A 34-year-old woman presented to the emergency department (ED) for the seventh time in 2 months after swallowing an eight-pack of triple A batteries. Five of her six prior ED visits were due to ingestion of a variety of batteries, whereas an overdose of acetominophen (eight 350-mg tablets) was the chief complaint of her ED visit immediately prior to her current ED presentation.
Immediately after ingesting the batteries the patient texted her husband, who then called emergency services. After arriving at the ED by ambulance, the patient expressed concern that her new husband of 6 months no longer loved her due to her escalating weight, which was now more than 400 pounds. The patient also shared feelings of missing her mother, with whom she had lived prior to her current (second) husband. The patient reported having mixed emotions about her recent marriage, including excitement leading up to the wedding combined with stress about leaving her mother's home. Over time, the patient began to experience her new husband as dull and boring. When asked about prior relationships, the patient reported she had been married once before to a kind man whom she missed, similar to the feelings she had about missing her mother.
The patient noted a pattern of difficulty staying in relationships for long periods and expressed intermittent feelings of emptiness. She described multiple, brief stints of employment due to constantly changing career goals, which was a source of tension in her current and prior relationships. After an overnight stay in the ED, the patient reported feeling significantly better and was discharged home.
Borderline Personality Disorder
The patient's instability in long-term relationships, recurrent attempts at suicide, irritability, fear of abandonment, and feeling of emptiness all provided clues to the diagnosis of borderline personality disorder.
Patients with borderline personality disorder (BPD) often have chronic suicidality that may not be improved with hospitalization. In fact, hospitalization after repeated suicide attempts can have negative effects in BPD patients.1 Dialectal behavior therapy and pharmacotherapy with selective serotonin reuptake inhibitors2 are common treatment recommendations.
Patients with BPD often present with a history of unstable interpersonal relationships combined with affective and behavioral impulsivity that result in impairment. Affective instability with BPD often mimics mood swings seen with bipolar disorder. Because many clinicians are reluctant to make a personality disorder diagnosis early on during treatment, patients are often overdiagnosed with bipolar disorder and underdiagnosed with BPD. Repeated ED presentation due to threats or attempts of self-harm or suicide can hint at the diagnosis.3,4
The prevalence rate for BPD in the United States is 1.6% of the adult population,5 and lifetime prevalence is approximately 6%.6 The female to male ratio of BPD in clinical settings is 3:1,7 but epidemiological surveys of the general US population reveal there is no significant difference in lifetime prevalence between genders. These combined data suggest that female patients with BPD are more likely to seek treatment compared to male patients with BPD.
- Joel P. Is hospitalization useful for suicidal patients with borderline personality disorder?J Pers Disord. 2004;18(3):240–247. doi:. doi:10.1521/pedi.22.214.171.124443 [CrossRef]
- American Psychiatric Association Practice Guidelines. Practice guideline for the treatment of patients with borderline personality disorder. Am J Psychiatry. 2001;158(suppl 10):1–52.
- Biskin RS, Paris J. Diagnosing borderline personality disorder. CMAJ. 2012;184(16):1789–1794. doi:. doi:10.1503/cmaj.090618 [CrossRef]
- National Institute of Mental Health. Borderline personality disorder. https://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml. Accessed December 11, 2017.
- Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. DSM-IV personality disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007;62(6):553–564. doi:. doi:10.1016/j.biopsych.2006.09.019 [CrossRef]
- Morgan TA, Zimmerman M. Is borderline personality disorder underdiagnosed and bipolar disorder overdiagnosed? In: Choi-Kain L, Gunderson J (eds). Borderline Personality and Mood Disorders. New York, NY: Springer; 2015:65–78.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders [text revision]. 4th ed. Washington, DC: American Psychiatric Publishing; 2000.