type of Personality disorder Spectrum of

Diagnostic and Statistical Manual of Mental Disorders-V. It is generally claiming its positive

impressions along with a multiple co-morbid psychiatric conditions. Generally Borderline

Severe Borderline Personality Disorder with bizarre fantasies accommodated by beastly attitudes. 3

Personality Disorder happens to show its positive symptoms with co-morbid conditions of

depression, anxiety spectrum, and other personality disorder traits like paranoia or narcissism,

bipolar illness. [Fathema Zora et.al, October, 2018, 002]. The Borderline Personality Disorder

comprises of 20% of the entire world population diagnosed with Mental Health Issues, with a

lifetime risk for expression of one or more co-morbid conditions to be 100%. This disorder is mostly

prevalent among females amounting upto 75%, [DSM V-P: 666, Gender-Related Diagnostic issues],

than males and exhibit mostly in urban psychogenic demographic conditions.

Diagnosis as per DSM-V 301.83 (F60.3)

As per the Diagnostic and Statistical Manual for Mental Disorders, (P-663), by American

Psychiatric Association, 5th Edition, and the Code of Borderline Personality Disorders [301.83

(F60.3)], the main positive symptoms of BPD are as follows:

“A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked

impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five

(or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or

self-mutilating behavior covered in Criterion 5.)

2. A pattern of unstable and intense interpersonal relationships characterized by alternating

between extremes of idealization and devaluation.

3. Identity disturbance: markedly and persistently unstable self-image or sense of self.

4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex,

substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self

mutilating behavior covered in Criterion 5.)

5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,
Severe Borderline Personality Disorder with bizarre fantasies accommodated by beastly attitudes. 4

irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling

anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

9. Transient, stress-related paranoid ideation or severe dissociative symptoms.”

With reference cited in DSM V manual, published by APA, (P: 665-666), the gist inference

that are drawn and listed above, also adds some other criterion tagged as associated features

supporting but not limited to the primary 9 criteria diagnosis, like “Prevalence, Development and

Course, Risk and Prognostic Factors, Culture-Related Diagnostic Issues, Gender-Related

Diagnostic issues, Differential Diagnosis like Depressive and bipolar disorders. Also other

personality disorders like Personality change due to another medical condition, Substance use

disorders, and Identity problems.”

The main idea of the diagnosis is that the Borderline Personality Disordered persons often try

to perverse the surrounding interpersonal relationships and his interactions with a variety of

emotional deregulation and exhibiting instabilities of self-image, and affects with markedly showing

up rigorous self-mutilations and self-lacerations, imposed narcissism, impulsivities, delusional

paranoia and hyper vigilance, anxiety and mood disorders- often in the depressive or major

depressive levels with suicidal gestures or even multiple attempts.

Also to highlight about a minute comparison of DSM IV criteria of Borderline Personality

Disorder [DSM IV - TR 301.83], the methodology of deciding the construct varies. This is so like by

evincing the decreased modus operandi of the 4th Edition over the latest on dis-inhibition and

antagonism with an increased interpersonal dependency. The reference is drawn here because the

case study of the patient was penned down in January 1987. [Douglas B. Samuel et al., (2011-Aug)]

The DSM 4th Edition was published on 1952. So, the case study falls during the 4th edition of DSM.

Thus the edition stands for some more value editions to the diagnostic methodology.
Severe Borderline Personality Disorder with bizarre fantasies accommodated by beastly attitudes. 5

Interventions as per DSM-V 301.83 (F60.3)

As per the latest edition, an early diagnosis of such a type of mental health disorder is most

important. As early as the diagnosis being made, so the control over the relapse and the symptoms

can be taken. There are certain mandatory norms for the initial assessment and determination of the

clinical diagnosis and treatment settings, comprehensive evaluation criteria, along with the

establishment of the treatment framework. American Psychiatric Association on Treatment

Guidelines, (2001-October), (P: 14-17), Part-A: Executive Summary of Recommendations. The

steering committee also emphasized on the sustained evidences and epidemiology of the onset of the

disorders. They primarily focused on interventions of the behavioral medicines and other invasive

somatic treatments.

Discussion and description on the presenting problem

Case presentation

A 23 year old white man named Mr. Jacob who has recently graduated from a commerce

school with Honors, started working with an accounting firm. It is also pertinent to mention that he

had to shift his primary home location, where he was staying with his widowed mother for joining

the job. He had just met with a female psychiatrist. The Primary complaint of his problem was that

he was suffering from insomnia for the last 5 years. There was also a sense of feelings which

includes guilt and anxiety. There were no reasons behind the identification of the same. Also, there

was no psychiatric contact history. The psychiatrist had initially started with Psychotherapy.

Within 2 months, the situation massively deteriorated. He was immediately admitted to

hospital. He was hospitalized for almost 3 months. The primary reason was he had grown to be

increasingly depressed, committed self-mutilations with a razor and tried to attempt suicide. This

was the first time he was diagnosed with Major Depression and Borderline Personality Disorder.

Post-hospitalization he was undergoing out-patient therapy. He was also having depressive

Severe Borderline Personality Disorder with bizarre fantasies accommodated by beastly attitudes. 6

symptoms, started drinking heavily, and was intermittently showing himself to be anorexic and

bulimic. There was lots of expression of suicidal gestures, with many superficial self-mutilations.

Within the short span of time of 2 months only, the patient was hospitalized. He was treated

with both behavioral medicines as well as behavioral therapies. A variety of psychotropic

medications like Tricyclic, MAOI antidepressants, Lithium, High and Low potency neuroleptics

were tried. It is that after which the patient started to reveal information about his past in the later

outpatient therapies. Thou the patient were responding quite well, and almost controlled, there was

surge of psychotic symptoms mostly started with renewed insomnia, anxiety and guilt feelings with a

lot of depressions. He started to disclose about some kind of bizarre fantasies. He also revealed that

these fantasies were slowly getting so vivid and intense, that he thought of testing it out one day. He

had also informed the female therapist that, he was not happy with his initial coping style of self-

mutilation and self-harming which he did with razor blades.

The bizarre activities out from his fantasy that he performed was that one night he went out

of his house, and in a very lone dark road, approached a beautiful young woman. The young woman

was walking in a dark, isolated area and he stopped her asked for directions. The conversation

though had lasted for just 10 secs, and then the lady departed. The actually fantasy was that he would

try to distract her attention for a question, knock her unconscious, and proceed to severely mutilate

her body especially her sex organs with a sharp razor blade that was already there in his pocket.

Such a type of fantasies was present in him for some time. He was increasingly feeling the

need and felt compulsive as well as compelled to act on it, while shaping it to a reality. Now at the

same time, he was distraught for having such a fantasy within him, but was also unable to control

their forces on him to perform such a kind of acts.

After hearing all these, the female psychiatrist again advised to hospitalize him immediately.

The female psychiatrist shifted his case to a male psychiatrist because there was a high risk to work

with him anymore. After such a move from his female psychiatrist, he initially responded as very
Severe Borderline Personality Disorder with bizarre fantasies accommodated by beastly attitudes. 7

raged, rejected and abandoned.

It is this time that the original author, Paul D. Zislis came to know about him. About his

appearance was he was very intense and his face was showing internal torment. He was highly

anxious and rarely made any kind of eye contact. He thou spoke with a very articulate voice but were

also very quiet and low. His physical body showed many superficial scars, which are almost 8 inches

in length. They were generally presented in cluster, in his forearms, shoulders, chest, abdomen and

legs. He had caused them by self-induced lacerations which were primarily made by razor blades or

paper clips. He was officially cutting himself since 13 years. He was actually showing an expression

of ritualistic cutting. There was initial hopelessness, followed by self-doubts, sense of failure,

depression and guilt feelings, disappointments, also accompanied by abandonment and loneliness.

The onset of self mutilation was that, he started to dislike watching the wounds getting

healed and disappearing. He also felt that the wounds were having an identity of themselves and a

life of their own. He was accusing himself for the disappearance of the wounds, as he believed that

the wounds were leaving him because he did not pay attention to it. He thought, the wounds were

feeling bad as he represented abandonment from him. The self-laceration was done not in a brief

period exhibiting some slashing moment of anger but they were acted with well-defined purpose,

attention and care. He was also showing a massive sense of fear and panic. He was feeling that he

was peering out at the world from the bell jar. He was also having a sense that, all the walls of the

rooms, buildings and other inanimate objects for example laundry were getting personified.

With much more menace and hostile intensions, which was continuously creeping him to feel

overwhelmed to have a disintegration of his body and as if he was disappearing with the universe.

The act of self-mutilation was his relief to such kinds of mental pains, which makes him sense to

release his anxiety and stress and also was also used as a coping mechanism. He believed this was a

means to recapture him to prevent him from disappearing.

Severe Borderline Personality Disorder with bizarre fantasies accommodated by beastly attitudes. 8

Psycho Analysis of the key Psychodynamic issues of Presented Case

The original author focused in the main document with a psychodynamic approach on the

root cause of such a kind of behavioral expressions. The author, Paul D. Zislis, clearly mentioned

that about the patient’s childhood trauma and history. As a child and young adolescent Jacob was not

able to make friends thou he longed to have one. He had only one friend who was older to him by 2

years. His relationship with his mother was also very disturbing and not sounded normal. He had lost

his father when he was just 12 years old, in a motor vehicle accident. He was raised in a catholic

upbringing.

His mother since his childhood was behaving as a psychopath and distant cold to him, and

also was blaming him for everything in his life. She was accusing him for his disappearance from

her, and not having her love for him was actually his mistake, not hers. She was just not leaving her

child but was actually trying to dictate over his emotions and relationships. He also felt that he was

born in this world to save humanity and become a saint in catholic regime. He believed sex is an evil

act and people have sex because of the influence of Satan. He disliked her mother too much and was

blaming her for making her an object of sex, an evil act, available to her husband. He primarily

believed and thought his father was influenced by Satan and evil spirits, with the cause of his death

as a punishment of his acts from the God.

Now, during his childhood there were two major incidents. His only friend, who was 2 years

older than him, had raped him. He was 13 and his friend was 15 during that time of the occurrence of

the event. He was really feeling deceived and distrustful with such an abuse. Again some years later,

he was visiting a night party with some of his local acquaintances, where a young girl and her friends

were forcing him to have a consensus physical intercourse and sex with the young girl. He thou

agreed but during the course of such physical relationship, he was facing a huge de-personification.

He at the same time believed that he was abusing the lady and also felt raged in the sense of how he

was abused by his only friend. He started to believe that with such an act of evilness, sex is
Severe Borderline Personality Disorder with bizarre fantasies accommodated by beastly attitudes. 9

something where a person feels himself both as a tormentor and an abuser.

He felt highly guilty and started accusing himself for everything. He then took resort to self-

mutilation initially to give him relief to such pains, by punishing himself. The same kind of self-

harming acts aggravated when he had such beastly attitudes and bizarre fantasies, and also thought of

murdering woman, just to see how it feels. He thou never committed them like torturing others

especially woman in their genital parts with razor blades and killing them, as he was also knowing

them to be a crime and an evil act. He however, took himself to such an identity for punishments and

committed beastly activities on him as a kind of relief and coping mechanism for his mental pain.

Interventions of the Presented Case

As the case is also reflected from an adolescent period, an early diagnosis of the same was

quite necessary. Some kind of RCT-Randomized Control Trials in the adolescence period is quite

important also a food intake with Omega-3 fatty acid supplementation.

In this case initially the interventions started with psychotherapy, and later changed to

psychopharmacologic nature, with 5 times hospitalizations in just seventeen months. He was also

undergoing outpatient therapies with a combination of psychopharmacology as well as

psychotherapies under contained and controlled clinical settings.

The initial pharmacology prior to hospitalization was some kind of neuroleptics, thioridazine,

initiated at 300 mg/day. Prior to this, and the hospitalization, he was treated with phenelzine, an

antidepressant, which was increased from 60 mg/day to 75 mg/day. Later, in the last phase of the

hospitalization, he was continuously reaching the ceiling and was again suffering from the relapse of

the symptoms. His was treated with higher dosages of neuroleptics and psychotics, with a ceiling of

800 mg/day of thioridazine, and discontinued with Chlorpromazine upto 1400 mg/day. Later he was

advised ECT to decrease his symptoms and control his relapse, so that he sounds well with the

behavioral medicine.
 Severe Borderline Personality Disorder with bizarre fantasies accommodated by beastly attitudes.
10

In the hospital, he was also treated with Electro Convulsion Therapy to control his major

depressive phases. The patient was later discharged on desipramine, 150 mg/day. He was also

advised to return to his own family in another state.

There are at least 8 best psychotherapies that can be listed for sounding well for the BPD

patients vis-à-vis, DBT- Dialectical behavior therapy, CAT-Cognitive Analytic Therapy, ERT-

Emotion Regulation Training, MBT-Metallization Based Treatment, some are mainly falling under

the umbrella of CBT-Cognitive Behavioral Therapy, STEPPS- Systems Training for Emotional

Predictability and Problem Solving (STEPPS), SFT- Solution Focused Therapy, TFT-Transference

Focused Therapy, But a lot of pharmacology interventions are much required like antidepressants,

mood stabilizers, antipsychotic, with vitamins like folic acids.

Disclosure

The case study is presented in order to analyze an already documented psychiatric condition

of a patient suffering from Borderline Personality Disorder. It generally highlights the symptoms,

diagnosis and the interventions of the patient as stated in the original documented version. The case

study also refers to all the details of Borderline Personality Disorder as stated and referred from 5 th

edition of Diagnostic and Statistical manual of Mental Health Disorders. The author also tried

referring her own interventions for better management of the disorder.

Conflict of Interest

The case study presented here does not reflect any objectives of the author for challenging

any further investigation purposes on the original documented paper. The case study is fully written

and submitted by the author for educational perspective only. The further inferences drawn by the

author needs to be clinically validated and testified. The author has simply put her own interventions

for educational purposes only.

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Severe Borderline Personality Disorder with bizarre fantasies accommodated by beastly attitudes.
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References

Paul D. Zislis, (1987- January), Beastly Beatitudes (1): The Case of a Patient with Severe Borderline

Personality Disorder

https://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1154&context=jeffjpsychiatry

American Psychiatric Association, 5th Edition-2013, Diagnostic and Statistical Manual of Mental

Disorders, (663-667) https://cdn.website-

editor.net/30f11123991548a0af708722d458e476/files/uploaded/DSM%2520V.pdf

Fathema Zora et al, (2018-October), A Case Report of Borderline Personality Disorder

https://juniperpublishers.com/pbsij/pdf/PBSIJ.MS.ID.555780.pdf

Suprakash C et al, (2019-May), Borderline Personality Disorder: Two Case Reports

https://medwinpublishers.com/MJCCS/MJCCS16000218.pdf

Andrew M.Chanen et al. (2014-October), Preventive Strategies for Borderline Personality Disorder

in Adolescents

https://link.springer.com/article/10.1007/s40501-014-0029-y

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Douglas B. Samuel et al., (2011-August), Conceptual Changes to the Definition of Borderline

Personality Disorder Proposed for DSM-5

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3706458/

Robert S Biskin & Joel Paris, 2012, (P-426), Evaluating Treatments of Borderline Personality

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