23 Borderline Personality Disorder

Kenneth Lakritz

Clinical Vignette

A 23-year-old woman was hospitalized after her parents brought her to the emergency department (ED) for treatment of an overdose of acetaminophen. Because of her history of drug abuse, her parents had refused to underwrite a spring-break vacation and the patient took the overdose to “punish” her parents The ingestion was minor and the patient was initially calm and friendly, but when ED staff expressed uncertainty about sending her home, the patient flew into a rage, accused staff of conspiring with her parents, and tried to bite a nurse.

This was her fifth psychiatric hospitalization in 3 years; all but one had been preceded by a suicide gesture or attempt. She lived with her parents and sporadically took adult education courses with a vague ambition to direct films. Despite high intelligence, she had failed three tries at college; in one instance, she had been dismissed for selling drugs. Although she had seen four respected therapists, she derided them as “only being in it for the money.”

Her arms showed multiple burn marks, and she admitted to burning herself with cigarettes “to relieve tension.” Her dentition was poor, and she acknowledged binge eating and purging.

Once admitted, she quickly established an alliance with a psychotic male patient and announced plans to move in with him when she was discharged. She was angry and sarcastic with some staff members but pleasant with others, leading to disagreements over her treatment and disposition.

Psychoanalysts of the 1920s and 1930s described patients who appeared superficially healthy but could not be psychoanalyzed because of their inability to establish a stable therapeutic relationship. These patients tended to have tumultuous life histories, poor social and vocational adjustment, and occasional brief regressions to psychosis. They were called “ambulatory schizophrenics,” “pseudoneurotic schizophrenics,” or “borderline schizophrenics.” The term borderline personality disorder

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