An Enraged 36-Year-Old Man With Razorblade Slashes on His Arms

Jeffrey S. Forrest, MD; Alexander B. Shortridge

Disclosures

September 18, 2020

BPD is typically treated with different forms of psychotherapy.[18] Although many approaches to treating BPD are recognized, most emphasize teaching patients to recognize what triggers their affective reactions. Patients are also encouraged to connect their actions with their thoughts and feelings.[18]

One frequently recommended approach is dialectical behavior therapy. Dialectical behavior therapy is a widely used and effective form of cognitive behavior therapy that targets suicidal and self-harm behaviors using eight treatment strategies[19,20]:

  • Dialectical strategies foster the patient's ability to accept reality as it is. Therapists might accomplish this through the use of myth and paradox, a focus on reality as constantly changing, nonresolution of ambiguity, and cognitive challenging and restructuring.

  • Problem-solving strategies support the patient's ability to recognize sources of distress and address them in an adaptive way.

  • Validation strategies utilize empathetic, nonjudgmental acceptance of the patient's condition.

  • Irreverent communication strategies call for the therapist to respond in a matter-of-fact, irreverent way to the patient's suicidal tendencies. Such strategies are in direct contrast to validation strategies.

  • Consultant strategies emphasize the therapist's role as a consultant to the patient directly and not as a consultant to other treatment professionals.

  • Capability enhancement strategies serve to keep patients engaged in acquiring and practicing skills required to cope with everyday life.

  • Relationship strategies emphasize building a strong patient-therapist relationship, addressing interpersonal problems with this relationship as they arise, and learning to apply these skills to other relationships in the patient's life.

  • Contingency strategies involve the therapist being up-front with the patient about what outcomes reasonably can be expected from therapy.

BPD may be treated adjunctively with medication when appropriate.[21] Although no medications have been approved by the US Food and Drug Administration to specifically treat BPD, a broad spectrum of pharmacologic agents can be used to address specific symptoms.

Among antidepressants, one review of randomized controlled trials found that sertraline was effective in decreasing symptoms of depression, hypersensitivity in interpersonal relationships, and obsession in patients with BPD.[21] Among mood stabilizers, topiramate and lamotrigine were shown to reduce anger in patients with BPD. In regard to antipsychotics, olanzapine was found to reduce anger, paranoia, anxiety, and interpersonal sensitivity in patients with BPD.[21]

Clinicians should note that treating BPD with medication has limitations. Whereas some patients with BPD may respond to various medications initially, only about 30% of patients respond satisfactorily over an extended period.[18]

Although BPD is viewed as a lifelong condition, its prognosis widely varies. Diagnostic criteria and standards have changed over time, and presentations may vary widely among patients, so predicting outcomes with precision is difficult. Research has shown that a diagnosis of early-onset BPD is associated with poor functioning in adolescence.[22] Evidence also suggests that the course of adolescent-onset BPD is similar to that seen in adult populations.

The rate of suicide associated with BPD is estimated to range between 8% and 10%.[22] Many persons who qualify for a diagnosis of BPD likely either take their lives by suicide before presenting or go through life without ever coming to clinical attention. Nonetheless, evidence indicates that early diagnosis and intervention can improve patient outcomes.[22]

Comorbid substance use disorders are associated with an increased risk of suicide in patients with BPD. Substance dependence or abuse is observed in more than 50% of patients with BPD.[23] Higher rates of comorbid psychiatric disorders are also seen in patients with BPD, including mood disorders (particularly major depressive disorder), anxiety disorders, and eating disorders.[22]

After his evaluation, the patient in this case was referred to a social worker, who assisted him in engaging with an appropriate dialectical behavior therapist for longitudinal management of his condition. The patient was also provided with a psychiatric referral to assess for the appropriateness of medical intervention.

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